Neurodevelopmental Disorders

- a group of conditions with onset in the developmental period

- characterized by developmental deficits or differences in brain processes that produce impairments of
personal, social, academic, or occupational functioning
Intellectual Developmental Disorders
Intellectual Developmental Disorder (Intellectual Disability)
Criteria:
- is a disorder with onset during the developmental period that includes both intellectual and adaptive
functioning deficits in conceptual, social, and practical domains. The following three criteria must be met:
A. Deficits in intellectual functions
B. Deficits in adaptive functioning
C. Onset of intellectual and adaptive deficits during the developmental period.

Specify current severity:

- Mild
- Moderate
- Severe
- Profound
Differential Diagnosis
Major and mild neurocognitive disorders Major neurocognitive disorder may co-occur with intellectual
developmental disorder → both diagnoses are given
Communication disorders and specific learning specific to the communication and learning domains and do not
disorder show deficits in intellectual and adaptive behavior
*if criteria are met, both diagnoses are given
Autism spectrum disorder presence of persistent deficits in social communication and
social interaction, along with restricted, repetitive patterns of
behaviors, interests, or activities
*if criteria are met, both diagnoses are given
Comorbidity:
- mental disorders, cerebral palsy, and epilepsy
- communication disorders, autism spectrum disorder, and motor, sensory, or other disorders.
- attention-deficit/hyperactivity disorder
- depressive and bipolar disorders (MDD)
- anxiety disorders
- autism spectrum disorder
- stereotypic movement disorder (with or without self-injurious behavior)
- impulse-control disorders
- major neurocognitive disorder

Global Developmental Delay

Criteria:
- individuals under the age of 5 years when the clinical severity level cannot be reliably assessed during early
childhood.
- individual fails to meet expected developmental milestones in several areas of intellectual functioning
- individuals who are unable to undergo systematic assessments of intellectual functioning, including children
who are too young to participate in standardized testing
Communication Disorders
- deficits in language, speech, and communication
- Speech is the expressive production of sounds and includes an individual’s articulation, fluency, voice, and
resonance quality.
- Language includes the form, function, and use of a conventional system of symbols (i.e., spoken words, sign
language, written words, pictures) in a rule-governed manner for communication.
- Communication includes any verbal or nonverbal behavior (whether intentional or unintentional) that has the
potential to influence the behavior, ideas, or attitudes of another individual.
Language Disorder
Criteria:
A. Persistent difficulties in the acquisition and use of language across modalities (i.e., spoken, written, sign
language, or other) due to deficits in comprehension or production that include the following:
1. Reduced vocabulary
2. Limited sentence structure
3. Impairments in discourse
B. Language abilities are substantially and quantifiably below those expected for age, resulting in functional
limitations in effective communication, social participation, academic achievement, or occupational
performance, individually or in any combination.
C. Onset of symptoms is in the early developmental period.
D. The difficulties are not attributable to hearing or other sensory impairment, motor dysfunction, or another
medical or neurological condition and are not better explained by intellectual developmental disorder
(intellectual disability) or global developmental delay.

Language learning and use is dependent on both receptive and expressive skills.
Expressive ability refers to the production of vocal, gestural, or verbal signals
Receptive ability refers to the process of receiving and comprehending language messages.
Differential Diagnosis
Normal variations in Regional, social, or cultural/ethnic variations of language (e.g., dialects) must be
language considered when an individual is being assessed for language impairment
Hearing or other sensory Language Disorder - when language deficits are in excess of those usually associated
impairment with these problems
Intellectual developmental Language disorder - can occur with varying degrees of intellectual ability, and a
disorder (intellectual discrepancy between verbal and nonverbal ability is not necessary for a diagnosis of
disability) language disorder
Autism spectrum disorder accompanied by behaviors not present in language disorder, such as lack of social
interest or unusual social interactions, odd play patterns, unusual communication
patterns, and rigid adherence to routines and repetitive behaviors
Neurological disorders can be acquired in association with neurological disorders, including epilepsy
Language regression Loss of speech and language in a child at any age warrants thorough assessment to
determine if there is a specific neurological condition
Comorbidity:
- specific learning disorder (literacy and numeracy)
- intellectual developmental disorder
- attentiondeficit/hyperactivity disorder
- autism spectrum disorder
- developmental coordination disorder
- social (pragmatic) communication disorder
- speech sound disorder
- major neurocognitive disorder
Speech Sound Disorder
Criteria:
A. Persistent difficulty with speech sound production that interferes with speech intelligibility or prevents verbal
communication of messages.
B. disturbance causes limitations in effective communication that interfere with social participation, academic
achievement, or occupational performance, individually or in any combination.
C. Onset of symptoms is in the early developmental period.
D. The difficulties are not attributable to congenital or acquired conditions, such as cerebral palsy, cleft palate,
deafness or hearing loss, traumatic brain injury, or other medical or neurological conditions.

Speech sound production describes the clear articulation of the phonemes (individual sounds) that in combination make
up spoken words. It requires both the phonological knowledge of speech sounds and the ability to coordinate the
movements of the articulators (i.e., the jaw, tongue, and lips,) with breathing and vocalizing for speech
Differential Diagnosis
Normal variations in speech Regional, social, or cultural/ethnic variations of speech should be considered before
making the diagnosis.
Bilingual children may demonstrate lower intelligibility rating, make more consonant
and vowel errors, and produce more uncommon error patterns than monolingual
English-speaking children when assessed only in English.
Hearing or other sensory when speech deficits are in excess of those usually associated with these problems, a
impairment diagnosis of speech sound disorder may be made.
Structural deficits Speech impairment may be due to structural deficits (e.g., cleft palate)
Dysarthria Speech impairment may be attributable to a motor disorder, such as cerebral palsy. Has
neurological signs, as well as distinctive features of voice
Selective mutism exhibit normal speech in “safe” settings, such as at home or with close friends
Comorbidity:
- Language disorder
- developmental coordination disorder
Childhood-Onset Fluency Disorder (Stuttering)
Criteria:
A. Disturbances in the normal fluency and time patterning of speech that are inappropriate for the individual’s age
and language skills, persist over time, and are characterized by frequent and marked occurrences of one (or more)
of the following:
1. Sound and syllable repetitions.
2. Sound prolongations of consonants as well as vowels.
3. Broken words (e.g., pauses within a word).
4. Audible or silent blocking (filled or unfilled pauses in speech).
5. Circumlocutions (word substitutions to avoid problematic words).
6. Words produced with an excess of physical tension.
7. Monosyllabic whole-word repetitions (e.g., “I-I-I-I see him”).
B. disturbance causes anxiety about speaking or limitations in effective communication, social participation, or
academic or occupational performance, individually or in any combination.
C. onset of symptoms is in the early developmental period.
D. not attributable to a speech-motor or sensory deficit, dysfluency associated with neurological insult or another
medical condition and is not better explained by another mental disorder.
Differential Diagnosis
Sensory deficits When the speech dysfluencies are in excess of those usually associated with these
problems, a diagnosis of childhood-onset fluency disorder may be made.
Normal speech dysfluencies If difficulties increase in frequency or complexity as the child grows older, a diagnosis
of childhood-onset fluency disorder may be appropriate
Specific learning disorder, with Oral reading fluency typically is measured by timed assessments. Slower reading rates
impairment in reading may not accurately reflect the actual reading ability of children who stutter.
Bilingualism attempts to learn a new language, dysfluencies that indicate a fluency disorder, which
typically appear in both languages
Medication side effects Stuttering may occur as a side effect of medication and may be detected by a temporal
relationship with exposure to the medication
Adult-onset dysfluencies If onset of dysfluencies is during or after adolescence
Tourette’s disorder Vocal tics and repetitive vocalizations of Tourette’s disorder should be distinguishable
from the repetitive sounds of childhood-onset fluency disorder by their nature and
timing.
Comorbidity:
- attention deficit/hyperactivity disorder
- autism spectrum disorder
- intellectual developmental disorder (intellectual disability)
- language disorder or specific learning disorder
- seizure disorders
- social anxiety disorder
- speech sound disorder
Social (Pragmatic) Communication Disorder
Criteria:
A. Persistent difficulties in the social use of verbal and nonverbal communication as manifested by all of the
following:
1. Deficits in using communication for social purposes
2. Impairment of the ability to change communication to match context
3. Difficulties following rules for conversation
4. Difficulties understanding what is not explicitly stated
B. deficits result in functional limitations in effective communication, social participation, social relationships,
academic achievement, or occupational performance, individually or in combination.
C. The onset of the symptoms is in the early developmental period
D. not attributable to another medical or neurological condition or to low abilities in language domains and are not
better explained by autism spectrum disorder, intellectual developmental disorder, global developmental delay,
or another mental disorder.
Differential Diagnosis
Autism spectrum disorder restricted/repetitive patterns of behavior, interests, or activities and their absence in
social (pragmatic) communication disorder
social communication symptoms may be milder in social (pragmatic) communication
disorder than in autism spectrum disorder,
Attention-deficit/hyperactivity If difficulties increase in frequency or complexity as the child grows older, a diagnosis
disorder of childhood-onset fluency disorder may be appropriate
Specific learning disorder, Oral reading fluency typically is measured by timed assessments. Slower reading rates
with impairment in reading may not accurately reflect the actual reading ability of children who stutter.
Bilingualism attempts to learn a new language, dysfluencies that indicate a fluency disorder, which
typically appear in both languages
Medication side effects Stuttering may occur as a side effect of medication and may be detected by a temporal
relationship with exposure to the medication
Adult-onset dysfluencies If onset of dysfluencies is during or after adolescence
Tourette’s disorder Vocal tics and repetitive vocalizations of Tourette’s disorder should be distinguishable
from the repetitive sounds of childhood-onset fluency disorder by their nature and
timing.
Comorbidity:
- attention deficit/hyperactivity disorder
- autism spectrum disorder
- intellectual developmental disorder (intellectual disability)
- language disorder or specific learning disorder
- seizure disorders
- social anxiety disorder
- speech sound disorder
Autism Spectrum Disorder
Criteria:
A. Persistent deficits in social communication and social interaction across multiple contexts, as manifested by all of
the following:
1. Deficits in social-emotional reciprocity
2. Deficits in nonverbal communicative behaviors
3. Deficits in developing, maintaining, and understanding relationships
B. Restricted, repetitive patterns of behavior, interests, or activities, as manifested by at least two of the following:
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
4. Hyper- or hyporeactivity to sensory input
C. must be present in the early developmental period
D. cause clinically significant impairment in social, occupational, or other important areas of current functioning.
E. These disturbances are not better explained by intellectual disability or global developmental delay
Differential Diagnosis
ADHD ADHD - developmental course and absence of restricted, repetitive behaviors and unusual interests
intellectual when social communication and interaction are significantly impaired relative to the developmental
disability without level of the individual’s nonverbal skills
autism spectrum IDD - is the appropriate diagnosis when there is no apparent discrepancy between the level of
disorder social communicative skills and other intellectual skills.
Language disorders Not specific language disorder - not usually associated with abnormal nonverbal communication,
and social nor with the presence of restricted, repetitive patterns of behavior, interests, or activities
(pragmatic) social (pragmatic) communication disorder - shows impairment in social communication and
communication social interactions but does not show restricted and repetitive behavior or interests
disorder autism spectrum disorder - criteria are met, and care should be taken to enquire carefully
regarding past or current restricted/repetitive behavior
Selective mutism early development is not typically disturbed
exhibits appropriate communication skills in certain contexts and settings
social reciprocity is not impaired, nor are restricted or repetitive patterns of behavior present.
Stereotypic not - repetitive behaviors are better explained by the presence of ASD
movement disorder stereotypies cause self-injury and become a focus of treatment, both may be diagnosed
Rett syndrome improve their social communication skills, and autistic features are no longer a major area of
concern
Symptoms social withdrawal and repetitive behaviors are core features of autism spectrum disorder but may
associated with also be expressions of anxiety.
anxiety disorders
OCD OCD - intrusive thoughts related to contamination, organization, sexual, religious themes and
compulsions are performed in response to these in attempts to relieve anxiety.
ASD - repetitive behaviors classically include more stereotyped motor behaviors or more complex
behaviors, such as insistence on routines, repetitive behaviors may be perceived as pleasurable and
reinforcing
Schizophrenia Hallucinations and delusions are not features
Personality ASD - early developmental course (lack of imaginative play, restricted/repetitive behavior, sensory
disorders sensitivities)
Comorbidity:
- intellectual developmental disorder
- language disorder
- Specific learning difficulties
- developmental coordination disorder
- autism spectrum disorder
- Anxiety disorders, Depression
- ADHD
- Avoidant/restrictive food intake disorder
- epilepsy and constipation
Attention-Deficit/Hyperactivity Disorder
Criteria:
A. persistent pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning:
1. Inattention: Six (or more) of the following symptoms, persisted for at least 6 months
- For older adolescents and adults (age 17 and older), at least five symptoms are required.
a. fails to give close attention to details
b. difficulty sustaining attention
c. does not seem to listen when spoken to directly
d. does not follow instructions
e. difficulty organizing
f. avoids, dislikes, or is reluctant to engage in tasks that require sustained mental
g. loses things
h. easily distracted
i. forgetful
2. Hyperactivity and impulsivity: Six (or more) of the following symptoms, persisted for at least 6 months
- For older adolescents and adults (age 17 and older), at least five symptoms are required
a. fidgets
b. leaves seat in situations when remaining seated is expected
c. runs or climbs in situations where it is inappropriate
d. unable to play or engage in leisure activities quietly
e. often “on the go,” acting as if “driven by a motor”
f. talks excessively.
g. blurts out an answer before a question has been completed
h. difficulty waiting his or her turn
i. interrupts or intrudes on others
B. Several symptoms were present prior to age 12 years.
C. present in two or more settings
D. symptoms interfere with, or reduce the quality of, social, academic, or occupational functioning
E. do not occur exclusively during the course of schizophrenia or another psychotic disorder and are not better
explained by another mental disorder

Specify whether:
Combined presentation: If both Criterion A1 (inattention) and Criterion A2 (hyperactivity-impulsivity) are met for the
past 6 months.
Predominantly inattentive presentation: If Criterion A1 (inattention) is met but Criterion A2 (hyperactivity-
impulsivity) is not met for the past 6 months.
Predominantly hyperactive/impulsive presentation: If Criterion A2 (hyperactivity-impulsivity) is met and Criterion A1
(inattention) is not met for the past 6 months.
Differential Diagnosis
Oppositional ODD - may resist tasks that require self-application because they resist conforming to others'
defiant disorder demands, behavior is characterized by negativity, hostility, and defiance.
ADHD - aversion to mentally demanding tasks because of difficulty in sustaining mental effort,
forgetting instructions, and impulsivity
Intermittent IED - show serious aggression toward others and do not experience problems with sustaining
explosive disorder attention → rare in childhood
Other stereotypic movement disorder - the motoric behavior is generally fixed and repetitive
neurodevelopmental ADHD - fidgetiness and restlessness are typically generalized and not characterized by repetitive
disorders stereotypic movements
Tourette’s - observation is needed to differentiate fidgetiness from bouts of multiple tics
Specific learning inattention is much reduced when performing a skill that does not require the impaired cognitive
disorder process
intellectual symptoms are not evident during nonacademic tasks
disability ADHD in intellectual developmental disorder requires that inattention or hyperactivity be
excessive for mental age
Autism spectrum ADHD - social dysfunction and peer rejection, misbehave or have a tantrum during a major
disorder transition because of impulsivity or poor self-control
ASD - social disengagement, isolation, and indifference to facial and tonal communication cues,
display tantrums because of an inability to tolerate a change from their expected course of events.
Reactive attachment display other features such as a lack of enduring relationships that are not characteristic of ADHD
disorder
Anxiety disorders ADHD - inattentive → preferential engagement with novel and stimulating activities or
preoccupation, not associated with worry and rumination
 Anxiety disorders - inattention → attributable to worry and rumination, restlessness
PTSD comprehensive assessment of past exposure to traumatic events can rule out PTSD
Depressive poor concentration in mood disorders becomes prominent only during a depressive episode
disorders
Bipolar disorder Bipolar - features are episodic, increased impulsivity or inattention is accompanied by elevated
mood, grandiosity, and other specific bipolar features, rare in preadolescents
ADHD - symptoms are persistent, show significant changes in mood within the same day; such
lability is distinct from a manic or hypomanic episode
Disruptive mood characterized by pervasive irritability, and intolerance of frustration, but impulsiveness and
dysregulation disorganized attention are not essential features
disorder
Substance use Clear evidence of ADHD before substance misuse from informants or previous records may be
disorders essential for differential diagnosis
Personality ADHD is not characterized by fear of abandonment, self-injury, extreme ambivalence, or other
disorders features of personality disorder
Psychotic disorders ADHD is not diagnosed if the symptoms of inattention and hyperactivity occur exclusively during
the course of a psychotic disorder
Medication-induced attributable to the use of medication
symptoms of
ADHD
Neurocognitive must represent a decline from a previous level of performance in order to justify a diagnosis of
disorders major or mild neurocognitive disorder
ADHD - must have been present prior to age 12 and does not represent a decline from previous
functioning
Comorbidity:
- oppositional defiant disorder
- autism spectrum disorder
- personality and substance use disorders
- conduct disorder
- disruptive mood dysregulation disorder
- anxiety disorders
- major depressive disorder
- obsessive-compulsive disorder
- intermittent explosive disorder
- neurodevelopmental disorders, including specific learning disorder, autism spectrum disorder, intellectual
developmental disorder, language disorders, developmental coordination disorder, and tic disorders
- sleep disorders
Specific Learning Disorder
Criteria:
A. Difficulties learning and using academic skills at least one of the following symptoms, persisted for at least 6
months, despite the provision of interventions that target those difficulties:
1. Inaccurate or slow and effortful word reading
2. Difficulty understanding the meaning of what is read
3. Difficulties with spelling
4. Difficulties with written expression
5. Difficulties mastering number sense, number facts, or calculation
6. Difficulties with mathematical reasoning
B. affected academic skills are substantially and quantifiably below those expected for the individual’s
chronological age, and cause significant interference with academic or occupational performance, or with
activities of daily living
C. begin during school-age years
D. learning difficulties are not better accounted for by intellectual disabilities, uncorrected visual or auditory acuity,
other mental or neurological disorders, psychosocial adversity, lack of proficiency in the language of academic
instruction, or inadequate educational instruction.
Differential Diagnosis
Normal variations in academic learning difficulties persist in the presence of adequate educational opportunity and
attainment exposure to the same instruction as the peer group, and competency in the language of
instruction, even when it is different from one’s primary spoken language
intellectual disability SLD - learning difficulties occur in the presence of normal levels of intellectual
functioning, learning difficulties are in excess of those usually associated with the
intellectual developmental disorder.
Learning difficulties due to there are abnormal findings on neurological examination
neurological or sensory
disorders
Neurocognitive disorders SLD - occurs during the developmental period, only becomes evident when learning
demands exceed the individual’s limited capacities and the difficulties do not manifest
as a marked decline from a former state.
ADHD not necessarily reflect specific difficulties in learning academic skills but rather may
reflect difficulties in performing those skills.
Psychotic disorders there is a decline (often rapid) in these functional domains
Comorbidity:
- neurodevelopmental disorders (ADHD, communication disorders, developmental coordination disorder, autism
spectrum disorder)
- anxiety and depressive disorders
- behavioral problems
Motor Disorders
Developmental Coordination Disorder
Criteria:
A. acquisition and execution of coordinated motor skills is substantially below that expected given the individual’s
chronological age and opportunity for skill learning and use. Difficulties are manifested as clumsiness as well as
slowness and inaccuracy of performance of motor skills
B. significantly and persistently interferes with activities of daily living appropriate to chronological age
C. Onset of symptoms is in the early developmental period.
D. The motor skills deficits are not better explained by intellectual developmental disorder (intellectual disability)
or visual impairment and are not attributable to a neurological condition affecting movement
Differential Diagnosis
Motor impairments due to may be associated with visual function impairment and specific neurological disorders,
another medical condition there are additional findings on neurological examination
intellectual disability DCD - if the motor difficulties are in excess of what could be accounted for by the
intellectual developmental disorder
ADHD if lack of motor competence is attributable to distractibility and impulsiveness rather
than to developmental coordination disorder
Autism spectrum disorder may be uninterested in participating in tasks requiring complex coordination skills,
which will affect test performance and function but not reflect core motor competence
Joint hypermobility syndrome syndromes causing hyperextensible joints (found on physical examination; often with a
complaint of pain)
Comorbidity:
- communication disorders
- specific learning disorder (especially reading and writing)
- problems of inattention, including ADHD
- autism spectrum disorder
- disruptive and emotional behavior problems
- joint hypermobility syndrome.
Stereotypic Movement Disorder
Criteria:
A. Repetitive, seemingly driven, and apparently purposeless motor behavior
B. interferes with social, academic, or other activities and may result in self-injury
C. Onset is in the early developmental period.
D. not attributable to the physiological effects of a substance or neurological condition and is not better explained
by another neurodevelopmental or mental disorder
Specify if:
• With self-injurious behavior (or behavior that would result in an injury if preventive measures were not used)
• Without self-injurious behavior

Specify current severity:

• Mild: Symptoms are easily suppressed by sensory stimulus or distraction.
• Moderate: Symptoms require explicit protective measures and behavioral modification.
• Severe: Continuous monitoring and protective measures are required to prevent serious injury.
Differential Diagnosis
Normal development individual’s daily routine is rarely affected and the movements generally do not cause the child
distress
Autism spectrum SMD - Absence of deficits of social communication and reciprocity, when there is self-injury or
disorder when the stereotypic behaviors are sufficiently severe to become a focus of treatment.
Tic disorders SMD - earlier age at onset (before 3 years), consistent and fixed in their pattern or topography,
may involve arms, hands, or the entire body, more fixed, rhythmic, and prolonged in duration,
ego-syntonic (children enjoy them)
Tics - mean age at onset of 4–6 years, typically changing in character over time, involve eyes,
face, head, and shoulders, are brief, rapid, random, and fluctuating, ego-dystonic
OCD and related OCD - driven to perform repetitive behaviors in response to an obsession or according to rules
disorders that must be applied rigidly
SMD - behaviors are seemingly driven but apparently purposeless
Trichotillomania and excoriation disorder - body-focused repetitive behaviors that may be
seemingly driven but not apparently purposeless, and may not be patterned or rhythmical
Other neurological SMD - requires the exclusion of habits, mannerisms, paroxysmal dyskinesias, and benign
and medical hereditary chorea
conditions Neuro conditions - do not result in self-injury
Substance-induced not appropriate for repetitive skin picking or scratching associated with amphetamine
repetitive behaviors intoxication or abuse → diagnosis of substance/medication-induced obsessive-compulsive and
related disorder
Functional Sudden onset, distractibility, changing pattern with unexplained improvement or aggravation,
(conversion) and the coexistence of other symptoms of functional neurological symptom disorder (conversion
stereotypies disorder)
Comorbidity:
- chronic motor stereotypies
- attention-deficit hyperactivity disorder
- motor coordination problems
- tics/Tourette’s disorder
- anxiety
Tic Disorders - sudden, rapid, recurrent, nonrhythmic motor movement or vocalization
Tourette’s Disorder
A. Both multiple motor and one or more vocal tics have been present at some time during the illness
B. tics may wax and wane in frequency persisted for more than 1 year since first tic onset
C. Onset is before age 18 years
D. not attributable to the physiological effects of a substance or another medical condition
Persistent (Chronic) Motor or Vocal Tic Disorder
A. Single or multiple motor or vocal tics have been present during the illness, but not both motor and vocal.
B. may wax and wane in frequency but persisted for more than 1 year since first tic onset
C. Onset is before age 18 years.
D. Not attributable to the physiological effects of a substance or another medical condition
E. Criteria have never been met for Tourette’s disorder.
Specify if:
With motor tics only
With vocal tics only
Provisional Tic Disorder
A. Single or multiple motor and/or vocal tics
B. tics have been present for less than 1 year since first tic onset
C. Onset is before age 18 years
D. not attributable to the physiological effects of a substance or another medical condition
E. Criteria have never been met for Tourette’s disorder or persistent (chronic) motor or vocal tic disorder.
Differential Diagnosis
Abnormal Motor stereotypies - earlier age at onset (often younger than 3 years), prolonged duration
movements that may (seconds to minutes), being repetitive and rhythmic in form and location, lacking a premonitory
accompany other sensation or urge, and cessation with distraction
medical conditions, Chorea - timing, direction, and distribution of movements vary from moment to moment, and
including other movements usually worsen during attempted voluntary action
movement disorders Dystonia - simultaneous sustained contraction of both agonist and antagonist muscles, resulting
in a distorted posture or movement of parts of the body, triggered by attempts at voluntary
movements and are not seen during sleep.
Paroxysmal episodic involuntary dystonic or choreoathetoid movements that are precipitated by voluntary
dyskinesias movement or exertion and less commonly arise from normal background activity.
Myoclonus rapidity, lack of suppressibility, and absence of a premonitory sensation or urge
OCD and related OCD - compulsions are aimed at preventing or reducing anxiety or distress and are usually
disorders performed in response to an obsession
Tic - feel the need to perform the action in a particular fashion, equally on both sides of the body
a certain number of times or until a “just right” feeling is achieved
Body-focused repetitive behavior disorder - more goal-directed and complex
Functional tic presents with “tic attacks” that can go on for extended periods of time lasting from 15 minutes to
disorder several hours
Comorbidity:
- ADHD
- disruptive behavior
- OCD and related disorder
- movement disorders (e.g., Sydenham’s chorea, stereotypic movement disorder)
- autism spectrum disorder and specific learning disorder
- increased risk for developing a mood, anxiety, or substance use disorder
Other Specified
- presentations in which symptoms characteristic of a disorder predominate but do not meet the full criteria
- cause clinically significant distress or impairment in social, occupational, or other important areas of
functioning.
- used in situations in which the clinician chooses to communicate the specific reason that the presentation does
not meet the criteria for a specific neurodevelopmental disorder.
Unspecified
- presentations in which symptoms characteristic of a disorder predominate but do not meet the full criteria
- cause clinically significant distress or impairment in social, occupational, or other important areas of
functioning.
- used in situations in which the clinician chooses not to specify the reason that the criteria are not met for a
specific neurodevelopmental disorder and includes presentations in which there is insufficient information to
make a more specific diagnosis.
 Disruptive, Impulse-Control, and Conduct Disorders
- Patterns in self-control of emotions and behavior
- Violates rights of others
- Conflicts with societal norms/ authority figures
Oppositional Defiant Disorder
Criteria:
- 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 his or her mistakes or misbehavior.
Vindictiveness
8. Has been spiteful or vindictive at least twice within the past 6 months.
- distress in the individual or others in his or her immediate social context or it impacts negatively on social,
educational, occupational, or other important areas of functioning.
- do not occur exclusively during the course of a psychotic, substance use, depressive, or bipolar disorder
- criteria are not met for disruptive mood dysregulation disorder
Specify current severity:
Mild: Symptoms are confined to only one setting (e.g., at home, at school, at work, with peers).
Moderate: Some symptoms are present in at least two settings.
Severe: Some symptoms are present in three or more settings.
Differential Diagnosis
Conduct disorder ODD - less severe nature than those of conduct disorder
- do not include aggression toward people or animals, destruction of property, or a
pattern of theft or deceit
includes problems of emotion dysregulation (i.e., angry and irritable mood) → not included in
conduct disorder
Adjustment disorder Temporal association with a stressor and symptom duration of less than 6 months after the
resolution of the stressor
PTSD association with a traumatic event and with other specific symptoms (traumatic play)
ADHD ODD - individual’s failure to conform to requests of others is not solely in situations that
demand sustained effort and attention or demand that the individual sit still
Depressive and bipolar ODD should not be made if the symptoms occur exclusively during the course of a mood
disorders disorder
Disruptive mood if the irritable mood and other symptoms meet criteria for DMDD, a diagnosis of ODD is not
dysregulation disorder given, even if all criteria for ODD are met
*DMDD can have ODD
Intermittent explosive involves high rates of anger, show serious aggression toward others → not part of ODD
disorder
Intellectual ODD - if the oppositional behavior is markedly greater than is commonly observed among
developmental disorder individuals of comparable mental age and with comparable severity of intellectual disability
(intellectual disability)
Language disorder failure to follow directions that is the result of impaired language comprehension (e.g., hearing
loss)
Social anxiety disorder fear of negative evaluation
Comorbidity:
- ADHD, conduct disorder
- anxiety disorders and major depressive disorder
- disruptive mood dysregulation disorder
- higher rate of substance use disorders
Conduct Disorder
Criteria:
 - 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 (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.
- causes clinically significant impairment in social, academic, or occupational functioning.
- individual is age 18 years or older, criteria are not met for antisocial personality disorder.

Specify whether:
Childhood-onset type: Individuals show at least one symptom characteristic of conduct disorder prior to age 10 years.
Adolescent-onset type: Individuals show no symptom characteristic of conduct disorder prior to age 10 years.
Unspecified onset: Criteria for a diagnosis of conduct disorder are met, but there is not enough information available to
determine whether the onset of the first symptom was before or after age 10 years.

Lack of remorse or guilt: Does not feel bad or guilty when he or she does something wrong, general lack of concern
about the negative consequences of his or her actions.
Callous—lack of empathy: Disregards and is unconcerned about the feelings of others. described as cold and uncaring.
appears more concerned about the effects of his or her actions on himself or herself, rather than their effects on others,
even when they result in substantial harm to others.
Unconcerned about performance: Does not show concern about poor/problematic performance at school, at work, or in
other important activities. The individual does not put forth the effort necessary to perform well, even when expectations
are clear, and typically blames others for his or her poor performance.
Shallow or deficient affect: Does not express feelings or show emotions to others, except in ways that seem shallow,
insincere, or superficial (e.g., actions contradict the emotion displayed; can turn emotions “on” or “off” quickly) or when
emotional expressions are used for gain (e.g., emotions displayed to manipulate or intimidate others).

Differential Diagnosis
Oppositional defiant - less severe nature than those of individuals with conduct disorder and do not include
disorder aggression toward people or animals, destruction of property, or a pattern of theft or
deceit.
*When criteria are met, both diagnoses can be given
ADHD does not by itself violate societal norms or the rights of others and therefore does not usually
meet criteria for conduct disorder
*When criteria are met, both diagnoses can be given
Depressive and bipolar conduct disorder - will display substantial levels of aggressive or nonaggressive conduct
disorders problems during periods in which there is no mood disturbance, either historically or
concurrently
*When criteria are met, both diagnoses can be given
Intermittent explosive IED is limited to impulsive aggression and is not premeditated, and it is not committed in
disorder order to achieve some tangible objective
- does not include the non-aggressive symptoms of conduct disorder
Adjustment disorders should be considered if clinically significant conduct problems that do not meet the criteria
for another specific disorder develop in clear association with the onset of a psychosocial
stressor and do not resolve within 6 months of the termination of the stressor (or its
consequences).
Comorbidity:
- ADHD
- oppositional defiant
- antisocial personality disorder
- anxiety disorders, depressive or bipolar disorders, and substance-related disorders
- specific learning disorder or communication disorder

Pyromania
Criteria:
- Deliberate and purposeful fire setting on more than one occasion.
- Tension or affective arousal before the act.
- Fascination with, interest in, curiosity about, or attraction to fire and its situational contexts (e.g., paraphernalia,
uses, consequences).
- Pleasure, gratification, or relief when setting fires or when witnessing or participating in their aftermath.
- 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 (e.g., in major neurocognitive disorder, intellectual developmental disorder
[intellectual disability], substance intoxication).
- not better explained by conduct disorder, a manic episode, or antisocial personality disorder.

Differential Diagnosis
Other causes of intentional Intentional fire setting may occur for profit, sabotage, or revenge; to conceal a crime; to
fire setting make a political statement (e.g., an act of terrorism or protest); or to attract attention or
recognition (e.g., setting a fire in order to discover it and save the day)
OCD kleptomania – satisfaction, OCD – reducing anxiety
Other mental disorders - when fire setting occurs as part of conduct disorder, a manic episode, or antisocial
personality disorder, or if it occurs in response to a delusion or a hallucination (e.g., in
schizophrenia) or is attributable to the physiological effects of another medical condition
(e.g., epilepsy).
- results from impaired judgment associated with major neurocognitive disorder, intellectual
developmental disorder, or substance intoxication
Comorbidity:
- substance use disorders
- gambling disorder
- depressive and bipolar disorders
- other disruptive, impulse-control, and conduct disorders with pyromania.

Kleptomania
Criteria:
- Recurrent failure to resist impulses to steal objects that are not needed for personal use or for their monetary value.
- Increasing sense of tension immediately before committing the theft.
- Pleasure, gratification, or relief at the time of committing the theft.
- The stealing is not committed to express anger or vengeance and is not in response to a delusion or a hallucination.
 - not better explained by conduct disorder, a manic episode, or antisocial personality disorder.

Differential Diagnosis
Ordinary theft is deliberate and is motivated by the usefulness of the object or its monetary worth
Malingering individuals may simulate the symptoms of kleptomania to avoid criminal prosecution
Antisocial personality general pattern of antisocial behavior
disorder and conduct disorder
Manic episodes, psychotic intentional or inadvertent stealing that may occur during a manic episode, in response to
episodes, and major delusions or hallucinations (e.g., in schizophrenia), or as a result of a major
neurocognitive disorder neurocognitive disorder.
Comorbidity:
- compulsive buying
- depressive and bipolar disorders (especially major depressive disorder)
- anxiety disorders
- eating disorders (particularly bulimia nervosa)
- personality disorders
- substance use disorders (especially alcohol use disorder)
- other disruptive, impulse-control, and conduct disorders

Personality Disorders - an enduring pattern of inner experience and behavior that deviates markedly from the norms
and expectations of the individual’s culture, is pervasive and inflexible, has an onset in adolescence or early
adulthood, is stable over time, and leads to distress or impairment.
Cluster A includes paranoid, schizoid, and schizotypal personality disorders. Individuals with these disorders often
appear odd or eccentric.
Cluster B includes antisocial, borderline, histrionic, and narcissistic personality disorders. Individuals with these
disorders often appear dramatic, emotional, or erratic.
Cluster C includes avoidant, dependent, and obsessive-compulsive personality disorders. Individuals with these
disorders often appear anxious or fearful.
General Personality Disorder
Criteria:
- An enduring pattern of inner experience and behavior that deviates markedly from the expectations of the
individual’s culture. This pattern is manifested in two (or more) of the following areas:
1. Cognition (i.e., ways of perceiving and interpreting self, other people, and events).
2. Affectivity (i.e., the range, intensity, lability, and appropriateness of emotional response).
3. Interpersonal functioning.
4. Impulse control.
- inflexible and pervasive across a broad range of personal and social situations.
- distress or impairment in social, occupational, or other important areas of functioning.
- pattern is stable and of long duration, and its onset can be traced back at least to adolescence or early
adulthood.
- not better explained as a manifestation or consequence of another mental disorder.
- not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another
medical condition (e.g., head trauma).
Differential Diagnosis
Other mental disorders and GPD - defining characteristics appeared before early adulthood, are typical of the
personality traits. individual’s long-term functioning, and do not occur exclusively during an
episode of another mental disorder
- personality traits that do not reach threshold for a personality disorder
*Personality traits are diagnosed as a personality disorder only when they are
inflexible, maladaptive, and persisting and cause significant functional
impairment or subjective distress.
Psychotic disorders GPD - pattern of behavior does not occurred exclusively during the course of
schizophrenia, a bipolar or depressive disorder with psychotic features, or another
psychotic disorder.
Anxiety and depressive disorders
Posttraumatic stress disorder PTSD - When personality changes emerge and persist after an individual has been
exposed to extreme stress
Substance use disorders not to make a personality disorder diagnosis based solely on behaviors that are
consequences of substance intoxication or withdrawal or that are associated with
activities in the service of sustaining substance use
Personality change due to another enduring changes in personality arise as a result of the physiological effects of
medical condition another medical condition

Cluster A Personality Disorders

Paranoid Personality Disorder
Criteria:
- 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 him or her
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 him or her.
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.
- 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.
Differential Diagnosis
Other mental disorders characterized by a period of persistent psychotic symptoms (e.g., delusions and
and personality traits. hallucinations)
PPD – additionally, if the personality disorder must have been present before the onset of
psychotic symptoms and must persist when the psychotic symptoms are in remission.
Personality change due traits that emerge are a direct physiological consequence of another medical condition
to another medical
condition
Substance use disorders symptoms that may develop in association with persistent substance use
Other personality schizotypal personality disorder - includes symptoms such as magical thinking, unusual
disorders and perceptual experiences, and odd thinking and speech. do not have prominent paranoid
personality traits ideation
borderline personality disorder - exhibits higher levels of impulsivity and self-destructive
behavior
avoidant personality disorder - fear of being embarrassed or found inadequate than from fear
of others’ malicious intent
antisocial personality disorder - not usually motivated by a desire for personal gain or to
exploit others but rather is more often attributable to a desire for revenge
narcissistic personality disorder - derives primarily from fears of having their imperfections
or flaws revealed
*if an individual has personality features that meet criteria for one or more personality
disorders in addition to paranoid personality disorder, all can be diagnosed.
Paranoid traits paranoid traits associated with the development of physical handicaps (e.g., a hearing
associated with impairment)
physical handicaps
Comorbidity:
- Brief psychotic episodes (lasting minutes to hours)
- Premorbid antecedent of delusional disorder or schizophrenia
- Major depressive disorder, agoraphobia, and obsessive-compulsive disorder.
- Alcohol and other substance use disorders
- most common co-occurring personality disorders → schizotypal, schizoid, narcissistic, avoidant, and
borderline.

Schizoid Personality Disorder

Criteria:
- 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.
- 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.
Differential Diagnosis
Other mental disorders and characterized by a period of persistent psychotic symptoms (e.g., delusions and
personality traits. hallucinations)
Schizoid personality disorder – additionally, if the personality disorder must have
been present before the onset of psychotic symptoms and must persist when the
psychotic symptoms are in remission.
Autism spectrum disorder autism spectrum disorder - may be differentiated by stereotyped behaviors and
interests
Personality change due to another traits that emerge are a direct physiological consequence of another medical
medical condition condition
Substance use disorders symptoms that may develop in association with persistent substance use
Other personality disorders and schizotypal personality disorder - with cognitive and perceptual distortions
personality traits paranoid personality disorder - with suspiciousness and paranoid ideation
avoidant personality disorder - fear of being embarrassed or found inadequate and
excessive anticipation of rejection
obsessive-compulsive personality disorder - show apparent social detachment
stemming from devotion to work and discomfort with emotions, but they do have
an underlying capacity for intimacy
 *if an individual has personality features that meet criteria for one or more
personality disorders in addition to schizoid personality disorder, all can be
diagnosed
Comorbidity:
- Brief psychotic episodes (lasting minutes to hours)
- Premorbid antecedent of delusional disorder or schizophrenia
- Major depressive disorder
- Co-occurs with schizotypal, paranoid, and avoidant personality disorders.

Schizotypal Personality Disorder

Criteria:
- 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.
- 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.
Differential Diagnosis
Other mental characterized by a period of persistent psychotic symptoms (e.g., delusions and hallucinations)
disorders and schizotypal personality disorder – additionally, if the personality disorder must have been
personality traits. present before the onset of psychotic symptoms and must persist when the psychotic symptoms
are in remission.
Neurodevelopmental communication disorders - primacy and severity of the disorder in language and by the
disorders characteristic features of impaired language found in a specialized language assessment
autism spectrum disorder - lack of social awareness and emotional reciprocity and stereotyped
behaviors and interests.
Personality change traits that emerge are a direct physiological consequence of another medical condition
due to another
medical condition
Substance use symptoms that may develop in association with persistent substance use
disorders
Other personality avoidant personality disorder - an active desire for relationships is constrained by a fear of
disorders and rejection
personality traits schizotypal personality disorder - lack of desire for relationships and persistent detachment

narcissistic personality disorder - may also display suspiciousness, social withdrawal, or

alienation, derive primarily from fears of having imperfections or flaws revealed.

borderline personality disorder - have transient, psychotic-like symptoms, but are more closely
related to affective shifts in response to stress (e.g., intense anger, anxiety, disappointment) and
are usually more dissociative (e.g., derealization, depersonalization).
schizotypal personality disorder - more likely to have enduring psychotic-like symptoms that
may worsen under stress but are less likely to be invariably associated with pronounced
affective symptoms

*if an individual has personality features that meet criteria for one or more personality
disorders in addition to schizotypal personality disorder, all can be diagnosed
Comorbidity
- Transient psychotic episodes (lasting minutes to hours)
- co-occurrence with schizoid, paranoid, avoidant, and borderline personality disorders.

Cluster B Personality Disorders

Antisocial Personality Disorder
Criteria:
- 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.
- at least age 18 years.
- There is evidence of conduct disorder with onset before age 15 years.
- not exclusively during the course of schizophrenia or bipolar disorder.
Differential Diagnosis
Conduct disorder APD - not given if younger than 18 years and is given only if there is evidence of conduct disorder
before age 15 years.
Conduct disorder - older than 18 years and if the criteria for antisocial personality disorder are not
met.
Substance use antisocial personality disorder - is not made unless the signs of antisocial personality disorder were
disorders also present in childhood and have continued into adulthood

both – if began in childhood and continued into adulthood and if the criteria for both are met, even
though some antisocial acts may be a consequence of the substance use disorder
Other personality narcissistic personality disorder - not include characteristics of impulsivity, aggression, and deceit.
disorders and usually lack the history of conduct disorder in childhood or criminal behavior in adulthood.
personality traits antisocial personality disorder - may not be as needy of the admiration and envy of others

histrionic personality disorder - more exaggerated in their emotions and do not characteristically
engage in antisocial behaviors

histrionic and borderline personality disorders - manipulative to gain nurturance

antisocial personality disorder - manipulative to gain profit, power, or some other material
gratification. less emotionally unstable and more aggressive than those with borderline personality
disorder

*if an individual has personality features that meet criteria for one or more personality disorders in
addition to antisocial personality disorder, all can be diagnosed.
Criminal criminal behavior undertaken for gain that is not accompanied by the personality features
behavior not characteristic of this disorder
associated with a
mental disorder
Schizophrenia Antisocial behavior that occurs exclusively during the course of schizophrenia or a bipolar disorder
and bipolar should not be diagnosed as antisocial personality disorder
disorders
Comorbidity:
- Dysphoria, including complaints of tension, inability to tolerate boredom, and depressed mood
- anxiety disorders, mood disorders, substance use disorders, somatic symptom disorder, and gambling disorder
- personality features that meet criteria for other personality disorders, particularly borderline, histrionic, and
narcissistic personality disorders.
- accompanying attention-deficit/hyperactivity disorder.
Borderline Personality Disorder
Criteria:
- 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. (Note: Do not include suicidal or self-mutilating
behavior covered in Criterion 5.)
2. 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). (Note: 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.
Differential Diagnosis
Depressive and bipolar *Borderline personality disorder often co-occurs with depressive or bipolar disorders, and
disorders when criteria for both are met, both should be diagnosed
Separation anxiety both - characterized by fear of abandonment by loved ones
disorder in adults borderline personality disorder - problems in identity, self-direction, interpersonal
functioning, and impulsivity
Other personality narcissistic personality disorder - not include characteristics of impulsivity, aggression, and
disorders and deceit. usually lack the history of conduct disorder in childhood or criminal behavior in
personality traits adulthood.
antisocial personality disorder - may not be as needy of the admiration and envy of others

histrionic personality disorder - more exaggerated in their emotions and do not

characteristically engage in antisocial behaviors

histrionic and borderline personality disorders - manipulative to gain nurturance

antisocial personality disorder - manipulative to gain profit, power, or some other material
gratification. less emotionally unstable and more aggressive than those with borderline
personality disorder

*if an individual has personality features that meet criteria for one or more personality
disorders in addition to borderline personality disorder, all can be diagnosed.
Criminal behavior not criminal behavior undertaken for gain that is not accompanied by the personality features
associated with a characteristic of this disorder
mental disorder
Schizophrenia and Antisocial behavior that occurs exclusively during the course of schizophrenia or a bipolar
bipolar disorders disorder should not be diagnosed as antisocial personality disorder
Comorbidity:
- Dysphoria, including complaints of tension, inability to tolerate boredom, and depressed mood
- anxiety disorders, mood disorders, substance use disorders, somatic symptom disorder, and gambling disorder
- personality features that meet criteria for other personality disorders, particularly borderline, histrionic, and
narcissistic personality disorders.
- accompanying attention-deficit/hyperactivity disorder.

Histrionic Personality Disorder

Criteria:
- 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 he or she is 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.
Differential Diagnosis
Other personality borderline personality disorder - self-destructiveness, angry disruptions in close relationships, and
disorders and chronic feelings of deep emptiness and identity disturbance
personality traits
histrionic personality disorder - manipulative to gain nurturance, tend to be more exaggerated in
their emotions and do not characteristically engage in antisocial behaviors
antisocial personality disorder - are manipulative to gain profit, power, or some other material
gratification

narcissistic personality disorder - usually want praise for their “superiority”

histrionic personality disorder - willing to be viewed as fragile or dependent if this is instrumental
in getting attention

dependent personality disorder - excessively dependent on others for praise and guidance
histrionic personality disorder - flamboyant, exaggerated, emotional features
*if an individual has personality features that meet criteria for one or more personality disorders in
addition to histrionic personality disorder, all can be diagnosed.
Personality change traits that emerge are a direct physiological consequence of another medical condition
due to another
medical condition
Substance use symptoms that may develop in association with persistent substance use
disorders
Comorbidity:
- borderline, narcissistic, paranoid, dependent, and antisocial personality disorders
- alcohol and other substance use and misuse
- aggression and violence
- somatic symptom disorder, functional neurological symptom disorder (conversion disorder)
- major depressive disorder

Narcissistic Personality Disorder

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 him or her.
9. Shows arrogant, haughty behaviors or attitudes.
Differential Diagnosis
Other (not) histrionic, antisocial, and borderline personality disorders - interactive styles are coquettish,
personality callous, and needy, respectively, is the grandiosity characteristic of narcissistic personality disorder
disorders - may require much attention
and narcissistic personality disorder – need that attention to be admiring
personality
traits (not) borderline personality disorder - relative stability of self-image and self-control as well as the
relative lack of self-destructiveness, impulsivity, separation insecurity, and emotional hyper reactivity
 (not) histrionic personality disorder - excessive pride in achievements, a relative lack of emotional
display, and ignorance of or disdain for others’ sensitivities

narcissistic personality disorder - does not include characteristics of impulsive aggressivity and
deceitfulness, lack the history of conduct disorder in childhood or criminal behavior in adulthood.
antisocial personality disorder - more indifferent and less sensitive to others’ reactions or criticism

obsessive-compulsive personality disorder - more immersed in perfectionism related to order and

rigidity
narcissistic personality disorder - set high perfectionistic standards, especially for appearance and
performance, and to be critically concerned if they are not measuring up

schizotypal, avoidant, or paranoid personality disorder - Suspiciousness and social withdrawal

narcissistic personality disorder - derive primarily from shame and fear of failure, or fear of having
imperfections or flaws revealed

*if an individual has personality features that meet criteria for one or more personality disorders in
addition to narcissistic personality disorder, all can be diagnosed.
Mania or association with mood change or functional impairments
hypomania
Substance symptoms that may develop in association with persistent substance use
use
disorders
Persistent threaten self-esteem can result to persistent negative feelings resembling those seen in persistent
depressive depressive disorder
disorder *If criteria are also met for persistent depressive disorder, both conditions can be diagnosed.
Comorbidity:
- depressive disorders (persistent depressive disorder and major depressive disorder)
- anorexia nervosa
- substance use disorders (especially related to cocaine)
- Histrionic, borderline, antisocial, and paranoid personality disorders
Cluster C Personality Disorders
Avoidant Personality Disorder
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.
Differential Diagnosis
Social anxiety disorder - avoidant personality disorder may be a more severe form of social anxiety disorder
- negative self-concept in social anxiety disorder may be unstable and less pervasive and
entrenched than in avoidant personality disorder
*avoidant personality disorder frequently occurs in the absence of social anxiety disorder
Agoraphobia motivation for the avoidance → fear of panic or physical harm in agoraphobia
Other personality avoidant personality disorder - avoidance of social, unassertiveness is described as more
disorders and closely related to fears of being rejected or humiliated
personality traits dependent personality disorder - proximity-seeking, motivated by the desire to avoid being
left to fend for oneself

avoidant personality disorder - want to have relationships with others and feel their loneliness
deeply
schizoid or schizotypal personality disorder - may be content with and even prefer their
social isolation

paranoid personality disorder - fear of others’ malicious intent

avoidant personality disorder - fear of humiliation or being found inadequate
*if an individual has personality features that meet criteria for one or more personality
disorders in addition to avoidant personality disorder, all can be diagnosed.
Personality change due traits that emerge are a direct physiological consequence of another medical condition
to another medical
condition
Substance use disorders symptoms that may develop in association with persistent substance use
Comorbidity:
- depressive disorders and anxiety disorders, especially social anxiety disorder
- schizoid personality disorder
- increased rates of substance use disorders
- generalized form of social anxiety disorder.
Dependent Personality Disorder
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 his or her life.
3. Has difficulty expressing disagreement with others because of fear of loss of support or approval. (Note: Do not
include realistic fears of retribution.)
4. Has difficulty initiating projects or doing things on his or her 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 himself or
herself.
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 himself or herself.
Differential Diagnosis
Separation Sep anx - over concerned about offspring, spouses, parents, and pets, and experience marked
anxiety discomfort when separated from them
disorder in dependent personality disorder - feel uncomfortable or helpless when alone because of exaggerated
adults fears of being unable to take care of themselves
Other mental dependency arising as a consequence of other mental disorders (e.g., depressive disorders, panic
disorders and disorder, agoraphobia) and as a result of other medical conditions.
medical
conditions
Other borderline personality disorder - reacts to abandonment with feelings of emotional emptiness, rage,
personality and demands, typical pattern of unstable and intense relationships
disorders and dependent personality disorder - reacts with increasing appeasement and submissiveness and urgently
personality seeks a replacement relationship to provide caregiving and support
traits
histrionic personality disorder - gregarious flamboyance with active demands for attention, less insight
regarding their underlying dependency needs

avoidant personality disorder - strong fear of humiliation and rejection that they withdraw until they
are certain they will be accepted
dependent personality disorder - have a pattern of seeking and maintaining connections to important
others

*if an individual has personality features that meet criteria for one or more personality disorders in
addition to dependent personality disorder, all can be diagnosed.
Personality traits that emerge are a direct physiological consequence of another medical condition
change due to
another
medical
condition
Substance use symptoms that may develop in association with persistent substance use
disorders
Comorbidity:
 - depressive disorders, anxiety disorders, and adjustment disorders
- 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.

Obsessive-Compulsive Personality Disorder

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 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.

Differential Diagnosis
Obsessive- OCD - presence of true obsessions and compulsions
compulsive * When criteria for both are met, both diagnoses should be recorded.
disorder
(OCD
Hoarding when hoarding is extreme
disorder * When criteria for both are met, both diagnoses should be recorded.
Other narcissistic personality disorder - more likely to believe that they have achieved perfection
personality obsessive-compulsive personality disorder - are usually self-critical
disorders and
personality narcissistic or antisocial personality disorder - lack generosity but will indulge themselves
traits obsessive-compulsive personality disorder - adopt a miserly spending style toward both self and others

schizoid personality disorder - there is a fundamental lack of capacity for intimacy

obsessive-compulsive personality disorder - stems from discomfort with emotions and excessive
devotion to work

*if an individual has personality features that meet criteria for one or more personality disorders in
addition to obsessive-compulsive personality disorder, all can be diagnosed.
Personality traits that emerge are a direct physiological consequence of another medical condition
change due to
another
medical
condition
Substance use symptoms that may develop in association with persistent substance use
disorders
Comorbidity:
- anxiety disorders (e.g., generalized anxiety disorder, separation anxiety disorder, social anxiety disorder,
specific phobias)
- Obsessive-compulsive disorder (OCD)
- many of the features overlap with “type A” personality characteristics (e.g., preoccupation with work,
competitiveness, time urgency), and these may be present in individuals at risk for myocardial infarction.
 - depressive and bipolar disorders and eating disorders

Other Personality Disorders

Personality Change Due to Another Medical Condition
Criteria:
- A persistent personality disturbance that represents a change from the individual’s previous characteristic
personality pattern.
Note: In children, the disturbance involves a marked deviation from normal development or a significant
change in the child’s usual behavior patterns, lasting at least 1 year.
- direct pathophysiological consequence of another medical condition.
- not better explained by another mental disorder (including another mental disorder due to another medical
condition).
- does not occur exclusively during the course of a delirium.
- causes distress or impairment in social, occupational, or other important areas of functioning.
Specify whether:
Labile type: If the predominant feature is affective lability.
Disinhibited type: If the predominant feature is poor impulse control as evidenced by sexual indiscretions, etc.
Aggressive type: If the predominant feature is aggressive behavior.
Apathetic type: If the predominant feature is marked apathy and indifference.
Paranoid type: If the predominant feature is suspiciousness or paranoid ideation.
Other type: If the presentation is not characterized by any of the above subtypes.
Combined type: If more than one feature predominates in the clinical picture.
Unspecified type
Differential Diagnosis
Chronic medical (not) change is due to a behavioral or psychological adjustment or response to another
conditions associated medical condition
with pain and disability
Delirium or major personality change due to another medical condition - if the personality change is judged to
neurocognitive disorder be a physiological consequence of the pathological process causing the neurocognitive
disorder and if the personality change is a prominent part of the clinical presentation
Another mental if the disturbance is better explained by another mental disorder due to another medical
disorder due to another condition
medical condition - depressive disorder due to brain tumor
Substance use disorders symptoms that may develop in association with persistent substance use
Other mental disorders no specific physiological factor is judged to be etiologically related to the personality change
Other personality clinically significant change from baseline personality functioning and the presence of a
disorders specific etiological medical condition
Comorbidity:
- anxiety disorders (e.g., generalized anxiety disorder, separation anxiety disorder, social anxiety disorder,
specific phobias)
- Obsessive-compulsive disorder (OCD)
- many of the features overlap with “type A” personality characteristics (e.g., preoccupation with work,
competitiveness, time urgency), and these may be present in individuals at risk for myocardial infarction.
- depressive and bipolar disorders and eating disorders
SCHIZOPHRENIA SPECTRUM AND OTHER PSYCHOTIC DISORDERS
● Psychotic disorders are heterogeneous, and the severity of symptoms predict important aspects of the illness, such
as the degree of cognitive or neuro-biological deficits.
Delusions
● Fixed beliefs that are not amenable to change in light of conflicting evidence.
○ Persecutory Delusions – most common; belief that one is going to be harmed, harassed, and so forth, by
an organization, individual or other group.
○ Referential Delusions – belief that certain gestures, comments, environmental cues, and so forth are
directed to oneself.
○ Grandiose Delusions – when an individual believes that he or she has exceptional abilities, wealth or
fame.
○ Erotomanic Delusions – when an individual believes falsely that another person is in love with him or
her.
○ Nihilistic Delusions – involve conviction that a major catastrophe will occur
○ Somatic Delusions – focus on preoccupations regarding health and organ function
● Bizarre Delusions – clearly implausible and not understandable to same-culture peers and do not derive from
ordinary life experiences.
○ B. Delusions – outside forces removed his or her internal organs and replaced them with someone else’s
organs without leaving any wounds or scars.
○ NB. Delusions – belief that one is under surveillance by the police despite a lack of convincing evidence.
● Thought withdrawal – one’s thoughts are removed by some outside force.
● Thought insertion – alien thoughts have been put into one’s mind.
● Delusions of Control – one’s body or actions are being acted on or manipulated by some outside force.

Hallucinations
● Perception-like experiences that occur without an external stimulus. They are vivid and clear, with the full force
and impact of normal perceptions, and not under voluntary control.
● May occur in any sensory modality but auditory hallucinations are most common.
● Auditory hallucinations – are usually experienced as voices, whether familiar or unfamiliar, that are perceived as
distinct from an individual's own thoughts.
● Those that occur in the following are considered to be within the normal range experience.
○ Hypnagogic – occur while falling asleep
○ Hypnopompic – occur while waking up
● May be a normal part of religious experience in certain cultural contexts.

Disorganized Thinking
● Formal thought disorder
● Typically inferred from the individual’s speech.
● Derailment or loose associations – may switch from one topic to another.
● Tangentiality – answers to questions may be obliquely related or completely related,
● Incoherence or “word salad” – speech is severely disorganized that is nearly incomprehensible and resembles
receptive aphasia in its linguistic disorganization.

Grossly Disorganized or Abnormal Motor Behavior

● May manifest itself in a variety of ways, ranging from childlike silliness ro unpredictable agitation.
● Catatonic behavior – is a marked decrease in reactivity to the environment
● Negativism – resistance to instructions
● Mutism and stupor – maintaining a rigid, inappropriate or bizarre posture; to a complete lack of verbal and
motor responses.
 ● Catatonic excitement – purposeless and excessive motor activity without obvious cause.

Negative Symptoms
● Account for substantial portions of the morbidity associated with schizophrenia but are less prominent in other
psychotic disorders.
● Diminished emotional expression – reductions in the expression of emotions in the face, eye contact, intonation
of speech (prosody), and movements of the hand, head, and face that normally give an emotional emphasis to
speech.
● Avolition – decrease in motivated self-initiated purposeful activities. May sit for long periods of time and show
little interest in participating in work or social activities.
● Alogia – is manifested by diminished speech output
● Anhedonia – decreased ability to experience pleasure; as for schizophrenia patients, they show a reduction in the
frequency of engaging in pleasurable activities.
● Asociality – apparent lack of interest in social interactions and may be associated with avolition, but it can also be
a manifestation of limited opportunities for social interactions.

Delusional Disorder

Key features:
● One or more delusions with a duration of 1 month or longer
● Criteria A of schizophrenia is not met
● Apart from the impact of delusions, functioning is not markedly impaired, and behavior is not bizarre or odd.
● Manic and/or depressive episodes (if occurs) must be relative to the duration of the delusional periods.
● Not attributable to substance, medical condition, or another mental disorder.

Specify if:
● Erotomanic type – another person is in love with them
● Grandiose type – convention of having some great talent or insight ot having made an important discovery
● Jealous type – delusion that partner or spouse is unfaithful
● Persecutory type – belief that he or she is being conspired against, cheated on, spied on, followed, poised,
drugged, or maliciously maligned, harassed, or obstructed in pursuit of long-term goals.
● Somatic type – delusions involve bodily functions or sensations.
● Mixed type – no one of the delusional themes predominates.
● Unspecified type – cannot be clearly determined or is not described in the specific types.

Specify if:
● With bizarre content

Specify if:
● First episode, currently in acute episode – currently meeting symptom and time criteria.
● First episode, currently in partial remission – criteria is only partially fulfilled.
● First episode, currently in full remission – no disorder-specific symptoms are present.
● Multiple episodes, currently in acute episode
● Multiple episodes, currently in partial remission
● Multiple episodes, currently in full remission
● Continuous – symptoms are fulfilled for the remaining majority of the illness course with subthreshold
symptom periods being very brief relative to the overall course.
● Unspecified

Differential Diagnosis

OCD and Related Disorders OCD – if completely convinced that their OCD thoughts
 are true, OCD with absent insight/delusional beliefs
specifier should be given
Body Dysmorphic – if completely convinced about their
beliefs about their body, Body Dysmorphic with absent
insight/delusional beliefs specifier should be given.

Delirium, Major neurocognitive disorder, and Individuals with these disorders may present with
psychotic disorder due to another medical condition symptoms that suggest delusional disorder.
Persecutory delusions – may be diagnosed as major
neurocognitive disorders, with behavioral disturbance.

Substance/Medication Induced Psychotic Disorder May be identical in symptomatology to delusional

disorder but can be distinguished by the chronological
relationship of substance use to the onset and remission of
delusional beliefs.

Schizophrenia and Schizophreniform Disorder Delusional Disorder – absence of characteristic

symptoms of active phase schizophrenia. Show greater
conviction, greater extension, and greater pressure.
Schizophrenia – delusions show greater disorganization.

Depressive and bipolar disorders and schizoaffective Major Depressive/Bipolar Disorder – if delusions occur
disorder during mood episodes (Major Depressive/Bipolar Disorder
w/ Psychotic Features)
Delusional disorder – if the total duration of mood
episode remains brief relative to the total duration of the
delusional disturbance.
Other specified, Unspecified accompanied with other
specified depressive disorder, unspecified depressive,
other specified bipolar, unspecified bipolar – if the total
duration of mood episode is not brief relative to the total
duration of the delusional disturbance.
Brief Psychotic Disorder

Key features:
● Presence of one (or more) of the following symptoms. Atleast of the of the following must be included:
○ Delusions
○ Hallucinations
○ Disorganized speech
○ Grossly disorganized or catatonic behavior
● Duration: 1 day to less than 1 month, with eventual full return to premorbid level functioning.
● Not better explained by MDD, Bipolar disorder with psychotic features or another psychotic disorder such as
schizophrenia or catatonia, and is not attributable to physiological effects of substance or another medical
condition

Specify if:
● With marked stressors – occurring in response to events would be markedly stressful to almost anyone in
similar circumstances in the individual’s culture.
● Without marked stressors – do not occur in response to an event that would be markedly stressful to almost
anyone in similar circumstances in the individual’s culture.
● With peripartum onset – onset is during pregnancy or within 4 weeks postpartum.

Specify if:
● With catatonia

Differential Diagnosis

Other medical conditions Delirium – is diagnosed when there is evidence from the
history, physical examination, or laboratory tests that the
delusions or hallucinations are the direct physiological
consequence of a specific medical condition

Substance-related disorders Substance-induced – a substance is judged to be

etiologically related to the psychotic symptoms.

Depressive and bipolar disorders Brief Psychotic Disorder – cannot be diagnosed if the
psychotic disorder can be explained by the mood
disturbance or episode.

Other psychotic disorders Schizophreniform, Delusional, Schizophreniform,

Depression with Psychotic, Bipolar with psychotic,
other specified, unspecified – if it lasts more than 1
month.

Malingering and factitious disorders Mal./Factitious Dis – symptoms are intentionally

produced. There is usually evidence that the illness is
being feigned for an understandable goal.

Personality Disorder PD – psychosocial stressors may precipitate brief periods

of psychotic symptoms. Symptoms are usually transient
and do not warrant a separate diagnosis.
Brief Psychotic Dis. – If persists for at least 1 day, an
additional diagnosis of brief psychotic disorder may be
appropriate
Schizophreniform Disorder

Key features:
● Two or more of the following for a significant portion of time during a 1 month period or less if successfully
treated. At least one should be
○ Delusions
○ Hallucinations
○ Disorganized Speech
○ Grossly disorganized or catatonic behavior
○ Negative symptoms
● Duration: at least 1 month but less than 6 months
● Schizoaffective, Depressive or Bipolar disorder should be ruled out (no major depressive/manic symptoms,
mood symptoms should have been present for a minority of the total duration of the active and residual periods
of the illness.
● Not attributable to psychological effects of substance.

Specify if:
● With good prognostic features
● Without good prognostic features

Specify if:
● With catatonia

Differential Diagnosis

Other mental disorders and medical conditions Psych. Dis. due to another medical condition – delirium
or major neurocognitive disorder; substance/medication
induced psychotic disorder or delirium; major depressive
or bipolar disorder with psychotic features; schizoaffective
disorder; other specified or unspecified bipolar and related
disorder; major depressive or bipolar disorder with
catatonic features; schizophrenia; delusional disorder;
other specified or unspecified schizophrenia spectrum and
other psychotic disorder; schizotypal, schizoid, or
paranoid personality disorders; autism spectrum disorder;
disorders presenting in childhood with disorganized
speech; attention-deficit/hyperactivity disorder; obsessive
compulsive disorder; posttraumatic stress disorder; and
traumatic brain injury

Brief Psychotic Disorder Schizophreniform – duration (1 month to 6 months)

Brief Psychotic Disorder – duration (1 day to 1 month)
Schizophrenia

Key features:
● Two or more of the following for a significant portion of time during a 1 month period or less if successfully
treated. At least one should be
○ Delusions
○ Hallucinations
○ Disorganized Speech
○ Grossly disorganized or catatonic behavior
○ Negative symptoms
● Duration: Continuous for at least 6 months, must include at least 1 month of symptoms.
● Schizoaffective, Depressive or Bipolar disorder should be ruled out (no major depressive/manic symptoms,
mood symptoms should have been present for a minority of the total duration of the active and residual periods
of the illness.
● Not attributable to psychological effects of substance.

Specify if:
● First episode, currently in acute episode – currently meeting symptom and time criteria.
● First episode, currently in partial remission – criteria is only partially fulfilled.
● First episode, currently in full remission – no disorder-specific symptoms are present.
● Multiple episodes, currently in acute episode
● Multiple episodes, currently in partial remission
● Multiple episodes, currently in full remission
● Continuous – symptoms are fulfilled for the remaining majority of the illness course with subthreshold
symptom periods being very brief relative to the overall course.
● Unspecified

Specify if:
● With catatonia

Differential Diagnosis

Major depressive or bipolar disorder with psychotic or Distinction depends on the relationship of the mood
catatonic features disturbance and the psychosis and the severity of the
depressive/manic episode.
Depressive/Bipolar Disorder with Psychotic features –
if delusions/hallucinations occur exclusively during the
episode.

Schizoaffective Disorder Schizoaffective – major depressive/manic episodes occur

concurrently with the active-phase symptoms and that
mood symptoms are present for the majority of the total
duration of the active periods.

Schizophreniform disorder and brief psychotic Schizophrenia - 6 months (at least)

disorder Schizophreniform - 1 month (at least)
Brief Psychotic Disorder - 1 day (at least)

Delusional Disorder Delusional – absence of the other symptoms characteristic

of schizophrenia

Schizotypal Personality Disorder Schizotypal – subthreshold symptoms that are associated

with persistent personality features.

OCD and Body Dysmorphic disorder OCD/Body Dys – poor or absent insight and the
 preoccupations may reach delusional proportions. Has
obsessions, compulsions, preoccupations with appearance
or body odor, hoarding, or body focused repetitive
behaviors.

PTSD PTSD – includes traumatic events and characteristic

symptom features relating to reliving or reacting to the
vent are required.

ASD or other communication disorders ASD/Communication Dis. – must meet full criteria of
schizophrenia with prominent hallucinations and delusions
for at least 1 month for a comorbid diagnosis.

Other mental disorders associated with a psychotic Schizophrenia – only diagnosed if the psychotic episode
episode is persistent and not attributable to the physiological
effects of a substance or another medical condition.
Delirium Maj/Min Neurocognitive Dis – temporal
relationship to the onset of the cognitive changes
consistent with those disorders.

Substance/medication induced psychotic disorder Has a chronological relationship with substance use to the
onset and remission of the psychosis in the absence of
substance use.

Comorbidity:
● Substance-related disorders
● OCD
● Panic Disorders
● Weight gain
● Metabolic syndrome
● Cardiovascular and pulmonary disease
Schizoaffective Disorder

Key features:
● An uninterrupted period of illness during which there is a major mood episode concurrent with Criterion A of
schizophrenia.
● Delusions/Hallucinations for 2 or more weeks in the absence of a major mood episode
● Symptoms that meet criteria for major mood episodes are present for the majority of the tidal duration of the
active and residual portions of the illness.
● Disturbance is not attributable to the effects of substance or other medical conditions.

Specify
● Bipolar type
● Depressive type

Specify
● With catatonia

Specify if
● First episode, currently in acute episode – currently meeting symptom and time criteria.
● First episode, currently in partial remission – criteria is only partially fulfilled.
● First episode, currently in full remission – no disorder-specific symptoms are present.
● Multiple episodes, currently in acute episode
● Multiple episodes, currently in partial remission
● Multiple episodes, currently in full remission
● Continuous – symptoms are fulfilled for the remaining majority of the illness course with subthreshold
symptom periods being very brief relative to the overall course.
● Unspecified

Differential Diagnosis

Other mental disorder and medical conditions Other mental disorder and medical conditions –
delirium or major neurocognitive disorder;
substance/medication induced psychotic disorder or
delirium; major depressive or bipolar disorder with
psychotic features; schizoaffective disorder; other
specified or unspecified bipolar and related disorder;
major depressive or bipolar disorder with catatonic
features; schizophrenia; delusional disorder; other
specified or unspecified schizophrenia spectrum and other
psychotic disorder; schizotypal, schizoid, or paranoid
personality disorders

Psychotic disorder due to another medical condition Other medical conditions and substance use can
manifest with a combination of psychotic and mood
symptoms, and thus psychotic disorder due to another
medical condition needs to be excluded.

Schizophrenia, bipolar, and depressive disorders Schizoaffective

● differ from schizophrenia because of Criteria C
(third bullet)
● Differ from depressive and bipolar with psychotic
features because of Criteria B (second bullet)
(may symptoms pa rin after 2 weeks from mood
episode)
Comorbidity:
● substance -use disorder
● Anxiety
● Metabolic Syndrome
NEUROCOGNITIVE DISORDERS

Cognitive Domain Examples of Symptoms or Examples of Assessments

Observations

Complex Attention Major – increased difficulty in Sustained Attention – maintenance

● Sustained Attention environments with multiple stimuli. of attention over time
● Divided Attention Unable to attend unless input is Selective Attention – maintenance of
● Selective Attention restricted and simplified. Difficulty attention in the presence of competing
● Processing Speed holding new information. Unable to stimuli
perform mental calculations. Divided attention – attending to two
Mild – normal tasks take longer than tasks at a time.
previously. Frequent errors in routine Processing speed – quantified on nay
tasks. Frequent double checking than task by timing it.
previously. Thinking is easier without
competition with other things.

Executive function Major – abandons complex projects. Planning – ability to find the exit to a
● Planning Need to focus on one task at a time. maze; interpret sequential picture
● Decision-making Reliance on others to plan Decision-making – performance of
● Working memory instrumental activities of daily tasks that assess the process of
● Responding to feedback/error living/making decisions. deciding in the face of competing
correction Mild – increased effort to complete alternatives.
● Overriding habits/inhibiting multistage projects. Increased Working memory – ability to hold
● Mental Flexibility difficulty multitasking or resuming a information for a brief period and to
task interrupted by a distraction. manipulate it.
Increased fatigue from the extra effort Feedback/error utilization – ability
required to function. LArge social to benefit from feedback to infer the
gatherings are more taxing and less rules for solving problems.
enjoyable. Overriding habits/inhibitions –
ability to choose more complex and
effortful solutions to be correct.
Mental/Cognitive flexibility – ability
to shift between two concepts, tasks,
or response rules.

Learning and Memory Major – repeats self in conversations Immediate memory span – ability to
● Immediate memory within the same conversation. Cannot repeat a list of words or digits.
● Recent memory (Free recall, keep track of short list items. Requires Recent memory – assess the process
cued recall, and recognition frequent reminders to orient to the of encoding new information. The
memory) task at hand. aspects of recent memory that can be
● Very-long-term memory Mild – difficulty recalling recent tested include
(semantic, autobiographical, events, relied increasingly on list 1. Free recall
implicit learning) making or calendar/ needs occasional 2. Cued recall
reminders or rereading to keep track 3. Recognition memory
of characters in a movie/novel. May Other aspects of memory that can be
repeat himself over a few weeks to the assessed induce semantic memory,
same person. Loses track of whether autobiographical memory, and
the bills have been paid. implicit learning.

Language Major – significant difficulties with Expressive language –

● Expressive language expressive or receptive language. confrontational naming; fluency;
● Receptive Language Used phrases such as “that thing” and phonemic
“you know what I mean” prefer Grammar and syntax – errors
general pronouns rather than observed during naming and fluency
 names.May forget names of closer tests are compared with norms to
friends and family. Idiosyncratic word assess frequency of errors and
usage, grammatical errors and compare with normal slips of tongue.
spontaneity of output and economy of Receptive Language –
utterance occur. Stereotypy speech: comprehension: performance of
echolalia and automatic speech actions according to verbal command.
occurs.
Mild – noticeable work finding
difficulty. Substitute general for
specific terms. Avoid using specific
names of acquaintances. Subtle
grammatical errors.

Perceptual-motor Major – difficulties with previously Visual perception – line bisection

● Visual perception familiar activities, navigating in a tasks can be used to detect basic
● Visuoconstructional familiar environment is often more visual defects or attentional neglect.
perceptual-motor confused at dusk. Motor free perceptual tasks
● Praxis Mild– need to rely more on maps for Visuoconstructional – assembly of
● Gnosis directions. Uses notes and follows items requiring hand-eye
others to get to a new place. May find coordination.
yourself lost when not concentrating Perceptual motor – integration
to the task perception with purposeful
movement.
Praxis – integrating of learned
movements, such as ability to imitate
gestures or pantomime use of objects
to command.
Gnosis – perceptual integrity of
awareness and recognition

Social Cognition Major – clearly out of acceptable Recognition of emotions –

● Recognition of emotions social range; shows insensitivity to Identification of emotion in images of
● Theory of mind social standards/ focuses excessively faces representing a variety of both
on a topic despite group’s disinterest positive and negative emotions
or direct feedback. Behavioral
intention without regard to family or Theory of mind – Ability to consider
friends. another person’s mental state
Mild – subtle change in behavior or (thoughts, desires, intentions) or
attitude. Less ability to recognize experience
social cues, decreased empathy,
increased extraversion or introversion,
apathy, restlessness.
Delirium

Key features:
● An impaired state of consciousness in the setting of an aroused cortex.
● A disturbance in attention accompanied by reduced awareness of the environment.
● Disturbance develops over a short period of time, represents a change from baseline attention and awareness,
and tends to fluctuate in severity during the course of the day.
● Additional disturbance in cognition
● Disturbances in A and C are not better explained by another preexisting, established, or evolving
neurocognitive disorder and do not occur in the context of a severely reduced level of arousal, such as a coma.
● Evidence from the history, physical examination, or laboratory findings that disturbance is a direct
physiological consequence of another medical condition, substance use/withdrawal, or exposure to toxin or is
due to multiple etiologies.

Specify if:
● Acute - few hours or days
● Persistent - weeks or months

Specify if:
● Hyperactive - hyperactive level of psychomotor activity with mood lability, agitation, and/or refusal to
cooperate with medical care.
● Hypoactive - hypoactive level of psychomotor activity with sluggishness and lethargy that approaches stupor
● Mixed level of activity – normal level of psychomotor activity. Activity levels rapidly fluctuate.

Specify whether:
● Substance Intoxication Delirium
● Substance withdrawal delirium
● Medication-induced delirium
● Delirium due to multiple etiologies

Differential Diagnosis

Psychotic disorders and bipolar and depressive Delirium – characterized by vivid hallucinations,
disorders with psychotic features delusions, language disturbances and agitation.
Disturbances in cognition, language, visuospatial ability.
Psychotic Disorders – not due to the direct physiological
effects of a general medical condition or
substance/medication use.

Acute Stress Disorder Acute Stress Disorder – precipitated by exposure to a

severely traumatic event.

Malingering and Factitious Disorder Mal. & Factitious Dis – of another medical condition or
substance that is etiologically related to the apparent
cognitive disturbance?

Other Neurocognitive Disorders The clinician must determine whether the individual has
delirium; a delirium superimposed on a preexisting NCD,
such as that due to Alzheimer’s disease; or an NCD
without delirium. The traditional distinction between
delirium and major NCD according to acuteness of onset
and temporal course is particularly difficult in those
elderly individuals who had a prior NCD that may not
have been recognized, or who developed persistent
cognitive impairment following an episode of
 delirium. When delirium and major NCD are comorbid,
the management of the delirium should generally be given
priority

Subsyndromal Delirium – delirium like presentation involving disturbance in attention, higher-level thought, and
circadian rhythm, i. which the severity of cognitive impairment falls short of that required for the diagnosis of delirium.
Major Neurocognitive Disorder

Key features:
● Evidence of significant cognitive decline from a previous level of performance in one or more cognitive
domains
○ Concert in the individual, a knowledgeable informant, or clinician that there has been a significant
decline in cog. function.
○ Substantial impairment in cognitive performance, preferable documented by another standardized
neuropsychological testing or, in its absence, another quantifies clinical assessment.
● Cognitive deficits impair daily functioning and independence.
● Cognitive deficits do not occur exclusively in the context of a delirium
● Not better explained by another mental disorder

Specify whether due to:

● Alzheimer’s disease
● Frontotemporal degeneration
● Lewy body disease
● Vascular Disease
● TBI
● Substance/Medication Use
● HIV
● Prion disease
● Parkinson’s
● Huntington’s
● Another medical condition
● Multiple etiologies
● Unspecified etiology

Specify:
● With behavioral disturbance
● Without behavioral disturbance

Specify current severity:

● Mild
● Moderate
● Severe

Mild Neurocognitive Disorder

Key features:
● Evidence of modest cognitive decline from a previous level of performance in one of more cognitive domains
based on:
○ Concern of individual, a knowledgeable informance, or the clinician
○ Modest impairment in cognitive performance
● Deficits do not interfere with capacity for independence and everyday activities
● Not in the context of a delirium
● Not better explained by another mental disorder

Specify whether due to:

● Alzheimer’s disease
● Frontotemporal degeneration
● Lewy body disease
● Vascular Disease
● TBI
 ● Substance/Medication Use
● HIV
● Prion disease
● Parkinson’s
● Huntington’s
● Another medical condition
● Multiple etiologies
● Unspecified etiology

Specify if:
● Without behavioral disturbance
● With behavioral disturbance
●

Differential Diagnosis

Normal Cognition ● Careful history taking and objective assessment

● Longitudinal evaluation using quantified
assessment may be key in detecting mild NCD.

Delirium Careful assessment of attention and arousal make the

distinction.
Delirium – develops over a short period of time, usually
hours, and tends to fluctuate during the course of the day.
Maj./Mild NCD – gradual onset and a gradually
deteriorating course.

MDD Mild NCD – direct effect of medical condition or

substance/medication use
MDD – deficits improve when the depression remits, not
due to another medical condition or substance/medication
use.

Specific learning disorder and other NCD – decline from previous cognitive functioning
neurodevelopmental disorders NeuroDev – onset during developmental period

Comorbidity:
● Delirium
● Increase prevalence with older age
● Co-occurs with NeuroDev Disorders, caused by: head injuries as a child.
Major/Mild Neurocognitive Disorder due to Alzheimer’s Disease

Key features:
● Criteria is met for major/mild neurocognitive disorder
● Insidious onset and gradual progression of impairment in one or more cognitive domains
● Criteria are met for either probably or possible Alzheimer’s disease as follows
Major neurocog
● Probable Alz’s Disease – diagnosed if following is present
● Possible Alz’s Disease – diagnosed if otherwise
○ Evidence of causative Alz’s disease genetic mutation from family history or genetic testing.
○ All three of the following
■ Clear evidence of decline in memory and learning and at least one other cognitive domain
■ Steadily progressive, gradual decline in cognition, without extended plateaus
■ No evidence of mixed etiology
Mild Neurocog
● Probable Alz’ disease – if there is evidence of causative Alz’s disease genetic mutation from either genetic
testing or family history
● Possible Alz’ disease – is there is no evidence of a causative Alz’s disease genetic mutation from their genetic
testing or family history, and all three of the following are present
○ Clear evidence of decline in memory and learning
○ Steadily progressive, gradual decline in cognition, without extended plateaus
○ No evidence of mixed etiologies

● Disturbance is not better explained by cerebrovascular disease, another neurodegenerative disease, the effects of
substance, or another mental, neurological, or systemic disorder.

Differential Diagnosis

Other neurocognitive disorders NCD with Lewy Bodies – frequent fluctuations in

cognition early in the disease, parkinsonian features, gait
imbalances, and visual hallucinations.
Frontotemporal NCD – distinct behavioral or language
variant. Behavioral Variant – changes in social
behaviors, disinhibition, apathy, perseverative behavior.
Language variant – impairments in expressive language
or word comprehension.
Mild/Maj Vascular NCD – history of stroke related to the
onset of the cognitive impairment, and infarcts or
hemosiderin deposits observed on brain imaging can be
judged sufficient to account for the clinical picture.

Other concurrent, active neurological or systemic Other neurolo/systemic illness – there is an appropriate
illness temporal relationship and severity to account for the
clinical picture

MDD MDD – improvement upon the treatment of depression.

Depressive disorder due to Alz’s Disease, with major
depressive-like episode – depressive episode is due to the
physiological effects of Alz’s disease

Comorbidity:
● Cerebrovascular disease
● Multiple etiologies
Major or Mild Frontotemporal Neurocognitive Disorder

Key features:
● Criteria are met for major or mild neurocog disorder
● Insidious onset and gradual progression
● Either of the following
○ Behavioral variant
■ Three or more of the following
● Behavioral disinhibition
● Apathy or inertia
● Loss of sympathy or empathy
● Perseverative, stereotypes or compulsive/ritualistic behavior
● Hyperorality
■ Prominent decline in social cognition and/or executive abilities
○ Language variant
■ Prominent decline in language ability
● Relative sparing of learning and memory and perceptual-motor function
● Not better explained by cerebrovascular disease, another neurodegenerative disease, effects of substance,
another mental, neurological, or systemic disorder.

● Probably frontotemporal neurocognitive disorder – either of the following is present. Otherwise, possible
frontotemporal neurocognitive disorder should diagnosed
1. Evidence of a causative frontotemporal neurocog dis genetic mutation, from either family history or
genetic testing
2. Evidence of disproportional frontal and/or temporal lobe involvement from neuroimaging

● Possible frontotemporal neurocognitive disorder – if there is no evidence of genetic mutation, and

neuroimaging has not been performed

Differential Diagnosis

Other neurocognitive disorders Maj/Mild NCD due to Alz’s Dis – decline in learning
and memory is an early feature
Maj/Mild NCD w Lewy bodies – core and suggestive
features of Lewy bodies must be present
Maj/Mild NCD due to Parkinson’s –spontaneous
parkinsonism emerges before cognitive decline.
Maj/Mild Vascular NCD – loss of executive function and
behavioral changes such as apathy.
History of cerebrovascular event – related to the onset of
cognitive impairment in major or mild vascular NCD; has
infarctions or white matter lesions.

Other neurological disorders Progressive supranuclear palsy – supranuclear gaze

palsies and axial-predominant parkinsonism. Pseudobulbar
signs may be present and retropulsion
Corticobasal degeneration – asymmetric rigidity, limb
apraxia, postural instability, myoclonus, alien limb
phenomenon, and cortical sensory loss

Other mental disorders Behavioral-variant major or mild frontotemporal NCD

– may be mistaken for a primary mental disorder, such as
major depression, bipolar disorders, or schizophrenia, and
individuals with this variant often present initially to
psychiatry.
Major or Mild NCD with Lewy Bodies

Key features:
● Criteria met for NCD
● Insidious onset and gradual progression
● Meets a combination of core diagnostic features and suggestive diagnostic features for either probable or
possible neurocognitive disorder with Lewy bodies.

For probable major or mild neurocognitive disorder with Lewy bodies, the individual has two core features, or one
suggestive feature with one or more core features. For possible major or mild neurocognitive disorder with Lewy
bodies, the individual has only one core feature, or one or more suggestive features:
● Core diagnostic features
○ Fluctuating cognition with pronounced variations in attention and alertness.
○ Recurrent visual hallucinations that are well formed and detailed.
○ Spontaneous features of parkinsonism, with onset subsequent to the development of cognitive decline
● Suggestive diagnostic features:
○ Meets criteria for rapid eye movement sleep behavior disorder.
○ Severe neuroleptic sensitivity
● Not better explained by cerebrovascular disease, another neurodegenerative disease, the effects of a substance,
or another mental, neurological, or systemic disorder.

Differential diagnosis

Maj/Mild NCD due to Parkinson’s Parkison’s – diagnosis must be present for at least 1 year
before cognitive decline.
NCDLB – symptoms occur before, with, or in the absence
of parkinsonism.

Comorbidity
● Lewy body pathology
● Alz’s Dis
● Cerebrovascular disease
● Neurodegenerative disorders
Major/Mild Vascular NCD

Key Features:
● Criteria is met for major/mild NCD
● Features are consistent with vascular etiology
○ Onset of the cognitive deficits is temporally related to one or more cerebrovascular events
○ Evidence for decline is prominent in complex attention (including processing speed) and
frontal-executive function
● evidence of the presence of cerebrovascular disease from history, physical examination, and/or neuroimaging
considered sufficient to account for the neurocognitive deficits
● not better explained by another brain disease or systemic disorder.

Probable vascular neurocognitive disorder is diagnosed if one of the following is present; otherwise possible
vascular neurocognitive disorder should be diagnosed:
● Clinical criteria are supported by neuroimaging evidence of significant parenchymal injury attributed to
cerebrovascular disease (neuroimaging supported).
● The neurocognitive syndrome is temporally related to one or more documented cerebrovascular events. 3
● Both clinical and genetic (e.g., cerebral autosomal dominant arteriopathy with subcortical infarcts and
leukoencephalopathy) evidence of cerebrovascular disease is present.

Possible vascular neurocognitive disorder is diagnosed if the clinical criteria are met but neuroimaging is not
available and the temporal relationship of the neurocognitive syndrome with one or more cerebrovascular events is not
established.

Differential Diagnosis

Other neurocognitive disorders Alzheimer’s disease - history of memory deficit early in

the course, and progressive worsening of memory,
language, executive function, and perceptual motor
abilities in the absence of corresponding focal lesions on
brain imaging
Lewy bodies - fluctuating cognition, visual hallucinations,
and spontaneous parkinsonism.
Frontotemporal - insidious onset and gradual progression
of behavioral features or language impairment and are not
typical of vascular etiology.

Other medical conditions other diseases (e.g., brain tumor, multiple sclerosis,
encephalitis, toxic or metabolic disorders) are present and
are of sufficient severity to account for the cognitive
impairment

Other mental disorders if the symptoms can be entirely attributed to delirium →

both diagnoses can be made
If the criteria for major depressive disorder are met and the
cognitive impairment is temporally related to the likely
onset of the depression → major or mild vascular NCD
should not be diagnosed.
if the NCD preceded the development of the depression, or
the severity of the cognitive impairment is out of
proportion to the severity of the depression → depressive
disorder due to cerebrovascular disease should be
diagnosed instead of major depressive disorder
Major/Mild NCD due to TBI

Key features:
● Criteria is met for Mild/Major NCD
● Evidence of TBI
○ Loss of consciousness
○ Posttraumatic Amnesia
○ Disorientation/Confusion
○ Neurological signs
● The neurocognitive disorder presents immediately after the occurrence of the traumatic brain injury or
immediately after recovery of consciousness and persists past the acute post-injury period.

Differential Diagnosis

Other mental disorders and medical conditions Mental disorders (e.g., major depressive disorder, anxiety
disorders, PTSD, alcohol and other substance use
disorders, sleep disturbances), prescribed medications
(e.g., typical antipsychotics, benzodiazepines, drugs with
anticholinergic properties, antiepileptic drugs), and other
medical conditions may contribute to or account for
cognitive impairments among individuals with TBI, and
need to be considered in the differential diagnosis of major
or mild NCD due to TBI

Factitious Disorder / Malingering neurocognitive symptoms and functional limitations are

inconsistent with the cognitive outcomes expected after
TBI—and particularly mild TBI—and when
neuropsychological assessment reveals poor effort or is
otherwise not valid for interpretation

Comorbidity:
● Unspecified/other specified Depressive/Anxiety
● Physical disturbances
● PTSD
● Sleep disorders
● Panic attacks
Substance/Medication-Induced Major/Mild NCD

Key features:
● Criteria is met for NCD
● Impairment do not occur exclusively during the course of a delirium and persist beyond the usual duration of
intoxication and scute withdrawal
● Involved substance/Medication and duration and extent of use of are capable of producing the neurocognitive
impairment
● Course of deficits is consistent with the timing of substance or medication use and abstinence.
● Not attributable to another medical condition or another mental disorder.

Differential Diagnosis

Substance use disorders, substance intoxication, and Individuals with substance use disorders, substance
substance withdrawal intoxication, and
substance withdrawal are at increased risk for other
conditions that may
independently, or through a compounding effect, result in
neurocognitive
disturbance.

Substance/Medication-induced Mild NCD – are

sometimes augmented by reduced cognitive efficiency and
difficulty concentrating beyond that seen in many other
NCDs.

Comorbidity
● Substance use
● Substance intoxication
● Substance withdrawal
● PTSD
● Psychotic dis
● Depression
● Bipolar Dis
● Neurodev Dis
Maj/Mild NCD due to HIV Infection

Key features:
● Criteria is met for major/mild NCD
● Documented infection with HIV
● Not better explained by non-HIV conditions, including secondary brain diseases
● Not attributable to another medical condition or mental disorder

Differential Diagnosis
In the presence of comorbidities, such as other infections (e.g., hepatitis C virus, syphilis), substance use disorder (e.g.,
methamphetamine use disorder), prior traumatic brain injury, or neurodevelopmental conditions, major or mild NCD
due to HIV infection can be diagnosed provided there is evidence that infection with HIV has worsened any NCDs
because of such preexisting or comorbid conditions. Among older adults, onset of neurocognitive decline related to
cerebrovascular disease or primary neurodegeneration (e.g., major or mild NCD due to Alzheimer’s disease)
may need to be differentiated; these conditions may be suggested by a relatively more progressive course of decline
than is seen in NCD due to HIV. HIV infection itself has been shown to increase the risk of
cerebrovascular disease. Because more severe immunodeficiency can result in opportunistic infections of the brain (e.g.,
toxoplasmosis; cryptococcosis) and neoplasia (e.g., CNS lymphoma), sudden onset of an NCD or sudden worsening of
an NCD demands active investigation of non-HIV etiologies. Delirium is important to consider because it occurs
frequently over the disease course of individuals with HIV and may be due to multiple etiologies (including
SARS-CoV-2 co-infection).

Comorbidity
● chronic systemic and CNS inflammation
● ANI due to HIV
Maj/Mild NCD due to Prion Disease

Key features:
● Criteria is met for NCD
● Insidious onset and rapid progression of impairment
● Motor features of prior disease (myoclonus or ataxia, biomarker evidence)
● Not attributable to another medical condition and is not better explained by another mental disorder.

Differential Diagnosis

Other major neurocognitive disorders Prion disease – rapid progression and prominent
cerebellar and motor symptoms
Maj/Mild NCD due to Parkinson’s disease

Key features:
● Criteria is met for nCD
● Disturbance occurs in the setting of established Parkinson’s disease
● Insidious onset and gradual progression of impairment
● Not attributable to another medical condition or mental disorder

Major or mild neurocognitive disorder probably due to Parkinson’s disease should be diagnosed if 1 and 2 are both
met. Major or mild neurocognitive disorder possibly due to Parkinson’s disease should be diagnosed if 1 or 2 is
met:
1. There is no evidence of mixed etiology (i.e., absence of other neurodegenerative or cerebrovascular disease or
another neurological, mental, or systemic disease or condition likely contributing to cognitive decline).
2. The Parkinson’s disease clearly precedes the onset of the neurocognitive disorder

Differential Diagnosis

NCDLB NCD due to Parkinson’s – diagnosis of Parkinson’s

disease diagnosis must be present for at least 1 year before
cognitive decline.

Maj/Mild NCD due to Alzheimer’s NCD due to Parkinson’s – motor features

Maj/Mild Vascular NCD NCD due to parkinson’s – parkinsonian features are

typically not enough for a diagnosis of Parkison’s, the
could of the NCD usually has a clear association
cerebrovascular changes.

NCD due to another medical condition NCD due to Parkinson’s – the distinction must also be
made from other brain disorders, such as progressive
supranuclear palsy, corticobasal degeneration, multiple
system atrophy, tumors, and hydrocephalus.

Antipsychotic Antipsychotic (or other dopamine receptor–blocking

drug)–induced parkinsonism – can occur in individuals
with other NCDs, particularly when antipsychotic
medications are prescribed for the behavioral
manifestations of such disorders.

Comorbidity
● Alzheimer’s
● Cerebrovascular dis
● Depression
● Psychosis
● REM sleep behavior disorder
● Apathy
Major/Mild NCD due to Huntington’s

Key features:
● Criteria are met for NCD
● Insidious onset and gradual progression
● Established Huntington’s or risk for Huntington’s in family or genetics.
● Not attributable to another medical condition or mental disorder

Differential Diagnosis

Other mental disorders Early symptoms of Huntington’s disease may include

instability of mood, irritability, or compulsive behaviors
that may suggest another mental disorder. However,
genetic testing or the development of motor symptoms
will distinguish the presence of Huntington’s disease. In
such cases, if the mood symptoms are a focus of clinical
attention, they may be indicated by an additional diagnosis
of depressive disorder due to Huntington’s disease, with
depressive features

Other NCDs The early symptoms of Huntington’s disease, particularly

symptoms of executive dysfunction and impaired
psychomotor speed, may resemble other neurocognitive
disorders (NCDs), such as major or mild vascular NCD

Other movement disorders Huntington’s disease must also be differentiated from

other disorders or conditions associated with chorea, such
as Wilson’s disease, drug-induced tardive dyskinesia,
Sydenham’s chorea, systemic lupus erythematosus, or
senile chorea. Rarely, individuals may present with a
course similar to that of Huntington’s disease but without
positive genetic testing; this is considered to be a
Huntington’s disease phenocopy that results from a variety
of potential genetic factors
Maj/Mild NCD due to another medical condition

Key features:
● Criteria are met for NCD
● Evidence from the history, physical examination, or laboratory findings that the neurocognitive disorder is the
pathophysiological consequence of another medical condition (e.g., multiple sclerosis).
● Not better explained by another mental disorder or another specific NCD

Differential diagnosis

Other maj/mild NCD The presence of an attributable medical condition does not
entirely exclude the possibility of another etiological type
of major or mild NCD. If cognitive deficits persist
following successful treatment of an associated medical
condition, then another etiology may be responsible for
the cognitive decline.
Maj/Mild NCD due to Multiple Etiologies

Key features:
● Criteria is met for NCD
● There is evidence from the history, physical examination, or laboratory findings that the neurocognitive
disorder is the pathophysiological consequence of more than one etiological process, excluding substances
● The cognitive deficits are not better explained by another mental disorder and do not occur exclusively during
the course of a delirium

Unspecified NCD

Key features:
● Do not meet full criteria of NCD
● Precise etiology cannot be determined with sufficient certainty to make an etiological attribution
SUBSTANCE USE DIFFERENTIAL DIAGNOSIS AND COMORBIDITY ONLY

ALCOHOL-RELATED

Alcohol Use Disorder (Diff. Diagnosis)

Non Pathological use of alcohol AUD – use of heavy doses of alcohol with resulting
repeated and significant distress or impaired functioning.
Casual Drinking – even if done daily, in low doses and
occasional intoxication do not by themselves make this
diagnosis

Alcohol Intoxication, alcohol withdrawal, and AUD – problematic patter of alcohol use that involves
alcohol-induced mental disorders impaired control over alcohol use, social impairment,
risky alcohol use and pharmacological symptoms
(development of tolerance or withdrawal)
Alc Intoxication, Withdrawal, and Induced mental
disorders – psychiatric syndromes that develop in the
context of heavy use.

Sedative, Hypnotic, or Anxiolytic use disorder ** the course may be different, especially in relation to
medical problems.

Conduct disorder in childhood and ASPD AUD – (along with other substance-use disorders) may be
seen in the majority of individuals with ASPD.

Comorbidity
● Bipolar
● Schizophrenia
● ASPD
● Depressive Disorders
● Anxiety Disorders
● Predisposition to infections
● Increase risk of cancer

Alcohol Intoxication

Other medical conditions ** several medical and neurological conditions can

temporarily resemble alcohol intoxication.

Alcohol-induced mental disorders Alc Intoxication – the symptoms in these latter disorders
are excess of those usually associated with alcohol
intoxication, predominate in the clinical presentation, and
are severe enough to warrant clinical attention

Sedative, hypnotic, or anxiolytic intoxication Alc Intoxication – smell of alcohol in breath, blood and
breath alcohol levels, medical workup, and history.
Depressant drugs –no smell of alcohol, evidence of
misuse in the blood or urine toxicology analysis.

Comorbidity
● Conduct disorder
● ASPD
● Same with Alcohol Use Disorder
Alcohol Withdrawal

Other medical conditions ** symptoms may be similar to alcohol withdrawal

Essential tremor (usually runs in families) may
erroneously suggest to be associated with alcohol
withdrawal

Alcohol-induced mental disorders Induced mental disorders – the symptoms in these latter
disorders are excess of those usually associated with
alcohol intoxication, predominate in the clinical
presentation, and are severe enough to warrant clinical
attention

Sedative, Hypnotic, or Anxiolytic Withdrawal ** produces a syndrome very similar to that of alcohol
withdrawal

Comorbidity
● Same as AUD
CAFFEINE-RELATED

Caffeine Intoxication

Independent mental disorders Caffeine Intox – symptoms are not associated with
another medical condition or mental disorder.

Caffeine-induced mental disorders Caffeine Intox – onset during intoxication and there is an
excess of those usually enough to warrant independent
clinical attention

Comorbidity
● Anxiety
● Somatic symptoms
● Grand mal symptoms
● Respiratory failure
● Depressive disorders
● Bipolar Disorders
● Eating disorders
● Psychotic Disorders
● Sleep Disorders
● Substance-related disorders

Caffeine withdrawal

Other medical conditions and medication side effects Withdrawal – determination of the pattern and amount
consumed, the time interval between caffeine abstinence
and onset of symptoms, and the particular clinical features
presented by the individual.determination of the pattern
and amount consumed, the time interval between caffeine
abstinence and onset of symptoms, and the particular
clinical features presented by the individual.

Caffeine-induced sleep disorder Induced sleep disorder – the sleep symptoms are in
excess of those usually associated with caffeine
withdrawal, predominate in the clinical presentation, and
are severe enough to warrant clinical attention.

Comorbidity
● MDD
● GAD
● Panic Disorder
● ASPD
● Moderate to Severe alcohol use disorder
● Cannabis & Cocaine use
CANNABIS-RELATED DISORDERS

Cannabis use disorder

Non problematic use of cannabis ** Differentiating nonproblematic use of cannabis and

cannabis use disorder can be challenging because
individuals may not attribute cannabis-related social,
behavioral, or psychological problems to the substance,
especially in the context of polysubstance use.

Cannabis intox, withdrawal, and induced mental CUD – describes a problematic pattern of cannabis use
disorders that involves impaired control over cannabis use, social
impairment due to cannabis use, risky cannabis use, and
pharmacological symptoms
Intoxication, withdrawal and induced mental disorders
– describe psychiatric syndromes that develop in the
context of heavy use.

Comorbidity
● Other substance–use disorder
● Tobacco-use disorder
● MDD
● Bipolar 1 and 2
● Anxiety
● PTSD
● Personality Disorders
● Schizophrenia
● Nausea
● Cyclic vomiting
● Respiratory disorders

Cannabis Intoxication

Other substance intoxication Alcohol, sedative, hypnotic and anxiolytic intox –

frequently decrease appetite, increase aggressive behavior,
and produce nystagmus or ataxia.
Phencyclidine intox – perceptual changes, ataxia,
aggressive behavior

Cannabis-induced mental disorders Induced mental disorders – are in excess of those

usually associated with cannabis intoxication, predominate
in the clinical presentation, and are severe enough to
warrant independent clinical attention.

Comorbidity
● Same with CUD
Cannabis withdrawal

Generally: ensuring that the symptoms are not better explained by

cessation of another substance (e.g., tobacco or alcohol
withdrawal), another mental disorder (generalized anxiety
disorder, major depressive disorder), or another medical
condition.

Comorbidity:
● Depression
● Anxiety
● ASPD
● Same with CUD
HALLUCINOGEN-RELATED DISORDERS

Phencyclidine Use Disorder

Other Substance Use Disorders Distinguishing the effects of phencyclidine from those of
other substances may be important, because phencyclidine
can be an additive to other substances (e.g., cannabis,
cocaine

Phencyclidine intoxication and phencyclidine-induced phencyclidine use disorder describes a problematic

mental disorders pattern of phencyclidine use that involves impaired control
over phencyclidine use, social impairment attributable to
phencyclidine use, risky phencyclidine use (e.g., driving
while intoxicated), and pharmacological symptoms (the
development of tolerance)
phencyclidine intoxication and phencyclidine-induced
mental disorders describe psychiatric syndromes that
occur in the context of heavy use.

Independent mental disorders Some of the effects of phencyclidine use may resemble
symptoms of independent mental disorders, such as
psychosis (schizophrenia); low mood (major depressive
disorder); and violent, aggressive behaviors (conduct
disorder, antisocial personality disorder). Discerning
whether these behaviors occurred before the intake of the
drug is important in the differentiation of acute drug
effects from a preexisting mental disorder.

Comorbidity
● Conduct Disorder
● ASPD
● Other substance use disorders

Other Hallucinogen Use Disorder

Other substance disorders The effects of hallucinogen use must be distinguished

from those of other substances (e.g., amphetamine use
disorder, alcohol or sedative withdrawal), especially
because contamination of the hallucinogens with other
drugs is relatively common.

Hallucinogen intox and induced mental disorders Use disorder – impaired control over hallucinogen use,
social impairment attributable to hallucinogen use, risky
hallucinogen use (e.g., driving while intoxicated), and
pharmacological symptoms (the development of tolerance)
Intoxication – describe psychiatric syndromes that occur
in the context of heavy use

Independent mental disorders ** Intake of drugs before the existing symptoms of mental
disorder

Comorbidity:
● Cocaine, stimulant, other substance use disorder
● Personality, PTSD, and Panic Attacks
Phencyclidine Intoxication

Other substance intox - Nystagmus and bizarre and violent behavior may
distinguish intoxication due to phencyclidine from
that due to other substances
- Toxicological tests

Phencyclidine-induced mental disorders ** in excess of those usually associated with

phencyclidine intoxication

Other medical conditions Medical conditions to be considered include certain

metabolic disorders like hypoglycemia and hyponatremia,
central nervous system tumors, seizure disorders, sepsis,
neuroleptic malignant syndrome, and vascular insults

Comorbidities
● Same with use disorders

Other Hallucinogen Intoxication

Other substance intoxication Other hallucinogen intoxication should be differentiated

from intoxication with amphetamine-type substances,
cocaine, or other stimulants; anticholinergics, inhalants,
and phencyclidine. Toxicological tests are useful in
making this distinction, and determining the route of
administration may also be useful.

Other conditions Other disorders and conditions to be considered include

schizophrenia, depression, withdrawal from other drugs
(e.g., sedatives, alcohol), certain metabolic disorders (e.g.,
hypoglycemia), seizure disorders, tumors of the central
nervous system, and vascular insults.

Hallucinogen persisting perception disorder Other hallucinogen intoxication is distinguished from

Hallucinogen-induced mental disorders. F16.983
hallucinogen persisting perception disorder because the
symptoms in the latter continue episodically or
continuously for weeks (or longer) after the most recent
intoxication

Hallucinogen-induced mental disorders ** are in excess of those usually associated with other
hallucinogen intoxication, predominate in the clinical
presentation, and are severe enough to warrant
independent clinical attention.
Hallucinogen Persisting Perception Disorder

Generally Conditions to be ruled out include schizophrenia, other

drug effects, neurodegenerative disorders, stroke, brain
tumors, infections, and head trauma. Neuroimaging results
in hallucinogen persisting perception disorder cases are
typically negative. As noted earlier, reality testing remains
intact (i.e., the individual is aware that the disturbance is
linked to the effect of the drug); if this is not the case,
another disorder (e.g., psychotic disorder, another medical
condition) might better explain the abnormal perceptions.

Comorbidity:
● Panic Disorder
● Alc Use
● MDD
● Bipolar 1
● Schizophrenia spectrum disorders
INHALANT USE DISORDERS

Inhalant use disorder

Inhalant exposure (unintentional) A diagnosis of inhalant use disorder only applies if the
inhalant exposure is intentional.

Inhalant intoxication, without meeting criteria for use Inhalant intoxication occurs frequently during inhalant use
disorder but also may occur among individuals whose use
does not meet criteria for inhalant use disorder

Inhalant intoxication meeting criteria for use/Inhalant inhalant use disorder describes a problematic pattern of
Induced Disorders inhalant use that involves impaired control over inhalant
use, social impairment attributable to inhalant use, risky
inhalant use (e.g., inhalant use despite medical
complications), and pharmacological symptoms (the
development of tolerance),
inhalant intoxication and inhalant-induced mental
disorders describe psychiatric syndromes that develop in
the context of heavy use.

Other substance use disorders Inhalant use disorder commonly co-occurs with other
substance use disorders, and the symptoms of the disorders
may be similar and overlapping. To disentangle symptom
patterns, it is helpful to inquire about which symptoms
persisted during periods when some of the substances were
not being used.

Comorbidities
● Other substance se
● Mood, Anxiety & Personality Disorders
● ASPD
● Conduct disorder
● Hepatic & renal damage
● rhabdomyolysis, methemoglobinemia, or symptoms of other gastrointestinal, cardiovascular, or pulmonary
diseases

Inhalant Intoxication

Intoxication from other substances ● Toxicology screen

● Lingering odors
● Possession
● Perioral or perinasal

Inhalant- induced mental disorders ** are in excess of those usually associated with inhalant
intoxication, predominate in the clinical presentation, and
are severe enough to warrant independent clinical
attention.

Other toxic, metabolic, traumatic, neoplastic, or Numerous neurological and other medical conditions may
infectious disorders that impair brain function and produce the clinically significant behavioral or
cognition psychological changes (e.g., belligerence, assaultiveness,
apathy, impaired judgment) that also characterize inhalant
intoxication.
OPIOID RELATED DISORDERS

Opioid use disorder

Intoxication, withdrawal and induced mental disorders opioid use disorder describes a problematic pattern of
opioid use that involves impaired control over opioid use,
social impairment attributable to opioid use, risky opioid
use (e.g., continued opioid use despite medical
complications), and pharmacological symptoms (the
development of tolerance or withdrawal),
opioid intoxication, opioid withdrawal, and
opioid-induced mental disorders describe psychiatric
syndromes that occur in the context of heavy use.

Other substance intoxication A diagnosis of alcohol or sedative, hypnotic, or anxiolytic

intoxication can usually be made based on the absence of
pupillary constriction or the lack of a response to naloxone
challenge. In some cases, intoxication may be due both to
opioids and to alcohol or other sedatives.

Other Withdrawal disorders ● Rhinorrhea

● Lacrimation
● Pupillary dilation

Opioid (there is no…):

● Nausea
● Vomiting
● Abdominal cramps
● Rhinorrhea
● Lacrimation

Independent mental disorders Some of the effects of opioid use may resemble symptoms
(e.g., depressed mood) of an independent mental disorder
(e.g., persistent depressive disorder). Opioids are less
likely to produce symptoms of mental disturbance than are
most other drugs of abuse

Comorbidities
● Viral and basterial infections
● PDD
● MDD
● Bipolar 1
● PTSD
● ASPD
● BPD
● Schizotypal
Opioid Intoxication

Other substance intoxication A diagnosis of alcohol or sedative-hypnotic intoxication

can usually be made based on the absence of pupillary
constriction or the lack of a response to a naloxone
challenge.

Opioid induced mental disorders ** are in excess of those usually associated with opioid
intoxication, predominate in the clinical presentation, and
are severe enough to warrant clinical attention.

Opioid withdrawal

Other withdrawal disorders The anxiety and restlessness associated with opioid
withdrawal resemble symptoms seen in sedative-hypnotic
withdrawal. However, opioid withdrawal is also
accompanied by rhinorrhea, lacrimation, and pupillary
dilation, which are not seen in sedative type withdraw

Other substance intoxication Dilated pupils are also seen in hallucinogen intoxication
and stimulant intoxication. However, other signs or
symptoms of opioid withdrawal, such as nausea, vomiting,
diarrhea, abdominal cramps, rhinorrhea, and lacrimation,
are not present.

Opioid induced mental disorders ** are in excess of those usually associated with opioid
withdrawal, predominate in the clinical presentation, and
are severe enough to warrant clinical attention.
SEDATIVE, HYPNOTIC, & ANXIOLYTIC RELATED DISORDERS

SHA Use Disorder

Sedative, hypnotic, or anxiolytic intoxication; sedative, Use dis – describes a problematic pattern 626 of sedative,
hypnotic, or anxiolytic withdrawal; and sedative-, hypnotic, or anxiolytic use that involves impaired control
hypnotic-, or anxiolytic-induced mental disorders over such use; social impairment attributable to this use
Induced mental disorders – describe psychiatric
syndromes that occur in the context of heavy use

Other medical conditions The slurred speech, incoordination, and other associated
features characteristic of sedative, hypnotic, or anxiolytic
intoxication could be the result of another medical
condition (e.g., multiple sclerosis) or of a prior head
trauma (e.g., a subdural hematoma).

Alcohol use disorder Sedative, hypnotic, or anxiolytic use disorder must be

differentiated from alcohol use disorder. The differential
diagnosis is determined mostly through clinical history,
although liver damage and other potential signs of chronic
alcohol toxicity (e.g., cardiomyopathy) can also be more
suggestive of alcohol use disorder than of sedative,
hypnotic, or anxiolytic use disorder.

Clinically recommended Individuals may continue to take benzodiazepine

medication according to a physician’s direction for a
legitimate medical indication over extended periods of
time. Even if physiological signs of tolerance or
withdrawal are manifested, many of these individuals do
not develop symptoms that meet the criteria for sedative,
hypnotic, or anxiolytic use disorder because they are not
preoccupied with obtaining the substance and its use does
not interfere with their performance of usual social or
occupational roles.

Comorbidity
● Alc, Tobacco Use Dis
● ASPD
● Bipolar
● Depressive
● Anxiety
SHA Intoxication

Alcohol use Because the clinical presentations may be identical,

distinguishing sedative, hypnotic, or anxiolytic
intoxication from alcohol use disorder requires evidence
for recent ingestion of sedative, hypnotic, or anxiolytic
medications by self-report, informant report, or
toxicological testing. Many individuals who misuse
sedatives, hypnotics, or anxiolytics may also misuse
alcohol and other substances, and so multiple intoxication
diagnoses are possible.

Alcohol Intoxication Alcohol intoxication may be distinguished from sedative,

hypnotic, or anxiolytic intoxication by the smell of alcohol
on the breath. Otherwise, the features of the two disorders
may be similar.

SHA Induced mental disorders Sedative, hypnotic, or anxiolytic intoxication is

distinguished from sedative-, hypnotic-, or
anxiolytic-induced mental disorders (e.g., sedative-,
hypnotic-, or anxiolytic-induced anxiety disorder, with
onset during withdrawal) because the symptoms (e.g.,
anxiety) in the latter disorders are in excess of those
usually associated with sedative, hypnotic, or anxiolytic
intoxication; predominate in the clinical presentation; and
are severe enough to warrant clinical attention.

Neurocog In situations of cognitive impairment, traumatic brain

injury, and delirium from other causes, sedatives,
hypnotics, or anxiolytics may be intoxicating at quite low
dosages. The differential diagnosis in these complex
settings is based on the predominant syndrome. An
additional diagnosis of sedative, hypnotic, or anxiolytic
intoxication may be appropriate even if the substance has
been ingested at a low dosage in the setting of these other
(or similar) co-occurring conditions
SHA Withdrawal

Other medical conditions The symptoms of sedative, hypnotic, or anxiolytic

withdrawal may be mimicked by other medical conditions
(e.g., hypoglycemia, diabetic ketoacidosis). If seizures are
a feature of the sedative, hypnotic, or anxiolytic
withdrawal, the differential diagnosis includes the various
causes of seizures (e.g., infections, head injury,
poisonings).

Essential tremor Essential tremor, a neurological condition that frequently

runs in families, may erroneously suggest the
tremulousness associated with sedative, hypnotic, or
anxiolytic withdrawal.

Alc Withdrawal Alcohol withdrawal produces a syndrome very similar to

that of sedative, hypnotic, or anxiolytic withdrawal. The
differential diagnosis is determined mostly through
clinical history, although liver damage and other potential
signs of chronic alcohol toxicity (e.g., cardiomyopathy)
can also be more suggestive of alcohol withdrawal than of
sedative, hypnotic, or anxiolytic withdrawal.

SHA Induced mental disorders Sedative, hypnotic, or anxiolytic withdrawal is

distinguished from sedative-, hypnotic-, or
anxiolytic-induced mental disorders (e.g., sedative-,
hypnotic-, or anxiolytic-induced anxiety disorder, with
onset during withdrawal) because the symptoms (e.g.,
anxiety) in the latter disorders are in excess of those
usually associated with sedative, hypnotic, or anxiolytic
withdrawal; predominate in the clinical presentation; and
are severe enough to warrant clinical attention.

Anxiety Recurrence or worsening of an underlying anxiety

disorder produces a syndrome similar to sedative,
hypnotic, or anxiolytic withdrawal, although the most
extreme manifestations of withdrawal, such as delirium
tremens or true seizures, are not symptoms of any anxiety
disorder. Withdrawal would be suspected with an abrupt
reduction in the dosage of a sedative, hypnotic, or
anxiolytic medication. When a taper is under way,
distinguishing the withdrawal syndrome from the
underlying anxiety disorder can be difficult. As with
alcohol, lingering withdrawal symptoms (e.g., anxiety,
moodiness, trouble sleeping) can be mistaken for
independent anxiety or depressive disorders (e.g.,
generalized anxiety disorder).
STIMULANT RELATED DISORDERS

Stimulant Use Disorder

Phencyclidine intoxication Intoxication with phencyclidine (PCP or “angel dust”) or

synthetic “designer drugs” such as mephedrone (known by
different names, including “bath salts”) may cause a
similar clinical picture and can only be distinguished from
stimulant intoxication by the presence of cocaine or
amphetamine-type substance metabolites in a urine or
plasma sample

Stimulant intoxication, stimulant withdrawal, and stimulant use disorder describes a problematic pattern of
stimulant-induced mental disorders. stimulant use that involves impaired control over stimulant
use, social impairment attributable to stimulant use, risky
stimulant use (e.g., continued stimulant use despite
medical complications), and pharmacological symptoms
(the development of tolerance or withdrawal),
Stimulant intoxication, stimulant withdrawal, and
stimulant-induced mental disorders describe psychiatric
syndromes that occur in the context of heavy use.

Independent mental disorder Some of the effects of stimulant use may resemble
symptoms of independent mental disorders, such as
psychosis (schizophrenia) and low mood (major
depressive disorder). Discerning whether these behaviors
occurred before the intake of the drug is important in the
differentiation of acute drug effects from a preexisting
mental disorder.

Comorbidities
● Cocaine use
● PTSD
● ASPD
● ADHD
● Gambling Disorder
● Cardiopulmonary problems
Stimulant Intoxication

Stimulant-induced mental disorders Stimulant intoxication is distinguished from

stimulant-induced mental disorders (e.g.,
stimulant-induced anxiety disorder, with onset during
intoxication) because the symptoms (e.g., anxiety) in the
latter disorders are in excess of those usually seen in
stimulant intoxication, predominate in the clinical
presentation, and meet full criteria for the relevant
disorder.

Independent mental disorders Salient mental disturbances associated with stimulant

intoxication should be distinguished from the symptoms of
schizophrenia, bipolar and depressive disorders,
generalized anxiety disorder, and panic disorder as
described in this manual.

Stimulant Withdrawal

Stimulant-induced mental disorders. Stimulant withdrawal is distinguished from

stimulant-induced mental disorders (e.g.,
stimulant-induced depressive disorder, with onset during
withdrawal) because the symptoms (e.g., depressed mood)
in these latter disorders are in excess of those usually
associated with stimulant withdrawal, predominate in the
clinical presentation, and are severe enough to warrant
clinical attention
TOBACCO RELATED DISORDERS

Tobacco use disorders

Comorbidity
● Cardiovascular illness
● COPD
● Cancers
● MDD
● Bipolar
● Anxiety
● Personality
● ADHD
● PAnic disorder
● GAD
● PTSD
● BPD
● ASPD

Tobacco Withdrawal

Generally The symptoms of tobacco withdrawal overlap with those

of other substance withdrawal syndromes (e.g., alcohol
withdrawal; sedative, hypnotic, or anxiolytic withdrawal;
stimulant withdrawal; caffeine withdrawal; opioid
withdrawal); caffeine intoxication; anxiety, depressive,
bipolar, and sleep disorders; and medication-induced
akathisia. Admission to smoke-free inpatient units or
voluntary smoking cessation can induce withdrawal
symptoms that mimic, intensify, or disguise other
disorders or adverse effects of medications used to treat
mental disorders (e.g., irritability thought to be due to
alcohol withdrawal could be due to tobacco withdrawal).
Reduction in symptoms with the use of nicotine confirms
the diagnosis.
OTHER OR UNKNOWN SUBSTANCE RELATED DISORDERS

Other or Unknown Substance Use Disorder

Use of other or unknown substances without meeting Use of unknown substances is not rare among adolescents,
criteria for other (or unknown) substance use disorder. but most use does not meet the diagnostic standard of two
or more criteria for other (or unknown) substance use
disorder in a 12-month period.

Substance use disorders Other (or unknown) substance use disorder may co-occur
with various substance use disorders that involve any of
the nine substance classes presented earlier in this chapter,
and the symptoms of the disorders may be similar and
overlapping. To disentangle symptom patterns, it is helpful
to inquire about which symptoms persisted during periods
when some of the substances were not being used

Other (or unknown) substance intoxication, other (or substance use disorder describes a problematic pattern
unknown) substance withdrawal, and other (or of use of the other (or unknown) substance that involves
unknown) substance–induced mental disorders. impaired control over the use of the substance, social
impairment attributable to use of the substance, risky use
of the substance (e.g., continued use despite medical
complications), and pharmacological symptoms
substance intoxication, other (or unknown) substance
withdrawal, and other (or unknown)
substance-induced mental disorders describe psychiatric
syndromes that occur in the context of heavy use.

Other or Unknown Substance Intoxication

Use of other or unknown substance, without meeting The individual used an other or unknown substance(s), but
criteria for other (or unknown) substance intoxication the dose was insufficient to produce symptoms that meet
the diagnostic criteria required for the diagnosis.

Substance intoxication or other Familiar substances may be sold in the black market as
substance/medication-induced mental disorders. novel products, and individuals may experience
intoxication from those substances. History, toxicology
screens, or chemical testing of the substance itself may
help to identify it. Other substance intoxication is
distinguished from other substance/medication-induced
mental disorders (e.g., corticosteroid-induced anxiety
disorder) because the symptoms (e.g., anxiety) in these
latter disorders are in excess of those (if known) usually
associated with the specific substance intoxication,
predominate in the clinical presentation, and are severe
enough to warrant clinical attention.

Other toxic, metabolic, traumatic, neoplastic, vascular, Numerous neurological and other medical conditions may
or infectious disorders that impair brain function and produce rapid onset of signs and symptoms mimicking
cognition. those of intoxications, including the examples in Criterion
B. Paradoxically, drug withdrawals also must be ruled out;
for example, lethargy may indicate withdrawal from one
drug or intoxication with another substance.
Other or Unknown Substance Withdrawal

Dose reduction after extended dosing, but not meeting The individual used other (or unknown) substances, but
the criteria for other (or unknown) substance the dose that was used was insufficient to produce
withdrawal. symptoms that meet the criteria required for the
withdrawal diagnosis.

Substance withdrawal or other Familiar substances may be sold in the black market as
substance/medication-induced mental disorders. novel products, and individuals may experience
withdrawal when discontinuing those substances. History,
toxicology screens, or chemical testing of the substance
itself may help to identify it. Other substance withdrawal
is distinguished from other substance/medication-induced
mental disorders (e.g., venlafaxine induced anxiety
disorder, with onset during withdrawal) because the
symptoms (e.g., anxiety) in these latter disorders are in
excess of symptoms (if known) usually associated with the
specific substance withdrawal, predominate in the clinical
presentation, and are severe enough to warrant clinical
attention.

Other toxic, metabolic, traumatic, neoplastic, vascular, Numerous neurological and other medical conditions may
or infectious disorders that impair brain function and produce rapid onset of signs and symptoms mimicking
cognition those of withdrawals. Paradoxically, drug intoxications
also must be ruled out; for example, lethargy may indicate
withdrawal from one drug or intoxication with another
substance.
NON SUBSTANCE RELATED DISORDERS
Gambling Disorder

Nondisordered gambling Gambling disorder must be distinguished from

professional and social gambling. In professional
gambling, risks are limited and discipline is central. Social
gambling typically occurs with friends or colleagues and
lasts for a limited period of time, with acceptable losses.
Some persons can experience problems associated with
gambling (e.g., short-term chasing behavior and loss of
control) that do not meet the full criteria for gambling
disorder

Manic episode Loss of judgment and excessive gambling may occur

during a manic episode. An additional diagnosis of
gambling disorder should be given only if the gambling
behavior is not better explained by manic episodes (e.g., a
history of maladaptive gambling behavior at times other
than during a manic episode). Alternatively, an individual
with gambling disorder may during a period of gambling,
exhibit behavior that resembles a manic episode, but once
the individual is away from the gambling, these manic-like
features dissipate.

Personality disorders Problems with gambling may occur in individuals with

antisocial personality disorder and other personality
disorders. If the criteria are met for both disorders, both
can be diagnosed.

Gambling symptoms due to dopaminergic medications. Some individuals taking dopaminergic medications (e.g.,
for Parkinson‘s disease) may experience urges to gamble
that might be distressing or impairing enough to meet
criteria for gambling disorder. In such cases, a diagnosis of
gambling disorder would be warranted.

Comorbidity
● Other substance use
● Tobacco use
● Depressive
● Anxiety
● Personality Dis
● Bipolar
 SUBSTANCE-RELATED and ADDICTIVE DISORDERS

DISORDER SIGNS AND SYMPTOMS DIAGNOSIS ONSET TREATMENT

1. Alcohol- Related Disorders
Mid- teens; Alcohol related
problems that do not meet full Three general steps are involved in treating
1. Alcohol Use Disorder See Substance Use Disorder Criteria
criteria may occur prior to age the alcoholic person after the disorder has
20 years been diagnosed:
1. Slurred speech
2. Incoordination 1. Intervention:
One or more signs and symptoms Average age onset:15 years
3. Unsteady gait - The goal is to break through feelings of
2. Alcohol Intoxication developing during, or shortly after, Highest prevalence: 18-25
4. Nystagmus denial and help the patient recognize the
caffeine use years
5. Impairment in attention/memory adverse consequences likely to occur if the
6. Stupor/ coma disorder is not treated
- Convincing patients that they are
responsible for their own actions while
reminding them of how alcohol has created
significant life impairments.
- Family can be a great help in the
intervention by learning not to protect the
patient from the problems caused by the
alcohol

2. Detoxification
1. Autonomic hyperactivity
- Mild/Moderate Withdrawal
2. Increased hand tremor
- Severe Withdrawal
3. Insomnia
- Protracted Withdrawal
4. Nausea/ vomiting Two or more signs and symptoms
Relatively rare in individuals
3. Alcohol Withdrawal 5. Transient visual, tactile, or auditory developing within several hours to a few
younger than 30 years 3. Rehabilitation
hallucinations/ illusions days
- continued efforts to increase and maintain
6. Psychomotor agitation
high levels of motivation for abstinence
7. Anxiety
- work to help the patient readjust to a lifestyle
8. Generalized tonic-clonic seizures
free of alcohol
- Relapse prevention: the counselor must help
the patient develop modes of coping to be
used when the craving for alcohol increases/
return
- Counselling (may be group/individual)
efforts in the first several months should focus
on day-to-day life issues to help patients
maintain a high level of motivation for
abstinence and to enhance their functioning

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 SUBSTANCE-RELATED and ADDICTIVE DISORDERS

- Medications
2. Caffeine- Related Disorders
1. Restlessness.
2. Nervousness.
3. Excitement.
4. Insomnia.
5. Flushed face.
Five or more of the following signs or
6. Diuresis. Pharmacotherapy
4. Caffeine Intoxication symptoms developing during, or shortly
7. Gastrointestinal disturbance.
after, caffeine use
8. Muscle twitching. The first step in reducing/eliminating caffeine
9. Rambling flow of thought and speech. use is to have patients determine their daily
10. Tachycardia or cardiac arrhythmia. All ages consumption of caffeine
11. Periods of inexhaustibility.
12. Psychomotor agitation. The patient and clinician should then decide
1. Headache. on a fading schedule for caffeine
2. Marked fatigue or drowsiness. consumption
3. Dysphoric mood, depressed mood, or
Followed within 24 hours by three or
5. Caffeine Withdrawal irritability.
more of the following signs or symptoms
4. Difficulty concentrating.
5. Flu-like symptoms (nausea, vomiting, or
muscle pain/stiffness).
3. Cannabis- Related Disorders

6. Cannabis Use Disorder See Substance Use Disorder Criteria Abstinence can be achieved through direct
intervention, such as hospitalization, or
1. Conjunctival injection. through careful monitoring on an outpatient
Two or more following of the signs or
2. Increased appetite. basis by the use of urine drug screens, which
7. Cannabis Intoxication symptoms developing within 2 hours of
3. Dry mouth. can detect cannabis for up to 4 weeks after use
cannabis use
4. Tachycardia.
Support can be achieved through the use of
1. Irritability, anger, or aggression. Adolescence or young
individual, family, and group psychotherapy
2. Nervousness or anxiety. adulthood
3. Sleep difficulty (e.g., insomnia, disturbing
Education should be a cornerstone for both
dreams). Three or more of the following signs and
abstinence and support programs
8. Cannabis Withdrawal 4. Decreased appetite or weight loss. symptoms develop within approximately
5. Restlessness. 1 week
A patient who does not understand the
6. Depressed mood.
intellectual reason for addressing a substance-
7. At least one of the following physical
abuse problem has little motivation to stop
symptoms causing significant discomfort:

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 SUBSTANCE-RELATED and ADDICTIVE DISORDERS

abdominal pain, shakiness/tremors, Pharmacotherapy, such as antianxiety drug,

sweating, fever, chills, or headache. for short- term relief

4. Hallucinogen- Related Disorders

9. Phencyclidine Use Disorder See Substance Use Disorder Criteria
1. Vertical or horizontal nystagmus.
2. Hypertension or tachycardia.
3. Numbness or diminished responsiveness
to pain.
Within 1 hour, two or more of the
10. Phencyclidine Intoxication 4. Ataxia. No drug is known to function as a direct PCP
following signs and symptoms
5. Dysarthria. antagonist
6. Muscle rigidity.
7. Seizures or coma. A basic principle in treatment is providing
Age onset is unknown
8. Hyperacusis. reassurance and supportive care.
11. Other Hallucinogen Use
See Substance Use Disorder Criteria Note: When the drug is
Disorder Can be helped by a quiet environment
smoked, “snorted”, or used
1. Pupillary dilation.
intravenously, the onset may be
2. Tachycardia. Pharmacotherapy
rapid
3. Sweating.
12. Other Hallucinogen Two or more of the following signs
4. Palpitations.
Intoxication developing during, or shortly after
5. Blurring of vision.
6. Tremors.
7. Incoordination.
1. Correct identification of the disorder
13. Hallucinogen Persisting re-experiencing of one or more of the
Perception Disorder perceptual symptoms that were experienced while intoxicated with the hallucinogen Pharmacological approaches and
antipsychotic agents
5. Inhalant- Related Disorder
Inhalant intoxication usually requires no
14. Inhalant Use Disorder See Substance Use Disorder Criteria medical attention and resolves spontaneously.
However, the effects of the intoxication
1. Dizziness. (physical effects) need treatment
2. Nystagmus.
3. Incoordination. 12- 17 years Day treatment and Residential Programs,
Two (or more) of the following signs or
4. Slurred speech. especially for adolescent abusers with
15. Inhalant Intoxication symptoms developing during, or shortly
5. Unsteady gait. combined substance dependence and other
after
6. Lethargy. psychiatric disorders
7. Depressed reflexes.
8. Psychomotor retardation. Treatment usually lasts 3-12 months

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 SUBSTANCE-RELATED and ADDICTIVE DISORDERS

9. Tremor.
10. Generalized muscle weakness.
11. Blurred vision or diplopia.
12. Stupor or coma.
13. Euphoria.

6. Opioid- Related Disorders

Overdose treatment
16. Opioid Use Disorder See Substance Use Disorder Criteria
Medically Supervised Withdrawal and
Pupillary constriction (or pupillary Detoxification
dilation due to anoxia from severe - Opioid Agents such as Methadone
overdose) and - Opioid substitutes
1. Drowsiness or coma. one (or more) of the following signs or
17. Opioid Intoxication 2. Slurred speech. symptoms developing during, or shortly Pregnant Women with Opioid Dependence
3. Impairment in attention or memory. after - Neonatal addiction is a significant problem

Specify if: with/without perceptual Psychotherapy

disturbances - Individual psychotherapy, Behavioral
Can begin at any age, but are
psychotherapy, cognitive- behavioral
most common in the late teens
therapy, family therapy, support groups, and
or early 20s
1. Dysphoric mood. social skills training
2. Nausea or vomiting.
3. Muscle aches. Therapeutic Communities
4. Lacrimation or rhinorrhea. - Abstinence is the rule
5. Pupillary dilation, piloerection, or Three (or more) of the following - To be admitted, a person must show a high
18. Opioid Withdrawal
sweating. developing within minutes to several days level of motivation
6. Diarrhea. - Education and Needle Exchange
7. Yawning.
8. Fever. Narcotic Anonymous
9. Insomnia. - Self- help group of abstinent drug addicts
modelled on the 12-step principles of
Alcoholics Anonymous
7. Sedative, Hypnotic, or Anxiolytic Related Disorders
19. Sedative, Hypnotic, or Medications
See Substance Use Disorder Criteria
Anxiolytic Use Disorder
1. Slurred speech. One (or more) of the following signs or Teens or 20s Overdose
20. Sedative, Hypnotic, or
2. Incoordination. symptoms developing during, or shortly - The patients should be kept from slipping
Anxiolytic Intoxication
3. Unsteady gait. after into unconsciousness

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 SUBSTANCE-RELATED and ADDICTIVE DISORDERS

4. Nystagmus. - Hospitalization
5. Impairment in cognition
6. Stupor or coma. Expert Opinion
1. Autonomic hyperactivity (e.g., sweating
or pulse rate greater than 100 bpm).
2. Hand tremor.
3. Insomnia.
Two (or more) of the following,
21. Sedative, Hypnotic, or 4. Nausea or vomiting.
developing within several hours to a few
Anxiolytic Withdrawal 5. Transient visual, tactile, or auditory
days after the cessation
hallucinations or illusions.
6. Psychomotor agitation.
7. Anxiety.
8. Grand mal seizures.
8. Stimulant- Related Disorders
22. Stimulant Use Disorder See Substance Use Disorder Criteria Physicians should establish a therapeutic
1. Tachycardia or bradycardia. alliance with patients to deal with the
2. Pupillary dilation. underlying depression, personality disorders,
3. Elevated or lowered blood pressure. or both. Because many patients are heavily
4. Perspiration or chills. dependent on the drug, however
5. Nausea or vomiting. psychotherapy may be especially difficult
Two (or more) of the following signs or
6. Evidence of weight loss.
23. Stimulant Intoxication symptoms, developing during, or shortly
7. Psychomotor agitation or retardation. Detoxification
after
8. Muscular weakness, respiratory
depression, chest pain, or cardiac Psychosocial Therapy
arrhythmias. - Individual therapy focuses on the dynamics
9. Confusion, seizures, dyskinesias, leading to stimulant use, the perceived
dystonias, or coma. positive effects, and other ways to achieve
12- 25 years
these effects
- Group therapy and other support groups
focuses on discussions with other persons
who use stimulants and on sharing
1. Fatigue. experiences and effective coping methods
Dysphoric mood and two (or more) of the
2. Vivid, unpleasant dreams. - Family therapy is often an essential
following physiological changes,
24. Stimulant Withdrawal 3. Insomnia or hypersomnia. component of the treatment strategy.
developing
4. Increased appetite. Common issues discussed in family therapy
within a few hours to several days
5. Psychomotor retardation or agitation. are the ways the patient’s past behavior has
harmed the family and the responses of family
members to these behaviors. The therapy
should also focus on the future and on
changes in the family’s activities that may

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 SUBSTANCE-RELATED and ADDICTIVE DISORDERS

help the patient stay off the drug and direct

energies in different directions

Network Therapy
- Uses both psychodynamic and cognitive-
behavioral approaches to individual therapy,
while engaging the patient in a group support
(composed of family and peers) network

Pharmacological adjuncts
9. Tobacco- Related Disorders
Psychosocial Therapies
25. Tobacco Use Disorder See Substance Use Disorder Criteria - Behavior therapy, skills training and relapse
prevention
1. Irritability, frustration, or anger. - Stimulus control
2. Anxiety. Abrupt cessation of tobacco use, or - Aversive Therapy make smokers smoke
18 years
3. Difficulty concentrating. reduction in the amount of tobacco used, repeatedly. (Requires a good therapeutic
26. Tobacco Withdrawal 4. Increased appetite. followed alliance)
5. Restlessness. within 24 hours by four (or more) of the - Psychopharmacological Therapies,
6. Depressed mood. following signs or symptoms Combined Psychosocial and Pharmacological
7. Insomnia. therapy
10. Other (or unknown) Substance Use Disorder
27. Other (or unknown) Psychosocial support systems
See Substance Use Disorder Criteria
Substance Use Disorder
28. Other (or unknown) No single pattern of 2 major treatments for substance abuse
See Substance Intoxication Criteria
Substance Intoxication development - Abstinence from substance
29. Other (or unknown) - Physical, psychiatric, and psychosocial
See Substance Withdrawal Criteria well- being of the patient
Substance Withdrawal
Non- Substance- Related Disorders
Gamblers seldom come forward voluntarily
1. Needs to gamble with increasing amounts
Persistent and recurrent problematic to be treated.
of money in order to achieve the desired
gambling behavior leading to clinically
excitement.
significant Legal difficulties, family pressures, or other
2. Is restless or irritable when attempting to
impairment or distress, as indicated by the Can occur during adolescence psychiatric complaints bring gamblers to
30. Gambling Disorder cut down or stop gambling.
individual exhibiting four (or more) of the or young adulthood treatment
3. Has made repeated unsuccessful efforts to
following
control, cut back, or stop gambling.
in a 12-month period: Gamblers Anonymous is a method of
4. Is often preoccupied with gambling
inspirational group therapy that involves
5. Often gambles when feeling distressed
public confessions, peer pressure, and the

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 SUBSTANCE-RELATED and ADDICTIVE DISORDERS

6. After losing money gambling, often returns presence of reformed gamblers available to
another day to get even help members resist the impulse to gamble.
7. Lies to conceal the extent of involvement
with gambling. Hospitalization may help by removing
8. Has jeopardized or lost a significant patients from their environments
relationship, job, or educational or career
opportunity because of gambling. Insight- oriented psychotherapy should not be
9. Relies on others to provide money to sought until patients have been away from
relieve desperate financial situations caused gambling for 3 months
by gambling.
Family therapy is often valuable

Cognitive- behavioral therapy (e.g. relaxation

techniques combined with visualization of
gambling avoidance) has had some success

Psychopharmacological treatment, once

largely unsuccessful, now plays a significant
role in the management of pathological
gamblers
1. preoccupation with Internet games
2. Withdrawal symptoms
3. Tolerance – the need to spend increasing
amounts of time
4. Unsuccessful attempts to control Persistent and recurrent use of the
5. Loss of interest in previous hobbies and Internet to engage in games, often with
entertainment other players, leading to clinically
31. Internet Gaming Disorder
6. continued use despite psychosocial significant impairment or distress as
problem indicated by five or more of the following
7. deception of people regarding the amount in a 12-month period
of Internet gaming
8. using to escape or relieve a negative mood
9. jeopardized or lost a significant major area
in life
A. more than minimal exposure to alcohol Criteria A, one in B, C, and two in D, one
32. Neurobehavioral Disorder
during gestation, including prior to pregnancy of which must be communication deficit
Associated with Prenatal
recognition or impairment in social communication
Alcohol Exposure
and interaction

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 SUBSTANCE-RELATED and ADDICTIVE DISORDERS

B. Impaired neurocognitive functioning as

manifested by one or more following
impairments
1. global intellectual performance
2. executive functioning
3. Learning
4. memory
5. Visual-spatial reasoning

C. Impaired self-regulation as manifested by

one or more:
1. impairment in mood or behavioral
regulation
2. attention deficit
3. impairment in impulse control

D. Impairment in adaptive functioning as

manifested by two or more, one of which
must be (1) or (2)
1. communication deficit
2. Impairment in social communication and
interaction
3. impairment in daily living skills
4. impairment in motor skills

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 SUBSTANCE-RELATED and ADDICTIVE DISORDERS

SUBSTANCE USE DISORDER

A problematic pattern of substance use leading to clinically significant impairment or distress, as manifested by at least two of the following, occurring within a 12- month period.

Impaired Control Social Impairment Risky Use of the Substance Pharmacological criteria

Criterion 1. The individual may take the Criterion 5. Recurrent substance use Criterion 8. This may take the form of recurrent substance Criterion 10. Tolerance is signalled by requiring a markedly
substance in larger amounts of over a longer may result in a failure to fulfil major use in situations in which it is physically hazardous increased dose of the substance to achieve the desired effect or a
period than was originally intended role obligation at work, school, or markedly reduced effect when the usual dose is consumed
home Criterion 9. The individual may continue substance use
Criterion 2. The Individual may express a despite knowledge of having a persistent or recurrent physical Criterion 11. Withdrawal is a syndrome that occurs when blood or
persistent desire to cut down or regulate Criterion 6. The individual may or psychological problem that is likely to have been caused tissue concentration of a substance decline in an individual who had
substance use and may report multiple continue substance use despite having or exacerbated by the substance. The key issue in evaluating maintained prolonged heavy use of the substance. After developing
unsuccessful efforts to decrease or discontinue persistent or recurrent social or this criterion is not the existence of the problem, but rather withdrawal symptoms, the individual is likely to consume the
use interpersonal problems caused or the individual’s failure to abstain from using the substance substance to relieve the symptoms
exacerbated by the effects of the despite the difficulty it is causing
Criterion 3. The individual may spend a great substance
deal of time obtaining the substance, using the
substance, or recovering from its effects. In
some instances of more severe substance use
disorders, virtually all of the individual’s daily
activities revolve around the substance

Criterion 4. Craving is manifested by an

increase desire or urge for the drug that may
occur at any time but is more likely when in an
environment where the drug previously was
obtained or used

SUBSTANCE INTOXICATION SUBSTANCE WITHDRAWAL SEVERITY SPECIFIERS

Criterion A. The essential feature is the development of Criterion A. The essential feature is the development of a Mild: 2 or 3 symptoms Early Remission: >3 months, <12 months
a reversible substance- specific syndrome due to the substance- specific sections of behavioral change, with Moderate: 4-5 symptoms
recent ingestion of a substance physiological and cognitive concomitants, that is due to the Severe: 6 or more symptoms Sustained Remission: after full criteria were
cessation or reduction in heavy and prolonged substance use previously met, none of the criteria have been met
Criterion B. The clinically significant problematic during a period of 12 months
behavioral or psychological changes associated with
intoxication are attributable to the physiological effects of Controlled Environment: substance is restricted
the substance on the central nervous system and develop With/Without Perceptual Disturbances: Rare
during or shortly after use of the substance instance when hallucinations occur with intact
reality testing, or auditory, visual or tactile
illusions occur in the absence of a delirium

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