Section Syndrome Learn all symptoms from:

Developmental Autism Spectrum A Persistent deficits in social communication and social interaction
across multiple contexts:

1. Deficits in social-emotional reciprocity

2. Deficits in nonverbal communicative behaviors used for social

interaction

3. Deficits in developing, maintaining, and understanding

relationships

B Restricted, repetitive patterns of behavior, interests, or activities:

1. Stereotyped or repetitive motor movements, use of objects, or

speech

2. Insistence on sameness, inflexible adherence to routines, or

ritualized patterns of verbal or nonverbal behavior

3. Highly restricted, fixated interests that are abnormal in intensity

or focus

4. Hyper/hyporeactivity to sensory input or unusual interest in

sensory aspects of the environment

Specifiers for severity: social communication impairments and restricted,

repetitive patterns of behavior

ADHD A Persistent pattern of inattention and/or hyperactivity-impulsivity that

interferes with functioning or development:

- Inattention: failed attention to detail/careless mistakes, difficulty

sustaining attention, not listening when spoken to, not following
through on instruction/fail to finish work, difficulty organizing,
avoid/dislike/not starting tasks requiring sustained mental effort,
lose things, easily distracted, forgetful

- Hyperactivity and impulsivity: fidgeting/squirming, inappropriate

seat leaving or running/climbing, unable to play/leisure quietly,
on the go/seems driven by motor, excessive talking, answer
before question is completed, difficulty awaiting turn,
interrupt/intrude on others

Psychotic Delusional A The presence of 1+ delusions for 1+ month

Brief Psychotic A 1+ of symptoms:
1. Delusions at least 1 must be [1 2 3]
2. Hallucinations
3. Disorganized speech (derailment/incoherence)
4. Grossly disorganized/catatonic behavior

B Duration of episode > 1 day but < 1 month, with eventual full return to
premorbid level of functioning.

Schizophreniform A 2+ of symptoms:
1. Delusions 1+ must be [1 2 3]
2. Hallucinations
3. Disorganized speech (derailment/incoherence)
4. Grossly disorganized/catatonic behavior
5. Negative symptoms (less emo expression/avolition)

B Duration of episode > 1 month but < 6 months

Schizophrenia A 2+ of symptoms:
1. Delusions 1+ must be [1 2 3]
2. Hallucinations
3. Disorganized speech (derailment/incoherence)
4. Grossly disorganized/catatonic behavior
5. Negative symptoms (less emo expression/avolition)

B For significant portion of time since onset, level of functioning in 1+

major areas (work, interpersonal, self-care) markedly below level prior
to onset

C Continuous signs for 6+ months, with 1+ months of critA symptoms,

may include periods of prodromal/residual symptoms of only negative
symptoms or 2+ attenuated critA symptoms

Schizoaffective A Uninterrupted period of illness with a major mood episode (major

depressive* or manic) + critA of schizophrenia
* necessitates depressed mood

B Delusions or hallucinations for 2+ weeks in absence of major mood

episode (depressive or manic) during the lifetime duration of the illness.

C Presence of mood episode for majority of total illness duration (active

and residual portions)
Bipolar Manic episode A Distinct period of abnormally and persistently elevated/expansive/
(ME) irritable mood + increased activity/energy (> 1 week, most of day, nearly
every day or any duration if hospitalization is necessary)

B During this period, 3+ of symptoms* (4+ if mood only irritable):

* present to significant degree & noticeable change from usual behavior

1. Inflated self-esteem / grandiosity

2. Decreased need for sleep (e.g., feels rested after only 3h sleep)

3. More talkative than usual / pressure to keep talking

4. Flight of ideas / racing thoughts (subjective experience)

5. Distractibility (reported or observed)

6. Increased goal-directed activity (socially/at work or school/

sexually) or psychomotor agitation (purposeless activity)

7. Excessive involvement in activities with high potential for painful

consequences (unrestrained buying sprees/sexual
indiscretions/foolish investments)

C Mood disturbance is sufficiently severe to cause marked impaired

social/occupational functioning or necessitate hospitalization or when
there are psychotic features

Note: episode = criterion for a syndrome, not syndrome itself

Hypomanic A Distinct period of abnormally and persistently elevated/expansive/

episode (HE) irritable mood + increased activity/energy (> 4 consecutive days, most
of day, nearly every day)

B During this period, 3+ of symptoms* (4+ if mood only irritable):

* present to significant degree & noticeable change from usual behavior

1. Inflated self-esteem / grandiosity

2. Decreased need for sleep (e.g., feels rested after only 3h sleep)

3. More talkative than usual / pressure to keep talking

4. Flight of ideas / racing thoughts (subjective experience)

5. Distractibility (reported or observed)

 6. Increased goal-directed activity (socially/at work or school/
sexually) or psychomotor agitation (purposeless activity)

7. Excessive involvement in activities with high potential for painful

consequences (unrestrained buying sprees/sexual
indiscretions/foolish investments)

C Associated with an unequivocal change in functioning that is

uncharacteristic of the individual when not symptomatic

D Mood disturbance & change in functioning are observable by others

Depressive A 5+ of symptoms during same 2-week period + change in functioning

episode (DE) 1+ must be [1 2]
1. Depressed mood most of day, nearly every day, by subjective
report or observation.

2. Markedly diminished interest or pleasure in (almost) all activities

most of the day, nearly every day, subjective account or
observation

3. Significant weight loss or gain (when not dieting, e.g. >5% of

body weight in 1 month) or decrease or increase in appetite
nearly every day

4. Insomnia or hypersomnia nearly every day

5. Psychomotor agitation or retardation nearly every day

(observable by others, not merely subjective feelings of
restlessness or being slowed down)

6. Fatigue or loss of energy nearly every day

7. Feelings of worthlessness or excessive/inappropriate guilt

nearly every day (may be delusional, not merely self-reproach or
guilt about being sick)

8. Diminished ability to think/concentrate / indecisiveness, nearly

every day (subjective account or observed)

9. Recurrent thoughts of death (not just fear of dying), recurrent

suicidal ideation without a specific plan, or a suicide
attempt/specific plan for committing suicide

Note: Do not include symptoms clearly attributable to another medical

condition
Note: In children and adolescents, [1] mood can be irritable mood, [3]
can be failure to make expected weight gain
 Bipolair I A At least one lifetime manic episode, which may have been preceded
and followed by hypomania or major depressive episodes

Bipolair II A Current or past hypomanic AND major depressive episode

Depressive Depressive A Presence of a depressive episode

Persistent A Depressed mood for most of the day, more days than not, by
Depressive subjective account or observation, for at least 2 years.

B While depressed, 2+ of:

1. Poor appetite or overeating.

2. Insomnia or hypersomnia.

3. Low energy or fatigue.

4. Low self-esteem.

5. Poor concentration or difficulty making decisions.

6. Feelings of hopelessness

Specifiers for type of persistence:

1. Pure dysthymic syndrome: not meeting criteria for major
depressive episode in preceding 2+ years

2. Persistent major depressive episode: meeting criteria for major

depressive episode throughout preceding 2 years

3. Intermittent major depressive episodes, with current episode:

currently meeting criteria for major depressive episode, but with
periods of 8+ weeks below threshold in preceding 2+ years

4. Intermittent major depressive episodes, without current

episode: not currently meeting criteria for major depressive
episode, but 1+ episodes in preceding 2+ years

Note: In children and adolescents, mood can be irritable and >1 year
Anxiety Specific phobia A Marked fear or anxiety about a specific object or situation
Note: In children, the fear/anxiety may be expressed by crying, tantrums,
freezing, or clinging.

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.
Note: only anxiety disorder that does not require duration of 6+ months

Social anxiety A Marked fear or anxiety about one or more social situations in which
the individual is exposed to possible scrutiny by others. E.g. social
interactions, being observed, 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

Note: In children, (A) the anxiety must occur in peer settings and not just
during interactions with adults, (C) the fear or anxiety may be expressed
by crying, tantrums, freezing, clinging, shrinking, or failing to speak in
social situations.

Panic attack (PA) An abrupt surge of intense fear/discomfort that reaches a peak within
specifyer minutes, and during which 4+ of:
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 dying.

Panic disorder A Recurrent unexpected panic attacks

B 1+ of attacks followed by 1+ month of either/both:

1. Persistent concern/worry about additional panic attacks or their

consequences (losing control, heart attack, “going crazy”)

2. Significant maladaptive behavioral change related to the attacks

(avoidance)

Agoraphobia A Marked fear or anxiety about 2+ of:

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 Fear about/avoidance of 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 (e.g., fear of falling in the elderly; fear of incontinence).

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 6+ months

 Generalized A Excessive anxiety and worry, occurring more days than not for 6+
anxiety months, about a number of events/activities (e.g. work/school)

B The individual finds it difficult to control the worry.

C The anxiety and worry are associated with 3+ of symptoms*:

* some symptoms present for more days than not for 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)

Note: Only one item is required in children.

Obsessive- Obsessive- A Presence of obsessions, compulsions, or both:

compulsive compulsive
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 (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/distress, or preventing dreaded
event/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.
 Note: Young children may not be able to articulate the aims of these
behaviors or mental acts.

B The obsessions or compulsions are time-consuming (>1h/day) or cause

clinically significant distress or impairment in social, occupational, or
other important areas of functioning

Body Dysmorphic A Preoccupation with 1+ perceived defects/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

Trauma- Posttraumatic Note: Criteria apply to >6 years.

related Stress A Exposure to actual or threatened death, serious injury, or sexual
violence in 1+ 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) (e.g., first responders collecting human
remains; police officers repeatedly exposed to details of child
abuse). Note: Exposure through electronic media only counts
when work related.

B Presence of 1+ 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). Note: In children >6 years, repetitive play may occur in
which themes or aspects of the traumatic event(s) are expressed.

2. Recurrent distressing dreams in which the content and/or affect

of the dream are related to the traumatic event(s). Note: In children,
there may be frightening dreams without recognizable content.
 3. Dissociative reactions (e.g., flashbacks) in which the individual
feels or acts as if the traumatic event(s) were recurring. (May
occur on a continuum, with the most extreme expression being a
complete loss of awareness of present surroundings.) Note: In
children, trauma-specific reenactment may occur in play.

4. Intense or prolonged psychological distress at exposure to

internal or external cues that symbolize/resemble aspect(s) 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 any:

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, evidenced by 2+ of:

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 2+ of:

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) > 1 month.

Acute Stress A Exposure to actual or threatened death, serious injury, or sexual

violence in 1+ 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) (e.g., first responders collecting human
remains; police officers repeatedly exposed to details of child
abuse). Note: Exposure through electronic media only counts
when work related.
B Presence of 9+ of the following symptoms*:
* beginning or worsening after the trauma

Intrusion Symptoms
1. Recurrent, involuntary, and intrusive distressing memories of the
traumatic event(s). Note: In children >6 years, repetitive play may occur in
which themes or aspects of the traumatic event(s) are expressed.

2. Recurrent distressing dreams in which the content and/or affect

of the dream are related to the traumatic event(s). Note: In children,
there may be frightening dreams without recognizable content.

3. Dissociative reactions (flashbacks) in which the individual feels or

acts as if the traumatic event(s) were recurring. (May occur on a
continuum, with the most extreme expression being a complete
loss of awareness of present surroundings.) Note: In children, trauma-
specific reenactment may occur in play.

4. Intense or prolonged psychological distress at exposure to

internal or external cues that symbolize/resemble aspect(s) of
the traumatic event(s).

Negative Mood
5. Persistent inability to experience positive emotions (e.g.,
inability to experience happiness, satisfaction, or loving feelings).

Dissociative Symptoms
6. An altered sense of reality of one’s surroundings or oneself
(seeing oneself from another’s perspective, being in a daze, time
slowing).

7. 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).

Avoidance Symptoms
8. Efforts to avoid distressing memories, thoughts, or feelings about
or closely associated with the traumatic event(s).

9. 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).

Arousal Symptoms
10. Sleep disturbance (difficulty falling/staying asleep, restless sleep)
 11. Irritable behavior and angry outbursts (with little or no
provocation), typically verbal or physical aggression toward
people or objects.

12. Hypervigilance.

13. Problems with concentration.

14. Exaggerated startle response.

C Duration of the disturbance (critB) is 3 days to 1 month after trauma

Note: Symptoms typically begin immediately after the trauma, but need
to persist > 3 days (up to 1month) for diagnosis.

Adjustment A Development of emotional or behavioral symptoms in response to an

identifiable stressor(s) within 3 months of the onset of the stressor(s).

B Symptoms/behaviors are clinically significant, as evidenced by 1+ of:

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.

Dissociative Dissociative A Disruption of identity characterized by 2+ distinct personality states,

Identity 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. Observed by others or reported by the
individual.

B Recurrent gaps in recall of everyday events, important personal

information, and/or traumatic events that are inconsistent with ordinary
forgetting.

Dissociative A Inability to recall important autobiographical information, usually of a

amnesia traumatic or stressful nature, inconsistent with ordinary forgetting

Note: Most often consists of localized or selective amnesia for a specific

event or events; or generalized amnesia for identity and life history.
 Depersonalization A Presence of persistent or recurrent experiences of depersonalization,
/ derealization 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 (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 (individuals/objects are experienced as
unreal, dreamlike, foggy, lifeless, or visually distorted).

B During the depersonalization or derealization experiences, reality

testing remains intact.

Somatic Somatic Symptom A 1+ somatic symptoms that are distressing or disrupt daily life
symptom
B Excessive thoughts, feelings, or behaviors related to the somatic
symptoms or associated health concerns, as manifested by 1+ of:

1. Disproportionate and persistent thoughts about the seriousness

of symptoms

2. Persistently high level of anxiety about health or symptoms

3. Excessive time and energy devoted to these symptoms or health

concerns

Illness Anxiety A Preoccupation with having or acquiring a serious illness

B Somatic symptoms are not present or 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

(repeatedly checks his or her body for signs of illness) or exhibits
maladaptive avoidance (avoids doctor appointments and hospitals)

Conversion A 1+ symptoms of altered voluntary motor/sensory function

B Clinical findings provide evidence of incompatibility between the

symptom and recognized neurological or medical conditions
Eating Anorexia Nervosa A Restriction of energy intake relative to requirements, leading to a
significantly low body weight (< minimally normal/expected
(children/adolescents)) in the context of age, sex, developmental
trajectory, and physical health.

B Intense fear of gaining weight/becoming fat or persistent behavior

that interferes with weight gain, even though at a significantly low
weight.

C Disturbance in experience of one’s body weight or shape, undue

influence of body weight or shape on self-evaluation, or persistent lack
of recognition of the seriousness of the current low body weight.

Bulimia Nervosa A Recurrent episodes of binge eating, characterized by both:

1. Eating, in a discrete period of time, an amount of food definitely

larger than what most individuals would eat in a similar time
period under similar circumstances.

2. A sense of lack of control over eating during the episode (cannot

stop eating or control what/how much one is eating).

B Recurrent inappropriate compensatory behaviors to prevent weight

gain, such as self-induced vomiting; misuse of laxatives, diuretics, or
other medications; fasting; or excessive exercise.

C Binge eating + inappropriate compensatory behaviors both occur, on

average, 1+ times/week for 3+ months

D Self-evaluation is unduly influenced by body shape and weight.

Disruptive, Opposition- A Pattern of angry/irritable mood, argumentative/defiant behavior, or

impuls and Defiant vindictiveness for 6+ months, evidenced by 4+ of symptoms*:
control *exhibited during interaction with 1+ individual who is not a sibling.

1. Angry/Irritable Mood

2. Often loses temper.

3. Is often touchy or easily annoyed.

4. Is often angry and resentful.

Argumentative/Defiant Behavior
5. Often argues with authority figures or, for children and
adolescents, with adults.
 6. Often actively defies or refuses to comply with requests from
authority figures or with rules.

7. Often deliberately annoys others.

8. Often blames others for his or her mistakes or misbehavior.

Vindictiveness
9. Has been spiteful or vindictive 2+ times within past 6 months

Note: Persistence & frequency of behaviors should be used to distinguish

between “within normal limits” or “symptomatic”: For children < 5 years,
behavior should occur most days for 6+ months. For individuals > 5 years,
behavior should occur 1+ /week for 6+ months. Other factors should also
be considered, e.g. whether frequency & intensity of behaviors are
outside normative range for developmental level, gender, and culture.

Conduct A Repetitive and persistent pattern of behavior violating basic rights of

others or major age-appropriate societal norms or rules, as manifested
by 3+ of following criteria in past 12 months, with 1+ in 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’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 2+ times 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.

Substance- Substance use Criteria Alcohol Use Disorder (criteria for others are mostly the same)
related → I removed word ‘alcohol’

A Problematic pattern of alcohol use leading to clinically significant

impairment or distress, as manifested by 2+ of, within 12-month period:

1. Use of larger amounts or over longer period than intended

2. There is a persistent desire or unsuccessful efforts to cut down

or control use.

3. A great deal of time spent in activities necessary to obtain, use,

or recover from substance.

4. Craving, or strong desire/urge to use.

5. Recurrent use resulting in failure to fulfill major role obligations

at work, school, or home.

6. Continued use despite persistent/recurrent social or

interpersonal problems caused or exacerbated by the effects of
use.

7. Giving up/reducing important social, occupational, or

recreational activities because of use.

8. Recurrent use in situations in which it is physically hazardous.

9. Continued use despite knowledge of persistent/recurrent

physical or psychological problem likely caused/exacerbated by
use.
 10. Tolerance, as defined by either of the following:
a. Need for markedly increased amounts of substance to
achieve intoxication or desired effect.

b. Markedly diminished effect with continued use of same

amount.

11. Withdrawal, as manifested by either of the following:

a. The characteristic withdrawal syndrome for alcohol (refer to
Criteria A and B of the criteria set for alcohol withdrawal).

b. Substance (or closely related substance) is taken to relieve or

avoid withdrawal symptoms.

Personalty General criteria A Enduring pattern of inner experience and behavior that deviates
for PD markedly from the expectations of the individual’s culture. This pattern
is manifested in 2+ areas:

1. Cognition (perceiving & interpreting self, other people, events)

2. Affectivity (range, intensity, lability, appropriateness of

emotional response)

3. Interpersonal functioning

4. Impulse control

Note: beginning by early adulthood and present in a variety of contexts

PPP: Pervasive, Persistent, Pathological

Paranoide A pervasive distrust and suspiciousness of others such that their motives
are interpreted as malevolent, as indicated by 4+ of:

1. Suspects, without sufficient basis, that others are exploiting,

harming, or deceiving him or her.

2. Is preoccupied with unjustified doubts about 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 him or her.

4. Reads hidden demeaning or threatening meanings into benign

remarks or events.

5. Persistently bears grudges (unforgiving of insults, injuries, slights)

 6. Perceives attacks on his/her character or reputation that are not
apparent to others and is quick to react angrily or counterattack.

7. Has recurrent suspicions, without justification, regarding fidelity

of spouse or sexual partner.

Schizoide A pervasive pattern of detachment from social relationships and a

restricted range of expression of emotions in interpersonal settings, as
indicated by 4+ of:

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 sexual experiences with others.

4. Takes pleasure in few, if any, activities.

5. Lacks close friends/confidants other than first-degree relatives.

6. Appears indifferent to praise or criticism of others.

7. Shows emotional coldness, detachment, or flattened affectivity.

Schizotypische 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, as
indicated by 5+ of:

1. Ideas of reference (false beliefs that random/irrelevant

occurrences directly relates to person; 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 (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.
Antisocial A pervasive pattern of disregard for and violation of the rights of others,
occurring since age 15 years, as indicated by 3+ of:

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 / 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.

C Evidence of conduct disorder with onset before age 15 years

Borderline A pervasive pattern of instability of interpersonal relationships, self-

image, and affects, and marked impulsivity, as indicated by 5+ of:

1. Frantic efforts to avoid real or imagined abandonment. (Do not

include suicidal or self-mutilating behavior covered in Crit5)

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 2+ areas that are potentially self-damaging

(spending, sex, substance abuse, reckless driving, binge eating).
(Do not include suicidal or self-mutilating behavior covered in
Crit5)

5. Recurrent suicidal behavior, gestures, or threats, or self-

mutilating behavior.
 6. Affective instability due to a marked reactivity of mood (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

(frequent displays of temper, constant anger, recurrent physical
fights).

9. Transient, stress-related paranoid ideation or severe

dissociative symptoms.

Histrionic A pervasive pattern of excessive emotionality and attention seeking, as

indicated by 5+ of:

1. Uncomfortable when 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 (easily influenced by others or circumstances).

8. Considers relationships to be more intimate than they actually

are.

Narcististic A pervasive pattern of grandiosity (in fantasy or behavior), need for

admiration, and lack of empathy, as indicated by 5+ of:

1. Has a grandiose sense of self-importance (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 they are “special” and unique and can only be
understood by/should associate with other special or high-
status people/institutions.

4. Requires excessive admiration.

5. Has a sense of entitlement (unreasonable expectations of

especially favorable treatment or automatic compliance with
their expectations).

6. Is interpersonally exploitative (takes advantage of others to

achieve their 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.

Avoidant A pervasive pattern of social inhibition, feelings of inadequacy, and

hypersensitivity to negative evaluation, as indicated by 4+ of:

1. Avoids occupational activities involving 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/ridiculed.

4. Is preoccupied with being socially criticized or rejected.

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 engage in new

activities because they may prove embarrassing.
Dependent A pervasive and excessive need to be taken care of that leads to
submissive and clinging behavior and fears of separation, as indicated by
5+ of:

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/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.

Obsessive- A pervasive pattern of preoccupation with orderliness, perfectionism, and

Compulsive mental and interpersonal control, at the expense of flexibility, openness,
and efficiency, as indicated by 4+ of:

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 (unable

to complete projects because of own overly strict standards).

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 overconscientious, 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 work with others unless they

submit to exactly his or her 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.

DSM-5 Handbook of differential diagnosis

Chapter 1 Differential diagnosis step by step

Step 1: rule out malingering and factitious disorder

If the patient is not being honest regarding the nature or severity of his or her symptoms, all bets are off
regarding the clinician’s ability of arrive at an accurate psychiatric diagnosis.
Most psychiatric work depends on a good-faith collaborative effort between the clinician and the patient to
uncover the nature and cause of the presenting symptoms.

Two conditions in DSM-5 are characterized by feigning

These two are differentiated based on the motivation for the deception.

• Malingering
When the motivation is the achievement of a clearly recognizable goal
• Factitious disorder
When the deceptive behaviour is present even in the absence of obvious external rewards

The clinician’s index of suspicion should be raised when

• There are clear external incentives to the patient’s being diagnosed with a psychiatric condition
• The patient presents with a cluster of psychiatric symptoms that conforms more to a lay perception
of mental illness rather than to a recognized clinical entity
• The nature of the symptoms shift radically form one clinical encounter to another
• The patient has a presentation that mimics that of a role model
• The patient is characteristically manipulative or suggestible

It is useful for clinicians to become mindful of tendencies they might have toward being either excessively
sceptical or excessively gullible.
Step 2: rule out substance etiology (including drugs of abuse,
medications)
Whether the presenting symptoms arise from a substance that is exerting a direct effect on the central
nervous system.
Virtually any presentation encountered in a mental health setting can be caused by substance use.

The determination of whether psychopathology is due to substance use often can be difficult
because although substance use is fairly ubiquitous and a wide variety of different symptoms can
be caused by substances, the fact that substance use and psychopathology occur together does not
necessarily imply a cause-and-effect relationship between them.

The first task is to determine whether the person has been using a substance

This entails history taking and physical examinations for signs of substance intoxication or
substance withdrawal.
It is usually wise to consult with family members and obtain laboratory analysis of body fluids to
ascertain recent usage of particular substances.

Patients who use or are exposed to any of a variety of substances can and often do present with
psychiatric symptoms.

Once substance use has been established, the next task is to determine whether there is an
etiological relationship between it and the psychiatric symptomatology

This requires distinguishing among three possible relationships between the substance use and the
psychopathology

• The psychiatric symptoms result from the direct effects of the substance on the CNS
• The substance use is a consequence (or associated feature) of having a primary psychiatric disorder
• The psychiatric symptoms and the substance use are independent

In diagnosing a substance-induced disorder, there are three considerations in determining whether there is a
causal relationship between the substance use and the psychiatric symptomatology

• You must determine whether there is a close temporal relationship between the substance
or medication use and the psychiatric symptoms.
The determination of whether there was a period of time when the psychiatric symptoms were
present outside the context of substance/medication is the best method.
What happens to the psychiatric symptoms when the person is no longer taking the substance or
medication
o Persistence of the psychiatric symptomatology for a significant period of time beyond
periods of intoxication or withdrawal or medication use suggest that the psychopathology is
primary and not due to substance/medication use.
Sometimes, it is not possible to determine whether there was a period of time when the
psychiatric symptoms occurred outside of periods of substance/medication use.
o It may be necessary to assess the patient during a current period of abstinence form the
substance or to stop the medication suspected of causing the psychiatric symptoms.
• You must consider the likelihood that the particular pattern of substance/medication use can result
in the observed psychiatric symptoms.
 Consider whether the nature, amount, and duration of substance/medication cause are consistent
with eh development of the observed psychiatric symptoms
• You should consider whether there are better alternative explanations for the clinical picture
A history of many similar episodes not related to substance/medication use, a strong family history
of the particular primary disorder, or the presence of physical examination or laboratory findings
suggesting that a medical condition might be involved.

In some cases, the substance use can be the consequence or an associated feature (rather than cause)
of psychiatric symptomatology

The substance-taking behaviour can be considered a form of self-medication for the psychiatric
condition.
Individuals with particular psychiatric disorders often preferentially chose certain classes of
substances.

The hallmark of a primary psychiatric disorder with secondary substance use is that the primary
psychiatric disorder occurs first and/or exist at times during the person’s lifetime when he or she is
not using any substance.

In other cases, both the psychiatric disorder and the substance use can be initially unrelated
and relatively independent of each other

There are high prevalence rates of both psychiatric disorders and substance use disorders.
Even if initially independent, the two disorders may interact to exacerbate each other and
complicate the overall treatment.

This independent relationship is essentially a diagnosis made by exclusion.

A lack of a causal relationship in either direction is more likely if there are periods when the
psychiatric symptoms occur in the absence of substance use and if the substance use occurs at
times unrelated to the psychiatric symptomatology.

After deciding that a presentation is due to the indirect effect of a substance or medication,
you must then determine which DSM-5 substance-induced disorder best describes the
presentation.

Step 3: rule out a disorder due to a general medical condition

Determine whether the psychiatric symptoms are due to the direct effects of a general medical condition.

This differential diagnosis can be difficult for four reasons

• Symptoms of some psychiatric disorders and of many general medical conditions can be identical
• Sometimes the first presenting symptoms of a general medical condition are psychiatric
• The relationship between the general medical condition and the psychiatric symptoms may be
complicated
• Patients are often seen in settings primarily geared for the identification and treatment of mental
disorders in which there may be a lower expectation for, and familiarity with, the diagnosis of
medical conditions
Virtually any psychiatric presentation can be caused by the direct physiological effects of a general
medication condition, and these are diagnosed in DSM-5 as one of the mental disorders due to
another medical condition

You should direct the history, physical examination, and laboratory tests toward the diagnosis of
those general medical conditions that re most commonly encountered and most likely to account
for the presenting psychiatric symptoms.

Once a general medical condition is established, the next task is to determine its etiological
relationship, if any, to the psychiatric symptoms

There are five possible relationships

• The general medical condition causes the psychiatric symptoms through a direct physiological effect
on the brain
• The general medical condition causes the psychiatric symptoms through a psychological mechanism
• Medication taken for the general medical condition causes the psychiatric symptoms, in which case
the diagnosis is a Medication-induced mental disorder
• The psychiatric symptoms cause or adversely affect the general medical condition
• The psychiatric symptoms and the general medical condition are coincidental

There are two clues suggesting that psychopathology is caused by the direct physiological effect of
general medical condition

Neither of these is infallible.

• The nature of the temporal relationship.

Requires consideration of whether the psychiatric symptoms begin following the onset of the general
medical condition, vary in severity with the severity of the general medical condition, and disappear
when the general medical condition resolves.
• A general medical condition should be considered in the differential diagnosis if the psychiatric
presentation is atypical in symptom pattern, age of onset, or course.

If you have determined that a general medical condition is responsible for the psychiatric symptoms,
you must determine which of the DSM-5 mental disorders due to another medical condition best
describes the presentation.

Step 4: determine the specific primary disorders

Determine which among the primary DSM-5 mental disorders best accounts for the presenting
symptomatology.

Step 5: differentiate adjustment disorders from the residual other

specified or unspecified disorders
Many clinical presentations do not conform to the particular symptom patterns, or they fall below the
established severity or duration thresholds to qualify for one of the specific DSM-5 diagnoses.
In such situations, if the symptomatic presentations is severe enough to cause clinically significant
impairment or distress and represents a biological or psychological dysfunction in the individual, a diagnosis
of a mental disorder is still warranted and the differential outcomes down to either an Adjustment disorder
or one of the residual Other specified or Unspecified categories.

• If the clinical judgment is made that the symptoms have developed as a maladaptive response to a
psychosocial stressor, the diagnosis would be an Adjustment disorder.
• If it is judged that a stressor is not responsible for the development of the clinically significant
symptoms, then the relevant Other specified or Unspecified category may be diagnosed, with the
choice of the appropriate residual category depending on which DSM-5 diagnostic grouping best
covers the symptomatic presentation
o The differentiation of residual categories
If the clinician wants to indicate the specific reason, the name of the disorder is followed by
the reason why the presentation does not conform to any of the specific disorder definitions
If the clinician chooses not to indicate the specific reason why the presentation does not
conform to any of the specific disorder definitions, the Unspecified disorder designation is
used.

Step 6: establish the boundary with no mental disorder

Establish the boundary between a disorder and no mental disorder.
Generally, the rule of thumb, if the comorbid psychiatric presentation warrants clinical attention and
treatment, it is considered to be clinically significant.

Differential diagnosis and comorbidity

Differential diagnosis is generally based on the notion that the clinician is choosing a single diagnosis from
among a group of competing, mutually exclusive diagnosis to best explain a given symptom presentation.

Very often, DSM-5 diagnoses are not mutually exclusive, and the assignment of more than one DSM-
5 diagnosis to a given patient is both allowed and necessary to adequately describe the presenting
symptoms.
The use of multiple diagnoses is in itself neither good or bad as long as the implications are
understood.
There are sex different ways in which two so-called comorbid conditions may be related to one
other

• Condition A may cause or predispose to condition B

• Condition B may cause or predispose to condition A
• An underlying condition C may cause or predispose to both conditions A and B
• Conditions A and B may, in fact, be part of a more complex unified syndrome that has been artificially
split in the diagnostic system
• The relationship between conditions A and B may be artifactually enhanced by definitional overlap
• The comorbid is the result of a chance co-occurrence that may be particularly likely for those
conditions that have high base rates