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Diagnostic Criteria
A. Consistent failure to speak in specific social situations in which there is an expectation for speaking (e.g., at school) despite speaking in other situations.
B. The disturbance interferes with educational or occupational achievement or with social communication.
C. The duration of the disturbance is at least 1 month (not limited to the first month of school).
D. The failure to speak is not attributable to a lack of knowledge of, or comfort with, the spoken language required in the social situation.
E. The disturbance is not better explained by a communication disorder (e.g., stuttering) and does not occur exclusively during the course of autism spectrum disorder, schizophrenia, or another psychotic disorder.Associated Features
When encountering other individuals in social interactions, children with selective mutism do not initiate speech or reciprocally respond when spoken to by others. Lack of speech occurs in social interactions with children or adults. Children with selective mutism will speak in their home in the presence of immediate family members but often not even in front of close friends or second-degree relatives, such as grandparents or cousins. The disturbance is most often marked by high social anxiety. The lack of speech may interfere with social communication, although children with this disorder sometimes use nonspoken or nonverbal means (e.g., grunting, pointing, writing) to communicate and may be willing or eager to perform or engage in social encounters when speech is not required (e.g., nonverbal parts in school plays).
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In clinical settings, children with selective mutism are almost always given an additional diagnosis of another anxiety disorder— most commonly, social anxiety disorder.Differential Diagnoses
Communication Disorders, Autism Spectrum Disorder, Intellectual Disability, Social Anxiety DisorderComorbid Disorders
The most common comorbid conditions are other anxiety disorders, most often social anxiety disorder, followed by separation anxiety disorder and specific phobia. In clinical settings, selective mutism and autism spectrum disorder have also been noted as frequently co-occurring conditions. Oppositional behaviors can be observed in a substantial minority of children with selective mutism, although this oppositional behavior may be limited to situations requiring speech. Communication delays or disorders also may appear in some children with selective mutism.←

Diagnostic Criteria
A. Marked fear or anxiety about a specific object or situation.
B. The phobic object or situation almost always provokes immediate fear or anxiety.
C. The phobic object or situation is actively avoided or endured with intense fear or anxiety.
D. The fear or anxiety is out of proportion to the actual danger posed by the specific object or situation and to the sociocultural context.
E. The fear, anxiety, or avoidance is persistent, typically lasting for 6 months or more.
F. The fear, anxiety, or avoidance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
G. The disturbance is not better explained by the symptoms of another mental disorder, including fear, anxiety, and avoidance of situations associated with panic-like symptoms or other incapacitating symptoms (as in agoraphobia); objects or situations related to obsessions (as in obsessive-compulsive disorder); reminders of traumatic events (as in posttraumatic stress disorder); separation from home or attachment figures (as in separation anxiety disorder); or social situations (as in social anxiety disorder).Associated Features
It is common for individuals to have multiple specific phobias. The average individual with specific phobia fears three objects or situations, and approximately 75% of individuals with specific phobia fear more than one situation or object.
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Specific phobia sometimes develops following a traumatic event, observation of others going through a traumatic event, an unexpected panic attack in the to be feared situation, or informational transmission. However, many individuals with specific phobia are unable to recall the specific reason for the onset of their phobias. Specific phobia usually develops in early childhood, with the majority of cases developing prior to age 10 years. Although most specific phobias develop in childhood and adolescence, it is possible for a specific phobia to develop at any age, often as the result of experiences that are traumatic. For example, phobias of choking almost always follow a near-choking event at any age.Differential Diagnoses
Agoraphobia, Panic Disorder, Trauma- and Stressor- Related Disorders, Obsessive-Compulsive Disorder, Psychotic Disorders, Eating DisordersComorbid Disorders
Specific phobia is rarely seen in medical-clinical settings in the absence of other psychopathology and is more frequently seen in nonmedical mental health settings. Specific phobia is frequently associated with a range of other disorders. Because of early onset, specific phobia is typically the temporally primary disorder. Individuals with specific phobia are at increased risk for the development of other disorders, including other anxiety disorders, depressive and bipolar disorders, substance-related disorders, somatic symptom and related disorders, and personality disorders (particularly dependent personality disorder).←

Diagnostic Criteria
A. Marked fear or anxiety about one or more social situations in which the individual is exposed to possible scrutiny by others. Examples include social interactions, being observed, and performing in front of others.
B. The individual fears that he or she will act in a way or show anxiety symptoms that will be negatively evaluated (i.e., will be humiliating or embarrassing; will lead to rejection or offend others).
C. The social situations almost always provoke fear or anxiety.
D. The social situations are avoided or endured with intense fear or anxiety.
E. The fear or anxiety is out of proportion to the actual threat posed by the social situation and to the sociocultural context.
F. The fear, anxiety, or avoidance is persistent, typically lasting for 6 months or more.
G. The fear, anxiety, or avoidance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
H. The fear, anxiety, or avoidance is not attributable to the physiological effects of a substance or another medical condition.
I. The fear, anxiety, or avoidance is not better explained by the symptoms of another mental disorder, such as panic disorder, body dysmorphic disorder, or autism spectrum disorder.
J. If another medical condition is present, the fear, anxiety, or avoidance is clearly unrelated or is excessive.Associated Features
Individuals with social anxiety disorder may be inadequately assertive or excessively submissive or, less commonly, highly controlling of the conversation. They may show overly rigid body posture or inadequate eye contact, or speak with an overly soft voice. These individuals may be shy or withdrawn, and they may be less open in conversations and disclose little about themselves. They may seek employment in jobs that do not require social contact.Differential Diagnoses
Normative shyness, Agoraphobia, Generalized Anxiety Disorder, Body Dysmorphic Disorder, Autism Spectrum Disorder, Avoidant Personality DisorderComorbid Disorders
Social anxiety disorder is often comorbid with other anxiety disorders, major depressive disorder, and substance use disorders, and the onset of social anxiety disorder generally precedes that of the other disorders, except for specific phobia and separation anxiety disorder. Chronic social isolation in the course of social anxiety disorder may result in major depressive disorder. Comorbidity with depression is high also in older adults. Substances may be used as self-medication for social fears, but the symptoms of substance intoxication or withdrawal, such as trembling, may also be a source of (further) social fear. Social anxiety disorder is frequently comorbid with body dysmorphic disorder, and generalized social anxiety disorder is often comorbid with avoidant personality disorder.←

Panic Attack Criteria
An abrupt surge of intense fear or intense discomfort that reaches a peak within minutes, and during which time four (or more) of the following symptoms occur:
::::::::::::::1. Palpitations, pounding heart, or accelerated heart rate.
::::::::::::::2. Sweating.
::::::::::::::3. Trembling or shaking.
::::::::::::::4. Sensations of shortness of breath or smothering.
::::::::::::::5. Feelings of choking.
::::::::::::::6. Chest pain or discomfort.
::::::::::::::7. Nausea or abdominal distress
::::::::::::::8. Feeling dizzy, unsteady, light-headed, or faint.
::::::::::::::9. Chills or heat sensations.
::::::::::::::10. Paresthesias (numbness or tingling sensations).
::::::::::::::11. Derealization (feelings of unreality) or depersonalization (being detached from oneself).
::::::::::::::12. Fear of losing control or “going crazy."
::::::::::::::13. Fear of dyingPanic Disorder Diagnostic Criteria
A. Recurrent unexpected panic attacks.
B. At least one of the attacks has been followed by 1 month (or more) of one or both of the following:
::::::::::::::1. Persistent concern or worry about additional panic attacks or their consequences (e.g., losing control, having a heart attack, “going crazy”).
::::::::::::::2. A significant maladaptive change in behavior related to the attacks (e.g., behaviors designed to avoid having panic attacks, such as avoidance of exercise or unfamiliar situations).
C. The disturbance is not attributable to the physiological effects of a substance or another medical condition.
D. The disturbance is not better explained by another mental disorder (e.g., the panic attacks do not occur only in response to feared social situations, as in social anxiety disorder; in response to circumscribed phobic objects or situations, as in specific phobia; in response to obsessions, as in obsessive-compulsive disorder; in response to reminders of traumatic events, as in posttraumatic stress disorder; or in response to separation from attachment figures, as in separation anxiety disorder).Associated Features
In addition to worry about panic attacks and their consequences, many individuals with panic disorder report constant or intermittent feelings of anxiety that are more broadly related to health and mental health concerns. For example, individuals with panic disorder often anticipate a catastrophic outcome from a mild physical symptom or medication side effect (e.g., thinking that they may have heart disease or that a headache means presence of a brain tumor). Such individuals often are relatively intolerant of medication side effects. In addition, there may be pervasive concerns about abilities to complete daily tasks or withstand daily stressors, excessive use of drugs (e.g., alcohol, prescribed medications or illicit drugs) to control panic attacks, or extreme behaviors aimed at controlling panic attacks.Differential Diagnoses
Limited-symptom panic attacks, Panic attacks occurring in other anxiety disordersComorbid Disorders
The prevalence of panic disorder is elevated in individuals with other disorders, particularly other anxiety disorders (and especially agoraphobia), major depressive disorder, bipolar I and bipolar II disorder, and possibly mild alcohol use disorder. While panic disorder occasionally has an earlier age at onset than the comorbid disorder(s), onset often occurs after the comorbid disorder and may be seen as a severity marker of the comorbid illness.
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Reported lifetime rates of comorbidity between major depressive disorder and panic disorder vary widely, ranging from 10% to 65% in individuals with panic disorder. In approximately one-third of individuals with both disorders, the depression precedes the onset of panic disorder. In the remaining two-thirds, depression occurs coincident with or following the onset of panic disorder. Comorbidity with other anxiety disorders and illness anxiety disorder is also common.←

Diagnostic Criteria
A. Marked fear or anxiety about two (or more) of the following five situations:
::::::::::::::1. Using public transportation.
::::::::::::::2. Being in open spaces.
::::::::::::::3. Being in enclosed places.
::::::::::::::4. Standing in line or being in a crowd.
::::::::::::::5. Being outside of the home alone.
B. The individual fears or avoids these situations because of thoughts that escape might be difficult or help might not be available in the event of developing panic-like symptoms or other incapacitating or embarrassing symptoms.
C. The agoraphobic situations almost always provoke fear or anxiety.
D. The agoraphobic situations are actively avoided, require the presence of a companion, or are endured with intense fear or anxiety.
E. The fear or anxiety is out of proportion to the actual danger posed by the agoraphobic situations and to the sociocultural context.
F. The fear, anxiety, or avoidance is persistent, typically lasting for 6 months or more.
G. The fear, anxiety, or avoidance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
H. If another medical condition is present, the fear, anxiety, or avoidance is clearly excessive.
I. The fear, anxiety, or avoidance is not better explained by the symptoms of another mental disorder—for example, the symptoms are not confined to specific phobia, situational type; do not involve only social situations; and are not related exclusively to obsessions, perceived defects or flaws in physical appearance, reminders of traumatic events, or fear of separation.Associated Features
Avoidance can be behavioral (e.g., changing daily routines, choosing a job nearby to avoid using public transportation, arranging for food delivery to avoid entering shops and supermarkets) as
well as cognitive (e.g., using distraction to get through agoraphobic situations) in nature. The avoidance can become so severe that the individual is completely homebound. Often, an individual is better able to confront a feared situation when accompanied by a companion, such as a partner, friend, or health professional. Also, the individual may employ safety behaviors (e.g., sitting near exits when taking public transportation or at the movies) to better endure such situations.
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In its most severe forms, agoraphobia can cause individuals to become completely homebound, unable to leave their home and dependent on others for services or assistance to provide even for basic needs. Demoralization and depressive symptoms, as well as abuse of alcohol and sedative
medication as inappropriate self-medication strategies, are common.Differential Diagnoses
Specific Phobia, Social Anxiety Disorder, Major Depressive DisorderComorbid Disorders
About 90% of individuals with agoraphobia also have other mental disorders. The most frequent additional diagnoses are other anxiety disorders (e.g., specific phobias, panic disorder, social anxiety disorder), depressive disorders (major depressive disorder), PTSD, and alcohol use disorder. Whereas other anxiety disorders (e.g., separation anxiety disorder, specific phobias, panic disorder) frequently precede onset of agoraphobia, depressive disorders and substance use disorders typically occur secondary to agoraphobia.←

Diagnostic Criteria
A. Excessive anxiety and worry (apprehensive expectation), occurring more days than not for at least 6 months, about a number of events or activities (such as work or school performance).
B. The individual finds it difficult to control the worry.
C. The anxiety and worry are associated with three (or more) of the following six symptoms (with at least some symptoms having been present for more days than not for the past 6 months):
::::::::::::::1. Restlessness or feeling keyed up or on edge.
::::::::::::::2. Being easily fatigued.
::::::::::::::3. Difficulty concentrating or mind going blank.
::::::::::::::4. Irritability.
::::::::::::::5. Muscle tension.
::::::::::::::6. Sleep disturbance (difficulty falling or staying asleep, or restless, unsatisfying sleep).
D. The anxiety, worry, or physical symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
E. The disturbance is not attributable to the physiological effects of a substance or another medical condition.
F. The disturbance is not better explained by another mental disorder.Associated Features
Several features distinguish generalized anxiety disorder from nonpathological anxiety. First, the worries associated with generalized anxiety disorder are excessive and typically interfere significantly with psychosocial functioning, whereas the worries of everyday life are not excessive and are perceived as more manageable and may be put off when more pressing matters arise. Second, the worries associated with generalized anxiety disorder are more pervasive, pronounced, and distressing; have longer duration; and frequently occur without precipitants. The greater the range of life circumstances about which a person worries, the more likely his or her symptoms are to meet criteria for generalized anxiety disorder. Third, everyday worries are much less likely to be accompanied by physical symptoms (e.g., restlessness or feeling keyed up or on edge). Individuals with generalized anxiety disorder report subjective distress as a result of constant worry and related impairment in social, occupational, or other important areas of functioning.Differential Diagnoses
Other anxiety disorders, Illness Anxiety Disorder and Somatic Symptom Disorder, Obsessive-Compulsive Disorder, Adjustment Disorder, Posttraumatic Stress DisorderComorbid Disorders
Individuals whose presentation meets criteria for generalized anxiety disorder are likely to have met, or currently meet, criteria for other anxiety and unipolar depressive disorders. The negative affectivity (neuroticism) or emotional liability that underpins this pattern of comorbidity is associated with temperamental antecedents and genetic and environmental risk factors shared between these disorders, although independent pathways are also possible. Comorbidity with substance use, conduct, psychotic, neurodevelopmental, and neurocognitive disorders is less common.←

Diagnostic Criteria
A. Presence of obsessions, compulsions, or both.
:::::::Obsessions are defined by (1) and (2):
::::::::::::::1. Recurrent and persistent thoughts, urges, or images that are experienced, at some time during the disturbance, as intrusive and unwanted, and that in most individuals cause
marked anxiety or distress.
::::::::::::::2. The individual attempts to ignore or suppress such thoughts, urges, or images, or to neutralize them with some other thought or action (i.e., by performing a compulsion).
:::::::Compulsions are defined by (1) and (2):
::::::::::::::1. Repetitive behaviors (e.g., hand washing, ordering, checking) or mental acts (e.g., praying, counting, repeating words silently) that the individual feels driven to perform in response to an obsession or according to rules that must be applied rigidly.
::::::::::::::2. The behaviors or mental acts are aimed at preventing or reducing anxiety or distress, or preventing some dreaded event or situation; however, these behaviors or mental acts are not connected in a realistic way with what they are designed to neutralize or prevent, or are clearly excessive.
B. The obsessions or compulsions are time-consuming or cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
C. The obsessive-compulsive symptoms are not attributable to the physiological effects of a substance or another medical condition.
D. The disturbance is not better explained by the symptoms of another mental disorder (e.g., excessive worries, as in generalized anxiety disorder; preoccupation with appearance, as in body dysmorphic disorder; difficulty discarding or parting with possessions, as in hoarding disorder; hair pulling, as in trichotillomania [hair-pulling disorder]; skin picking, as in excoriation [skin-picking] disorder; stereotypies, as in stereotypic movement disorder; ritualized eating behavior, as in eating disorders; preoccupation with substances or gambling, as in substance-related and addictive disorders; preoccupation with having an illness, as in illness anxiety disorder; sexual urges or fantasies, as in paraphilic disorders; impulses, as in disruptive, impulse-control, and conduct disorders; guilty ruminations, as in major depressive disorder; thought insertion or delusional preoccupations, as in schizophrenia spectrum and other psychotic disorders; or repetitive patterns of behavior, as in autism spectrum disorder).Specifiers
With good or fair insight: The individual recognizes that obsessive-compulsive disorder beliefs are definitely or probably not true or that they may or may not be true.
With poor insight: The individual thinks obsessivecompulsive disorder beliefs are probably true.
With absent insight/delusional beliefs: The individual is completely convinced that obsessive-compulsive disorder beliefs are true.Associated Features
Individuals with obsessive-compulsive disorder (OCD) vary in the degree of insight they have about the accuracy of the beliefs that underlie their obsessive-compulsive symptoms. Many individuals have good or fair insight (e.g., the individual believes that the house definitely will not, probably will not, or may or may not burn down if the stove is not checked 30 times). Some have poor insight (e.g., the individual believes that the house will probably burn down if the stove is not checked 30 times), and a few have absent insight/delusional beliefs (e.g., the individual is convinced that the house will burn down if the stove is not checked 30 times). Insight can vary within an individual over the course of the illness.
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Individuals with OCD experience a range of affective responses when confronted with situations that trigger obsessions and compulsions. For example, many individuals experience marked anxiety that can include recurrent panic attacks. Others report strong feelings of disgust. While performing compulsions, some individuals report a distressing sense of “incompleteness” or uneasiness until things look, feel, or sound “just right.”
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It is common for individuals with the disorder to avoid people, places, and things that trigger obsessions and compulsions. For example, individuals with contamination concerns might avoid public situations (e.g., restaurants, public restrooms) to reduce exposure to feared contaminants; individuals with intrusive thoughts about causing harm might avoid social interactions.
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Many individuals with OCD have dysfunctional beliefs. These beliefs can include an inflated sense of responsibility and the tendency to overestimate threat; perfectionism and intolerance of uncertainty; and over-importance of thoughts (e.g., believing that having a forbidden thought is as bad as acting on it) and the need to control thoughts. These beliefs, however, are not specific to OCD. The involvement of family or friends in compulsive rituals, termed accommodation, can exacerbate or maintain symptoms and is an important target in treatment, especially in children.Differential Diagnoses
Anxiety Disorders, Other obsessive-compulsive disorders, Psychotic DisordersComorbid Disorders
Individuals with OCD often have other psychopathology. Many adults with the disorder in the United States have a lifetime diagnosis of an anxiety disorder or a depressive or bipolar disorder; a lifetime diagnosis of an impulse-control disorder or a substance use disorder is also common. Onset of OCD is usually later than for most comorbid anxiety disorders (with the exception of separation anxiety disorder) and PTSD but often precedes that of depressive disorders.
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Up to 30% of individuals with OCD also have a lifetime tic disorder. A comorbid tic disorder is most common in men with onset of OCD in childhood. These individuals tend to differ from those without a history of tic disorders in the themes of their OCD symptoms, comorbidity, course, and pattern of familial transmission. A triad of OCD, tic disorder, and attention-deficit/hyperactivity disorder can also be seen in children.←

Diagnostic Criteria
A. Preoccupation with one or more perceived defects or flaws in physical appearance that are not observable or appear slight to others.
B. At some point during the course of the disorder, the individual has performed repetitive behaviors (e.g., mirror checking, excessive grooming, skin picking, reassurance seeking) or mental acts (e.g., comparing his or her appearance with that of others) in response to the appearance concerns.
C. The preoccupation causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
D. The appearance preoccupation is not better explained by concerns with body fat or weight in an individual whose symptoms meet diagnostic criteria for an eating disorder.Specifiers
With muscle dysmorphia: The individual is preoccupied with the idea that his or her body build is too small or insufficiently muscular. This specifier is used even if the individual is preoccupied with other body areas, which is often the case.
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With good or fair insight: The individual recognizes that the body dysmorphic disorder beliefs are definitely or probably not true or that they may or may not be true.
With poor insight: The individual thinks that the body dysmorphic disorder beliefs are probably true.
With absent insight/delusional beliefs: The individual is completely convinced that the body dysmorphic disorder beliefs are true.Associated Features
Muscle dysmorphia, a form of body dysmorphic disorder, consists of preoccupation with the idea that one’s body is too small or insufficiently lean or muscular. Individuals with this form of the disorder actually have a normal-looking body or are even very muscular. They may also be preoccupied with other body areas, such as skin or hair. A majority (but not all) diet, exercise, and/or lift weights excessively, sometimes causing bodily damage. Some use potentially dangerous anabolic-androgenic steroids and other substances to try to make their body bigger and more muscular.
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Preoccupations can focus on one or many body areas, most commonly the skin (e.g., perceived acne, scars, lines, wrinkles, paleness), hair (e.g., “thinning” hair or “excessive” body or facial hair), or nose (e.g., size or shape). However, any body area can be the focus of concern (e.g., eyes, teeth, weight, stomach, breasts, legs, face size or shape, lips, chin, eyebrows, genitals). Some individuals are concerned about perceived asymmetry of body areas.
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Many individuals with body dysmorphic disorder have ideas or delusions of reference, believing that other people take special notice of them or mock them because of how they look. Body dysmorphic disorder is associated with high levels of anxiety, social anxiety, social avoidance, depressed mood, negative affectivity (neuroticism), rejection sensitivity, and perfectionism as well as low extroversion and low self-esteem.Differential Diagnoses
Normal appearance concerns, Eating Disorders, Anxiety Disorders, Psychotic Disorders, Gender Dysphoria, Body Integrity DysphoriaComorbid Disorders
Major depressive disorder is the most common comorbid disorder, with onset usually after that of body dysmorphic disorder. Comorbid social anxiety disorder, OCD, and substance-related disorders (including use of anabolic-androgenic steroids in the muscle dysmorphia form of body dysmorphic disorder) are also common.←

Diagnostic Criteria
A. Persistent difficulty discarding or parting with possessions, regardless of their actual value.
B. This difficulty is due to a perceived need to save the items and to distress associated with discarding them.
C. The difficulty discarding possessions results in the accumulation of possessions that congest and clutter active living areas and substantially compromises their intended use. If living areas are uncluttered, it is only because of the interventions of third parties (e.g., family members).
D. The hoarding causes clinically significant distress or impairment in social, occupational, or other important areas of functioning (including maintaining a safe environment for self and others).
E. The hoarding is not attributable to another medical condition.
F. The hoarding is not better explained by the symptoms of another mental disorder.Specifiers
With excessive acquisition: If difficulty discarding possessions is accompanied by excessive acquisition of items that are not needed or for which there is no available space.
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With good or fair insight: The individual recognizes that hoarding-related beliefs and behaviors (pertaining to difficulty discarding items, clutter, or excessive acquisition) are problematic.
With poor insight: The individual is mostly convinced that hoarding-related beliefs and behaviors (pertaining to difficulty discarding items, clutter, or excessive acquisition) are not problematic despite evidence to the contrary.
With absent insight/delusional beliefs: The individual is completely convinced that hoarding-related beliefs and behaviors (pertaining to difficulty discarding items, clutter, or excessive acquisition) are not problematic despite evidence to the contrary.Associated Features
Other common features of hoarding disorder include indecisiveness, perfectionism, avoidance, procrastination, difficulty planning and organizing tasks, and distractibility. Some individuals with hoarding disorder live in unsanitary conditions that may be a logical consequence of severely cluttered spaces and/or that are related to planning and organizing difficulties.Differential Diagnoses
Autism Spectrum Disorder, Intellectual Disability, Psychotic Disorders, Major Depressive Episode, OCDComorbid Disorders
Approximately 75% of individuals with hoarding disorder have a comorbid mood or anxiety disorder. The most common comorbid conditions are major depressive disorder, social anxiety disorder, and generalized anxiety disorder. Approximately 20% of individuals with hoarding disorder also have symptoms that meet diagnostic criteria for OCD. These comorbidities may often be the main reason for consultation, because individuals are unlikely to spontaneously report hoarding symptoms, and hoarding symptoms are often not asked about in routine clinical interviews.←

Diagnostic Criteria
A. Recurrent pulling out of one’s hair, resulting in hair loss.
B. Repeated attempts to decrease or stop hair pulling.
C. The hair pulling causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
D. The hair pulling or hair loss is not attributable to another medical condition.
E. The hair pulling is not better explained by the symptoms of another mental disorder.Associated Features
Hair-pulling sites may vary over time. Hair pulling may occur in brief episodes scattered throughout the day or during less frequent but more sustained periods that can continue for hours, and such hair pulling may endure for months or years. The term distress includes negative affects that may be experienced by individuals with hair pulling, such as feeling a loss of control, embarrassment, and shame.
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Hair pulling may be accompanied by a range of behaviors or rituals involving hair. Thus, individuals may search for a particular kind of hair to pull (e.g., hairs with a specific texture or color), may try to pull out hair in a specific way (e.g., so that the root comes out intact), or may visually examine or tactilely or orally manipulate the hair after it has been pulled (e.g., rolling the hair between the fingers, pulling the strand between the teeth, biting the hair into pieces, or swallowing the hair).
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Hair pulling does not usually occur in the presence of other individuals, except immediate family members. Some individuals may deny their hair pulling to others. The majority of individuals with
trichotillomania also have one or more other body-focused repetitive behaviors, including skin picking, nail biting, and lip chewing.Differential Diagnoses
Hair removal or manipulation for cosmetic purposes, Other obsessive-compulsive disorders, Stereotypic Movement DisorderComorbid Disorders
Trichotillomania is often accompanied by other mental disorders, most commonly major depressive disorder and excoriation (skin-picking) disorder. Repetitive body-focused symptoms other than hair pulling or skin picking (e.g., nail biting) occur in the majority of individuals with trichotillomania and may deserve an additional diagnosis of other specified obsessive-compulsive and related disorder (i.e., other body-focused repetitive behavior disorder).←

Diagnostic Criteria
A. Recurrent skin picking resulting in skin lesions.
B. Repeated attempts to decrease or stop skin picking.
C. The skin picking causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
D. The skin picking is not attributable to the physiological effects of a substance or another medical condition.
E. The skin picking is not better explained by symptoms of another mental disorder.Associated Features
The most commonly picked sites are the face, arms, and hands, but many individuals pick from multiple body sites. Individuals may pick at healthy skin, at minor skin irregularities, at lesions such as pimples or calluses, or at scabs from previous picking. Most individuals pick with their fingernails, although many use tweezers, pins, or other objects. In addition to skin picking, there may be skin rubbing, squeezing, lancing, and biting. Individuals with excoriation disorder often spend significant amounts of time on their picking behavior, sometimes several hours per day, and such skin picking may endure for months or years.
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Skin picking may be accompanied by a range of behaviors or rituals involving skin or scabs. Thus, individuals may search for a particular kind of scab to pull, and they may examine, play with, or mouth or swallow the skin after it has been pulled. Skin picking may also be preceded or accompanied by various emotional states. Skin picking may be triggered by feelings of anxiety or boredom, may be preceded by an increasing sense of tension (either immediately before picking the skin or when attempting to resist the urge to pick), and may lead to gratification, pleasure, or a sense of relief when the skin or scab has been picked. Some individuals report picking in response to a minor skin irregularity or to relieve an uncomfortable bodily sensation.Differential Diagnoses
Other obsessive-compulsive disorders, Neurodevelopmental DisordersComorbid Disorders
Excoriation disorder is often accompanied by other mental disorders. Such disorders include OCD and trichotillomania (hair-pulling disorder), as well as major depressive disorder. Repetitive body-focused symptoms other than skin picking and hair pulling (e.g., nail biting) occur in many individuals with excoriation disorder and may deserve an additional diagnosis of other specified obsessive-compulsive and related disorder (i.e., other body-focused repetitive behavior disorder).←

Other Specified Obsessive-Compulsive and Related Disorder
This category applies to presentations in which symptoms characteristic of an obsessive-compulsive and related disorder that cause clinically significant distress or impairment in social, occupational, or other important areas of functioning predominate but do not meet the full criteria for any of the disorders in the obsessive-compulsive and related disorders diagnostic class. The other specified obsessive-compulsive and related disorder category is used in situations in which the clinician chooses to communicate the specific reason that the presentation does not meet the criteria for any specific obsessive-compulsive and related disorder.
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Examples of presentations that can be specified using the “other specified” designation include:
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1. Body dysmorphic–like disorder with actual flaws: This is similar to body dysmorphic disorder except that the defects or flaws in physical appearance are clearly observable by others (i.e., they are more noticeable than “slight”). In such cases, the preoccupation with these flaws is clearly excessive and causes significant impairment or distress.
2. Body dysmorphic–like disorder without repetitive behaviors: Presentations that meet body dysmorphic disorder except that the individual has never performed repetitive behaviors or mental acts in response to the appearance concerns.
3. Other body-focused repetitive behavior disorder: Presentations involving recurrent body-focused repetitive behaviors other than hair pulling and skin picking (e.g., nail biting, lip biting, cheek chewing) that are accompanied by repeated attempts to decrease or stop the behaviors and that cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
4. Obsessional jealousy: This is characterized by non-delusional preoccupation with a partner’s perceived infidelity. The preoccupations may lead to repetitive behaviors or mental acts in response to the infidelity concerns; they cause clinically significant distress or impairment in social,
occupational, or other important areas of functioning; and they are not better explained by another mental disorder such as delusional disorder, jealous type, or paranoid personality disorder.
5. Olfactory reference disorder (olfactory reference syndrome): This is characterized by the individual’s persistent preoccupation with the belief that they are emitting a foul or offensive body odor that is unnoticeable or only slightly noticeable to others; in response to this preoccupation, these individuals often engage in repetitive and excessive behaviors such as repeatedly checking for body odor, excessive showering, or seeking reassurance, as well as excessive attempts to camouflage the perceived odor. These symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.←

Diagnostic Criteria
A. Exposure to actual or threatened death, serious injury, or sexual violence in one (or more) of the following ways:
::::::::::::::1. Directly experiencing the traumatic event(s).
::::::::::::::2. Witnessing, in person, the event(s) as it occurred to others.
::::::::::::::3. Learning that the traumatic event(s) occurred to a close family member or close friend. In cases of actual or threatened death of a family member or friend, the event(s) must have been violent or accidental.
::::::::::::::4. Experiencing repeated or extreme exposure to aversive details of the traumatic event(s) in a work-related context.
B. Presence of one (or more) of the following intrusion symptoms associated with the traumatic event(s), beginning after the traumatic event(s) occurred:
::::::::::::::1. Recurrent, involuntary, and intrusive distressing memories of the traumatic event(s).
::::::::::::::2. Recurrent distressing dreams in which the content and/or affect of the dream are related to the traumatic event(s).
::::::::::::::3. Dissociative reactions (e.g., flashbacks) in which the individual feels or acts as if the traumatic event(s) were recurring. (Such reactions may occur on a continuum, with the most extreme expression being a complete loss of awareness of present surroundings.)
::::::::::::::4. Intense or prolonged psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event(s).
::::::::::::::5. Marked physiological reactions to internal or external cues that symbolize or resemble an aspect of the traumatic event(s).
C. Persistent avoidance of stimuli associated with the traumatic event(s), beginning after the traumatic event(s) occurred, as evidenced by one or both of the following:
::::::::::::::1. Avoidance of or efforts to avoid distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s).
::::::::::::::2. Avoidance of or efforts to avoid external reminders (people, places, conversations, activities, objects, situations) that arouse distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s).
D. Negative alterations in cognitions and mood associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred, as evidenced by two (or more) of the following:
::::::::::::::1. Inability to remember an important aspect of the traumatic event(s) (typically due to dissociative amnesia and not to other factors such as head injury, alcohol, or drugs).
::::::::::::::2. Persistent and exaggerated negative beliefs or expectations about oneself, others, or the world (e.g., “I am bad,” “No one can be trusted,” “The world is completely dangerous,” “My whole nervous system is permanently ruined”).
::::::::::::::3. Persistent, distorted cognitions about the cause or consequences of the traumatic event(s) that lead the individual to blame himself/herself or others.
::::::::::::::4. Persistent negative emotional state (e.g., fear, horror, anger, guilt, or shame).
::::::::::::::5. Markedly diminished interest or participation in significant activities.
::::::::::::::6. Feelings of detachment or estrangement from others.
::::::::::::::7. Persistent inability to experience positive emotions (e.g., inability to experience happiness, satisfaction, or loving feelings).
E. Marked alterations in arousal and reactivity associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred, as evidenced by two (or more) of the following:
::::::::::::::1. Irritable behavior and angry outbursts (with little or no provocation) typically expressed as verbal or physical aggression toward people or objects.
::::::::::::::2. Reckless or self-destructive behavior.
::::::::::::::3. Hypervigilance.
::::::::::::::4. Exaggerated startle response.
::::::::::::::5. Problems with concentration.
::::::::::::::6. Sleep disturbance (e.g., difficulty falling or staying asleep or restless sleep).
F. Duration of the disturbance (Criteria B, C, D, and E) is more than 1 month.
G. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
H. The disturbance is not attributable to the physiological effects of a substance or another medical condition.Associated Features
The essential feature of posttraumatic stress disorder (PTSD) is the development of characteristic symptoms following exposure to one or more traumatic events. The clinical presentation of PTSD varies. In some individuals, fear-based reexperiencing, emotional, and behavioral symptoms may predominate. In others, anhedonic or dysphoric mood states and negative cognitions may be most prominent. In some other individuals, arousal and reactive-externalizing symptoms are prominent, while in yet others, dissociative symptoms predominate. Finally, some individuals exhibit combinations of these symptom patterns. A significant subgroup of individuals with PTSD experience persistent dissociative symptoms of either depersonalization (detachment from their bodies) or derealization (detachment from the world around them).
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The traumatic events in Criterion A all involve actual or threatened death, serious injury, or sexual violence in some way but differ in how the individual is exposed to them, which can be through directly experiencing the traumatic event, witnessing in person the event as it occurred to others, learning that the event occurred to a family member or a close friend, or indirect exposure in the course of occupational duties, through being exposed to grotesque details of an event. The disorder may be especially severe or long lasting when the stressor is interpersonal and intentional.
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Auditory pseudo-hallucinations, such as having the sensory experience of hearing one’s thoughts spoken in one or more different voices, as well as paranoid ideation, can be present. Following prolonged, repeated, and severe traumatic events (e.g., childhood abuse, torture), the individual may additionally experience difficulties in regulating emotions or maintaining stable interpersonal relationships, or dissociative symptoms. When the traumatic event involves the violent death of someone with whom the individual had a close relationship, symptoms of both prolonged grief
disorder and PTSD may be present.
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In adjustment disorders, the stressor can be of any severity or type rather than a stressor involving exposure to actual or threatened death, serious injury, or sexual violence as required by PTSD Criterion A. The diagnosis of an adjustment disorder is used when the response to a stressor that meets PTSD Criterion A does not meet all other PTSD criteria. An adjustment disorder is also diagnosed when the symptom pattern of PTSD occurs in response to a stressor that does not meet PTSD Criterion A.Differential Diagnoses
Adjustment Disorder, Acute Stress DisorderComorbid Disorders
Individuals with PTSD are more likely than those without PTSD to have symptoms that meet diagnostic criteria for at least one other mental disorder, such as depressive, bipolar, anxiety, or substance use disorders. PTSD is also associated with increased risk of major neurocognitive disorder.←

Diagnostic Criteria
A. The development of emotional or behavioral symptoms in response to an identifiable stressor(s) occurring within 3 months of the onset of the stressor(s).
B. These symptoms or behaviors are clinically significant, as evidenced by one or both of the following:
::::::::::::::1. Marked distress that is out of proportion to the severity or intensity of the stressor, taking into account the external context and the cultural factors that might influence symptom severity and presentation.
::::::::::::::2. Significant impairment in social, occupational, or other important areas of functioning.
C. The stress-related disturbance does not meet the criteria for another mental disorder and is not merely an exacerbation of a preexisting mental disorder.
D. The symptoms do not represent normal bereavement and are not better explained by prolonged grief disorder.
E. Once the stressor or its consequences have terminated, the symptoms do not persist for more than an additional 6 months.
:
With depressed mood: Low mood, tearfulness, or feelings of hopelessness are predominant.
With anxiety: Nervousness, worry, jitteriness, or separation anxiety is predominant.
With mixed anxiety and depressed mood: A combination of depression and anxiety is predominant.
With disturbance of conduct: Disturbance of conduct is predominant.
With mixed disturbance of emotions and conduct: Both emotional symptoms and a
disturbance of conduct are predominant.Associated Features
The presence of emotional or behavioral symptoms in response to an identifiable stressor is the essential feature of adjustment disorders. The stressor may be a single event, or there may be multiple stressors. Stressors may be recurrent or continuous.Differential Diagnoses
Major Depressive Disorder, Posttraumatic Stress Disorder, Personality Disorders, BereavementComorbid Disorders
Adjustment disorders can accompany most mental disorders and any medical condition. Adjustment disorders can be diagnosed in addition to another mental disorder only 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 and at the same time have a diagnosis of obsessive-compulsive disorder. Or, an individual may have a depressive or bipolar disorder and an adjustment disorder as long as the criteria for both are met.←

Diagnostic Criteria
A. The death, at least 12 months ago, of a person who was close to the bereaved individual (for children and adolescents, at least 6 months ago).
B. Since the death, the development of a persistent grief response characterized by one or both of the following symptoms, which have been present most days to a clinically significant degree. In addition, the symptom(s) has occurred nearly every day for at least the last month:
::::::::::::::1. Intense yearning/longing for the deceased person.
::::::::::::::2. Preoccupation with thoughts or memories of the deceased person (in children and adolescents, preoccupation may focus on the circumstances of the death).
C. Since the death, at least three of the following symptoms have been present most days to a clinically significant degree. In addition, the symptoms have occurred nearly every day for at least the last month:
::::::::::::::1. Identity disruption (e.g., feeling as though part of oneself has died) since the death.
::::::::::::::2. Marked sense of disbelief about the death.
::::::::::::::3. Avoidance of reminders that the person is dead (in children and adolescents, may be characterized by efforts to avoid reminders).
::::::::::::::4. Intense emotional pain (e.g., anger, bitterness, sorrow) related to the death.
::::::::::::::5. Difficulty reintegrating into one’s relationships and activities after the death (e.g., problems engaging with friends, pursuing interests, or planning for the future).
::::::::::::::6. Emotional numbness (absence or marked reduction of emotional experience) as a result of the death.
::::::::::::::7. Feeling that life is meaningless as a result of the death.
::::::::::::::8. Intense loneliness as a result of the death.
D. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
E. The duration and severity of the bereavement reaction clearly exceed expected social, cultural, or religious norms for the individual’s culture and context.
F. The symptoms are not better explained by another mental disorder, such as major depressive disorder or posttraumatic stress disorder, and are not attributable to the physiological effects of a substance or another medical condition.Associated Features
Individuals with symptoms of prolonged grief disorder often experience maladaptive cognitions about the self, guilt about the death, and diminished future life expectancy and life goals. Somatic complaints commonly accompany the condition and may be related to comorbid depression and anxiety, social identity disruption, and increased health care visits; the somatic symptoms may be associated with those that were experienced by the deceased. Harmful health behaviors related to decreased self-care and concern are also common in individuals with symptoms of prolonged grief disorder. Hallucinations about the deceased (e.g., hearing the deceased person’s voice) may occur during normal grief but may be more common in individuals with symptoms of prolonged grief disorder; hallucinations experienced by individuals with prolonged grief disorder symptoms may be associated with disruptions of social identity and purpose related to the death (e.g., confusion about one’s role in life, feeling of meaninglessness). Other associated features of prolonged grief disorder include bitterness, anger, or restlessness; blaming others for the death; and decreased sleep quantity and quality.Differential Diagnoses
Normal grief reactionsComorbid Disorders
The most common comorbid disorders with symptoms of prolonged grief disorder are major depressive disorder, PTSD, and substance use disorders. PTSD is more frequently comorbid with prolonged grief disorder symptoms when the death occurred in violent or accidental circumstances. Separation anxiety disorder involving major living attachment figures may be comorbid with symptoms of prolonged grief disorder.←

Diagnostic Criteria
A. Disruption of identity characterized by two or more distinct personality states, which may be described in some cultures as an experience of possession. The disruption in identity involves marked discontinuity in sense of self and sense of agency, accompanied by related alterations in affect, behavior, consciousness, memory, perception, cognition, and/or sensory-motor functioning. These signs and symptoms may be observed by others or reported by the individual.
B. Recurrent gaps in the recall of everyday events, important personal information, and/or traumatic events that are inconsistent with ordinary forgetting.
C. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
D. The disturbance is not a normal part of a broadly accepted cultural or religious practice.
E. The symptoms are not attributable to the physiological effects of a substance or another medical condition.Associated Features
The overtness or covertness of these personality states varies as a function of psychological motivation, current level of stress, cultural context, internal conflicts and dynamics, and emotional resilience, among other factors. Sustained periods of identity confusion/alteration may occur when psychosocial pressures are severe and/or prolonged. In those cases of dissociative identity disorder that present as the individual being possessed by external identities (possession-form dissociative identity disorder), and in a small proportion of non-possession-form cases, manifestations of alternate identities are readily observable. Most individuals with non-possession-form dissociative identity disorder do not overtly display, or only subtly display, their discontinuity of identity, and only a minority present to clinical attention with discernible alternation of identities. The elaboration of dissociative personality states with different names, wardrobes, hairstyles, handwritings, accents, and so forth, occurs in only a minority of individuals with the non-possession-form dissociative identity disorder and is not essential to diagnosis. In those cases where alternate personality states cannot be directly observed, the presence of distinct personality states can be identified by sudden alterations or discontinuities in the individual’s sense of self and sense of agency, and recurrent dissociative amnesias.
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Criterion A symptoms are related to discontinuities of experience that can affect any aspect of an individual’s functioning. Individuals with dissociative identity disorder may report the feeling that they have suddenly become depersonalized observers of their own speech and actions, which they may feel powerless to stop. These individuals may also report perceptions of voices (e.g., a child’s voice, voices commenting on the individual’s thoughts or behavior, persecutory voices and command hallucinations). In some cases, hearing voices is specifically denied, but the individual reports multiple, perplexing, independent thought streams over which the individual experiences no control. Individuals with dissociative identity disorder may report hallucinations in all sensory modalities: auditory, visual, tactile, olfactory, and gustatory.
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Strong emotions, impulses, thoughts, and even speech or other actions may suddenly materialize, without a sense of personal ownership or control. Conversely, thoughts and emotions may unexpectedly vanish, and speech and actions are abruptly inhibited. These experiences are frequently reported as ego-dystonic and puzzling. Attitudes, outlooks, and personal preferences (e.g., about food, activities, gender identity) may suddenly shift. Individuals may report that their bodies feel different (e.g., like a small child, the opposite gender, different ages simultaneously). Alterations in sense of self and agency may be accompanied by a feeling that attitudes, emotions, and behaviors—even the individual’s own body—are “not mine” or are “not under my control.”
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In most individuals with dissociative identity disorder, switching/shifting of states is subtle and may occur with only subtle changes in overt presentation. State switching may be more overt in the possession form of dissociative identity disorder. In general, the individual with dissociative identity disorder experiences themself as multiple, simultaneously overlapping and interfering states.
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Individuals with dissociative identity disorder often conceal, or are not fully aware of, disruptions in consciousness, amnesia, or other dissociative symptoms. Many individuals with dissociative identity disorder report dissociative flashbacks during which they experience a sensory reliving of a previous event as though it were occurring in the present, often with a change of identity, a partial or complete loss of contact with or disorientation to current reality during the flashback, and a subsequent amnesia for the content of the flashback.
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The disorder may first manifest at almost any age from early childhood to late life. Overt identity alteration/confusion may be triggered by many factors, such as later traumatic experiences (e.g., sexual assault), or even seemingly inconsequential stressors, like a minor motor vehicle accident. The experience of other major or cumulative life stressors may also worsen symptoms, including life events such as the individual’s children reaching the same age at which the individual was significantly abused or traumatized. The death of, or the onset of a fatal illness in, the individual’s abuser(s) is another example of an event that may worsen symptoms.Differential Diagnoses
Dissociative Amnesia, Depersonalization/Derealization Disorder, Bipolar Disorder, Posttraumatic Stress Disorder, Psychotic Disorders, Personality DisordersComorbid Disorders
Disorders that are comorbid with dissociative identity disorder include PTSD, depressive disorders, substance-related disorders, feeding and eating disorders, obsessive-compulsive disorder, antisocial personality disorder, and other specified personality disorder with avoidant, obsessive-compulsive, or borderline personality traits. The most common forms of functional neurological symptom disorder include nonepileptic seizures, gait disturbances, and paralyses. Most commonly, nonepileptic seizures resemble grand mal seizures or complex partial seizures with temporal lobe foci; others may mimic absence or partial seizures.←

Diagnostic Criteria
A. An inability to recall important autobiographical information, usually of a traumatic or stressful nature, that is inconsistent with ordinary forgetting.
B. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
C. The disturbance is not attributable to the physiological effects of a substance or a neurological or other medical condition.
D. The disturbance is not better explained by dissociative identity disorder, posttraumatic stress disorder, acute stress disorder, somatic symptom disorder, or major or mild neurocognitive disorder.Associated Features
A variety of types of dissociative amnesia may manifest. In general, the memory deficit in dissociative amnesia is retrograde and, except in rare cases, is not associated with ongoing amnesia for contemporary life events. Retrospective memory impairments include not only lost memories of traumatic experiences but also lost memories of everyday life during which no trauma occurred. Most commonly, individuals with dissociative amnesia report localized amnesia—a failure to recall events during a circumscribed period of time; and/or selective amnesia—the individual can recall some, but not all, of the events during a circumscribed period of time. In systematized amnesia the individual fails to recall a specific category of important information (e.g., fragmentary recall of home growing up, but continuous memory for school; no recall of a violent older sibling; lack of recall of a specific room in the individual’s childhood home). Individuals rarely overtly complain of symptoms of these forms of dissociative amnesia and attempt to minimize and rationalize the memory loss.
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Generalized dissociative amnesia involves a complete loss of memory for most or all of the individual’s life history. Individuals with generalized amnesia may forget personal identity, lose previous knowledge about the world, and less commonly lack access to well-learned skills. Generalized dissociative amnesia has an acute onset; the perplexity, disorientation, and purposeless wandering of individuals with generalized amnesia usually bring them to the attention of the police or psychiatric emergency services.
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Individuals with dissociative amnesia are frequently unaware (or only partially aware) of their memory problems. They may recall some traumatic events, or parts of traumatic events, but not others of the same type. Many, especially those with localized amnesia, minimize the importance of their memory loss and may become uncomfortable when prompted to address it.Differential Diagnoses
Dissociative Identity Disorder, Posttraumatic Stress Disorder, Other Specified Dissociative DisorderComorbid Disorders
As is common in individuals with a history of trauma, many comorbidities co-occur with dissociative amnesia, particularly as dissociative amnesia begins to remit. A wide variety of affective phenomena may surface, including dysphoria, grief, rage, shame, guilt, and psychological conflict and turmoil. Individuals may engage in self-injury and other high-risk behaviors. These individuals may have symptoms that meet diagnostic criteria for persistent depressive disorder, major depressive disorder, or subthreshold depression (other specified depressive disorder). Many individuals with dissociative amnesia develop PTSD at some point during their life, especially when the traumatic antecedents of their amnesia are brought into conscious awareness. Many of these individuals may show symptoms of the dissociative subtype of PTSD. Many individuals with dissociative amnesia have symptoms that meet diagnostic criteria for a comorbid somatic symptom and related disorder (and vice versa), particularly functional neurological symptom disorder (conversion disorder). Substance-related and addictive disorders may be comorbid with dissociative amnesia, as well as feeding and eating disorders and sexual dysfunctions. The most common comorbid personality disorder is other specified personality disorder (with mixed personality disorder features), which often includes avoidant, obsessive-compulsive, dependent, and borderline features.←

Diagnostic Criteria
A. The presence of persistent or recurrent experiences of depersonalization, derealization, or both:
::::::::::::::1. Depersonalization: Experiences of unreality, detachment, or being an outside observer with respect to one’s thoughts, feelings, sensations, body, or actions (e.g., perceptual alterations, distorted sense of time, unreal or absent self, emotional and/or physical numbing).
::::::::::::::2. Derealization: Experiences of unreality or detachment with respect to surroundings (e.g., individuals or objects are experienced as unreal, dreamlike, foggy, lifeless, or visually distorted).
B. During the depersonalization or derealization experiences, reality testing remains intact.
C. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
D. The disturbance is not attributable to the physiological effects of a substance or another medical condition.
E. The disturbance is not better explained by another mental disorder, such as schizophrenia, panic disorder, major depressive disorder, acute stress disorder, posttraumatic stress disorder, or another dissociative disorder.Associated Features
Individuals with depersonalization/derealization disorder may have difficulty describing their symptoms and may think they are “crazy” or “going crazy.” Another common experience is the fear of irreversible brain damage. A commonly associated symptom is a subjectively altered sense of time (i.e., too fast or too slow), as well as a subjective difficulty in vividly recalling past memories and owning them as personal and emotional. Vague somatic symptoms, such as head fullness, tingling, or lightheadedness, are not uncommon. Individuals may experience extreme rumination or obsessional preoccupation (e.g., constantly obsessing about whether they really exist, or checking their perceptions to determine whether they appear real). Varying degrees of anxiety and depression are also common associated features.
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The presence of intact reality testing specifically regarding the depersonalization/derealization symptoms is essential to differentiating depersonalization/derealization disorder from psychotic disorders. Rarely, positive-symptom schizophrenia can pose a diagnostic challenge when nihilistic delusions are present. For example, an individual may complain that he or she is dead or the world is not real; this could be either a subjective experience that the individual knows is not true or a delusional conviction.Differential Diagnoses
Major Depressive Disorder, Other dissociative disorders, Panic attacks, Psychotic DisordersComorbid Disorders
In a convenience sample of adults recruited for a number of depersonalization research studies, lifetime comorbidities were high for unipolar depressive disorder and for any anxiety disorder, with a significant proportion of the sample having both disorders. Comorbidity with posttraumatic stress disorder was low. The three most commonly co-occurring personality disorders were avoidant, borderline, and obsessive-compulsive.←

Diagnostic Criteria
This category applies to presentations in which symptoms characteristic of a dissociative disorder that cause clinically significant distress or impairment in social, occupational, or other important areas of functioning predominate but do not meet the full criteria for any of the disorders in the dissociative disorders diagnostic class. The other specified dissociative disorder category is used in situations in which the clinician chooses to communicate the specific reason that the presentation does not meet the criteria for any specific dissociative disorder.
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Examples of presentations that can be specified using the “other specified” designation include:
:
1. Chronic and recurrent syndromes of mixed dissociative symptoms: This category includes identity disturbance associated with less-than-marked discontinuities in sense of self and agency, or alterations of identity or episodes of possession in an individual who reports no dissociative amnesia.
2. Identity disturbance due to prolonged and intense coercive persuasion: Individuals who have been subjected to intense coercive persuasion (e.g., brainwashing, thought reform, indoctrination while captive, torture, long-term political imprisonment, recruitment by sects/cults or by terror organizations) may present with prolonged changes in, or conscious questioning of, their identity.
3. Acute dissociative reactions to stressful events: This category is for acute, transient conditions that typically last less than 1 month, and sometimes only a few hours or days. These conditions are characterized by constriction of consciousness; depersonalization; derealization; perceptual disturbances (e.g., time slowing, macropsia); microamnesias; transient stupor; and/or alterations in sensory-motor functioning (e.g., analgesia, paralysis).
4. Dissociative trance: This condition is characterized by an acute narrowing or complete loss of awareness of immediate surroundings that manifests as profound unresponsiveness or insensitivity to environmental stimuli. The unresponsiveness may be accompanied by minor stereotyped behaviors (e.g., finger movements) of which the individual is unaware and/or that he or she cannot control, as well as transient paralysis or loss of consciousness. The dissociative trance is not a normal part of a broadly accepted collective cultural or religious practice.←

Diagnostic Criteria
A. One or more somatic symptoms that are distressing or result in significant disruption of daily life.
B. Excessive thoughts, feelings, or behaviors related to the somatic symptoms or associated health concerns as manifested by at least one of the following:
::::::::::::::1. Disproportionate and persistent thoughts about the seriousness of one’s symptoms.
::::::::::::::2. Persistently high level of anxiety about health or symptoms.
::::::::::::::3. Excessive time and energy devoted to these symptoms or health concerns.
C. Although any one somatic symptom may not be continuously present, the state of being symptomatic is persistent (typically more than 6 months).Associated Features
Individuals with somatic symptom disorder typically have multiple, current, somatic symptoms that are distressing or result in significant disruption of daily life (Criterion A), although sometimes only one severe symptom, most commonly pain, is present. Symptoms may be specific (e.g., localized pain) or relatively nonspecific (e.g., fatigue). The symptoms sometimes represent normal bodily sensations or discomfort that does not generally signify serious disease. Somatic symptoms without an evident medical explanation are not sufficient to make this diagnosis. The individual’s suffering is authentic, whether or not it is medically explained.
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Cognitive features include attention focused on somatic symptoms, attribution of normal bodily sensations to physical illness (possibly with catastrophic interpretations), worry about illness, a self-concept of bodily weakness, and intolerance of bodily complaints. Besides health anxiety, emotional features may include negative affectivity, desperation, and demoralization related to somatic symptoms. The relevant associated behavioral features may include repeated bodily checking for abnormalities, repeated seeking of medical help and reassurance, and avoidance of physical activity.Comorbid Disorders
Somatic symptom disorder is associated with high rates of comorbidity with other mental disorders as well as general medical conditions. The most relevant co-occurring mental disorders are anxiety and depressive disorders, each of which occurs in up to 50% of cases of somatic symptom disorders and significantly contributes to overall functional impairment and poorer quality of life. Other mental disorders that have been found to co-occur with somatic symptom disorder are posttraumatic stress disorder and obsessive-compulsive disorder.←

Diagnostic Criteria
A. Preoccupation with having or acquiring a serious illness.
B. Somatic symptoms are not present or, if present, are only mild in intensity. If another medical condition is present or there is a high risk for developing a medical condition (e.g., strong family history is present), the preoccupation is clearly excessive or disproportionate.
C. There is a high level of anxiety about health, and the individual is easily alarmed about personal health status.
D. The individual performs excessive health-related behaviors (e.g., repeatedly checks his or her body for signs of illness) or exhibits maladaptive avoidance (e.g., avoids doctor appointments and hospitals).
E. Illness preoccupation has been present for at least 6 months, but the specific illness that is feared may change over that period of time.
F. The illness-related preoccupation is not better explained by another mental disorder, such as somatic symptom disorder, panic disorder, generalized anxiety disorder, body dysmorphic disorder, obsessive-compulsive disorder, or delusional disorder, somatic type.Associated Features
Illness concerns assume a prominent place in the individual’s life, affecting daily activities, and may even result in invalidism. Illness becomes a central feature of the individual’s identity and self-image, a frequent topic of social discourse, and a characteristic response to stressful life events. Individuals with the disorder often examine themselves repeatedly (e.g., examining one’s throat in the mirror). They research their suspected disease excessively and repeatedly seek reassurance from family, friends, or physicians.Differential Diagnoses
Anxiety Disorders, Obsessive-Compulsive Related Disorders, Psychotic DisordersComorbid Disorders
Illness anxiety disorder co-occurs with anxiety disorders (in particular, generalized anxiety disorder and panic disorder), OCD, and depressive disorders. Approximately two-thirds of individuals with illness anxiety disorder are likely to have at least one other comorbid major mental disorder. Individuals with illness anxiety disorder may have an elevated risk for personality disorders.←

Diagnostic Criteria
A. One or more symptoms of altered voluntary motor or sensory function.
B. Clinical findings provide evidence of incompatibility between the symptom and recognized neurological or medical conditions.
C. The symptom or deficit is not better explained by another medical or mental disorder.
D. The symptom or deficit causes clinically significant distress or impairment in social, occupational, or other important areas of functioning or warrants medical evaluation.Associated Features
In functional neurological symptom disorder (conversion disorder), there may be one or more neurological symptoms of various types. Motor symptoms include weakness or paralysis; abnormal movements, such as tremor, jerks, or dystonic movements; and gait abnormalities. Sensory symptoms include altered, reduced, or absent skin sensation, vision, or hearing. Episodes of apparent unresponsiveness with or without limb movements may resemble epileptic seizures, syncope, or coma (also called dissociative, psychogenic, or nonepileptic seizures or attacks). Other symptoms include reduced or absent speech volume (dysphonia/aphonia); altered speech articulation, prosody, or fluency; a sensation of a lump in the throat (globus); and diplopia. This disorder has been called “conversion disorder” in prior editions of DSM as well as in much of the psychiatric research literature. The term “conversion” originated in psychoanalytic theory, which proposes that unconscious psychic conflict is “converted” into physical symptoms.
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Functional neurological symptom disorder is often associated with dissociative symptoms, such as depersonalization, derealization, and dissociative amnesia, particularly at symptom onset or during attacks. The phenomenon of la belle indifférence (i.e., lack of concern about the nature or implications of the symptom) has been associated with functional neurological symptom disorder, but it is not specific and should not be used to make the diagnosis. Similarly, the concept of secondary gain (i.e., when individuals derive external benefits such as money or release from responsibilities) is also not specific to functional neurological symptom disorder.Comorbid Disorders
Anxiety disorders, especially panic disorder, and depressive disorders commonly co-occur with functional neurological symptom disorder. Somatic symptom disorder may co-occur as well. Personality disorders are more common in individuals with functional neurological symptom disorder than in the general population. Neurological or other medical conditions commonly coexist with functional neurological symptom disorder as well.←

Factitious Disorder Imposed on Self Diagnostic Criteria
A. Falsification of physical or psychological signs or symptoms, or induction of injury or disease, associated with identified deception.
B. The individual presents himself or herself to others as ill, impaired, or injured.
C. The deceptive behavior is evident even in the absence of obvious external rewards.
D. The behavior is not better explained by another mental disorder, such as delusional disorder or another psychotic disorder.Factitious Disorder Imposed on Another Diagnostic Criteria
A. Falsification of physical or psychological signs or symptoms, or induction of injury or disease, in another, associated with identified deception.
B. The individual presents another individual (victim) to others as ill, impaired, or injured.
C. The deceptive behavior is evident even in the absence of obvious external rewards.
D. The behavior is not better explained by another mental disorder, such as delusional disorder or another psychotic disorder.Associated Features
The essential feature of factitious disorder is the falsification of medical or psychological signs and symptoms in the individual or others that are associated with the identified deception. The diagnosis requires demonstrating that the individual is taking surreptitious actions to misrepresent, simulate, or cause signs or symptoms of illness or injury even in the absence of obvious external rewards. The diagnosis of factitious disorder emphasizes the objective identification of falsification of signs and symptoms of illness and not the individual motivations of the falsifier.
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Methods of illness falsification can include exaggeration, fabrication, simulation, and induction. While a pre-existing medical condition may be present, the deceptive behavior or induction of injury associated with deception causes others to view such individuals as more ill or impaired, and this can lead to excessive clinical intervention. Individuals with factitious disorder might, for example, report feelings of depression and suicidal thoughts or behavior following the death of a spouse despite the death not being true or the individual’s not having a spouse; deceptively report episodes of neurological symptoms; manipulate a laboratory test to falsely indicate an abnormality; falsify medical records to indicate an illness; ingest a substance to induce an abnormal laboratory result or illness; or physically injure themselves or induce illness in themselves or another. Although individuals with factitious disorder most often present to health care professionals for treatment of their factitious symptoms, some individuals with factitious disorder choose to mislead community members in person or online about illness or injury without necessarily engaging health care professionals.Differential Diagnoses
Malingering←

Diagnostic Criteria
A. Persistent eating of nonnutritive, nonfood substances over a period of at least 1 month.
B. The eating of nonnutritive, nonfood substances is inappropriate to the developmental level of the individual.
C. The eating behavior is not part of a culturally supported or socially normative practice.
D. If the eating behavior occurs in the context of another mental disorder (e.g., intellectual developmental disorder [intellectual disability], autism spectrum disorder, schizophrenia) or medical condition, it is sufficiently severe to warrant additional clinical attention.Differential Diagnoses
Anorexia Nervosa, Self-Injurious BehaviorComorbid Disorders
Disorders most commonly comorbid with pica are autism spectrum disorder and intellectual developmental disorder (intellectual disability) and, to a lesser degree, schizophrenia and obsessive-compulsive disorder. Pica can be associated with trichotillomania (hair-pulling disorder) and excoriation (skin-picking) disorder. In comorbid presentations, the hair or skin is typically ingested. Pica can also be associated with avoidant/restrictive food intake disorder, particularly in individuals with a strong sensory component to their presentation. When an individual is known to have pica, assessment should include consideration of the possibility of gastrointestinal complications, poisoning, infection, and nutritional deficiency.←

The diagnostic criteria for rumination disorder, avoidant/restrictive food intake disorder, anorexia nervosa, bulimia nervosa, and binge-eating disorder result in a classification scheme that is mutually exclusive, so that during a single episode, only one of these diagnoses can be assigned. The rationale for this approach is that, despite a number of common psychological and behavioral features, the disorders differ substantially in clinical course, outcome, and treatment needs. A diagnosis of pica, however, may be assigned in the presence of any other feeding and eating disorder.:::::::Diagnostic Criteria
A. An eating or feeding disturbance (e.g., apparent lack of interest in eating or food; avoidance based on the sensory characteristics of food; concern about aversive consequences of eating) associated with one (or more) of the following:
::::::::::::::1. Significant weight loss (or failure to achieve expected weight gain or faltering growth in children).
::::::::::::::2. Significant nutritional deficiency.
::::::::::::::3. Dependence on enteral feeding or oral nutritional supplements.
::::::::::::::4. Marked interference with psychosocial functioning.
B. The disturbance is not better explained by lack of available food or by an associated culturally sanctioned practice.
C. The eating disturbance does not occur exclusively during the course of anorexia nervosa or bulimia nervosa, and there is no evidence of a disturbance in the way in which one’s body weight or shape is experienced.
D. The eating disturbance is not attributable to a concurrent medical condition or not better explained by another mental disorder. When the eating disturbance occurs in the context of another condition or disorder, the severity of the eating disturbance exceeds that routinely associated with the condition or disorder and warrants additional clinical attention.:::::::Associated Features
In some individuals, food avoidance or restriction is based on the sensory characteristics of qualities of food, such as extreme sensitivity to appearance, color, smell, texture, temperature, or taste. Such behavior has been described as “restrictive eating,” “selective eating,” “choosy eating,” “perseverant eating,” “chronic food refusal,” and “food neophobia” and may manifest as refusal to eat particular brands of foods or to tolerate the smell of food being eaten by others. Individuals with heightened sensory sensitivities associated with autism may show similar behaviors.
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In other individuals, food avoidance or restriction represents a conditioned negative response associated with food intake following, or in anticipation of, an aversive experience, such as choking; a traumatic procedure, usually involving the gastrointestinal tract; or repeated vomiting. In yet other individuals, food avoidance or restriction manifests as a lack of interest in eating or food.
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Restriction of energy intake relative to requirements leading to significantly low body weight is a core feature of anorexia nervosa. However, individuals with anorexia nervosa also display a fear of gaining weight or of becoming fat, or persistent behavior that interferes with weight gain, as well as specific disturbances in relation to perception and experience of their own body weight and shape. These features are not present in avoidant/restrictive food intake disorder, and the two disorders should not be diagnosed concurrently.:::::::Differential Diagnoses
Autism Spectrum Disorder, Anxiety Disorders, Anorexia Nervosa:::::::Comorbid Disorders
The most commonly observed disorders comorbid with avoidant/restrictive food intake disorder are anxiety disorders, obsessive-compulsive disorder, and neurodevelopmental disorders (specifically autism spectrum disorder, attention-deficit/hyperactivity disorder, and intellectual developmental
disorder [intellectual disability]).←

The diagnostic criteria for rumination disorder, avoidant/restrictive food intake disorder, anorexia nervosa, bulimia nervosa, and binge-eating disorder result in a classification scheme that is mutually exclusive, so that during a single episode, only one of these diagnoses can be assigned. The rationale for this approach is that, despite a number of common psychological and behavioral features, the disorders differ substantially in clinical course, outcome, and treatment needs. A diagnosis of pica, however, may be assigned in the presence of any other feeding and eating disorder.:::::::Diagnostic Criteria
A. Restriction of energy intake relative to requirements, leading to a significantly low body weight in the context of age, sex, developmental trajectory, and physical health. Significantly low weight is defined as a weight that is less than minimally normal or, for children and adolescents, less than that minimally expected.
B. Intense fear of gaining weight or of becoming fat, or persistent behavior that interferes with weight gain, even though at a significantly low weight.
C. Disturbance in the way in which one’s body weight or shape is experienced, undue influence of body weight or shape on self-evaluation, or persistent lack of recognition of the seriousness of the current low body weight.Specifiers
Restricting type: During the last 3 months, the individual has not engaged in recurrent episodes of binge-eating or purging behavior (i.e., self-induced vomiting or the misuse of laxatives, diuretics, or enemas). This subtype describes presentations in which weight loss is accomplished primarily through dieting, fasting, and/or excessive exercise.
Binge-eating/purging type: During the last 3 months, the individual has engaged in recurrent episodes of binge-eating or purging behavior (i.e., self-induced vomiting or the misuse of laxatives, diuretics, or enemas).:::::::Associated Features
Obsessive-compulsive features, both related and unrelated to food, are often prominent. Most individuals with anorexia nervosa are preoccupied with thoughts of food. Some collect recipes or hoard food. Observations of behaviors associated with other forms of starvation suggest that obsessions and compulsions related to food may be exacerbated by undernutrition. When individuals with anorexia nervosa exhibit obsessions and compulsions that are not related to food, body shape, or weight, an additional diagnosis of obsessive-compulsive disorder (OCD) may be warranted.
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Other features sometimes associated with anorexia nervosa include concerns about eating in public, feelings of ineffectiveness, a strong desire to control one’s environment, inflexible thinking, limited social spontaneity, and overly restrained emotional expression.:::::::Differential Diagnoses
Bulimia Nervosa, Avoidant/Restrictive Food Intake Disorder:::::::Comorbid Disorders
Bipolar, depressive, and anxiety disorders commonly co-occur with anorexia nervosa. Many individuals with anorexia nervosa report the presence of either an anxiety disorder or symptoms of anxiety prior to onset of their eating disorder. OCD is described in some individuals with anorexia nervosa, especially those with the restricting type. Alcohol use disorder and other substance use disorders may also be comorbid with anorexia nervosa, especially among those with the binge-eating/purging type.←

The diagnostic criteria for rumination disorder, avoidant/restrictive food intake disorder, anorexia nervosa, bulimia nervosa, and binge-eating disorder result in a classification scheme that is mutually exclusive, so that during a single episode, only one of these diagnoses can be assigned. The rationale for this approach is that, despite a number of common psychological and behavioral features, the disorders differ substantially in clinical course, outcome, and treatment needs. A diagnosis of pica, however, may be assigned in the presence of any other feeding and eating disorder.:::::::Diagnostic Criteria
A. Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following:
::::::::::::::1. Eating, in a discrete period of time (e.g., within any 2-hour period), an amount of food that is definitely larger than what most individuals would eat in a similar period of time under similar circumstances.
::::::::::::::2. A sense of lack of control over eating during the episode (e.g., a feeling that one cannot stop eating or control what or how much one is eating).
B. Recurrent inappropriate compensatory behaviors in order to prevent weight gain, such as self-induced vomiting; misuse of laxatives, diuretics, or other medications; fasting; or excessive exercise.
C. The binge eating and inappropriate compensatory behaviors both occur, on average, at least once a week for 3 months.
D. Self-evaluation is unduly influenced by body shape and weight.
E. The disturbance does not occur exclusively during episodes of anorexia nervosa.:::::::Associated Features
Individuals with bulimia nervosa are typically ashamed of their eating problems and attempt to conceal their symptoms. Binge eating usually occurs in secrecy or as inconspicuously as possible. The binge eating often continues until the individual is uncomfortably, or even painfully, full. The most common antecedent of binge eating is negative affect. Other triggers include interpersonal stressors; dietary restraint; negative feelings related to body weight, body shape, and food; and boredom. Binge eating may minimize or mitigate factors that precipitated the episode in the short-term, but negative self-evaluation and dysphoria often are the delayed consequences.:::::::Differential Diagnoses
Anorexia Nervosa, binge-eating/purging type, Binge-Eating Disorder, Major Depressive Disorder, Borderline Personality Disorder:::::::Comorbid Disorders
Comorbidity with mental disorders is common in individuals with bulimia nervosa, with most experiencing at least one other mental disorder and many experiencing multiple comorbidities. Comorbidity is not limited to any particular subset but rather occurs across a wide range of mental disorders. There is an increased frequency of depressive symptoms (e.g., low self-esteem) and bipolar and depressive disorders (particularly depressive disorders) in individuals with bulimia nervosa. In many individuals, the mood disturbance begins at the same time as or following the development of bulimia nervosa, and individuals often ascribe their mood disturbances to the bulimia nervosa. However, in some individuals, the mood disturbance clearly precedes the development of bulimia nervosa. There may also be an increased frequency of anxiety symptoms (e.g., fear of social situations) or anxiety disorders. These mood and anxiety disturbances frequently remit following effective treatment of the bulimia nervosa.←

The diagnostic criteria for rumination disorder, avoidant/restrictive food intake disorder, anorexia nervosa, bulimia nervosa, and binge-eating disorder result in a classification scheme that is mutually exclusive, so that during a single episode, only one of these diagnoses can be assigned. The rationale for this approach is that, despite a number of common psychological and behavioral features, the disorders differ substantially in clinical course, outcome, and treatment needs. A diagnosis of pica, however, may be assigned in the presence of any other feeding and eating disorder.:::::::Diagnostic Criteria
A. Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following:
::::::::::::::1. Eating, in a discrete period of time, an amount of food that is definitely larger than
what most people would eat in a similar period of time under similar circumstances.
::::::::::::::2. A sense of lack of control over eating during the episode (e.g., a feeling that one cannot stop eating or control what or how much one is eating).
B. The binge-eating episodes are associated with three (or more) of the following:
::::::::::::::1. Eating much more rapidly than normal.
::::::::::::::2. Eating until feeling uncomfortably full.
::::::::::::::3. Eating large amounts of food when not feeling physically hungry.
::::::::::::::4. Eating alone because of feeling embarrassed by how much one is eating.
::::::::::::::5. Feeling disgusted with oneself, depressed, or very guilty afterward.
C. Marked distress regarding binge eating is present.
D. The binge eating occurs, on average, at least once a week for 3 months.
E. The binge eating is not associated with the recurrent use of inappropriate compensatory behavior as in bulimia nervosa and does not occur exclusively during the course of bulimia
nervosa or anorexia nervosa.:::::::Associated Features
The context in which the eating occurs may affect the estimation of whether the intake is excessive. For example, a quantity of food that might be regarded as excessive for a typical meal might be considered normal during a celebration or holiday meal. A “discrete period of time” refers to a limited period, usually less than 2 hours. A single episode of binge eating need not be restricted to one setting. For example, an individual may begin a binge in a restaurant and then continue to eat on returning home. Continual snacking on small amounts of food throughout the day would not be considered an eating binge.
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Some individuals describe a dissociative quality during, or following, the binge-eating episodes. The impairment in control associated with binge eating may not be absolute; for example, an individual may continue binge eating while the telephone is ringing but will cease if a roommate or spouse unexpectedly enters the room. Some individuals report that their binge-eating episodes are no longer characterized by an acute feeling of loss of control but rather by a more generalized pattern of uncontrolled eating. If individuals report that they have abandoned efforts to control their eating, loss of control may still be considered as present. Binge eating can also be planned in some instances.:::::::Differential Diagnoses
Bulimia Nervosa, Bipolar and Depressive Disorders, Borderline Personality Disorder:::::::Comorbid Disorders
Binge-eating disorder is associated with significant psychiatric comorbidity that is comparable to that of bulimia nervosa and anorexia nervosa. The most common comorbid disorders are major depressive disorder and alcohol use disorder.←

Diagnostic Criteria
This category applies to presentations in which symptoms characteristic of a feeding and eating disorder that cause clinically significant distress or impairment in social, occupational, or other important areas of functioning predominate but do not meet the full criteria for any of the disorders in the feeding and eating disorders diagnostic class. The other specified feeding or eating disorder category is used in situations in which the clinician chooses to communicate the specific reason that the presentation does not meet the criteria for any specific feeding and eating disorder.
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Examples of presentations that can be specified using the “other specified” designation include:
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1. Atypical anorexia nervosa: All of the criteria for anorexia nervosa are met, except that despite significant weight loss, the individual’s weight is within or above the normal range. Individuals with atypical anorexia nervosa may experience many of the physiological complications associated with
anorexia nervosa.
2. Bulimia nervosa (of low frequency and/or limited duration): All of the criteria for bulimia nervosa are met, except that the binge eating and inappropriate compensatory behaviors occur, on average, less than once a week and/or for less than 3 months.
3. Binge-eating disorder (of low frequency and/or limited duration): All of the criteria for binge-eating disorder are met, except that the binge eating occurs, on average, less than once a week and/or for less than 3 months.
4. Purging disorder: Recurrent purging behavior to influence weight or shape (e.g., self-induced vomiting; misuse of laxatives, diuretics, or other medications) in the absence of binge eating.
5. Night eating syndrome: Recurrent episodes of night eating, as manifested by eating after awakening from sleep or by excessive food consumption after the evening meal. There is awareness and recall of the eating. The night eating is not better explained by external influences such as changes in the individual’s sleep-wake cycle or by local social norms. The night eating causes significant distress and/or impairment in functioning. The disordered pattern of eating is not better explained by binge-eating disorder or another mental disorder, including substance use, and is not attributable to another medical condition or to an effect of medication.←

Diagnostic Criteria
A. A predominant complaint of dissatisfaction with sleep quantity or quality, associated with one (or more) of the following symptoms:
::::::::::::::1. Difficulty initiating sleep.
::::::::::::::2. Difficulty maintaining sleep, characterized by frequent awakenings or problems returning to sleep after awakenings.
::::::::::::::3. Early-morning awakening with inability to return to sleep.
B. The sleep disturbance causes clinically significant distress or impairment in social, occupational, educational, academic, behavioral, or other important areas of functioning.
C. The sleep difficulty occurs at least 3 nights per week.
D. The sleep difficulty is present for at least 3 months.
E. The sleep difficulty occurs despite adequate opportunity for sleep.
F. The insomnia is not better explained by and does not occur exclusively during the course of another sleep-wake disorder.
G. The insomnia is not attributable to the physiological effects of a substance.
H. Coexisting mental disorders and medical conditions do not adequately explain the predominant complaint of insomnia.Associated Features
Insomnia disorder involves daytime impairments as well as nighttime sleep difficulties. These include fatigue or, less commonly, daytime sleepiness; the latter is more common among older individuals and when insomnia is comorbid with another medical condition (e.g., chronic pain) or sleep disorder (e.g., sleep apnea). Impairment in cognitive performance may include difficulties with attention, concentration and memory, and performing complex manual skills. Associated mood disturbances are typically described as irritability or mood lability and less commonly as depressive or anxiety symptoms.Differential Diagnoses
Normal sleep variations, Situational/Acute InsomniaComorbid Disorders
Individuals with insomnia disorder frequently have a comorbid mental disorder, particularly bipolar, depressive, and anxiety disorders. Persistent insomnia represents a risk factor or an early symptom of subsequent bipolar, depressive, anxiety, and substance use disorders. Individuals with insomnia may misuse medications or alcohol to help with nighttime sleep, anxiolytics to combat tension or anxiety, and caffeine or other stimulants to combat excessive daytime fatigue. In addition to worsening the insomnia, this type of substance use may in some cases progress to a substance use disorder.←

Diagnostic Criteria
A. Self-reported excessive sleepiness (hypersomnolence) despite a main sleep period lasting at least 7 hours, with at least one of the following symptoms:
::::::::::::::1. Recurrent periods of sleep or lapses into sleep within the same day.
::::::::::::::2. A prolonged main sleep episode of more than 9 hours per day that is nonrestorative (i.e., unrefreshing).
::::::::::::::3. Difficulty being fully awake after abrupt awakening.
B. The hypersomnolence occurs at least three times per week, for at least 3 months.
C. The hypersomnolence is accompanied by significant distress or impairment in cognitive, social, occupational, or other important areas of functioning.
D. The hypersomnolence is not better explained by and does not occur exclusively during the course of another sleep disorder (e.g., narcolepsy, breathing-related sleep disorder, circadian rhythm sleep-wake disorder, or a parasomnia).
E. The hypersomnolence is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication).
F. Coexisting mental and medical disorders do not adequately explain the predominant complaint of hypersomnolence.Associated Features
About 40% of individuals with hypersomnolence disorder may have sleep inertia, and this symptom may help differentiate hypersomnolence disorder from other causes of sleepiness. They may have difficulty waking up in the morning, sometimes appearing confused, combative, or ataxic. Individuals may set multiple alarm clocks or rely on others to help get them out of bed. Sleep inertia can also occur upon awakening from a daytime nap. During that period, the individual appears awake, but motor coordination is impaired, behavior may be inappropriate, and memory deficits, disorientation in time and space, and feelings of grogginess may occur. This period may last some minutes to hours.Differential Diagnoses
Normative variations in sleep, narcolepsy, fatigue, hypersomnia as a symptom of another mental disorderComorbid Disorders
Many individuals with hypersomnolence disorder have symptoms of depression that may meet criteria for a depressive disorder. This presentation may be related to the psychosocial consequences of persistent increased sleep need. More than half of individuals with hypersomnolence disorder have attention-deficit/hyperactivity disorder symptoms. Individuals with hypersomnolence disorder are also at risk for substance-related disorders, particularly related to self-medication with stimulants.←

Diagnostic Criteria
A. Recurrent periods of an irrepressible need to sleep, lapsing into sleep, or napping occurring within the same day. These must have been occurring at least three times per week over the past 3 months.
B. The presence of at least one of the following:
::::::::::::::1. Episodes of cataplexy, defined as either (a) or (b), occurring at least a few times per month:
:::::::::::::::::::::::a. In individuals with long-standing disease, brief (seconds to minutes) episodes of sudden bilateral loss of muscle tone with maintained consciousness that are precipitated by laughter or joking.
:::::::::::::::::::::::b. In individuals within 6 months of onset, spontaneous grimaces or jaw-opening episodes with tongue thrusting or a global hypotonia, without any obvious emotional triggers.
::::::::::::::2. Hypocretin deficiency.
::::::::::::::3. Nocturnal sleep polysomnography showing rapid eye movement (REM) sleep latency less than or equal to 15 minutes, or a multiple sleep latency test showing a mean sleep latency less than or equal to 8 minutes and two or more sleep-onset REM periods.Differential Diagnoses
Hypersomnolence Disorder, Sleep deprivation, Major Depressive Disorder, Functional Neurological Symptom Disorder (with Pseudocataplexy), Atonic seizures, SyncopeComorbid Disorders
Medical and psychiatric comorbidities are common among individuals with narcolepsy and include obesity, bruxism, enuresis, mood disorders, and ADHD. Rapid weight gain is common in young children with a sudden disease onset. Parasomnias (e.g., sleepwalking, REM sleep behavior disorder), obstructive sleep apnea, restless legs syndrome, and periodic limb movements are common in individuals who develop narcolepsy. Comorbid sleep apnea should be considered if there is a sudden aggravation of preexisting narcolepsy.←

Diagnostic Criteria
A. A persistent or recurrent pattern of sleep disruption that is primarily due to an alteration of the circadian system or to a misalignment between the endogenous circadian rhythm and the sleep-wake schedule required by an individual’s physical environment or social or professional schedule.
B. The sleep disruption leads to excessive sleepiness or insomnia, or both.
C. The sleep disturbance causes clinically significant distress or impairment in social, occupational, and other important areas of functioning.
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Delayed sleep phase type: A pattern of delayed sleep onset and awakening times, with an inability to fall asleep and awaken at a desired or conventionally acceptable earlier time.
Advanced sleep phase type: A pattern of advanced sleep onset and awakening times, with an inability to remain awake or asleep until the desired or conventionally acceptable later sleep or wake times.
Irregular sleep-wake type: A temporally disorganized sleep-wake pattern, such that the timing of
sleep and wake periods is variable throughout the 24-hour period.
Non-24-hour sleep-wake type: A pattern of sleepwake cycles that is not synchronized to the 24-hour environment, with a consistent daily drift (usually to later and later times) of sleep onset and wake times.
Shift work type: Insomnia during the major sleep period and/or excessive sleepiness (including inadvertent sleep) during the major awake period associated with a shift work schedule (i.e., requiring unconventional work hours).←

Diagnostic Criteria
A. Repeated occurrences of extended, extremely dysphoric, and well-remembered dreams that usually involve efforts to avoid threats to survival, security, or physical integrity and that generally occur during the second half of the major sleep episode.
B. On awakening from the dysphoric dreams, the individual rapidly becomes oriented and alert.
C. The sleep disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
D. The nightmare symptoms are not attributable to the physiological effects of a substance.
E. Coexisting mental disorders and medical conditions do not adequately explain the predominant complaint of dysphoric dreams.Associated Features
Nightmares are typically lengthy, elaborate, story-like sequences of dream imagery that seem real and that incite anxiety, fear, or other dysphoric emotions. Nightmare content typically focuses on attempts to avoid or cope with imminent danger but may involve themes that evoke other negative emotions. Nightmares occurring after traumatic experiences may replicate the threatening situation, but most do not. On awakening, nightmares are well remembered and can be described in detail.
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Nightmares usually terminate with awakening and rapid return of full alertness. However, the dysphoric emotions may persist into wakefulness and contribute to difficulty returning to sleep and lasting daytime distress. Some nightmares, known as “bad dreams,” may not induce awakening and are recalled only later. If nightmares occur during sleep-onset REM periods, the dysphoric emotion is frequently accompanied by an awakening and being unable to move voluntarily (sleep paralysis), which may also occur in isolation without a preceding dream or nightmare.Differential Diagnoses
Sleep terrors, PTSD or Acute Stress DisorderComorbid Disorders
Nightmares may be comorbid with several medical conditions, including coronary heart disease, cancer, parkinsonism, and pain, and can accompany medical treatments, such as hemodialysis, or withdrawal from medications or substances of abuse. Nightmares frequently co-occur with other mental disorders, including PTSD, acute stress disorder, insomnia disorder, REM sleep behavior disorder, and psychotic, mood, anxiety, adjustment, and personality disorders, as well as with grief during bereavement. A concurrent nightmare disorder diagnosis should only be considered when
independent clinical attention is warranted.←

Diagnostic Criteria
A. A pattern of angry/irritable mood, argumentative/defiant behavior, or vindictiveness lasting at least 6 months as evidenced by at least four symptoms from any of the following categories, and exhibited during interaction with at least one individual who is not a sibling.
:::::::Angry/Irritable Mood
::::::::::::::1. Often loses temper.
::::::::::::::2. Is often touchy or easily annoyed.
::::::::::::::3. Is often angry and resentful.
:::::::Argumentative/Defiant Behavior
::::::::::::::4. Often argues with authority figures or, for children and adolescents, with adults.
::::::::::::::5. Often actively defies or refuses to comply with requests from authority figures or with rules.
::::::::::::::6. Often deliberately annoys others.
::::::::::::::7. Often blames others for their mistakes or misbehavior.
:::::::Vindictiveness
::::::::::::::8. Has been spiteful or vindictive at least twice within the past 6 months.
B. The disturbance in behavior is associated with distress in the individual or others in their immediate social context, or it impacts negatively on social, educational, occupational, or other important areas of functioning.
C. The behaviors do not occur exclusively during the course of a psychotic, substance use, depressive, or bipolar disorder. Also, the criteria are not met for disruptive mood dysregulation disorder.Associated Features
The symptoms of the disorder often are part of a pattern of problematic interactions with others. Furthermore, individuals with this disorder typically do not regard themselves as angry, oppositional, or defiant. Instead, they often justify their behavior as a response to unreasonable demands or circumstances. Thus, it can be difficult to disentangle the relative contribution of the individual with the disorder to the problematic interactions he or she experiences. For example, children with oppositional defiant disorder may have experienced a history of hostile parenting, and it is often impossible to determine if the child’s behavior caused the parents to act in a more hostile manner toward the child, if the parents’ hostility led to the child’s problematic behavior, or if there was some combination of both.Differential Diagnoses
Conduct Disorder, Disruptive Mood Dysregulation DisorderComorbid Disorders
Rates of oppositional defiant disorder are much higher in samples of children, adolescents, and adults with ADHD, and this may be the result of shared temperamental risk factors. Also, oppositional defiant disorder often precedes conduct disorder, although this appears to be most common in children with the childhood-onset subtype. Individuals with oppositional defiant disorder are also at increased risk for anxiety disorders and major depressive disorder, and this seems largely attributable to the presence of the angry-irritable mood symptoms.←

Diagnostic Criteria
A. Recurrent behavioral outbursts representing a failure to control aggressive impulses as manifested by either of the following:
::::::::::::::1. Verbal aggression (e.g., temper tantrums, tirades, verbal arguments or fights) or physical aggression toward property, animals, or other individuals, occurring twice weekly, on average, for a period of 3 months. The physical aggression does not result in damage or destruction of property and does not result in physical injury to animals or other individuals.
::::::::::::::2. Three behavioral outbursts involving damage or destruction of property and/or physical assault involving physical injury against animals or other individuals occurring within a 12-month period.
B. The magnitude of aggressiveness expressed during the recurrent outbursts is grossly out of proportion to the provocation or to any precipitating psychosocial stressors.
C. The recurrent aggressive outbursts are not premeditated (i.e., they are impulsive and/or anger-based) and are not committed to achieve some tangible objective.
D. The recurrent aggressive outbursts cause either marked distress in the individual or impairment in occupational or interpersonal functioning, or are associated with financial or legal consequences.
E. Chronological age is at least 6 years.
F. The recurrent aggressive outbursts are not better explained by another mental disorder (e.g., major depressive disorder, bipolar disorder, disruptive mood dysregulation disorder, a psychotic disorder, antisocial personality disorder, borderline personality disorder) and are not attributable to another medical condition or to the physiological effects of a substance. For children ages 6–18 years, aggressive behavior that occurs as part of an adjustment disorder should not be considered for this diagnosis.Differential Diagnoses
Disruptive Mood Dysregulation Disorder, Antisocial or Borderline Personality Disorder, ADHD, Conduct Disorder, Oppositional Defiant DisorderComorbid Disorders
Depressive disorders, anxiety disorders, posttraumatic stress disorder, bulimia nervosa, binge-eating disorder, and substance use disorders are most commonly comorbid with intermittent explosive disorder in community samples. In addition, individuals with antisocial personality disorder or borderline personality disorder, and individuals with a history of disorders with disruptive behaviors (e.g., ADHD, conduct disorder, oppositional defiant disorder), are at greater risk for comorbid intermittent explosive disorder.←

Diagnostic Criteria
A. A repetitive and persistent pattern of behavior in which the basic rights of others or major age-appropriate societal norms or rules are violated, as manifested by the presence of at least three of the following 15 criteria in the past 12 months from any of the categories below, with at least one criterion present in the past 6 months:
:::::::Aggression to People and Animals
::::::::::::::1. Often bullies, threatens, or intimidates others.
::::::::::::::2. Often initiates physical fights.
::::::::::::::3. Has used a weapon that can cause serious physical harm to others (e.g., a bat, brick, broken bottle, knife, gun).
::::::::::::::4. Has been physically cruel to people.
::::::::::::::5. Has been physically cruel to animals.
::::::::::::::6. Has stolen while confronting a victim (e.g., mugging, purse snatching, extortion, armed robbery).
::::::::::::::7. Has forced someone into sexual activity.
:::::::Destruction of Property
::::::::::::::8. Has deliberately engaged in fire setting with the intention of causing serious damage.
::::::::::::::9. Has deliberately destroyed others’ property (other than by fire setting).
:::::::Deceitfulness or Theft
::::::::::::::10. Has broken into someone else’s house, building, or car.
::::::::::::::11. Often lies to obtain goods or favors or to avoid obligations (i.e., “cons” others).
::::::::::::::12. Has stolen items of nontrivial value without confronting a victim (e.g., shoplifting, but without breaking and entering; forgery).
:::::::Serious Violations of Rules
::::::::::::::13. Often stays out at night despite parental prohibitions, beginning before age 13 years.
::::::::::::::14. Has run away from home overnight at least twice while living in the parental or parental surrogate home, or once without returning for a lengthy period.
::::::::::::::15. Is often truant from school, beginning before age 13 years.
B. The disturbance in behavior causes clinically significant impairment in social, academic, or occupational functioning.
C. If the individual is age 18 years or older, criteria are not met for antisocial personality disorder.Associated Features
Especially in ambiguous situations, aggressive individuals with conduct disorder frequently misperceive the intentions of others as more hostile and threatening than is the case and respond with aggression that they then feel is reasonable and justified. Personality features of trait negative emotionality and poor self-control, including poor frustration tolerance, irritability, temper outbursts, suspiciousness, insensitivity to punishment, thrill seeking, and recklessness, frequently co-occur with conduct disorder. Substance misuse is often an associated feature, particularly in adolescent
girls.Differential Diagnoses
Oppositional Defiant Disorder, Depressive and Bipolar Disorders, Intermittent Explosive Disorder, Adjustment DisorderComorbid Disorders
ADHD and oppositional defiant disorder are both common in individuals with conduct disorder, and this comorbid presentation predicts worse outcomes. Individuals who show the personality features associated with antisocial personality disorder often violate the basic rights of others or violate major age-appropriate societal norms, and as a result their pattern of behavior often meets criteria for conduct disorder. Conduct disorder may also co-occur with one or more of the following mental disorders: specific learning disorder, anxiety disorders, depressive or bipolar disorders, and substance-related disorders. Academic achievement, particularly in reading and other verbal skills, is often below the level expected on the basis of age and intelligence and may justify the additional diagnosis of specific learning disorder or a communication disorder.←

Diagnostic Criteria
A. Deliberate and purposeful fire setting on more than one occasion.
B. Tension or affective arousal before the act.
C. Fascination with, interest in, curiosity about, or attraction to fire and its situational contexts (e.g., paraphernalia, uses, consequences).
D. Pleasure, gratification, or relief when setting fires or when witnessing or participating in their aftermath.
E. The fire setting is not done for monetary gain, as an expression of sociopolitical ideology, to conceal criminal activity, to express anger or vengeance, to improve one’s living circumstances, in response to a delusion or hallucination, or as a result of impaired judgment.
F. The fire setting is not better explained by conduct disorder, a manic episode, or antisocial personality disorder.Associated Features
Individuals with pyromania may make considerable advance preparation for starting a fire. They may be indifferent to the consequences to life or property caused by the fire, or they may derive satisfaction from the resulting property destruction. The behaviors may lead to property damage, legal consequences, or injury or loss of life to the fire setter or to others.Differential Diagnoses
Other causes of intentional fire settingComorbid Disorders
There appears to be a high co-occurrence of substance use disorders, gambling disorder, depressive and bipolar disorders, and other disruptive, impulse-control, and conduct disorders with pyromania.←

Diagnostic Criteria
A. Recurrent failure to resist impulses to steal objects that are not needed for personal use or for their monetary value.
B. Increasing sense of tension immediately before committing the theft.
C. Pleasure, gratification, or relief at the time of committing the theft.
D. The stealing is not committed to express anger or vengeance and is not in response to a delusion or a hallucination.
E. The stealing is not better explained by conduct disorder, a manic episode, or antisocial personality disorder.Associated Features
Individuals with kleptomania typically attempt to resist the impulse to steal, and they are aware that the act is wrong and senseless. The individual frequently fears being apprehended and often feels depressed or guilty about the thefts.Differential Diagnoses
Ordinary theft, Antisocial Personality Disorder or Conduct DisorderComorbid Disorders
Kleptomania may be associated with compulsive buying as well as with depressive and bipolar disorders (especially major depressive disorder), anxiety disorders, eating disorders (particularly bulimia nervosa), personality disorders, substance use disorders (especially alcohol use disorder), and other disruptive, impulse-control, and conduct disorders.←

Diagnostic Criteria
A. A pervasive distrust and suspiciousness of others such that their motives are interpreted as malevolent, beginning by early adulthood and present in a variety of contexts, as indicated by four (or more) of the following:
::::::::::::::1. Suspects, without sufficient basis, that others are exploiting, harming, or deceiving them.
::::::::::::::2. Is preoccupied with unjustified doubts about the loyalty or trustworthiness of friends or associates.
::::::::::::::3. Is reluctant to confide in others because of unwarranted fear that the information will be used maliciously against them.
::::::::::::::4. Reads hidden demeaning or threatening meanings into benign remarks or events.
::::::::::::::5. Persistently bears grudges (i.e., is unforgiving of insults, injuries, or slights).
::::::::::::::6. Perceives attacks on his or her character or reputation that are not apparent to others and is quick to react angrily or to counterattack.
::::::::::::::7. Has recurrent suspicions, without justification, regarding fidelity of spouse or sexual partner.
B. Does not occur exclusively during the course of schizophrenia, a bipolar disorder or depressive disorder with psychotic features, or another psychotic disorder and is not attributable to the physiological effects of another medical condition.Associated Features
Their excessive suspiciousness and hostility may be expressed in overt argumentativeness, in recurrent complaining, or by hostile aloofness. They display a labile range of affect, with hostile, stubborn, and sarcastic expressions predominating. Their combative and suspicious nature may elicit a hostile response in others, which then serves to confirm their original expectations.
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Because individuals with paranoid personality disorder lack trust in others, they need to have a high degree of control over those around them. They are often rigid, critical of others, and unable to collaborate, although they have great difficulty accepting criticism themselves. They may blame others for their own shortcomings. Because of their quickness to counterattack in response to the threats they perceive around them, they may be litigious and frequently become involved in legal disputes. Individuals with this disorder seek to confirm their preconceived negative notions regarding people or situations they encounter, attributing malevolent motivations to others that are projections of their own fears. They may exhibit thinly hidden, unrealistic grandiose fantasies, are often attuned to issues of power and rank, and tend to develop negative stereotypes of others, particularly those from population groups distinct from their own.Differential Diagnoses
Psychotic Disorders, Other personality disordersComorbid Disorders
Particularly in response to stress, individuals with this disorder may experience very brief psychotic episodes (lasting minutes to hours). In some instances, paranoid personality disorder may appear as the premorbid antecedent of delusional disorder or schizophrenia. Individuals with paranoid personality disorder may develop major depressive disorder and may be at increased risk for agoraphobia and obsessive-compulsive disorder. Alcohol and other substance use disorders frequently occur. The most common co-occurring personality disorders appear to be schizotypal, schizoid, narcissistic, avoidant, and borderline.←

Diagnostic Criteria
A. A pervasive pattern of detachment from social relationships and a restricted range of expression of emotions in interpersonal settings, beginning by early adulthood and present in a variety of contexts, as indicated by four (or more) of the following:
::::::::::::::1. Neither desires nor enjoys close relationships, including being part of a family.
::::::::::::::2. Almost always chooses solitary activities.
::::::::::::::3. Has little, if any, interest in having sexual experiences with another person.
::::::::::::::4. Takes pleasure in few, if any, activities.
::::::::::::::5. Lacks close friends or confidants other than first-degree relatives.
::::::::::::::6. Appears indifferent to the praise or criticism of others.
::::::::::::::7. Shows emotional coldness, detachment, or flattened affectivity.
B. Does not occur exclusively during the course of schizophrenia, a bipolar disorder or depressive disorder with psychotic features, another psychotic disorder, or autism spectrum disorder and is not attributable to the physiological effects of another medical condition.Associated Features
Individuals with schizoid personality disorder may have particular difficulty expressing anger, even in response to direct provocation, which contributes to the impression that they lack emotion. Their lives sometimes seem directionless, and they may appear to “drift” in their goals. Such individuals often react passively to adverse circumstances and have difficulty responding appropriately to important life events. Because of their lack of social skills and lack of desire for sexual experiences, individuals with this disorder have few friendships, date infrequently, and often do not marry. Occupational functioning may be impaired, particularly if interpersonal involvement is required, but individuals with this disorder may do well when they work under conditions of social isolation.Differential Diagnoses
Psychotic Disorders, Autism Spectrum Disorder, Other personality disordersComorbid Disorders
Particularly in response to stress, individuals with this disorder may experience very brief psychotic episodes (lasting minutes to hours). In some instances, schizoid personality disorder may appear as the premorbid antecedent of delusional disorder or schizophrenia. Individuals with this disorder may sometimes develop major depressive disorder. Schizoid personality disorder most often co-occurs with schizotypal, paranoid, and avoidant personality disorders.←

Diagnostic Criteria
A. A pervasive pattern of 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, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:
::::::::::::::1. Ideas of reference (excluding delusions of reference).
::::::::::::::2. Odd beliefs or magical thinking that influences behavior and is inconsistent with subcultural norms (e.g., superstitiousness, belief in clairvoyance, telepathy, or “sixth sense”; in children and adolescents, bizarre fantasies or preoccupations).
::::::::::::::3. Unusual perceptual experiences, including bodily illusions.
::::::::::::::4. Odd thinking and speech (e.g., vague, circumstantial, metaphorical, overelaborate, or stereotyped).
::::::::::::::5. Suspiciousness or paranoid ideation.
::::::::::::::6. Inappropriate or constricted affect.
::::::::::::::7. Behavior or appearance that is odd, eccentric, or peculiar.
::::::::::::::8. Lack of close friends or confidants other than first-degree relatives.
::::::::::::::9. Excessive social anxiety that does not diminish with familiarity and tends to be associated with paranoid fears rather than negative judgments about self.
B. Does not occur exclusively during the course of schizophrenia, a bipolar disorder or depressive disorder with psychotic features, another psychotic disorder, or autism spectrum disorder.Associated Features
Individuals with schizotypal personality disorder often have ideas of reference (i.e., incorrect interpretations of casual incidents and external events as having a particular and unusual meaning specifically for the person). These should be distinguished from delusions of reference, in which the beliefs are held with delusional conviction. These individuals may be superstitious or preoccupied with paranormal phenomena that are outside the norms of their subculture. They may feel that they have special powers to sense events before they happen or to read others’ thoughts. They may believe that they have magical control over others, which can be implemented directly (e.g., believing that their spouse’s taking the dog out for a walk is the direct result of thinking an hour earlier it should be done) or indirectly through compliance with magical rituals (e.g., walking past a specific object three times to avoid a certain harmful outcome). Perceptual alterations may be present (e.g., sensing that another person is present or hearing a voice murmuring their name). Their speech may include unusual or idiosyncratic phrasing and construction. It is often loose, digressive, or vague, but without actual derailment or incoherence. Responses can be either overly concrete or overly abstract, and words or concepts are sometimes applied in unusual ways (e.g., the individual may state that they were not “talkable” at work).Differential Diagnoses
Psychotic Disorders, Neurodevelopmental Disorders, Other personality disordersComorbid Disorders
Particularly in response to stress, individuals with this disorder may experience transient psychotic episodes (lasting minutes to hours), although they usually are insufficient in duration to warrant an additional diagnosis such as brief psychotic disorder or schizophreniform disorder. In some cases, clinically significant psychotic symptoms may develop that meet criteria for brief psychotic disorder, schizophreniform disorder, delusional disorder, or schizophrenia. There is considerable co-occurrence with schizoid, paranoid, avoidant, and borderline personality disorders.←

Diagnostic Criteria
A. A pervasive pattern of disregard for and violation of the rights of others, occurring since age 15 years, as indicated by three (or more) of the following:
::::::::::::::1. Failure to conform to social norms with respect to lawful behaviors, as indicated by repeatedly performing acts that are grounds for arrest.
::::::::::::::2. Deceitfulness, as indicated by repeated lying, use of aliases, or conning others for personal profit or pleasure.
::::::::::::::3. Impulsivity or failure to plan ahead.
::::::::::::::4. Irritability and aggressiveness, as indicated by repeated physical fights or assaults.
::::::::::::::5. Reckless disregard for safety of self or others.
::::::::::::::6. Consistent irresponsibility, as indicated by repeated failure to sustain consistent work behavior or honor financial obligations.
::::::::::::::7. Lack of remorse, as indicated by being indifferent to or rationalizing having hurt, mistreated, or stolen from another.
B. The individual is at least age 18 years.
C. There is evidence of conduct disorder with onset before age 15 years.
D. The occurrence of antisocial behavior is not exclusively during the course of schizophrenia or bipolar disorder.Associated Features
Individuals with antisocial personality disorder frequently lack empathy and tend to be callous, cynical, and contemptuous of the feelings, rights, and sufferings of others. They may have an inflated and arrogant self-appraisal and may be excessively opinionated, self-assured, or cocky. Some antisocial individuals may display a glib, superficial charm and can be quite voluble and verbally facile.Differential Diagnoses
Conduct Disorder, Other personality disordersComorbid Disorders
Individuals with antisocial personality disorder may also experience dysphoria, including complaints of tension, inability to tolerate boredom, and depressed mood. They may have associated anxiety disorders, mood disorders, substance use disorders, somatic symptom disorder, and gambling disorder. Individuals with antisocial personality disorder also often have personality features that meet criteria for other personality disorders, particularly borderline, histrionic, and narcissistic personality disorders. The likelihood of developing antisocial personality disorder in adult life is increased if the individual experienced childhood onset of conduct disorder (before age 10 years) and accompanying ADHD.←

Diagnostic Criteria
A pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:
1. Frantic efforts to avoid real or imagined abandonment. Do not include suicidal or self-mutilating behavior covered in Criterion 5.
2. A pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation.
3. Identity disturbance: markedly and persistently unstable self-image or sense of self.
4. Impulsivity in at least two areas that are potentially self-damaging (e.g., spending, sex, substance abuse, reckless driving, binge eating). Do not include suicidal or self-mutilating behavior covered in Criterion 5.
5. Recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior.
6. Affective instability due to a marked reactivity of mood (e.g., intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days).
7. Chronic feelings of emptiness.
8. Inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights).
9. Transient, stress-related paranoid ideation or severe dissociative symptoms.Associated Features
They may idealize potential caregivers or lovers at the first or second meeting, demand to spend a lot of time together, and share the most intimate details early in a relationship. However, they may switch quickly from idealizing other people to devaluing them, feeling that the other person does not care enough, does not give enough, or is not “there” enough. These individuals can empathize with and nurture other people, but only with the expectation that the other person will “be there” in return to meet their own needs on demand. These individuals are prone to sudden and dramatic shifts in their view of others, who may alternatively be seen as beneficent supports or as cruelly punitive. Such shifts often reflect disillusionment with a caregiver whose nurturing qualities had been idealized or whose rejection or abandonment is expected.
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Although they usually have a self-image that is based on the feeling of being bad or evil, individuals with this disorder may at times have feelings that they do not exist at all. This can be both painful and frightening to those with this disorder. Such experiences usually occur in situations in which the individual feels a lack of a meaningful relationship, nurturing, and support. These individuals may show worse performance in unstructured work or school situations. This lack of a full and enduring identity makes it difficult for the individual with borderline personality disorder to identify maladaptive patterns of behavior and can lead to repetitive patterns of troubled relationships.
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During periods of extreme stress, transient paranoid ideation or dissociative symptoms (e.g., depersonalization) may occur, but these are generally of insufficient severity or duration to warrant an additional diagnosis. These episodes occur most frequently in response to a real or imagined abandonment. Symptoms tend to be transient, lasting minutes or hours. The real or perceived return of the caregiver’s nurturance may result in a remission of symptoms.
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Individuals with borderline personality disorder may have a pattern of undermining themselves at the moment a goal is about to be realized (e.g., dropping out of school just before graduation; regressing severely after a discussion of how well therapy is going; destroying a good relationship just when it is clear that the relationship could last). Individuals with this disorder may feel more secure with transitional objects (i.e., a pet or inanimate possession) than in interpersonal relationships.Differential Diagnoses
Depressive and Bipolar Disorder, Separation Anxiety Disorder, Other personality disorders, Identity problemsComorbid Disorders
Common co-occurring disorders include depressive and bipolar disorders, substance use disorders, anxiety disorders (particularly panic disorder and social anxiety disorder), eating disorders (notably bulimia nervosa and binge-eating disorder), posttraumatic stress disorder, and ADHD. Borderline personality disorder also frequently co-occurs with the other personality disorders.←

Diagnostic Criteria
A pervasive pattern of excessive emotionality and attention seeking, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:
1. Is uncomfortable in situations in which they are not the center of attention.
2. Interaction with others is often characterized by inappropriate sexually seductive or provocative behavior.
3. Displays rapidly shifting and shallow expression of emotions.
4. Consistently uses physical appearance to draw attention to self.
5. Has a style of speech that is excessively impressionistic and lacking in detail.
6. Shows self-dramatization, theatricality, and exaggerated expression of emotion.
7. Is suggestible (i.e., easily influenced by others or circumstances).
8. Considers relationships to be more intimate than they actually are.Associated Features
Impairment in general tends to be lower in histrionic personality disorder than in many other personality disorders. However, the impairment most associated with histrionic personality disorder appears to be interpersonal in nature. Individuals with histrionic personality disorder have an interpersonal style characterized by social dominance, which can span a spectrum of behaviors that include a “warmer dominance” that can be intrusive in nature (e.g., need to be center of attention; exhibitionistic) to a “colder dominance” that can include arrogant, controlling, and aggressive behaviors. Romantic relationships appear to be particularly impaired, with evidence suggesting that individuals with histrionic personality disorder symptoms are more likely to get divorced or never get married. Individuals with histrionic personality disorder may have difficulty achieving emotional intimacy in romantic or sexual relationships. These individuals may also alienate friends with demands for constant attention. They often become depressed and upset when they are not the center of attention. They may crave novelty, stimulation, and excitement and have a tendency to become bored with their usual routine. These individuals are often intolerant of, or frustrated by, situations that involve delayed gratification, and their actions are often directed at obtaining immediate satisfaction. Although they often initiate a job or project with great enthusiasm, their interest may lag quickly. Longer-term relationships may be neglected to make way for the excitement of new relationships.Differential Diagnoses
Other personality disordersComorbid Disorders
Histrionic personality disorder has been associated with higher rates of borderline, narcissistic, paranoid, dependent, and antisocial personality disorders; alcohol and other substance use and misuse; as well as aggression and violence. Histrionic personality disorder is also thought to be related to somatic symptom disorder, functional neurological symptom disorder (conversion disorder), and major depressive disorder.←

Diagnostic Criteria
A pervasive pattern of grandiosity (in fantasy or behavior), need for admiration, and lack of empathy, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:
1. Has a grandiose sense of self-importance (e.g., exaggerates achievements and talents, expects to be recognized as superior without commensurate achievements).
2. Is preoccupied with fantasies of unlimited success, power, brilliance, beauty, or ideal love.
3. Believes that he or she is “special” and unique and can only be understood by, or should associate with, other special or high-status people (or institutions).
4. Requires excessive admiration.
5. Has a sense of entitlement (i.e., unreasonable expectations of especially favorable treatment or automatic compliance with his or her expectations).
6. Is interpersonally exploitative (i.e., takes advantage of others to achieve his or her own ends).
7. Lacks empathy: is unwilling to recognize or identify with the feelings and needs of others.
8. Is often envious of others or believes that others are envious of them.
9. Shows arrogant, haughty behaviors or attitudes.Associated Features
Vulnerability in self-esteem makes individuals with narcissistic personality disorder very sensitive to criticism or defeat. Although they may not show it outwardly, such experiences may leave them feeling ashamed, humiliated, degraded, hollow, and empty. They may react with disdain, rage, or defiant counterattack. However, such experiences can also lead to social withdrawal or an appearance of humility that may mask and protect the grandiosity. Interpersonal relations are typically impaired because of problems related to self-preoccupation, entitlement, need for admiration, and relative disregard for the sensitivities of others.
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Low self-esteem with inferiority, vulnerability, and sustained feelings of shame, envy, and humiliation accompanied by self-criticism and insecurity can make individuals with narcissistic personality disorder susceptible to social withdrawal, emptiness, and depressed mood. High perfectionist standards are often associated with significant fear of exposure to imperfection, failure, and overwhelming emotions.Differential Diagnoses
Mania or hypomania, Other personality disordersComorbid Disorders
Narcissistic personality disorder is associated with depressive disorders (persistent depressive disorder and major depressive disorder), anorexia nervosa, and substance use disorders (especially related to cocaine). Histrionic, borderline, antisocial, and paranoid personality disorders may also be associated with narcissistic personality disorder.←

Diagnostic Criteria
A pervasive pattern of social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation, beginning by early adulthood and present in a variety of contexts, as indicated by four (or more) of the following:
1. Avoids occupational activities that involve significant interpersonal contact because of fears of criticism, disapproval, or rejection.
2. Is unwilling to get involved with people unless certain of being liked.
3. Shows restraint within intimate relationships because of the fear of being shamed or ridiculed.
4. Is preoccupied with being criticized or rejected in social situations.
5. Is inhibited in new interpersonal situations because of feelings of inadequacy.
6. Views self as socially inept, personally unappealing, or inferior to others.
7. Is unusually reluctant to take personal risks or to engage in any new activities because they may prove embarrassing.Associated Features
Individuals with avoidant personality disorder often vigilantly appraise the movements and expressions of those with whom they come into contact. They are likely to misinterpret social responses as critical, which in turn confirms their self doubts. They are described by others as being “shy,” “timid,” “lonely,” and “isolated.” The major problems associated with this disorder occur in social and occupational functioning. The low self-esteem and hypersensitivity to rejection are associated with restricted interpersonal contacts. These individuals may become relatively isolated and usually do not have a large social support network that can help them weather crises. They desire affection and acceptance and may fantasize about idealized relationships with others. Avoidant behaviors can also adversely affect occupational functioning because these individuals try to avoid the types of social situations that may be important for meeting the basic demands of the job or for advancement.
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Individuals with avoidant personality disorder have been reported as having insecure attachment styles characterized by a desire for emotional attachment (which may include a preoccupation with previous and current relationships), but their fears that others may not value them or may hurt them may lead them to respond with passivity, anger, or fear. These attachment patterns have been referred to variously as “preoccupied” or “fearful” depending on the model employed by researchers.Differential Diagnoses
Social Anxiety Disorder, Other personality disordersComorbid Disorders
Other disorders that are commonly diagnosed with avoidant personality disorder include depressive disorders and anxiety disorders, especially social anxiety disorder. Avoidant personality disorder also tends to be diagnosed with schizoid personality disorder. Avoidant personality disorder is associated with increased rates of substance use disorders at a similar rate to the generalized form of social anxiety disorder.←

Diagnostic Criteria
A pervasive and excessive need to be taken care of that leads to submissive and clinging behavior and fears of separation, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:
1. Has difficulty making everyday decisions without an excessive amount of advice and reassurance from others.
2. Needs others to assume responsibility for most major areas of their life.
3. Has difficulty expressing disagreement with others because of fear of loss of support or approval. Do not include realistic fears of retribution.
4. Has difficulty initiating projects or doing things on their own (because of a lack of self-confidence in judgment or abilities rather than a lack of motivation or energy).
5. Goes to excessive lengths to obtain nurturance and support from others, to the point of volunteering to do things that are unpleasant.
6. Feels uncomfortable or helpless when alone because of exaggerated fears of being unable to care for themself.
7. Urgently seeks another relationship as a source of care and support when a close relationship ends.
8. Is unrealistically preoccupied with fears of being left to take care of themself.Associated Features
The dependent and submissive behaviors are designed to elicit caregiving and arise from a self-perception of being unable to function adequately without the help of others.
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Individuals with dependent personality disorder are often characterized by pessimism and self-doubt and tend to belittle their abilities and assets. They take criticism and disapproval as proof of their worthlessness and lose faith in themselves. They may seek overprotection and dominance from others. Occupational functioning may be impaired if independent initiative is required. They may avoid positions of responsibility and become anxious when faced with decisions.Differential Diagnoses
Separation Anxiety Disorder, Other personality disordersComorbid Disorders
There may be an increased risk of depressive disorders, anxiety disorders, and adjustment disorders. Dependent personality disorder often co-occurs with other personality disorders, especially borderline, avoidant, and histrionic personality disorders. Chronic physical illness or persistent separation anxiety disorder in childhood or adolescence may predispose the individual to the development of this disorder.←

Diagnostic Criteria
A pervasive pattern of preoccupation with orderliness, perfectionism, and mental and interpersonal control, at the expense of flexibility, openness, and efficiency, beginning by early adulthood and present in a variety of contexts, as indicated by four (or more) of the following:
1. Is preoccupied with details, rules, lists, order, organization, or schedules to the extent that the major point of the activity is lost.
2. Shows perfectionism that interferes with task completion (e.g., is unable to complete a project because his or her own overly strict standards are not met).
3. Is excessively devoted to work and productivity to the exclusion of leisure activities and friendships (not accounted for by obvious economic necessity).
4. Is over-conscientious, scrupulous, and inflexible about matters of morality, ethics, or values (not accounted for by cultural or religious identification).
5. Is unable to discard worn-out or worthless objects even when they have no sentimental value.
6. Is reluctant to delegate tasks or to work with others unless others agree to submit to their exact way of doing things.
7. Adopts a miserly spending style toward both self and others; money is viewed as something to be hoarded for future catastrophes.
8. Shows rigidity and stubbornness.Associated Features
When rules and established procedures do not dictate the correct answer, decision-making may become a time-consuming, often painful process (e.g., exhaustively researching options before making a purchase). Individuals with obsessive-compulsive personality disorder may have such difficulty deciding which tasks take priority or what is the best way of doing some particular task that they may never get started on anything. They are prone to become upset or angry in situations in which they are not able to maintain control of their physical or interpersonal environment, although the anger is typically not expressed directly. For example, an individual may be angry when service in a restaurant is poor, but instead of complaining to the management, the individual ruminates about how much to leave as a tip. On other occasions, anger may be expressed with righteous indignation over a seemingly minor matter. Individuals with this disorder may be especially attentive to their relative status in dominance-submission relationships and may display excessive deference to an authority they respect and excessive resistance to authority they do not respect.
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Individuals with this disorder have difficulty relating to and sharing emotions. For example, they may express affection in a highly controlled or stilted fashion and may be very uncomfortable in the presence of others who are emotionally expressive. Their everyday relationships have a formal and serious quality, and they may be stiff in situations in which others would smile and be happy (e.g., greeting a lover at the airport). They carefully hold themselves back until they are sure that whatever they say will be perfect. They may be preoccupied with logic and intellect and intolerant of displays of emotion in others. They often have difficulty expressing tender feelings, rarely paying compliments. Individuals with this disorder may experience occupational difficulties and distress, particularly when confronted with new situations that demand flexibility and compromise.Differential Diagnoses
Hoarding Disorder, Other personality disordersComorbid Disorders
Individuals with anxiety disorders (e.g., generalized anxiety disorder, separation anxiety disorder, social anxiety disorder, specific phobias) and OCD have an increased likelihood of having a personality disturbance that meets criteria for obsessive-compulsive personality disorder. Even so, it appears that the majority of individuals with OCD do not have a pattern of behavior that meets criteria for this personality disorder. Many of the features of obsessive-compulsive personality disorder overlap with “type A” personality characteristics (e.g., preoccupation with work, competitiveness, time urgency), and these features may be present in individuals at risk for myocardial infarction. There may be an association between obsessive-compulsive personality disorder and depressive and bipolar disorders and eating disorders.←