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Social Communication Disorder Diagnostic 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, such as greeting and sharing information, in a manner that is appropriate for the social context.
::::::::::::::2. Impairment of the ability to change communication to match context or the needs of the listener, such as speaking differently in a classroom than on a playground,
talking differently to a child than to an adult, and avoiding use of overly formal language.
::::::::::::::3. Difficulties following rules for conversation and storytelling, such as taking turns in conversation, rephrasing when misunderstood, and knowing how to use verbal and nonverbal signals to regulate interaction.
::::::::::::::4. Difficulties understanding what is not explicitly stated (e.g., making inferences) and nonliteral or ambiguous meanings of language (e.g., idioms, humor, metaphors, multiple meanings that depend on the context for interpretation).
B. The 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 (but deficits may not become fully manifest until social communication demands exceed limited capacities).
D. The symptoms are not attributable to another medical or neurological condition or to low abilities in the domains of word structure and grammar, and are not better explained by autism spectrum disorder, intellectual developmental disorder (intellectual disability), global developmental delay, or another mental disorder.Associated Features & Development
The most common associated feature of social (pragmatic) communication disorder is language impairment, which is characterized by a history of delay in reaching language milestones, and historical, if not current, structural language problems. Individuals with social communication deficits may avoid social interactions.
Milder forms of the disorder may not become apparent until early adolescence, when language and social interactions become more complex. The outcome of social (pragmatic) communication disorder is variable, with some children improving substantially over time and others continuing to have difficulties persisting into adulthood. Even among those who have significant improvements, the early deficits in pragmatics may cause lasting impairments in social relationships and behavior and also low performance of other related skills, such as written expression, reading comprehension, and oral reading.Differential Diagnoses
Autism Spectrum Disorder: Autism spectrum disorder is the primary diagnostic consideration for
individuals presenting with social communication deficits. The two disorders can be differentiated by the presence in autism spectrum disorder of restricted/repetitive patterns of behavior, interests, or activities and their absence in social communication disorder. Individuals with autism spectrum disorder may only display the restricted/repetitive patterns of behavior, interests, and activities during the early developmental period, so a comprehensive history should be obtained. Current absence of symptoms would not preclude a diagnosis of autism spectrum disorder, if the restricted interests and repetitive behaviors were present in the past. A diagnosis of social communication disorder should be considered only if the current symptoms or developmental history fails to reveal evidence of symptoms that meet the diagnostic criteria for restricted/repetitive patterns of behavior, interests, or activities of autism spectrum disorder (i.e., Criterion B) causing current impairment. The social communication symptoms may be milder in social (pragmatic) communication disorder than in autism spectrum disorder, although qualitatively similar.

ADHD: Primary deficits of ADHD may cause impairments in social communication and functional limitations of effective communication, social participation, or academic achievement.

Social Anxiety Disorder: The symptoms of social communication disorder overlap with those of social anxiety disorder. The differentiating feature is the timing of the onset of symptoms. In social
communication disorder, the individual has never had effective social communication; in social anxiety disorder, the social communication skills developed appropriately but are not utilized because of anxiety, fear, or distress about social interactions.Comorbid Disorders
Attention-deficit/hyperactivity disorder (ADHD), emotional and behavioral problems, and specific learning disorders are also more common among affected individuals.←

Autism Spectrum Disorder Diagnostic Criteria
A. Persistent deficits in social communication and social interaction across multiple contexts, as manifested by all of the following, currently or by history:
::::::::::::::1. Deficits in social-emotional reciprocity: for example, in young children with little or no initiation of social interaction and no sharing of emotions, along with reduced or absent imitation of others’ behavior. What language exists is often one-sided, lacking in social reciprocity, and used to request or label rather than to comment, share feelings, or converse. In older children and adults without intellectual impairments or language delays, deficits in social-emotional reciprocity may be most apparent in difficulties processing and responding to complex social cues (e.g., when and how to join a conversation, what not to say). Individuals who have developed compensation strategies for some social challenges still struggle in novel or unsupported situations and suffer from the effort and anxiety of consciously calculating what is socially intuitive for most individuals. This behavior may contribute to lower ascertainment of autism spectrum disorder in these individuals, perhaps especially in adult women. If asked about the costs of social interaction, for example, these individuals might respond that social interactions are exhausting for them, that they are unable to concentrate because of the mental effort in monitoring social conventions, that their self-esteem is adversely affected by being unable to be themselves, and so forth.
::::::::::::::2. Deficits in nonverbal communicative behaviors used for social interaction: manifested by absent, reduced, or atypical use of eye contact (relative to cultural norms), gestures, facial expressions, body orientation, or speech intonation. An early feature of autism spectrum disorder is impaired joint attention as manifested by a lack of pointing, showing, or bringing objects to share interest with others, or failure to follow someone’s pointing or eye gaze. Individuals may learn a few functional gestures, but their repertoire is smaller than that of others, and they often fail to use expressive gestures spontaneously in communication. Among young people and adults with fluent language, the difficulty in coordinating nonverbal communication with speech may give the impression of odd, wooden, or exaggerated “body language” during interactions. Impairment may be relatively subtle within individual modes (e.g., someone may have relatively good eye contact when speaking) but noticeable in poor integration of eye contact, gesture, body posture, prosody, and facial expression for social communication, or in difficulty maintaining these for sustained periods or when under stress.
::::::::::::::3. Deficits in developing, maintaining, and understanding relationships: There may be absent, reduced, or atypical social interest, manifested by rejection of others, passivity, or inappropriate approaches that seem aggressive or disruptive. These difficulties are particularly evident in young children, in whom there is often a lack of shared social play and imagination (e.g., age-appropriate flexible pretend play) and, later, insistence on playing by very fixed rules. Older individuals may struggle to understand what behavior is considered appropriate in one situation but not another (e.g., casual behavior during a job interview), or the different ways that language may be used to communicate (e.g., irony, white lies). There may be an apparent preference for solitary activities or for interacting with much younger or older people. Frequently, there is a desire to establish friendships without a complete or realistic idea of what friendship entails (e.g., one-sided friendships or friendships based solely on shared special interests). Relationships with siblings, coworkers, and caregivers are also important to consider (in terms of reciprocity).
B. Restricted, repetitive patterns of behavior, interests, or activities, as manifested by at least two of the following, currently or by history:
::::::::::::::1. Stereotyped or repetitive motor movements, use of objects, or speech: includes simple motor stereotypies (e.g., hand flapping, finger flicking), repetitive use of objects (e.g., spinning coins, lining up toys), and repetitive speech (e.g., echolalia, the delayed or immediate parroting of heard words; use of “you” when referring to self; stereotyped use of words, phrases, or prosodic patterns).
::::::::::::::2. Insistence on sameness, inflexible adherence to routines, or ritualized patterns of verbal or nonverbal behavior: may manifest in resistance to change (e.g., distress at apparently small changes, such as taking an alternative route to school or work; insistence on adherence to rules; rigidity of thinking) or ritualized patterns of verbal or nonverbal behavior (e.g., repetitive questioning, pacing a perimeter).
::::::::::::::3. Highly restricted, fixated interests that are abnormal in intensity or focus: for example, strong attachment to or preoccupation with unusual objects, excessively circumscribed or perseverative interests.
::::::::::::::4. Hyper- or hypo-reactivity to sensory input or unusual interest in sensory aspects of the environment: manifested through extreme responses to specific sounds or textures, excessive smelling or touching of objects, fascination with lights or spinning objects, and sometimes apparent indifference to pain, heat, or cold. Extreme reaction to or rituals involving taste, smell, texture, or appearance of food or excessive food restrictions are common and may be a presenting feature of autism spectrum disorder.
C. Symptoms must be present in the early developmental period (but may not become fully manifest until social demands exceed limited capacities, or may be masked by learned strategies in later life).
D. Symptoms cause clinically significant impairment in social, occupational, or other important areas of current functioning.
E. These disturbances are not better explained by intellectual developmental disorder (intellectual disability).The severity specifiers may be used to describe succinctly the current symptomatology (which might fall below level 1), with the recognition that severity may vary by context and fluctuate over time. Severity of social communication difficulties and restricted, repetitive behaviors should be separately rated.Associated Features
The impairments in social communication and social interaction specified in Criterion A are pervasive and sustained. Even when formal language skills (e.g., vocabulary, grammar) are intact, the use of language for reciprocal social communication is impaired in autism spectrum disorder.
Many individuals with autism spectrum disorder also have intellectual and/or language impairment. Even those with average or high intelligence usually have an uneven profile of abilities. The gap between intellectual and adaptive functional skills is often large. It is common for individuals with autism to have theory-of-mind deficits (i.e., to have difficulty seeing the world from another person’s perspective), but these are not necessarily present in all cases. Executive function deficits are also common but not specific, as are difficulties with central coherence (i.e., being able to
understand context or to “see the big picture,” and thus tending to over-focus on detail).
Motor deficits are often present, including odd gait, clumsiness, and other abnormal motor
signs (e.g., walking on tiptoes). Self-injury (e.g., head banging, biting the wrist) may occur, and
disruptive/challenging behaviors are more common in children and adolescents with autism
spectrum disorder than other disorders, including intellectual developmental disorder. Some
individuals develop catatonic-like motor behavior (slowing and “freezing” mid-action), but these
are typically not of the magnitude of a catatonic episode.Differential Diagnoses
ADHD: Abnormalities of attention (overly focused or easily distracted) are common in individuals with autism spectrum disorder, as is hyperactivity. Moreover, some individuals with ADHD may exhibit social communication deficits such as interrupting others, speaking too loudly, and not respecting personal space. Although potentially difficult to discriminate ADHD from autism spectrum disorder, the developmental course and absence of restricted, repetitive behaviors and unusual interests in ADHD help in differentiating the two conditions. A concurrent diagnosis of ADHD should be considered when attentional difficulties or hyperactivity exceeds that typically seen in individuals of comparable mental age, and ADHD is one of the most common comorbidities in autism spectrum disorder.

Social Communication Disorder: When an individual shows impairment in social communication and social interactions but does not show restricted and repetitive behavior or interests, criteria for social communication disorder, instead of autism spectrum disorder, may be met. The diagnosis of autism spectrum disorder supersedes that of social (pragmatic) communication disorder whenever the criteria for autism spectrum disorder are met.

Obsessive-Compulsive Disorder: Repetitive behavior is a defining feature of both obsessive-
compulsive disorder and autism spectrum disorder. In both conditions, repetitive behaviors are
considered to be inappropriate or odd. In obsessive-compulsive disorder, intrusive thoughts are
often related to contamination, organization, or sexual or religious themes. Compulsions are
performed in response to these intrusive thoughts in attempts to relieve anxiety. In autism spectrum disorder, repetitive behaviors classically include more stereotyped motor behaviors, such as hand flapping and finger shaking or more complex behaviors, such as insistence on routines or lining up objects. Contrary to obsessive-compulsive disorder, repetitive behaviors in autism spectrum disorder may be perceived as pleasurable and reinforcing.

Personality disorders: In adults without intellectual developmental disorder or significant
language impairment, some behaviors associated with autism spectrum disorder may be perceived by others as symptoms of narcissistic, schizotypal, or schizoid personality disorder. Schizotypal personality disorder in particular may intersect with autism spectrum disorder in unusual preoccupations and perceptual experiences, odd thinking and speech, constricted affect and social anxiety, lack of close friends, and odd or eccentric behavior. The early developmental course of autism spectrum disorder (lack of imaginative play, restricted/repetitive behavior, sensory sensitivities) is most helpful in differentiating it from personality disorders.

Symptoms associated with anxiety disorders: The overlap of anxiety symptoms with the core
symptoms of autism spectrum disorder can make the classification of anxiety symptoms in
autism spectrum disorder challenging. For example, social withdrawal and repetitive behaviors
are core features of autism spectrum disorder but may also be expressions of anxiety. The most
common anxiety disorders in autism spectrum disorder are specific phobia, and social anxiety and agoraphobia.Comorbid Disorders
Autism spectrum disorder is frequently associated with intellectual developmental disorder and language disorder (i.e., an inability to comprehend and construct sentences with proper grammar). Specific learning difficulties (literacy and numeracy) are common, as is developmental coordination disorder.
:
Psychiatric comorbidities also co-occur in autism spectrum disorder. About 70% of individuals with autism spectrum disorder may have one comorbid mental disorder, and 40% may have two or more comorbid mental disorders. Anxiety disorders, depression, and ADHD are particularly common. Avoidant/restrictive food intake disorder is a fairly frequent presenting feature of autism spectrum disorder, and extreme and narrow food preferences may persist.←

ADHD Diagnostic Criteria
A. A persistent pattern of inattention and/or hyperactivityimpulsivity that interferes with functioning or development, as characterized by (1) and/or (2):
::::::::::::::1. Inattention: Six (or more) of the following symptoms have persisted for at least 6 months to a degree that is inconsistent with developmental level and that negatively impacts directly on social and academic/occupational activities: For older adolescents and adults (age 17 and older), at least five symptoms are required.
::::::::::::::::::::::::::::a. Often fails to give close attention to details or makes careless mistakes in schoolwork, at work, or during other activities (e.g., overlooks or misses details, work is inaccurate).
::::::::::::::::::::::::::::b. Often has difficulty sustaining attention in tasks or play activities (e.g., has difficulty remaining focused during lectures, conversations, or lengthy reading).
::::::::::::::::::::::::::::c. Often does not seem to listen when spoken to directly (e.g., mind seems elsewhere, even in the absence of any obvious distraction).
::::::::::::::::::::::::::::d. Often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (e.g., starts tasks but quickly loses focus and is easily sidetracked).
::::::::::::::::::::::::::::e. Often has difficulty organizing tasks and activities (e.g., difficulty managing sequential tasks; difficulty keeping materials and belongings in order; messy, disorganized work; has poor time management; fails to meet deadlines).
::::::::::::::::::::::::::::f. Often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (e.g., schoolwork or homework; for older adolescents and adults, preparing reports, completing forms, reviewing lengthy papers).
::::::::::::::::::::::::::::g. Often loses things necessary for tasks or activities (e.g., school materials, pencils, books, tools, wallets, keys, paperwork, eyeglasses, mobile telephones).
::::::::::::::::::::::::::::h. Is often easily distracted by extraneous stimuli (for older adolescents and adults, may include unrelated thoughts).
::::::::::::::::::::::::::::i. Is often forgetful in daily activities (e.g., doing chores, running errands; for older adolescents and adults, returning calls, paying bills, keeping appointments).
::::::::::::::2. Hyperactivity and impulsivity: Six (or more) of the following symptoms have persisted for at least 6 months to a degree that is inconsistent with developmental level and that negatively impacts directly on social and academic/occupational activities: For older adolescents and adults (age 17 and older), at least five symptoms are required.
::::::::::::::::::::::::::::a. Often fidgets with or taps hands or feet or squirms in seat.
::::::::::::::::::::::::::::b. Often leaves seat in situations when remaining seated is expected (e.g., leaves their place in the classroom, in the office or other workplace, or in other situations that require remaining in place).
::::::::::::::::::::::::::::c. Often runs about or climbs in situations where it is inappropriate. In adolescents or adults, may be limited to feeling restless.
::::::::::::::::::::::::::::d. Often unable to play or engage in leisure activities quietly.
::::::::::::::::::::::::::::e. Is often “on the go,” acting as if “driven by a motor” (e.g., is unable to be or uncomfortable being still for extended time, as in restaurants, meetings; may be experienced by others as being restless or hard to keep up with).
::::::::::::::::::::::::::::f. Often talks excessively.
::::::::::::::::::::::::::::g. Often blurts out an answer before a question has been completed (e.g., completes people’s sentences; cannot wait for turn in conversation).
::::::::::::::::::::::::::::h. Often has difficulty waiting their turn (e.g., while waiting in line).
::::::::::::::::::::::::::::i. Often interrupts or intrudes on others (e.g., butts into conversations, games, or activities; may start using other people’s things without asking or receiving permission; for adolescents and adults, may intrude into or take over what others are doing).
B. Several inattentive or hyperactive-impulsive symptoms were present prior to age 12 years.
C. Several inattentive or hyperactive-impulsive symptoms are present in two or more settings (e.g., at home, school, or work; with friends or relatives; in other activities).
D. There is clear evidence that the symptoms interfere with, or reduce the quality of, social, academic, or occupational functioning.
E. The symptoms do not occur exclusively during the course of schizophrenia or another psychotic disorder and are not better explained by another mental disorder.

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.Associated Features
ADHD begins in childhood. The requirement that several symptoms be present before age 12 years conveys the importance of a substantial clinical presentation during childhood. At the same time, an earlier age at onset is not specified because of difficulties in establishing precise childhood onset retrospectively. ADHD cannot be diagnosed in the absence of any symptoms prior to age 12. When symptoms of what appears to be ADHD first occur after age 13, they are more likely to be explained by another mental disorder.Manifestations of the disorder must be present in more than one setting (e.g., home and school, or home and work). Confirmation of substantial symptoms across settings typically cannot be done accurately without consulting informants who have seen the individual in those settings. Typically, symptoms vary depending on context within a given setting. Signs of the disorder may be minimal or absent when the individual is receiving frequent rewards for appropriate behavior, is under close supervision, is in a novel setting, is engaged in especially interesting activities, has consistent external stimulation (e.g., via electronic screens), or is interacting in one-on-one situations (e.g., the clinician's office).Delays in language, motor, or social development are not specific to ADHD but often co-occur. Emotional dysregulation or emotional impulsivity commonly occurs in children and adults with ADHD. Individuals with ADHD self-report and are described by others as being quick to anger, easily frustrated, and overreactive emotionally.Even in the absence of a specific learning disorder, academic or work performance is often impaired. Individuals with ADHD may exhibit neurocognitive deficits in a variety of areas, including working memory, set shifting, reaction time variability, response inhibition, vigilance, and
planning/organization, although these tests are not sufficiently sensitive or specific to serve as diagnostic indices.Differential Diagnoses
Oppositional Defiant Disorder: Individuals with oppositional defiant disorder may resist work or school tasks that require self-application because they resist conforming to others' demands. Their behavior is characterized by negativity, hostility, and defiance. These symptoms must be differentiated from aversion to school or mentally demanding tasks because of difficulty in sustaining mental effort, forgetting instructions, and impulsivity in individuals with ADHD. Complicating the differential diagnosis is the fact that some individuals with ADHD may develop secondary oppositional attitudes toward such tasks and devalue their importance.

Autism Spectrum Disorder: Individuals with ADHD and those with autism spectrum disorder exhibit inattention, social dysfunction, and difficult-to-manage behavior. The social dysfunction and peer rejection seen in individuals with ADHD must be distinguished from the social disengagement, isolation, and indifference to facial and tonal communication cues seen in individuals with autism spectrum disorder.

Anxiety Disorders: ADHD shares symptoms of inattention with anxiety disorders. Individuals with ADHD are inattentive because of their preferential engagement with novel and stimulating activities or preoccupation with enjoyable activities. This is distinguished from the inattention attributable to worry and rumination seen in anxiety disorders. Restlessness might be seen in anxiety disorders. However, in ADHD, the symptom is not associated with worry and rumination.

Bipolar Disorders: Individuals with bipolar disorder may have increased activity, poor concentration, and increased impulsivity, but these features are episodic, unlike ADHD, in which the symptoms are persistent. Moreover, in bipolar disorder, increased impulsivity or inattention is accompanied by elevated mood, grandiosity, and other specific bipolar features.

Personality Disorders: In adolescents and adults, it may be difficult to distinguish ADHD from borderline, narcissistic, and other personality disorders. Some personality disorders tend to share
the features of disorganization, social intrusiveness, emotional dysregulation, and cognitive dysregulation. However, ADHD is not characterized by fear of abandonment, self-injury, extreme ambivalence, or other features of personality disorder. It may take extended clinical observation, informant interview, or detailed history to distinguish impulsive, socially intrusive, or inappropriate behavior from narcissistic, aggressive, or domineering behavior to make this differential diagnosis.Comorbid Disorders
Oppositional defiant disorder co-occurs with ADHD in approximately half of children with the combined presentation and about a quarter with the predominantly inattentive presentation. Conduct disorder co-occurs in about a quarter of children or adolescents with the combined
presentation, depending on age and setting. Most children and adolescents with disruptive mood dysregulation disorder have symptoms that also meet criteria for ADHD; a lesser percentage of children with ADHD have symptoms that meet criteria for disruptive mood dysregulation disorder.
Anxiety disorders, major depressive disorder, obsessive-compulsive disorder, and intermittent explosive disorder occur in a minority of individuals with ADHD but more often than in the general population. Although substance use disorders are relatively more frequent among adults with ADHD in the general population, the disorders are present in only a minority of adults with ADHD. In adults, antisocial and other personality disorders may co-occur with ADHD.
ADHD may co-occur in variable symptom profiles with other neurodevelopmental disorders, including specific learning disorder, autism spectrum disorder, intellectual developmental disorder, language disorders, developmental coordination disorder, and tic disorders.←

Specific Learning Disorder Diagnostic Criteria
A. Difficulties learning and using academic skills, as indicated by the presence of at least one of the following symptoms that have persisted for at least 6 months, despite the provision of interventions that target those difficulties:
::::::::::::::1. Inaccurate or slow and effortful word reading (e.g., reads single words aloud incorrectly or slowly and hesitantly, frequently guesses words, has difficulty sounding out words).
::::::::::::::2. Difficulty understanding the meaning of what is read (e.g., may read text accurately but not understand the sequence, relationships, inferences, or deeper meanings of what is read).
::::::::::::::3. Difficulties with spelling (e.g., may add, omit, or substitute vowels or consonants).
::::::::::::::4. Difficulties with written expression (e.g., makes multiple grammatical or punctuation errors within sentences; employs poor paragraph organization; written expression of ideas lacks clarity).
::::::::::::::5. Difficulties mastering number sense, number facts, or calculation (e.g., has poor understanding of numbers, their magnitude, and relationships; counts on fingers to add single-digit numbers instead of recalling the math fact as peers do; gets lost in the midst of arithmetic computation and may switch procedures).
::::::::::::::6. Difficulties with mathematical reasoning (e.g., has severe difficulty applying mathematical concepts, facts, or procedures to solve quantitative problems).
B. The 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, as confirmed by individually administered standardized achievement measures and comprehensive clinical assessment. For individuals age 17 years and older, a documented history of impairing learning difficulties may be substituted for the standardized assessment.
C. The learning difficulties begin during school-age years but may not become fully manifest until the demands for those affected academic skills exceed the individual’s limited capacities (e.g., as in timed tests, reading or writing lengthy complex reports for a tight deadline, excessively heavy academic loads).
D. The 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.
.
With impairment in reading: impairment in word reading accuracy, reading rate or fluency, and/or reading comprehension.
With impairment in written expression: impairment in spelling accuracy, grammar and punctuation accuracy, and/or clarity or organization of written expression.
With impairment in mathematics: impairment in number sense, memorization of arithmetic facts, accurate or fluent calculation, and/or accurate math reasoningAssociated Features
The symptoms of specific learning disorder (difficulty with aspects of reading, writing, or mathematics) frequently co-occur. An uneven profile of abilities is common, such as a combination of above-average abilities in drawing, design, and other visuospatial abilities, and slow, effortful, and inaccurate reading and poor reading comprehension and written expression. Specific learning disorder is frequently but not invariably preceded, in preschool years, by delays in attention, language, or motor skills that may persist and co-occur with specific learning disorder.Differential Diagnoses
ADHD: Specific learning disorder is distinguished from the poor academic performance associated with ADHD, because in the latter condition the problems may not necessarily reflect specific difficulties in learning academic skills but rather may reflect difficulties in performing those skills. However, the co-occurrence of specific learning disorder and ADHD is more frequent than expected by chance. If criteria for both disorders are met, both diagnoses can be given.Comorbid Disorders
The different types of specific learning disorder commonly co-occur with one another (e.g., specific learning disorder with impairment in mathematics and with impairment in reading) and with other
neurodevelopmental disorders (e.g., ADHD, communication disorders, developmental coordination disorder, autism spectrum disorder) or other mental disorders (e.g., anxiety and depressive disorders) or behavioral problems.←

Developmental Coordination Disorder Diagnostic Criteria
A. The 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 (e.g., dropping or bumping into objects) as well as slowness and inaccuracy of performance of motor skills (e.g., catching an object, using scissors or cutlery, handwriting, riding a bike, or participating in sports).
B. The motor skills deficit in Criterion A significantly and persistently interferes with activities of daily living appropriate to chronological age (e.g., self-care and self-maintenance) and impacts academic/school productivity, pre-vocational and vocational activities, leisure, and play.
C. Onset of symptoms is in the early developmental period.
D. The motor skills deficits are not better explained by intellectual developmental disorder or visual impairment and are not attributable to a neurological condition affecting movement.Associated Features
Young children may be delayed in achieving motor milestones (i.e., sitting, crawling, walking), although many achieve typical motor milestones. They also may be delayed in developing skills such as negotiating stairs, pedaling, buttoning shirts, completing puzzles, and using zippers. Even when the skill is achieved, movement execution may appear awkward, slow, or less precise than that of peers. Older children and adults may display slow speed or inaccuracy with motor aspects of activities such as assembling puzzles, building models, playing ball games (especially in teams), handwriting, typing, driving, or carrying out self-care skills.Some children with developmental coordination disorder show additional (usually suppressed)
motor activity, such as choreiform movements of unsupported limbs or mirror movements. These
“overflow” movements are referred to as neurodevelopmental immaturities or neurological soft
signs rather than neurological abnormalities.Differential Diagnoses
ADHD: Individuals with ADHD may fall, bump into objects, or knock things over. Careful observation across different contexts is required to ascertain if lack of motor competence is attributable to distractibility and impulsiveness rather than to developmental coordination disorder. If criteria for both ADHD and developmental coordination disorder are met, both diagnoses can be given.

Autism Spectrum Disorder: Individuals with autism spectrum disorder may be uninterested in
participating in tasks requiring complex coordination skills, such as ball sports, which will affect test performance and function but not reflect core motor competence. Co-occurrence of developmental coordination disorder and autism spectrum disorder is common. If criteria for both disorders are met, both diagnoses can be given.

Joint Hypermobility Syndrome: Individuals with syndromes causing hyperextensible joints (found
on physical examination; often with a complaint of pain) may present with symptoms similar to
those of developmental coordination disorder.Comorbid Disorders
Disorders that commonly co-occur with developmental coordination disorder include communication disorders; specific learning disorder (especially reading and writing); problems of inattention, including ADHD (the most frequent coexisting condition, with about 50% co-occurrence); autism spectrum disorder; disruptive and emotional behavior problems; and joint hypermobility syndrome. Different clusters of co-occurrence may be present (e.g., a cluster with severe reading disorders, fine motor problems, and handwriting problems; another cluster with impaired movement control and motor planning). Presence of other disorders does not exclude developmental coordination disorder but may make testing more difficult and may independently interfere with the execution of activities of daily living, thus requiring examiner judgment in ascribing impairment to motor skills.←

Stereotypic Movement Disorder Diagnostic Criteria
A. Repetitive, seemingly driven, and apparently purposeless motor behavior (e.g., hand shaking or waving, body rocking, head banging, self-biting, hitting own body).
B. The repetitive motor behavior interferes with social, academic, or other activities and may result in self-injury.
C. Onset is in the early developmental period.
D. The repetitive motor behavior is not attributable to the physiological effects of a substance or neurological condition and is not better explained by another neurodevelopmental or mental disorder.Associated Features
Stereotypic movements may occur many times during a day, lasting a few seconds to several minutes or longer. Frequency can vary from many occurrences in a single day to several weeks elapsing between episodes. The behaviors vary in context, occurring when the individual is engrossed in other activities, when excited, stressed, fatigued, or bored. Criterion A requires that the movements be “apparently” purposeless. However, some functions may be served by the movements. For example, stereotypic movements might reduce anxiety in response to external stressors.Differential Diagnoses
Autism Spectrum Disorder: Stereotypic movements may be a presenting symptom of autism
spectrum disorder and should be considered when repetitive movements and behaviors are being evaluated. Deficits of social communication and reciprocity manifesting in autism spectrum disorder are generally absent in stereotypic movement disorder, and thus social interaction, social communication, and rigid repetitive behaviors and interests are distinguishing features. When autism spectrum disorder is present, stereotypic movement disorder is diagnosed only when there is self-injury or when the stereotypic behaviors are sufficiently severe to become a focus of treatment.

Tic Disorder: Typically, stereotypies have an earlier age at onset (before 3 years) than do tics,
which have a mean age at onset of 4–6 years. They also are consistent and fixed in their pattern
or topography compared with tics, which are variable in their presentation, typically changing in character over time. Stereotypies may involve arms, hands, or the entire body, while tics commonly involve eyes, face, head, and shoulders. Stereotypies are more fixed, rhythmic, and prolonged in duration than tics, which, generally, are brief, rapid, random, and fluctuating. Stereotypies are ego-syntonic (children enjoy them) as opposed to tics, which are usually ego-dystonic. Tics wax and wane in location and time and are uniquely associated with premonitory urge (a physical feeling that precedes many tic movements). Tics and stereotypic movements are both reduced by distraction.

OCD: Stereotypic movement disorder is distinguished from obsessive-compulsive disorder (OCD) by the absence of obsessions, as well as by the nature of the repetitive behaviors. In OCD the individual feels driven to perform repetitive behaviors in response to an obsession or according to rules that must be applied rigidly, whereas in stereotypic movement disorder the behaviors are seemingly driven but apparently purposeless. Trichotillomania (hair-pulling disorder) and excoriation (skin-picking) disorder are characterized by body-focused repetitive behaviors (i.e., hair pulling and skin picking) that may be seemingly driven but that are not apparently purposeless, and that may not be patterned or rhythmical. Furthermore, onset in trichotillomania and excoriation disorder is not typically in the early developmental period, but rather around puberty or later.Comorbid Disorders
Common comorbidities in children with chronic motor stereotypies include attention-deficit hyperactivity disorder, motor coordination problems, tics/tourette’s disorder, and anxiety.←

Diagnostic Criteria for Tourette's Disorder
A. Both multiple motor and one or more vocal tics have been present at some time during the illness, although not necessarily concurrently.
B. The tics may wax and wane in frequency but have persisted for more than 1 year since first tic onset.
C. Onset is before age 18 years.
D. The disturbance is not attributable to the physiological effects of a substance or another medical condition.Diagnostic Criteria for 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. The tics may wax and wane in frequency but have persisted for more than 1 year since first tic onset.
C. Onset is before age 18 years.
D. The disturbance is not attributable to the physiological effects of a substance or another medical condition.
E. Criteria have never been met for Tourette’s disorder.Diagnostic Criteria for Provisional Tic Disorder
A. Single or multiple motor and/or vocal tics.
B. The tics have been present for less than 1 year since first tic onset.
C. Onset is before age 18 years.
D. The disturbance is 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.Other Specified Tic Disorder
This category applies to presentations in which symptoms characteristic of a tic disorder that cause clinically significant distress or impairment in social, occupational, or other important
areas of functioning predominate but do not meet the full criteria for a tic disorder or any of the disorders in the neurodevelopmental disorders diagnostic class. The other specified tic disorder category is used in situations in which the clinician chooses to communicate the specific reason that the presentation does not meet the criteria for a tic disorder or any specific neurodevelopmental disorder. This is done by recording “other specified tic disorder” followed by the specific reason (e.g., “with onset after age 18 years”).Associated Features
Tics are typically sudden, rapid, recurrent, nonrhythmic motor movements or vocalizations. Some motor tics can be slower twisting or tightening movements that occur over varying lengths of time. An individual may exhibit various tics over time, but, at any point in time, the tic repertoire may recur in a characteristic fashion. Although tics can include almost any muscle group or vocalization, certain tics, such as eye blinking or throat clearing, are common across patient populations. There is often a localized uncomfortable sensation (premonitory sensation) prior to a tic, and most individuals report an “urge” to tic. Consequently, tics are generally experienced as involuntary, but some tics can be voluntarily suppressed for varying lengths of time.

Explicit discussion of tics can serve as a trigger. Likewise, observing a gesture or sound in another person may result in an individual with a tic disorder making a similar gesture or sound, which may be incorrectly perceived by others as purposeful. This can be particularly problematic when the individual is interacting with authority figures who do not have an adequate understanding of tic disorders.
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Tics are classically categorized as either simple or complex. Simple motor tics are characterized by the limited involvement of specific muscle groups, often are of short duration, and can include eye blinks, facial grimaces, shoulder shrugs, or extension of the extremities. Simple vocal tics include throat clearing, sniffs, chirps, barks, or grunting often caused by contraction of the diaphragm or muscles of the oropharynx. Complex motor tics are of longer duration and often include a combination of simple tics such as simultaneous head turning and shoulder shrugging. Complex tics can appear purposeful, such as head gestures or torso movements. They can also include imitations of someone else’s movements (echopraxia) or sexual or taboo gestures (copropraxia). Similarly, complex vocal tics have linguistic meaning (words or partial words) and can include repeating one’s own sounds or words (palilalia), repeating the last-heard word or phrase (echolalia), or uttering socially unacceptable words, including obscenities, or ethnic, racial, or religious slurs (coprolalia). Importantly, coprolalia is an abrupt, sharp bark or grunt utterance and lacks the prosody of similar inappropriate speech observed in human interactions.Differential Diagnoses
Functional Neurological Symptom Disorder (Functional Tic Disorder): Functional disorders should also be considered when an individual presents with “tic attacks” that can go on for extended periods of time lasting from 15 minutes to several hours.

Myoclonus: Myoclonus is characterized by a sudden unidirectional movement that is often
nonrhythmic. It may be worsened by movement and occur during sleep. Myoclonus is differentiated from tics by its rapidity, lack of suppressibility, and absence of a premonitory sensation or urge.Comorbid Disorders
Many medical and psychiatric conditions have been described as co-occurring with tic disorders, and ADHD, disruptive behavior, and OCD and related disorders are particularly common. The obsessive-compulsive symptoms observed in tic disorders tend to have an earlier age at onset and often are characterized by a need for symmetry and exactness and/or forbidden or taboo thoughts. Individuals with tic disorders can also have other neurodevelopmental and psychiatric conditions, such as autism spectrum disorder and specific learning disorder. Teenagers and adults with a tic disorder are at increased risk for developing a mood, anxiety, or substance use disorder.←

you picked... schizophrenia spectrum and psychotic disorders!

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Delusional Disorder Diagnostic Criteria
A. The presence of one (or more) delusions with a duration of 1 month or longer.
B. Criterion A for schizophrenia has never been met. Hallucinations, if present, are not prominent and are related to the delusional theme.
C. Apart from the impact of the delusion(s) or its ramifications, functioning is not markedly impaired, and behavior is not obviously bizarre or odd.
D. If manic or major depressive episodes have occurred, these have been brief relative to the duration of the delusional periods.
E. The disturbance is not attributable to the physiological effects of a substance or another medical condition and is not better explained by another mental disorder, such as body dysmorphic disorder or obsessive-compulsive disorder.Specifiers
Erotomanic type: This subtype applies when the central theme of the delusion is that another person is in love with the individual.
Grandiose type: This subtype applies when the central theme of the delusion is the conviction of having some great (but unrecognized) talent or insight or having made some important discovery.
Jealous type: This subtype applies when the central theme of the individual’s delusion is that his or her spouse or lover is unfaithful.
Persecutory type: This subtype applies when the central theme of the delusion involves the individual’s belief that he or she is being conspired against, cheated, spied on, followed, poisoned or drugged, maliciously maligned, harassed, or obstructed in the pursuit of long-term goals.
Somatic type: This subtype applies when the central theme of the delusion involves bodily functions or sensations.
Mixed type: This subtype applies when no one delusional theme predominates.
Unspecified type: This subtype applies when the dominant delusional belief cannot be clearly determined or is not described in the specific types (e.g., referential delusions without a prominent persecutory or grandiose component).Associated Features
Social, marital, or work problems can result from the delusional beliefs of delusional disorder. Individuals with delusional disorder may be able to factually describe that others view their beliefs as irrational but are unable to accept this themselves (i.e., there may be “factual insight” but no true insight). Many individuals develop irritable or dysphoric mood, which can sometimes be understood as a reaction to their delusional beliefs. Anger and violent behavior can occur with persecutory, jealous, and erotomanic types. The individual may engage in litigious or antagonistic behavior (e.g.,
sending hundreds of letters of protest to the government).Differential Diagnoses
Obsessive-Compulsive Disorders: If an individual with obsessive-compulsive disorder is completely convinced that his or her obsessive-compulsive disorder beliefs are true, then the diagnosis of obsessive-compulsive disorder, with absent insight/delusional beliefs specifier, should be given rather than a diagnosis of delusional disorder. Similarly, if an individual with body dysmorphic disorder is completely convinced that his or her body dysmorphic disorder beliefs are true, then the diagnosis of body dysmorphic disorder, with absent insight/delusional beliefs specifier, should be given rather than a diagnosis of delusional disorder.

Schizophrenia or Schizophreniform Disorder: Delusional disorder can be distinguished from schizophrenia and schizophreniform disorder by the absence of the other characteristic symptoms of the active phase of schizophrenia. Furthermore, the quality of delusions can help distinguish between schizophrenia and delusional disorder. In schizophrenia, delusions show greater disorganization (the degree to which delusions are internally consistent, logical, and systematized), whereas in delusional disorder, they show greater conviction (the degree to which the individual is convinced of the reality of the delusion), greater extension (the degree to which the delusion involves various areas of the individual’s life), and greater pressure (the degree to which the individual is preoccupied and concerned with the expressed delusion).

Schizoaffective Disorder and psychotic mood disorders: These disorders may be distinguished from delusional disorder by the temporal relationship between the mood disturbance and the delusions and by the severity of the mood symptoms. If delusions occur exclusively during mood
episodes, the diagnosis is major depressive or bipolar disorder, with psychotic features. Mood symptoms that meet full criteria for a mood episode can be superimposed on delusional disorder. Delusional disorder can be diagnosed only if the total duration of all mood episodes remains brief relative to the total duration of the delusional disturbance. If not, then a diagnosis of other specified or unspecified schizophrenia spectrum and other psychotic disorder accompanied by
other specified depressive disorder, unspecified depressive disorder, other specified bipolar and related disorder, or unspecified bipolar and related disorder is appropriate.←

Brief Psychotic Disorder Diagnostic Criteria
A. Presence of one (or more) of the following symptoms. At least one of these must be (1), (2), or (3):
::::::::::::::1. Delusions.
::::::::::::::2. Hallucinations.
::::::::::::::3. Disorganized speech (e.g., frequent derailment or incoherence).
::::::::::::::4. Grossly disorganized or catatonic behavior.
B. Duration of an episode of the disturbance is at least 1 day but less than 1 month, with eventual full return to premorbid level of functioning.
C. The disturbance is not better explained by major depressive or bipolar disorder with psychotic features or another psychotic disorder such as schizophrenia or catatonia, and is not attributable to the physiological effects of a substance or another medical condition.Associated Features
Individuals with brief psychotic disorder typically experience emotional turmoil or overwhelming confusion. They may have rapid shifts from one intense affect to another. Although the disturbance is brief, the level of impairment may be severe, and supervision may be required to ensure that
nutritional and hygienic needs are met and that the individual is protected from the consequences of poor judgment, cognitive impairment, or acting on the basis of delusions.Differential Diagnoses
Other psychotic disorders: If the psychotic symptoms persist for 1 month or longer, the diagnosis
is either schizophreniform disorder, delusional disorder, depressive disorder with psychotic features, bipolar disorder with psychotic features, or other specified or unspecified schizophrenia spectrum and other psychotic disorder, depending on the other symptoms in the presentation. The differential diagnosis between brief psychotic disorder and schizophreniform disorder is difficult when the psychotic symptoms have remitted before 1 month in response to successful treatment with medication. Careful attention should be given to the possibility that a recurrent disorder (e.g., bipolar disorder, recurrent acute exacerbations of schizophrenia) may be responsible for any recurring psychotic episodes.

Personality Disorders: In certain individuals with personality disorders, psychosocial stressors may precipitate brief periods of psychotic symptoms. These symptoms are usually transient and do not warrant a separate diagnosis. If psychotic symptoms persist for at least 1 day, an additional diagnosis of brief psychotic disorder may be appropriate.←

Schizophreniform Diagnostic Criteria
A. Two (or more) of the following, each present for a significant portion of time during a 1-month period. At least one of these must be (1), (2), or (3):
::::::::::::::1. Delusions.
::::::::::::::2. Hallucinations.
::::::::::::::3. Disorganized speech (e.g., frequent derailment or incoherence).
::::::::::::::4. Grossly disorganized or catatonic behavior.
::::::::::::::5. Negative symptoms (i.e., diminished emotional expression or avolition).
B. An episode of the disorder lasts at least 1 month but less than 6 months.
C. Schizoaffective disorder and depressive or bipolar disorder with psychotic features have been ruled out because either 1) no major depressive or manic episodes have occurred concurrently with the active-phase symptoms, or 2) if mood episodes have occurred during active-phase symptoms, they have been present for a minority of the total duration of the active and residual periods of the illness.
D. The disturbance is not attributable to the physiological effects of a substance or another medical condition.Associated Features
The duration requirement for schizophreniform disorder is intermediate between that for brief psychotic disorder, which lasts more than 1 day and remits by 1 month, and schizophrenia, which lasts for at least 6 months. If the disturbance persists beyond 6 months, the diagnosis should be changed to schizophrenia.
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A distinguishing feature of schizophreniform disorder is the lack of a criterion requiring impaired social and occupational functioning. While such impairments may potentially be present, they are not necessary for a diagnosis of schizophreniform disorder.←

Schizophrenia Diagnostic Criteria
A. Two (or more) of the following, each present for a significant portion of time during a 1-month period. At least one of these must be (1), (2), or (3):
::::::::::::::1. Delusions [fixed beliefs that are not amenable to change in light of conflicting evidence].
::::::::::::::2. Hallucinations [perception-like experiences that occur without an external stimulus that are vivid and clear, with the full force and impact of normal perceptions].
::::::::::::::3. Disorganized speech (e.g., frequent derailment or incoherence).
::::::::::::::4. Grossly disorganized or catatonic behavior.
::::::::::::::5. Negative symptoms (avolition, anhedonia, alogia, asociality, and/or flat affect).
B. For a significant portion of the time since the onset of the disturbance, level of functioning in one or more major areas, such as work, interpersonal relations, or self-care, is markedly below the level achieved prior to the onset (or when the onset is in childhood or adolescence, there is failure to achieve expected level of interpersonal, academic, or occupational functioning).
C. Continuous signs of the disturbance persist for at least 6 months. This 6-month period must include at least 1 month of symptoms that meet Criterion A (i.e., active-phase symptoms) and may include periods of prodromal or residual symptoms. During these prodromal or residual periods, the signs of the disturbance may be manifested by only negative symptoms or by two or more symptoms listed in Criterion A present in an attenuated form (e.g., odd beliefs, unusual perceptual experiences).
D. Schizoaffective disorder and depressive or bipolar disorder with psychotic features have been ruled out because either 1) no major depressive or manic episodes have occurred concurrently with the active-phase symptoms, or 2) if mood episodes have occurred during active-phase symptoms, they have been present for a minority of the total duration of the active and residual periods of the illness.
E. The disturbance is not attributable to the physiological effects of a substance or another medical condition.
F. If there is a history of autism spectrum disorder or a communication disorder of childhood onset, the additional diagnosis of schizophrenia is made only if prominent delusions or hallucinations, in addition to the other required symptoms of schizophrenia, are also present for at least 1 month.Associated Features
Mood symptoms and full mood episodes are common in schizophrenia and may be
concurrent with active-phase symptomatology. However, as distinct from a psychotic mood
disorder, a schizophrenia diagnosis requires the presence of delusions or hallucinations in the
absence of mood episodes. In addition, mood episodes, taken in total, should be present for only
a minority of the total duration of the active and residual periods of the illness.

Prodromal symptoms often precede the active phase, and residual symptoms may follow it, characterized by mild or subthreshold forms of hallucinations or delusions. Individuals may express a variety of unusual or odd beliefs that are not of delusional proportions (e.g., ideas of reference or magical thinking); they may have unusual perceptual experiences (e.g., sensing the presence of an unseen person); their speech may be generally understandable but vague; and their behavior may be unusual but not grossly disorganized (e.g., mumbling in public). Negative symptoms are common in the prodromal and residual phases and can be severe. Individuals who had been socially active may become withdrawn from previous routines. Such behaviors are often the first sign of a disorder.

Individuals with schizophrenia may display inappropriate affect (e.g., laughing in the absence of an appropriate stimulus); a dysphoric mood that can take the form of depression, anxiety, or anger; a disturbed sleep pattern (e.g., daytime sleeping and nighttime activity); and a lack of interest in
eating or food refusal. Depersonalization, derealization, and somatic concerns may occur and sometimes reach delusional proportions. Anxiety and phobias are common. Some individuals with schizophrenia show social cognition deficits, including deficits in the ability to infer the intentions of other people (theory of mind), and may attend to and then interpret irrelevant events or stimuli as meaningful, perhaps leading to the generation of explanatory delusions. These impairments frequently persist during symptomatic remission.

Some individuals with psychosis may lack insight or awareness of their disorder (i.e., anosognosia). This lack of “insight” includes unawareness of symptoms of schizophrenia and may be present throughout the entire course of the illness. Unawareness of illness is typically a symptom of schizophrenia itself rather than a coping strategy.Differential Diagnoses
Other psychotic disorders: A diagnosis of schizoaffective disorder requires that a major depressive
or manic episode occur concurrently with the active-phase symptoms and that the mood symptoms be present for a majority of the total duration of the active periods. Additionally, schizophreniform and brief psychotic disorder are of shorter duration than schizophrenia as specified in Criterion C, which requires 6 months of symptoms. In schizophreniform disorder, the disturbance is present less than 6 months, and in brief psychotic disorder, symptoms are present at least 1 day but less than 1 month. Delusional disorder can be distinguished from schizophrenia by the absence of the other symptoms characteristic of schizophrenia (e.g., delusions, prominent auditory or visual hallucinations, disorganized speech, grossly disorganized or catatonic behavior, negative
symptoms).
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Major depressive or bipolar disorder with psychotic features: The distinction between
schizophrenia and major depressive or bipolar disorder with psychotic features or with catatonia
depends on the temporal relationship between the mood disturbance and the psychosis, and on
the severity of the depressive or manic symptoms. If delusions or hallucinations occur
exclusively during a major depressive or manic episode, the diagnosis is depressive or bipolar
disorder with psychotic features.
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Schizotypal Personality Disorder: Schizotypal personality disorder may be distinguished from
schizophrenia by subthreshold symptoms that are associated with persistent personality features.
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Obsessive-Compulsive Disorders: Individuals with obsessive-compulsive disorder and body dysmorphic disorder may present with poor or absent insight, and the preoccupations may reach delusional proportions. But these disorders are distinguished from schizophrenia by their prominent obsessions, compulsions, preoccupations with appearance or body odor, hoarding, or body-focused repetitive behaviors.
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Autism Spectrum Disorder: Autism spectrum disorder may also have symptoms resembling a psychotic episode but are distinguished by their respective deficits in social interaction with repetitive and restricted behaviors and other cognitive and communication deficits. An individual with autism spectrum disorder must have symptoms that meet full criteria for schizophrenia, with prominent hallucinations or delusions for at least 1 month, in order to be diagnosed with schizophrenia as a comorbid condition.Comorbid Disorders
Rates of comorbidity with substance-related disorders are high in schizophrenia. Over half of individuals with schizophrenia have tobacco use disorder and smoke cigarettes regularly. Comorbidity with anxiety disorders is increasingly recognized in schizophrenia. Rates of obsessive-compulsive disorder and panic disorder are elevated in individuals with schizophrenia compared with the general population. Schizotypal or paranoid personality disorder may sometimes precede the onset of schizophrenia.←

Schizoaffective Disorder Diagnostic Criteria
A. An uninterrupted period of illness during which there is a major mood episode (major depressive or manic) concurrent with Criterion A of schizophrenia. The major depressive episode must include depressed mood.
B. Delusions or hallucinations for 2 or more weeks in the absence of a major mood episode (depressive or manic) during the lifetime duration of the illness.
C. Symptoms that meet criteria for a major mood episode are present for the majority of the total duration of the active and residual portions of the illness.
D. The disturbance is not attributable to the effects of a substance or another medical condition.Associated Features
Occupational and social functioning is frequently impaired, but this is not a defining criterion (in contrast to schizophrenia). Restricted social contact and difficulties with self-care are associated with schizoaffective disorder, but negative symptoms may be less severe and less persistent than those seen in schizophrenia. Anosognosia (i.e., poor insight) is also common in schizoaffective disorder, but the deficits in insight may be less severe and pervasive than those in schizophrenia. Individuals with schizoaffective disorder may be at increased risk for later developing episodes of major depressive disorder or bipolar disorder if mood symptoms continue following the remission of symptoms meeting Criterion A for schizophrenia. There may be associated alcohol and other substance-related disorders.
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Criterion C for schizoaffective disorder specifies that mood symptoms meeting criteria for a major mood episode must be present for the majority of the total duration of the active and residual portion of the illness. Criterion C requires the assessment of mood symptoms for the entire lifetime course of a psychotic illness. If the mood symptoms are present for only a relatively brief period, the diagnosis is schizophrenia, not schizoaffective disorder. To separate schizoaffective disorder from a depressive or bipolar disorder with psychotic features, delusions or hallucinations must be present for at least 2 weeks in the absence of a major mood episode (depressive or manic) at some point during the lifetime duration of the illness.Differential Diagnoses
Schizophrenia, Bipolar, and Depressive disorders: Distinguishing schizoaffective disorder from schizophrenia and from depressive and bipolar disorders with psychotic features is often difficult. Criterion C is designed to separate schizoaffective disorder from schizophrenia, and Criterion B is designed to distinguish schizoaffective disorder from a depressive or bipolar disorder with psychotic features. More specifically, schizoaffective disorder can be distinguished from a major depressive or bipolar disorder with psychotic features based on the presence of prominent delusions and/or hallucinations for at least 2 weeks in the absence of a major mood episode. In contrast, in depressive or bipolar disorder with psychotic features, the psychotic features only occur during the mood episode(s). Because the relative proportion of mood to psychotic symptoms may change over time, the appropriate diagnosis may change from and to schizoaffective disorder. (For example, a diagnosis of schizoaffective disorder for a severe and prominent major depressive episode lasting 4 months during the first 6 months of a chronic psychotic illness would be changed to schizophrenia if active psychotic or prominent residual symptoms persist over several years without a recurrence of another mood episode).Comorbid Disorders
Many individuals diagnosed with schizoaffective disorder are also diagnosed with other mental disorders, especially substance use disorders and anxiety disorders. Similarly, the incidence of medical conditions, including metabolic syndrome, is increased above base rate for the general
population and leads to decreased life expectancy.←

Other Specified Schizophrenia Spectrum and Other Psychotic Disorder
This category applies to presentations in which symptoms characteristic of a schizophrenia spectrum and other psychotic disorder that cause clinically significant distress or impairment in
social, occupational, or other important areas of functioning predominate but do not meet the full criteria for any of the disorders in the schizophrenia spectrum and other psychotic disorders diagnostic class. The other specified schizophrenia spectrum and other psychotic disorder category is used in situations in which the clinician chooses to communicate the specific reason that the presentation does not meet the criteria for any specific schizophrenia spectrum and other psychotic disorder.

Examples of presentations that can be specified using the “other specified” designation include:

1. Persistent auditory hallucinations occurring in the absence of any other features.
2. Delusions with significant overlapping mood episodes: This includes persistent delusions with periods of overlapping mood episodes that are present for a substantial portion of the delusional disturbance (such that the criterion stipulating only brief mood disturbance in delusional disorder is not met).
3. Attenuated psychosis syndrome: This syndrome is characterized by psychotic-like symptoms that are below a threshold for full psychosis (e.g., the symptoms are less severe and more transient, and insight is relatively maintained).
4. Delusional symptoms in the context of relationship with an individual with prominent delusions: In the context of a relationship, the delusional material from the individual with a
psychotic disorder provides content for the same delusions held by the other person who may not otherwise have symptoms that meet criteria for a psychotic disorder.←

Catatonia Diagnostic Criteria
A. The clinical picture is dominated by three (or more) of the following symptoms:
::::::::::::::1. Stupor (i.e., no psychomotor activity; not actively relating to environment).
::::::::::::::2. Catalepsy (i.e., passive induction of a posture held against gravity).
::::::::::::::3. Waxy flexibility (i.e., slight, even resistance to positioning by examiner).
::::::::::::::4. Mutism (i.e., no, or very little, verbal response [exclude if known aphasia]).
::::::::::::::5. Negativism (i.e., opposition or no response to instructions or external stimuli).
::::::::::::::6. Posturing (i.e., spontaneous and active maintenance of a posture against gravity).
::::::::::::::7. Mannerism (i.e., odd, circumstantial caricature of normal actions).
::::::::::::::8. Stereotypy (i.e., repetitive, abnormally frequent, non-goal-directed movements).
::::::::::::::9. Agitation, not influenced by external stimuli.
::::::::::::::10. Grimacing.
::::::::::::::11. Echolalia (i.e., mimicking another’s speech).
::::::::::::::12. Echopraxia (i.e., mimicking another’s movements).←

you picked... bipolar disorders!

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At least one lifetime manic episode is required for the diagnosis of bipolar I disorder. The manic episode may have been preceded by and may be followed by hypomanic or major depressive episodes.:::::::Manic Episode Criteria
A. A distinct period of abnormally and persistently elevated, expansive, or irritable mood and abnormally and persistently increased activity or energy, lasting at least 1 week and present most of the day, nearly every day (or any duration if hospitalization is necessary).
B. During the period of mood disturbance and increased energy or activity, three (or more) of the following symptoms (four if the mood is only irritable) are present to a significant degree and represent a noticeable change from usual behavior:
::::::::::::::1. Inflated self-esteem or grandiosity.
::::::::::::::2. Decreased need for sleep (e.g., feels rested after only 3 hours of sleep).
::::::::::::::3. More talkative than usual or pressure to keep talking.
::::::::::::::4. Flight of ideas or subjective experience that thoughts are racing.
::::::::::::::5. Distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli), as reported or observed.
::::::::::::::6. Increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation (i.e., purposeless non-goal-directed activity).
::::::::::::::7. Excessive involvement in activities that have a high potential for painful consequences (e.g., engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments).
C. The mood disturbance is sufficiently severe to cause marked impairment in social or occupational functioning or to necessitate hospitalization to prevent harm to self or others, or there are psychotic features.
D. The episode is not attributable to the physiological effects of a substance or another medical condition.:::::::Bipolar I Diagnostic Criteria
A. Criteria have been met for at least one manic episode.
B. At least one manic episode is not better explained by schizoaffective disorder and is not superimposed on schizophrenia, schizophreniform disorder, delusional disorder, or other specified or unspecified schizophrenia spectrum and other psychotic disorder.:::::::Bipolar I Specifiers
With anxious distress: The presence of at least two of the following symptoms during the majority of days of the current episode in bipolar I disorder:
1. Feeling keyed up or tense.
2. Feeling unusually restless.
3. Difficulty concentrating because of worry.
4. Fear that something awful may happen.
5. Feeling that the individual might lose control of themself.With mixed features:
::::::::::::::::::::::::::::::::::::::::::Manic or hypomanic episode, with mixed features:
A. Full criteria are met for a manic episode or hypomanic episode, and at least three of the following symptoms are present during the majority of days of the current or most recent episode of mania or hypomania:
::::::::::::::1. Prominent dysphoria or depressed mood.
::::::::::::::2. Diminished interest or pleasure in all, or almost all, activities.
::::::::::::::3. Psychomotor slowness nearly every day (observable by others; not merely subjective feelings of being slowed down).
::::::::::::::4. Fatigue or loss of energy.
::::::::::::::5. Feelings of worthlessness or excessive or inappropriate guilt (not merely self-reproach or guilt about being sick).
::::::::::::::6. Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide.
B. Mixed symptoms are observable by others and represent a change from the person’s usual behavior.
C. For individuals whose symptoms meet full episode criteria for both mania and depression simultaneously, the diagnosis should be manic episode, with mixed features, due to the marked impairment and clinical severity of full mania.:::::::::::::::::::::::::::::::::::::::::::::::::::Depressive episode, with mixed features:
A. Full criteria are met for a major depressive episode, and at least three of the following manic/hypomanic symptoms are present during the majority of days of the current or most recent episode of depression:
::::::::::::::1. Elevated, expansive mood.
::::::::::::::2. Inflated self-esteem or grandiosity.
::::::::::::::3. More talkative than usual or pressure to keep talking.
::::::::::::::4. Flight of ideas or subjective experience that thoughts are racing.
::::::::::::::5. Increase in energy or goal-directed activity.
::::::::::::::6. Increased or excessive involvement in activities that have a high potential for painful consequences.
::::::::::::::7. Decreased need for sleep.
B. Mixed symptoms are observable by others and represent a change from the person’s usual behavior.
C. For individuals whose symptoms meet full episode criteria for both mania and depression simultaneously, the diagnosis should be manic episode, with mixed features.With rapid cycling: Presence of at least four mood episodes in the previous 12 months that meet the criteria for manic, hypomanic, or major depressive episode in bipolar I disorder.With melancholic features:
A. One of the following is present during the most severe period of the current or most recent major depressive episode:
::::::::::::::1. Loss of pleasure in all, or almost all, activities.
::::::::::::::2. Lack of reactivity to usually pleasurable stimuli.
B. Three (or more) of the following:
::::::::::::::1. A distinct quality of depressed mood characterized by profound despondency, despair, and/or moroseness or by so-called empty mood.
::::::::::::::2. Depression that is regularly worse in the morning.
::::::::::::::3. Early-morning awakening (i.e., at least 2 hours before usual awakening).
::::::::::::::4. Marked psychomotor abnormalities.
::::::::::::::5. Significant anorexia or weight loss.
::::::::::::::6. Excessive or inappropriate guilt.With atypical features: This specifier is applied when these features predominate during the majority of days of the current major depressive episode.
A. Mood reactivity (i.e., mood brightens in response to actual or potential positive events).
B. Two (or more) of the following:
::::::::::::::1. Significant weight gain or increase in appetite.
::::::::::::::2. Hypersomnia.
::::::::::::::3. Leaden paralysis (i.e., heavy, leaden feelings in arms or legs).
::::::::::::::4. A long-standing pattern of interpersonal rejection sensitivity (not limited to episodes of mood disturbance) that results in significant social or occupational impairment.
C. Criteria are not met for “with melancholic features” or “with catatonia” during the same episode.With psychotic features:
:::::::::::::::::::::::::::::::::::::::::::::::::::With mood-congruent psychotic features:
The content of all delusions and hallucinations is consistent with the typical manic themes of grandiosity, invulnerability, etc., but may also include themes of suspiciousness or paranoia, especially with respect to others’ doubts about the individual’s capacities, accomplishments, and so forth.
OR
The content of all delusions and hallucinations is consistent with the typical depressive themes of personal inadequacy, guilt, disease, death, nihilism, or deserved punishment.:::::::::::::::::::::::::::::::::::::::::::::::::With mood-incongruent psychotic features:
The content of the delusions and hallucinations does not involve typical manic themes as described above, or the content is a mixture of mood-incongruent and mood-congruent themes.
OR
The content of the delusions and hallucinations does not involve typical depressive themes of personal inadequacy, guilt, disease, death, nihilism, or deserved punishment, or the content is a mixture of mood-incongruent and mood-congruent themes.With seasonal pattern: This specifier applies to the lifetime pattern of mood episodes. The essential feature is a regular seasonal pattern of at least one type of episode (i.e., mania, hypomania, or depression). The other types of episodes may not follow this pattern. For example, an individual may have seasonal manias but have depressions that do not regularly occur at a specific time of year.
A. There has been a regular temporal relationship between the onset of manic, hypomanic, or major depressive episodes and a particular time of the year (e.g., in the fall or winter) in bipolar I.
B. Full remissions (or a change from major depression to mania or hypomania or vice versa) also occur at a characteristic time of the year (e.g., depression disappears in the spring).
C. In the last 2 years, the individual’s manic, hypomanic, or major depressive episodes have demonstrated a temporal seasonal relationship, as defined above, and no non-seasonal episodes of that polarity have occurred during that 2-year period.
D. Seasonal manias, hypomanias, or depressions (as described above) substantially outnumber any non-seasonal manias, hypomanias, or depressions that may have occurred over the individual’s lifetime.:::::::Associated Features
Bipolar I disorder is characterized by a clinical course of recurring mood episodes (manic, depressive, and hypomanic), but the occurrence of at least one manic episode is necessary for the diagnosis of bipolar I disorder. Rapid shifts in mood over brief periods of time may occur and are referred to as lability (i.e., the alternation among euphoria, dysphoria, and irritability).Mood in a manic episode is often described as euphoric, excessively cheerful, high, or “feeling on top of the world.” In some cases, the mood is of such a highly infectious quality that it is easily recognized as excessive and may be characterized by unlimited and haphazard enthusiasm for interpersonal, sexual, or occupational interactions. For example, the individual may spontaneously start extensive conversations with strangers in public. Often the predominant mood is irritable rather than elevated, particularly when the individual’s wishes are denied or if the individual has been using substances.During a manic episode, individuals often do not perceive that they are ill or in need of treatment
and vehemently resist efforts to be treated. Individuals may change their dress, makeup, or personal appearance to a more sexually suggestive or flamboyant style. Some perceive a sharper sense of smell, hearing, or vision. Gambling and antisocial behaviors may accompany the manic episode. Mood may shift very rapidly to anger or depression; some individuals may become hostile and physically threatening to others and, when delusional, become physically assaultive or suicidal:::::::Differential Diagnoses
Major Depressive Disorder: There is a risk of misdiagnosing bipolar I disorder as unipolar
depression because of the prominence of depression in the presentation of bipolar I disorder: 1)
the first episode of bipolar disorder is often depressive, 2) depressive symptoms are the most
frequent symptoms experienced across the long-term course of bipolar I disorder, and 3) the
problem for which individuals typically seek help is depression.

Other bipolar disorders: Bipolar II disorder, cyclothymic disorder, and other specified bipolar and related disorder are similar to bipolar I disorder by virtue of their including periods of hypomanic symptoms in their presentations but are differentiated from bipolar I disorder by the absence of any manic episodes.

Schizoaffective Disorder: Schizoaffective disorder is characterized by periods in which manic and
major depressive episodes are concurrent with the active phase symptoms of schizophrenia and
periods in which delusions or hallucinations occur for at least 2 weeks in the absence of a manic
or major depressive episode. The diagnosis is “bipolar I disorder, with psychotic features” if the
psychotic symptoms have occurred exclusively during manic and major depressive episodes.

ADHD: Attention-deficit/hyperactivity disorder is characterized by persistent symptoms of inattention, hyperactivity, and impulsivity, which may resemble the symptoms of a manic episode (e.g., distractibility, increased activity, impulsive behavior) and have their onset by age 12. In contrast, the symptoms of mania in bipolar I disorder occur in distinct episodes and typically begin in late adolescence or early adulthood.

Personality Disorders: Personality disorders such as borderline personality disorder may have substantial symptomatic overlap with bipolar I disorder, since mood lability and impulsivity are
common in both conditions. In order to make a diagnosis of bipolar I disorder, symptoms of
mood lability and impulsivity must represent a distinct episode of illness, or there must be a
noticeable increase in these symptoms over the individual’s baseline in order to justify an
additional diagnosis of bipolar I disorder.:::::::Comorbid Disorders
Co-occurring mental disorders are the norm in bipolar I disorder, with the majority of individuals having a history of three or more disorders. The most frequently comorbid disorders are anxiety disorders, alcohol use disorder, other substance use disorder, and attention-deficit/hyperactivity
disorder. Bipolar I disorder is frequently associated with borderline, schizotypal, and antisocial personality disorder. In particular, although the underlying nature of the relationship between bipolar I disorder and borderline personality disorder is unclear, the substantial comorbidity between the two may reflect similarities in phenomenology (i.e., misdiagnosing the emotional extremes of borderline personality disorder as bipolar I disorder), the influence of borderline personality features on vulnerability to bipolar I disorder, and the impact of early childhood adversity on the development of both bipolar I and borderline personality disorder.←

For a diagnosis of bipolar II disorder, it is necessary to meet the following criteria for a current or past hypomanic episode and the following criteria for a current or past major depressive episode.:::::::Hypomanic Episode Criteria
A. A distinct period of abnormally and persistently elevated, expansive, or irritable mood and abnormally and persistently increased activity or energy, lasting at least 4 consecutive days and present most of the day, nearly every day.
B. During the period of mood disturbance and increased energy and activity, three (or more) of the following symptoms (four if the mood is only irritable) have persisted, represent a noticeable change from usual behavior, and have been present to a significant degree:
::::::::::::::1. Inflated self-esteem or grandiosity.
::::::::::::::2. Decreased need for sleep (e.g., feels rested after only 3 hours of sleep).
::::::::::::::3. More talkative than usual or pressure to keep talking.
::::::::::::::4. Flight of ideas or subjective experience that thoughts are racing.
::::::::::::::5. Distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli), as reported or observed.
::::::::::::::6. Increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation.
::::::::::::::7. Excessive involvement in activities that have a high potential for painful consequences (e.g., engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments).
C. The episode is associated with an unequivocal change in functioning that is uncharacteristic of the individual when not symptomatic.
D. The disturbance in mood and the change in functioning are observable by others.
E. The episode is not severe enough to cause marked impairment in social or occupational functioning or to necessitate hospitalization. If there are psychotic features, the episode is, by definition, manic.
F. The episode is not attributable to the physiological effects of a substance or another medical condition.:::::::Major Depressive Episode Criteria
A. Five (or more) of the following symptoms have been present during the same 2-week period and represent a change from previous functioning; at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure.
::::::::::::::1. Depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad, empty, or hopeless) or observation made by others (e.g., appears tearful). (Note: In children and adolescents, can be irritable mood.)
::::::::::::::2. Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by either subjective account or observation).
::::::::::::::3. Significant weight loss when not dieting or weight gain, or decrease or increase in appetite nearly every day.
::::::::::::::4. Insomnia or hypersomnia nearly every day.
::::::::::::::5. Psychomotor disturbances nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down).
::::::::::::::6. Fatigue or loss of energy nearly every day.
::::::::::::::7. Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick).
::::::::::::::8. Diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others).
::::::::::::::9. Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide.
B. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
C. The episode is not attributable to the physiological effects of a substance or another medical condition.:::::::Bipolar II Diagnostic Criteria
A. Criteria have been met for at least one hypomanic episode and at least one major depressive episode.
B. There has never been a manic episode.
C. At least one hypomanic episode and at least one major depressive episode are not better explained by schizoaffective disorder and are not superimposed on schizophrenia, schizophreniform disorder, delusional disorder, or other specified or unspecified schizophrenia spectrum and other psychotic disorder.
D. The symptoms of depression or the unpredictability caused by frequent alternation between periods of depression and hypomania causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.:::::::Bipolar I Specifiers
With anxious distress: The presence of at least two of the following symptoms during the majority of days of the current or most recent mood episode in bipolar II disorder:
1. Feeling keyed up or tense.
2. Feeling unusually restless.
3. Difficulty concentrating because of worry.
4. Fear that something awful may happen.
5. Feeling that the individual might lose control of themself.With mixed features:
::::::::::::::::::::::::::::::::::::::::::::::::::::::Hypomanic episode, with mixed features:
A. Full criteria are met for a manic episode or hypomanic episode, and at least three of the following symptoms are present during the majority of days of the current or most recent episode of hypomania:
::::::::::::::1. Prominent dysphoria or depressed mood.
::::::::::::::2. Diminished interest or pleasure in all, or almost all, activities.
::::::::::::::3. Psychomotor slowness nearly every day (observable by others; not merely subjective feelings of being slowed down).
::::::::::::::4. Fatigue or loss of energy.
::::::::::::::5. Feelings of worthlessness or excessive or inappropriate guilt (not merely self-reproach or guilt about being sick).
::::::::::::::6. Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide.
B. Mixed symptoms are observable by others and represent a change from the person’s usual behavior.:::::::::::::::::::::::::::::::::::::::::::::::::::::::Depressive episode, with mixed features:
A. Full criteria are met for a major depressive episode, and at least three of the following hypomanic symptoms are present during the majority of days of the current or most recent episode of depression:
::::::::::::::1. Elevated, expansive mood.
::::::::::::::2. Inflated self-esteem or grandiosity.
::::::::::::::3. More talkative than usual or pressure to keep talking.
::::::::::::::4. Flight of ideas or subjective experience that thoughts are racing.
::::::::::::::5. Increase in energy or goal-directed activity.
::::::::::::::6. Increased or excessive involvement in activities that have a high potential for painful consequences.
::::::::::::::7. Decreased need for sleep.
B. Mixed symptoms are observable by others and represent a change from the person’s usual behavior.With rapid cycling: Presence of at least four mood episodes in the previous 12 months that meet the criteria for hypomanic or major depressive episode in bipolar II disorder.With melancholic features:
A. One of the following is present during the most severe period of the current or most recent major depressive episode:
::::::::::::::1. Loss of pleasure in all, or almost all, activities.
::::::::::::::2. Lack of reactivity to usually pleasurable stimuli.
B. Three (or more) of the following:
::::::::::::::1. A distinct quality of depressed mood characterized by profound despondency, despair, and/or moroseness or by so-called empty mood.
::::::::::::::2. Depression that is regularly worse in the morning.
::::::::::::::3. Early-morning awakening (i.e., at least 2 hours before usual awakening).
::::::::::::::4. Marked psychomotor abnormalities.
::::::::::::::5. Significant anorexia or weight loss.
::::::::::::::6. Excessive or inappropriate guilt.With atypical features: This specifier is applied when these features predominate during the majority of days of the current or most recent major depressive episode.
A. Mood reactivity (i.e., mood brightens in response to actual or potential positive events).
B. Two (or more) of the following:
::::::::::::::1. Significant weight gain or increase in appetite.
::::::::::::::2. Hypersomnia.
::::::::::::::3. Leaden paralysis (i.e., heavy, leaden feelings in arms or legs).
::::::::::::::4. A long-standing pattern of interpersonal rejection sensitivity (not limited to episodes of mood disturbance) that results in significant social or occupational impairment.
C. Criteria are not met for “with melancholic features” or “with catatonia” during the same episode.With psychotic features:
:::::::::::::::::::::::::::::::::::::::::::::::::::With mood-congruent psychotic features:
The content of all delusions and hallucinations is consistent with the typical depressive themes of personal inadequacy, guilt, disease, death, nihilism, or deserved punishment.:::::::::::::::::::::::::::::::::::::::::::::::::With mood-incongruent psychotic features:
The content of the delusions and hallucinations does not involve typical depressive themes of personal inadequacy, guilt, disease, death, nihilism, or deserved punishment, or the content is a mixture of mood-incongruent and mood-congruent themes.With catatonia: This specifier is applied to the current or most recent major depressive episode in bipolar II disorder if catatonic features are present during most of the episode.With seasonal pattern: This specifier applies to the lifetime pattern of mood episodes. The essential feature is a regular seasonal pattern of at least one type of episode (i.e., hypomania or depression). The other types of episodes may not follow this pattern. For example, an individual may have seasonal hypomanias but have depressions that do not regularly occur at a specific time of year.
A. There has been a regular temporal relationship between the onset of hypomanic or major depressive episodes and a particular time of the year (e.g., in the fall or winter) in bipolar II disorder.
B. Full remissions (or a change from major depression to hypomania or vice versa) also occur at a characteristic time of the year (e.g., depression disappears in the spring).
C. In the last 2 years, the individual’s hypomanic, or major depressive episodes have demonstrated a temporal seasonal relationship, as defined above, and no non-seasonal episodes of that polarity have occurred during that 2-year period.
D. Seasonal hypomanias or depressions (as described above) substantially outnumber any
non-seasonal hypomanias or depressions that may have occurred over the individual’s lifetime.:::::::Associated Features
A hypomanic episode should not be confused with the several days of euthymia and restored energy or activity that may follow remission of a major depressive episode. Despite the substantial differences in duration and severity between a manic and hypomanic episode, bipolar II disorder is not a “milder form” of bipolar I disorder. Compared to individuals with bipolar I disorder, individuals with bipolar II disorder have greater chronicity of illness and spend, on average, more time in the depressive phase of their illness, which can be severe and/or disabling.
:
There may be heightened levels of creativity during hypomanic episodes in some individuals with a bipolar II disorder. However, that relationship may be nonlinear; that is, greater lifetime creative accomplishments have been associated with milder forms of bipolar disorder, and higher creativity has been found in unaffected family members. The individual’s attachment to the prospect of heightened creativity during hypomanic episodes may contribute to ambivalence about seeking treatment or undermine adherence to treatment.:::::::Differential Diagnoses
Other Bipolar disorders: Diagnosis of bipolar II disorder should be differentiated from bipolar I
disorder by carefully considering whether there have been any past episodes of mania and from
other specified and unspecified bipolar and related disorders by confirming the presence of fully
syndromal hypomania and depression.

Major Depressive Disorder: Major depressive disorder is characterized by the absence of both
manic episodes and hypomanic episodes. Given that the presence of some manic or hypomanic symptoms (e.g., fewer symptoms or shorter duration than required for hypomania) may still be
compatible with a diagnosis of major depressive disorder, it is important to ascertain whether the symptoms meet criteria for a hypomanic episode to determine whether it is more appropriate to make the diagnosis of bipolar II disorder. Depressive episodes dominate the overall course of illness for most individuals with bipolar II disorder, contributing to the decade-long lag between illness onset and the diagnosis of bipolar II disorder. Because the diagnostic criteria for major depressive episode are identical in major depressive disorder and bipolar II disorder, the diagnosis of bipolar II disorder can be made only by eliciting information about at least one prior hypomanic episode in order to distinguish the bipolar II disorder from major depressive disorder.

Cyclothymic Disorder: In cyclothymic disorder, there are numerous periods of hypomanic symptoms that do not meet symptom or duration criteria for a hypomanic episode and numerous periods of depressive symptoms that do not meet symptom or duration criteria for a major depressive episode. Bipolar II disorder is distinguished from cyclothymic disorder by the presence of one or more hypomanic episodes and one or more major depressive episodes.

ADHD: Attention-deficit/hyperactivity disorder (ADHD) may be misdiagnosed as bipolar II disorder, especially in adolescents and children. Many symptoms of ADHD, such as excessive talking, distractibility, and less need for sleep, overlap with the symptoms of hypomania. The double counting of symptoms toward both ADHD and bipolar II disorder can be avoided if the clinician clarifies whether the symptoms represent a distinct episode and if the noticeable increase over baseline required for the diagnosis of bipolar II disorder is present.

Personality Disorders: The same convention as applies for ADHD also applies when evaluating an individual for a personality disorder such as borderline personality disorder because mood lability and impulsivity are common in both personality disorders and bipolar II disorder. Symptoms must represent a distinct episode, and the noticeable increase over baseline required for the diagnosis of bipolar II disorder must be present. A diagnosis of a personality disorder should not be made during an untreated mood episode unless the lifetime history supports the presence of a personality disorder.Comorbidity
Bipolar II disorder is more often than not associated with one or more co-occurring mental disorders, with anxiety disorders being the most common.Individuals with bipolar II disorder appear to have lower rates of comorbid posttraumatic stress disorder compared to individuals with bipolar I disorder.Approximately 14% of individuals with bipolar II disorder have at least one lifetime eating disorder, with binge-eating disorder being more common than bulimia nervosa and anorexia
nervosa.←

Cyclothymic Disorder Diagnostic Criteria
A. For at least 2 years (at least 1 year in adolescents) there have been numerous periods with hypomanic symptoms that do not meet criteria for a hypomanic episode and numerous periods with depressive symptoms that do not meet criteria for a major depressive episode.
B. During the above 2-year period (1 year in adolescents), Criterion A symptoms have been present for at least half the time and the individual has not been without the symptoms for more than 2 months at a time.
C. Criteria for a major depressive, manic, or hypomanic episode have never been met.
D. The symptoms in Criterion A are not better explained by schizoaffective disorder, schizophrenia, schizophreniform disorder, delusional disorder, or other specified or unspecified schizophrenia spectrum and other psychotic disorder.
E. The symptoms are not attributable to the physiological effects of a substance or another medical condition.
F. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.Associated Features
The essential feature of cyclothymic disorder is a chronic, fluctuating mood disturbance involving numerous periods of hypomanic symptoms and periods of depressive symptoms (Criterion A). The hypomanic symptoms are of insufficient number, severity, pervasiveness, and/or duration to meet full criteria for a hypomanic episode, and the depressive symptoms are of insufficient number, severity, pervasiveness, and/or duration to meet full criteria for a major depressive episode.

If an individual with cyclothymic disorder subsequently experiences a major depressive, manic, or hypomanic episode, the diagnosis changes to major depressive disorder, bipolar I disorder, or other specified bipolar and related disorder, respectively, and the cyclothymic disorder diagnosis is dropped.Differential Diagnoses
Bipolar I/II with rapid cycling: Both disorders may resemble cyclothymic disorder by virtue of the frequent marked shifts in mood. By definition, in cyclothymic disorder the criteria for a major depressive, manic, or hypomanic episode have never been met, whereas the bipolar I disorder and bipolar II disorder specifier “with rapid cycling” requires that full mood episodes be present.

Borderline Personality Disorder: Borderline personality disorder is associated with recurrent, brief marked shifts in mood that may suggest cyclothymic disorder. Engagement in potentially self-damaging behaviors can be seen in both conditions but would need to occur in the context of other hypomanic symptoms to be related to cyclothymia. Mood instability in borderline personality disorder occurs in the domains of anxiety, irritability, and sadness, whereas elation, euphoria, and/or increased energy are not characteristic features of borderline personality disorder. If the criteria are met for both disorders, both borderline personality disorder and cyclothymic disorder may be diagnosed.Comorbid Disorders
Substance-related disorders and sleep disorders (i.e., difficulties in initiating and maintaining sleep) may be present in individuals with cyclothymic disorder.←

Other Specified Bipolar Disorder
This category applies to presentations in which symptoms characteristic of a bipolar and related disorder that cause clinically significant distress or impairment in social, occupational,
or other important areas of functioning predominate but do not meet the full criteria for any of the disorders in the bipolar and related disorders diagnostic class. The other specified bipolar and related disorder category is used in situations in which the clinician chooses to communicate the specific reason that the presentation does not meet the criteria for any specific bipolar
and related disorder.

Examples of presentations that can be specified using the “other specified” designation include:

1. Short-duration hypomanic episodes (2–3 days) and major depressive episodes: A lifetime history of one or more major depressive episodes in individuals whose presentation has never met full criteria for a manic or hypomanic episode but who have experienced two or more episodes of short-duration hypomania that meet the full symptomatic criteria for a hypomanic episode but that only last for 2–3 days. The episodes of hypomanic symptoms do not overlap in time with
the major depressive episodes, so the disturbance does not meet criteria for major depressive episode, with mixed features.
2. Hypomanic episodes with insufficient symptoms and major depressive episodes: A lifetime history of one or more major depressive episodes in individuals whose presentation has never met full criteria for a manic or hypomanic episode but who have experienced one or more episodes of hypomania that do not meet full symptomatic criteria. The episodes of hypomanic symptoms
do not overlap in time with the major depressive episodes, so the disturbance does not meet criteria for major depressive episode, with mixed features.
3. Hypomanic episode without prior major depressive episode: One or more hypomanic episodes in an individual whose presentation has never met full criteria for a major depressive episode or a manic episode.
4. Short-duration cyclothymia (less than 24 months): Multiple episodes of hypomanic symptoms that do not meet criteria for a hypomanic episode and multiple episodes of depressive symptoms that do not meet criteria for a major depressive episode that persist over a period of less than 24
months (less than 12 months for adolescents) in an individual whose presentation has never met full criteria for a major depressive, manic, or hypomanic episode and does not meet criteria for any psychotic disorder. During the course of the disorder, the hypomanic or depressive symptoms are
present for more days than not, the individual has not been without symptoms for more than 2 months at a time, and the symptoms cause clinically significant distress or impairment.
5. Manic episode superimposed on schizophrenia, schizophreniform disorder, delusional disorder, or other specified and unspecified schizophrenia spectrum and other psychotic disorder.←

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Disruptive Mood Dysregulation Disorder Diagnostic Criteria
A. Severe recurrent temper outbursts manifested verbally (e.g., verbal rages) and/or behaviorally (e.g., physical aggression toward people or property) that are grossly out of proportion in intensity or duration to the situation or provocation.
B. The temper outbursts are inconsistent with developmental level.
C. The temper outbursts occur, on average, three or more times per week.
D. The mood between temper outbursts is persistently irritable or angry most of the day, nearly every day, and is observable by others.
E. Criteria A–D have been present for 12 or more months. Throughout that time, the individual has not had a period lasting 3 or more consecutive months without all of the symptoms in Criteria A–D.
F. Criteria A and D are present in at least two of three settings and are severe in at least one of these.
G. The diagnosis should not be made for the first time before age 6 years or after age 18 years.
H. By history or observation, the age at onset of Criteria A–E is before 10 years.
I. There has never been a distinct period lasting more than 1 day during which the full symptom criteria, except duration, for a manic or hypomanic episode have been met.
J. The behaviors do not occur exclusively during an episode of major depressive disorder and are not better explained by another mental disorder.
K. The symptoms are not attributable to the physiological effects of a substance or another medical or neurological condition.Associated Features
The onset of disruptive mood dysregulation disorder must be before age 10 years. This diagnosis cannot coexist with oppositional defiant disorder, intermittent explosive disorder, or bipolar disorder, though it can coexist with others, including major depressive disorder, attention-deficit/hyperactivity disorder, conduct disorder, and substance use disorders. Individuals whose
symptoms meet criteria for both disruptive mood dysregulation disorder and oppositional defiant disorder should only be given the diagnosis of disruptive mood dysregulation disorder. If an individual has ever experienced a manic or hypomanic episode, the diagnosis of disruptive mood dysregulation disorder should not be assigned.Differential Diagnoses
Bipolar Disorders: The central feature differentiating disruptive mood dysregulation disorder and bipolar disorders in children involves the longitudinal course of the core symptoms. In children, as in adults, bipolar I disorder and bipolar II disorder manifest as an episodic illness with discrete episodes of mood perturbation that can be differentiated from the child’s typical presentation. The mood perturbation that occurs during a manic episode is distinctly different from the child’s
usual mood. In addition, during a manic episode, the change in mood must be accompanied by the onset, or worsening, of associated cognitive, behavioral, and physical symptoms (e.g., distractibility, increased goal-directed activity), which are also present to a degree that is distinctly different from the child’s usual baseline. Thus, in the case of a manic episode, parents (and, depending on developmental level, children) should be able to identify a distinct time period during which the child’s mood and behavior were markedly different from usual. In contrast, the irritability of disruptive mood dysregulation disorder is persistent and is present over many months; while it may wax and wane to a certain degree, severe irritability is characteristic of the child with disruptive mood dysregulation disorder. Thus, while bipolar disorders are episodic conditions, disruptive mood dysregulation disorder is not. In fact, the diagnosis of disruptive mood dysregulation disorder cannot be assigned to a child who has ever experienced a full-duration hypomanic or manic episode or who has ever had a manic or hypomanic episode lasting more than 1 day. Another central differentiating feature between bipolar disorders and disruptive mood dysregulation disorder is the presence of elevated or expansive mood and grandiosity. These symptoms are common features of mania but are not characteristic of disruptive mood dysregulation disorder.

Oppositional Defiant Disorder: While symptoms of oppositional defiant disorder typically do occur in children with disruptive mood dysregulation disorder, mood symptoms of disruptive mood dysregulation disorder are relatively rare in children with oppositional defiant disorder. The key features that warrant the diagnosis of disruptive mood dysregulation disorder in children whose
symptoms also meet criteria for oppositional defiant disorder are the presence of severe and frequently recurrent outbursts and a persistent disruption in mood between outbursts. In addition, the diagnosis of disruptive mood dysregulation disorder requires severe impairment in at least one setting (i.e., home, school, or among peers) and mild to moderate impairment in a second setting. For this reason, while most children whose symptoms meet criteria for disruptive mood dysregulation disorder will also have a presentation that meets criteria for oppositional defiant disorder, the reverse is not the case. That is, in only approximately 15% of individuals with oppositional defiant disorder would criteria for disruptive mood dysregulation disorder be met.
Moreover, even for children in whom criteria for both disorders are met, only the diagnosis of disruptive mood dysregulation disorder should be made

ADHD, Major Depressive Disorder, Anxiety Disorders, and Autism Spectrum Disorder: Unlike children diagnosed with bipolar disorder or oppositional defiant disorder—for whom a diagnosis of disruptive mood dysregulation disorder cannot be given even if the symptoms meet diagnostic criteria for that disorder—children whose symptoms meet criteria for disruptive mood dysregulation disorder also can receive a comorbid diagnosis of ADHD, major depressive disorder, and/or anxiety disorder. However, children whose irritability is present only in the context of a major depressive episode or persistent depressive disorder should receive one of those diagnoses rather than disruptive mood dysregulation disorder. Children with disruptive mood dysregulation disorder may have symptoms that also meet criteria for an anxiety disorder and can receive both diagnoses, but children whose irritability is manifest only in the context of exacerbation of an anxiety disorder should receive the relevant anxiety disorder diagnosis rather than disruptive mood dysregulation disorder. In addition, children with autism spectrum disorders frequently present with temper outbursts when, for example, their routines are disturbed. In that instance, the temper outbursts would be considered secondary to the autism spectrum disorder, and the child should not receive the diagnosis of disruptive mood dysregulation disorder.

Intermittent Explosive Disorder: Children with symptoms suggestive of intermittent explosive disorder present with instances of severe temper outbursts, much like children with disruptive mood dysregulation disorder. However, unlike disruptive mood dysregulation disorder, intermittent explosive disorder does not require the individual’s mood to be persistently irritable or angry between outbursts. In addition, a diagnosis of intermittent explosive disorder involving verbal aggression or physical aggression that does not result in damage to property or physical injury to animals or other individuals occurring at least twice weekly can be made after only 3 months of symptoms, in contrast to the 12-month requirement for disruptive mood dysregulation disorder. Thus, these two diagnoses should not be made in the same child. For children with outbursts and intercurrent, persistent irritability, only the diagnosis of disruptive mood dysregulation disorder should be made.Comorbid Disorders
Rates of comorbidity in disruptive mood dysregulation disorder are extremely high. It is rare to find individuals whose symptoms meet criteria for disruptive mood dysregulation disorder alone. Comorbidity between disruptive mood dysregulation disorder and other DSM-defined syndromes
appears higher than for many other pediatric mental illnesses; the strongest overlap is with oppositional defiant disorder. Not only is the overall rate of comorbidity high in disruptive mood dysregulation disorder, but also the range of comorbid illnesses appears particularly diverse. These children typically present to the clinic with a wide range of disruptive behavior, mood, anxiety, and even autism spectrum symptoms and diagnoses. However, children with disruptive mood dysregulation disorder should not have symptoms that meet criteria for bipolar disorder, as in that context, only the bipolar disorder diagnosis should be made.←

Major Depressive Disorder Diagnostic Criteria
A. Five (or more) of the following symptoms have been present during the same 2-week period and represent a change from previous functioning; at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure.
::::::::::::::1. Depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad, empty, or hopeless) or observation made by others (e.g., appears tearful). (Note: In children and adolescents, can be irritable mood.)
::::::::::::::2. Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by either subjective account or observation).
::::::::::::::3. Significant weight loss when not dieting or weight gain, or decrease or increase in appetite nearly every day.
::::::::::::::4. Insomnia or hypersomnia nearly every day.
::::::::::::::5. Psychomotor disturbances nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down).
::::::::::::::6. Fatigue or loss of energy nearly every day.
::::::::::::::7. Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick).
::::::::::::::8. Diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others).
::::::::::::::9. Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide.
B. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
C. The episode is not attributable to the physiological effects of a substance or another medical condition.
D. At least one major depressive episode is not better explained by schizoaffective disorder and is not superimposed on schizophrenia, schizophreniform disorder, delusional disorder, or other specified and unspecified schizophrenia spectrum and other psychotic disorders.
E. There has never been a manic episode or a hypomanic episode.Major Depressive Disorder Specifiers
With anxious distress: Anxious distress is defined as the presence of at least two of the following symptoms during the majority of days of the current or most recent major depressive episode:
::::::::::::::1. Feeling keyed up or tense.
::::::::::::::2. Feeling unusually restless.
::::::::::::::3. Difficulty concentrating because of worry.
::::::::::::::4. Fear that something awful may happen.
::::::::::::::5. Feeling that the individual might lose control of himself or herself.With mixed features:
A. At least three of the following manic/hypomanic symptoms are present during the majority of days of the current or most recent major depressive episode:
::::::::::::::1. Elevated, expansive mood.
::::::::::::::2. Inflated self-esteem or grandiosity.
::::::::::::::3. More talkative than usual or pressure to keep talking.
::::::::::::::4. Flight of ideas or subjective experience that thoughts are racing.
::::::::::::::5. Increase in energy or goal-directed activity (either socially, at work or school, or sexually).
::::::::::::::6. Increased or excessive involvement in activities that have a high potential for painful consequences (e.g., engaging in unrestrained buying sprees, sexual indiscretions, or irresponsible business investments).
::::::::::::::7. Decreased need for sleep (feeling rested despite sleeping less than usual; to be contrasted with insomnia).
B. Mixed symptoms are observable by others and represent a change from the person’s usual behavior.
C. For individuals whose symptoms meet full criteria for either mania or hypomania, the diagnosis should be bipolar I or bipolar II disorder.
D. The mixed symptoms are not attributable to the physiological effects of a substance.With melancholic features:
A. One of the following is present during the most severe period of the current or most recent
major depressive episode:
::::::::::::::1. Loss of pleasure in all, or almost all, activities.
::::::::::::::2. Lack of reactivity to usually pleasurable stimuli (does not feel much better, even temporarily, when something good happens).
B. Three (or more) of the following:
::::::::::::::1. A distinct quality of depressed mood characterized by profound despondency, despair, and/or moroseness or by so-called empty mood.
::::::::::::::2. Depression that is regularly worse in the morning.
::::::::::::::3. Early-morning awakening (i.e., at least 2 hours before usual awakening).
::::::::::::::4. Marked psychomotor agitation or slowness.
::::::::::::::5. Significant anorexia or weight loss.
::::::::::::::6. Excessive or inappropriate guilt.With atypical features: This specifier is applied when these features predominate during the majority of days of the current or most recent major depressive episode.
A. Mood reactivity (i.e., mood brightens in response to actual or potential positive events).
B. Two (or more) of the following:
::::::::::::::1. Significant weight gain or increase in appetite.
::::::::::::::2. Hypersomnia.
::::::::::::::3. Leaden paralysis (i.e., heavy, leaden feelings in arms or legs).
::::::::::::::4. A long-standing pattern of interpersonal rejection sensitivity (not limited to episodes of mood disturbance) that results in significant social or occupational impairment.
C. Criteria are not met for “with melancholic features” or “with catatonia” during the same episode.With psychotic features: Delusions and/or hallucinations are present at any time in the current or most recent major depressive episode. If psychotic features are present, specify if mood-congruent or mood-incongruent:
With mood-congruent psychotic features: The content of all delusions and hallucinations is consistent with the typical depressive themes of personal inadequacy, guilt, disease, death, nihilism, or deserved punishment.
With mood-incongruent psychotic features: The content of the delusions or hallucinations does not involve typical depressive themes of personal inadequacy, guilt, disease, death, nihilism, or deserved punishment, or the content is a mixture of mood-incongruent and mood-congruent themes.With catatonia: This specifier is applied to the current or most recent major depressive episode if catatonic features are present during most of the episode.With seasonal pattern: This specifier applies to recurrent major depressive disorder.
A. There has been a regular temporal relationship between the onset of major depressive episodes in major depressive disorder and a particular time of the year (e.g., in the fall or winter).
B. Full remissions also occur at a characteristic time of the year (e.g., depression disappears in the spring).
C. In the last 2 years, two major depressive episodes have occurred that demonstrate the temporal seasonal relationships defined above and no nonseasonal major depressive episodes have occurred during that same period.
D. Seasonal major depressive episodes (as described above) substantially outnumber the nonseasonal major depressive episodes that may have occurred over the individual’s lifetime.Associated Features
Major depressive disorder is defined by the presence of at least one major depressive episode occurring in the absence of a history of manic or hypomanic episodes. To count toward a diagnosis of a major depressive episode, a symptom must either be newly present or have clearly worsened compared with the individual’s pre-episode status.

The course of major depressive disorder is quite variable, such that some individuals rarely, if ever, experience remission (a period of 2 or more months with no symptoms, or only one or two symptoms to no more than a mild degree), while others experience many years with few or no symptoms between discrete episodes.

Individuals frequently present with tearfulness, irritability, brooding, obsessive rumination, anxiety, phobias, excessive worry over physical health, and complaints of pain. Many of the functional consequences of major depressive disorder derive from individual symptoms. Impairment can be very mild, such that many of those who interact with the affected individual are unaware of depressive symptoms. Impairment may, however, range to complete incapacity such that the depressed individual is unable to attend to basic self-care needs or is mute or catatonic.Differential Diagnoses
Manic Episodes with irritable mood or with mixed features: Major depressive episodes with prominent irritable mood may be difficult to distinguish from manic episodes with irritable mood or with mixed features. This distinction requires a careful clinical evaluation of the presence of sufficient manic symptoms to meet threshold criteria (i.e., three if mood is manic, four if mood is irritable but not manic).

Bipolar Disorders: Major depressive episodes along with a history of a manic or hypomanic episode preclude the diagnosis of major depressive disorder. Major depressive episodes with a history of hypomanic episodes and without a history of manic episodes indicate a diagnosis of bipolar II disorder, whereas major depressive episodes with a history of manic episodes (with or without hypomanic episodes) indicate a diagnosis of bipolar I disorder. On the other hand, presentations of major depressive episodes with a history of periods of hypomania that do not meet criteria for a hypomanic episode may be diagnosed as either other specified bipolar and related disorder or major depressive disorder depending on where the clinician judges the presentation to best fall. For example, the presentation may be best considered other specified bipolar and related disorder because of the clinical significance of the subthreshold hypomanic symptoms, or the presentation may be best considered a case of major depressive disorder with some subthreshold hypomanic symptoms in between episodes.

Persistent Depressive Disorder: Persistent depressive disorder is characterized by depressed mood, more days than not, for at least 2 years. If criteria are met for both major depressive disorder and persistent depressive disorder, both can be diagnosed.

ADHD: Distractibility and low frustration tolerance can occur in both attention-deficit/hyperactivity disorder (ADHD) and a major depressive episode; if the criteria are met for both, ADHD may be diagnosed in addition to the mood disorder. However, the clinician must be cautious not to overdiagnose a major depressive episode in children with ADHD whose disturbance in mood is characterized by irritability rather than by sadness or loss of interest.Comorbid Disorders
Other disorders with which major depressive disorder frequently co-occurs are substance-related disorders, panic disorder, generalized anxiety disorder, posttraumatic stress disorder, obsessive-compulsive disorder, anorexia nervosa, bulimia nervosa, and borderline personality disorder.←

Persistent Depressive Disorder Diagnostic Criteria
A. Depressed mood for most of the day, for more days than not, as indicated by either subjective account or observation by others, for at least 2 years.
B. Presence, while depressed, of two (or more) of the following:
::::::::::::::1. Poor appetite or overeating.
::::::::::::::2. Insomnia or hypersomnia.
::::::::::::::3. Low energy or fatigue.
::::::::::::::4. Low self-esteem.
::::::::::::::5. Poor concentration or difficulty making decisions.
::::::::::::::6. Feelings of hopelessness.
C. During the 2-year period (1 year for children or adolescents) of the disturbance, the individual has never been without the symptoms in Criteria A and B for more than 2 months at a time.
D. Criteria for a major depressive disorder may be continuously present for 2 years.
E. There has never been a manic episode or a hypomanic episode.
F. The disturbance is not better explained by a persistent schizoaffective disorder, schizophrenia, delusional disorder, or other specified or unspecified schizophrenia spectrum and other psychotic disorder.
G. The symptoms are not attributable to the physiological effects of a substance or another medical condition.
H. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.Persistent Depressive Disorder Specifiers
With anxious distress: Anxious distress is defined as the presence of at least two of the following symptoms during the majority of days of the current persistent depressive disorder:
::::::::::::::1. Feeling keyed up or tense.
::::::::::::::2. Feeling unusually restless.
::::::::::::::3. Difficulty concentrating because of worry.
::::::::::::::4. Fear that something awful may happen.
::::::::::::::5. Feeling that the individual might lose control of himself or herself.With atypical features: This specifier is applied when these features predominate during the majority of days of the current persistent depressive disorder.
A. Mood reactivity (i.e., mood brightens in response to actual or potential positive events).
B. Two (or more) of the following:
::::::::::::::1. Significant weight gain or increase in appetite.
::::::::::::::2. Hypersomnia.
::::::::::::::3. Leaden paralysis (i.e., heavy, leaden feelings in arms or legs).
::::::::::::::4. A long-standing pattern of interpersonal rejection sensitivity (not limited to episodes of mood disturbance) that results in significant social or occupational impairment.Associated Features
Major depression may precede persistent depressive disorder, and major depressive episodes may occur during persistent depressive disorder. Individuals whose symptoms meet major depressive disorder criteria for 2 years should be given a diagnosis of persistent depressive disorder as well as major depressive disorder.

Individuals with persistent depressive disorder describe their mood as sad or “down in the dumps.” During periods of depressed mood, at least two of the six symptoms from Criterion B are present. Because these symptoms have become a part of the individual’s day-to-day experience, particularly in the case of early onset (e.g., “I’ve always been this way”), they may not be reported unless the individual is directly prompted.Differential Diagnoses
Major Depressive Disorder: If there is a depressed mood for more days than not plus two or more
persistent depressive disorder Criterion B symptoms for 2 years or more, then the diagnosis of persistent depressive disorder is made. If the symptom criteria are sufficient for a diagnosis of a major depressive episode at any time during this period, then the additional diagnosis of major depression should be made.

Other Specified Depressive Disorder: Because the criteria for a major depressive episode include symptoms (i.e., markedly diminished interest or pleasure in activities; psychomotor agitation or
slowness; recurrent thoughts of death, suicidal ideation, suicide attempt or plan) that are absent from the symptom list for persistent depressive disorder (i.e., depressed mood and two out of six Criterion B symptoms), a very limited number of individuals will have depressive symptoms that have persisted longer than 2 years but that do not meet criteria for persistent depressive disorder. If full criteria for a major depressive episode have been met at some point during the current episode of illness, a diagnosis of major depressive disorder would apply. Otherwise, a diagnosis of other specified depressive disorder or unspecified depressive disorder should be given.

Bipolar I or II: A history of a manic or hypomanic episode precludes the diagnosis of persistent depressive disorder. A history of manic episodes (with or without hypomanic episodes) indicates a diagnosis of bipolar I disorder. A history of hypomanic episodes (without any history of manic episodes in individuals with persistent depressive presentations during which criteria have been met for a major depressive episode) warrants a diagnosis of bipolar II disorder. Other specified bipolar disorder applies to individuals whose presentations include a history of hypomanic episodes along with persistent depressive presentation that has never met full criteria for a major depressive episode.

Cyclothymic Disorder: A diagnosis of cyclothymic disorder precludes the diagnosis of persistent
depressive disorder. Thus, if during the period lasting at least 2 years of depressed mood for most of the day, for more days than not, 1) there are numerous periods with hypomanic symptoms that do not meet criteria for a hypomanic episode, 2) there have not been any symptom-free periods of more than 2 months at a time, and 3) criteria have never been met for a major depressive, manic, or hypomanic episode, then the diagnosis would be cyclothymic disorder instead of persistent depressive disorder.Comorbid Disorders
In comparison to individuals with major depressive disorder, those with persistent depressive disorder are at higher risk for psychiatric comorbidity in general, and for anxiety disorders, substance use disorders, and personality disorders in particular. Early-onset persistent depressive disorder is strongly associated with Cluster B and C personality disorders.←

Premenstrual Dysphoric Disorder Diagnostic Criteria
A. In the majority of menstrual cycles, at least five symptoms must be present in the final week before the onset of menses, start to improve within a few days after the onset of menses, and become minimal or absent in the week post-menses.
B. One (or more) of the following symptoms must be present:
::::::::::::::1. Marked affective lability (e.g., mood swings; feeling suddenly sad or tearful, or increased sensitivity to rejection).
::::::::::::::2. Marked irritability or anger or increased interpersonal conflicts.
::::::::::::::3. Marked depressed mood, feelings of hopelessness, or self-deprecating thoughts.
::::::::::::::4. Marked anxiety, tension, and/or feelings of being keyed up or on edge.
C. One (or more) of the following symptoms must additionally be present, to reach a total of five symptoms when combined with symptoms from Criterion B above.
::::::::::::::1. Decreased interest in usual activities.
::::::::::::::2. Subjective difficulty in concentration.
::::::::::::::3. Lethargy, easy fatigability, or marked lack of energy.
::::::::::::::4. Marked change in appetite; overeating; or specific food cravings.
::::::::::::::5. Hypersomnia or insomnia.
::::::::::::::6. A sense of being overwhelmed or out of control.
::::::::::::::7. Physical symptoms such as breast tenderness or swelling, joint or muscle pain, a sensation of “bloating,” or weight gain.
D. The symptoms cause clinically significant distress or interference with work, school, usual social activities, or relationships with others (e.g., avoidance of social activities; decreased productivity and efficiency at work, school, or home).
E. The disturbance is not merely an exacerbation of the symptoms of another disorder, such as major depressive disorder, panic disorder, persistent depressive disorder, or a personality disorder (although it may co-occur with any of these disorders).
F. Criterion A should be confirmed by prospective daily ratings during at least two symptomatic cycles.
G. The symptoms are not attributable to the physiological effects of a substance or another medical condition.Associated Features
The essential features of premenstrual dysphoric disorder are the expression of mood lability, irritability, dysphoria, and anxiety symptoms that occur repeatedly during the premenstrual phase of the cycle and remit around the onset of menses or shortly thereafter. These symptoms may be accompanied by behavioral and physical symptoms. Symptoms must have occurred in most of the menstrual cycles during the past year and must have an adverse effect on work or social functioning. Typically, symptoms peak around the time of the onset of menses. Although it is not uncommon for symptoms to linger into the first few days of menses, the individual must have a symptom-free period in the follicular phase after the menstrual period begins.

Delusions and hallucinations have been described in the late luteal phase of the menstrual cycle but are rare.Differential Diagnoses
Premenstrual Syndrome: Premenstrual syndrome differs from premenstrual dysphoric disorder in that premenstrual syndrome does not require a minimum of five symptoms nor mood-related symptomatology, and it is generally considered to be less severe than premenstrual dysphoric disorder. While premenstrual syndrome shares the feature of symptom expression during the premenstrual phase of the menstrual cycle, the presence of somatic or behavioral symptoms, without the required affective symptoms, likely meets criteria for premenstrual syndrome and not for premenstrual dysphoric disorder.

Dysmenorrhea: Dysmenorrhea is a syndrome of painful menses, but this is distinct from a syndrome characterized by affective changes. Moreover, symptoms of dysmenorrhea begin with the onset of menses, whereas symptoms of premenstrual dysphoric disorder, by definition, begin before the onset of menses, even if they linger into the first few days of menses.

Bipolar, Major Depressive Disorder, or Persistent Depressive Disorder: Many people with
bipolar or major depressive disorder or persistent depressive disorder believe that they have premenstrual dysphoric disorder. However, when they chart symptoms, they realize that the symptoms do not follow a premenstrual pattern. Because the onset of menses constitutes a memorable event, they may report that symptoms occur only during the premenstruum or that symptoms worsen premenstrually. This is one of the rationales for the requirement that symptoms be confirmed by daily prospective ratings. The process of differential diagnosis, particularly if the clinician relies on retrospective symptoms only, is made more difficult because of the overlap between symptoms of premenstrual dysphoric disorder and some other diagnoses. The overlap of symptoms is particularly salient for differentiating premenstrual dysphoric disorder from major depressive episodes, persistent depressive disorder, bipolar disorders, and borderline personality disorder.Comorbid Disorders
A major depressive episode is the most frequently reported previous disorder in individuals presenting with premenstrual dysphoric disorder. A wide range of medical conditions (e.g., migraine, asthma, allergies, seizure disorders) or other mental disorders (e.g., depressive and bipolar disorders, anxiety disorders, bulimia nervosa, substance use disorders) may worsen in the premenstrual phase; however, the absence of a symptom-free period during the postmenstrual interval obviates a diagnosis of premenstrual dysphoric disorder. These conditions are better considered premenstrual exacerbation of a current mental disorder or medical condition. Although the diagnosis of premenstrual dysphoric disorder should not be assigned in situations in which an individual experiences only a premenstrual exacerbation of another mental or physical disorder, it can be considered in addition to the diagnosis of another mental disorder or medical condition if
the individual experiences symptoms and changes in level of functioning that are characteristic of premenstrual dysphoric disorder and markedly different from the symptoms experienced as part of the ongoing disorder.←

Other Specified Depressive Disorder
This category applies to presentations in which symptoms characteristic of a depressive disorder that cause clinically significant distress or impairment in social, occupational, or other important areas of functioning predominate but do not meet the full criteria for any of the disorders in the depressive disorders diagnostic class and do not meet criteria for adjustment disorder with depressed mood or adjustment disorder with mixed anxiety and depressed mood. The other specified depressive disorder category is used in situations in which the clinician chooses to communicate the specific reason that the presentation does not meet the criteria for any specific depressive disorder.

Examples of presentations that can be specified using the “other specified” designation include:

1. Recurrent brief depression: Concurrent presence of depressed mood and at least four other symptoms of depression for 2–13 days at least once per month (not associated with the menstrual cycle) for at least 12 consecutive months in an individual whose presentation has never met criteria for any other depressive or bipolar disorder and does not currently meet active or residual criteria for any psychotic disorder.
2. Short-duration depressive episode (4–13 days): Depressed affect and at least four of the other eight symptoms of a major depressive episode associated with clinically significant distress or impairment that persists for more than 4 days, but less than 14 days, in an individual whose presentation has never met criteria for any other depressive or bipolar disorder, does not currently meet active or residual criteria for any psychotic disorder, and does not meet criteria for recurrent brief depression.
3. Depressive episode with insufficient symptoms: Depressed affect and at least one of the other eight symptoms of a major depressive episode associated with clinically significant distress or impairment that persist for at least 2 weeks in an individual whose presentation has never met criteria for any other depressive or bipolar disorder, does not currently meet active or residual criteria for any psychotic disorder, and does not meet criteria for mixed anxiety and depressive disorder symptoms.
4. Major depressive episode superimposed on schizophrenia, schizophreniform disorder, delusional disorder, or other specified and unspecified schizophrenia spectrum and other psychotic disorder.←

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Separation Anxiety Disorder Diagnostic Criteria
A. Developmentally inappropriate and excessive fear or anxiety concerning separation from those to whom the individual is attached, as evidenced by at least three of the following:
::::::::::::::1. Recurrent excessive distress when anticipating or experiencing separation from home or from major attachment figures.
::::::::::::::2. Persistent and excessive worry about losing major attachment figures or about possible harm to them, such as illness, injury, disasters, or death.
::::::::::::::3. Persistent and excessive worry about experiencing an untoward event (e.g., getting lost, being kidnapped, having an accident, becoming ill) that causes separation from a major attachment figure.
::::::::::::::4. Persistent reluctance or refusal to go out, away from home, to school, to work, or elsewhere because of fear of separation.
::::::::::::::5. Persistent and excessive fear of or reluctance about being alone or without major attachment figures at home or in other settings.
::::::::::::::6. Persistent reluctance or refusal to sleep away from home or to go to sleep without being near a major attachment figure.
::::::::::::::7. Repeated nightmares involving the theme of separation.
::::::::::::::8. Repeated complaints of physical symptoms (e.g., headaches, stomachaches, nausea, vomiting) when separation from major attachment figures occurs or is anticipated.
B. The fear, anxiety, or avoidance is persistent, lasting at least 4 weeks in children and adolescents and typically 6 months or more in adults.
C. The disturbance causes clinically significant distress or impairment in social, academic, occupational, or other important areas of functioning.
D. The disturbance is not better explained by another mental disorder, such as refusing to leave home because of excessive resistance to change in autism spectrum disorder; delusions or hallucinations concerning separation in psychotic disorders; refusal to go outside without a trusted companion in agoraphobia; worries about ill health or other harm befalling significant others in generalized anxiety disorder; or concerns about having an illness in illness anxiety disorder.Associated Features
When separated from major attachment figures, children and adults with separation anxiety disorder may exhibit social withdrawal, apathy, sadness, or difficulty concentrating on work or play. Depending on their age, individuals may have fears of animals, monsters, the dark, muggers, burglars, kidnappers, car accidents, plane travel, and other situations that are perceived as presenting danger to the family or themselves. Some individuals become homesick and extremely uncomfortable when away from home. Separation anxiety disorder in children may lead to school
refusal, which in turn may lead to academic difficulties and social isolation.
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When extremely upset at the prospect of separation, children may show anger or occasionally aggression toward someone who is forcing separation. When alone, especially in the evening or the dark, young children may report unusual perceptual experiences (e.g., seeing people peering into their room, frightening creatures reaching for them, feeling eyes staring at them). Children with this disorder may be described as demanding, intrusive, and in need of constant attention, and, as adults, may appear dependent and overprotective as parents. Adults with the disorder are likely to text or phone their major attachment figures throughout the day and repeatedly check on their whereabouts.
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Individuals with separation anxiety disorder often limit independent activities away from home or attachment figures. Symptoms in adults are often debilitating and affect multiple areas of their lives. For example, adults with separation anxiety disorder may deliberately reorganize their work schedules and other activities because of their anxieties about possible separations from close attachment figures; they may often express frustration with the limitations on their lives because of their need to maintain proximity to, or at least virtual contact with, their key attachment figures.Differential Diagnoses
Personality Disorders: Dependent personality disorder is characterized by an indiscriminate tendency to rely on others, whereas separation anxiety disorder involves concern about the proximity and safety of key attachment figures. Borderline personality disorder is characterized by fear of abandonment by loved ones, but problems in identity, self-direction, interpersonal functioning, and impulsivity are additionally central to that disorder, whereas they are not central to separation anxiety disorder.Comorbid Disorders
In children, separation anxiety disorder is highly comorbid with generalized anxiety disorder and specific phobia. In adults, common comorbidities include specific phobia, PTSD, panic disorder, generalized anxiety disorder, social anxiety disorder, agoraphobia, obsessive-compulsive disorder,
prolonged grief disorder, and personality disorders. Among the personality disorders, dependent, avoidant, and obsessive-compulsive (Cluster C) personality disorders may be comorbid with separation anxiety disorder. Depressive and bipolar disorders are also comorbid with separation anxiety disorder in adults.←

Selective Mutism Diagnostic Criteria
A. Consistent failure to speak in specific social situations in which there is an expectation for speaking (e.g., at school) despite speaking in other situations.
B. The disturbance interferes with educational or occupational achievement or with social communication.
C. The duration of the disturbance is at least 1 month (not limited to the first month of school).
D. The failure to speak is not attributable to a lack of knowledge of, or comfort with, the spoken language required in the social situation.
E. The disturbance is not better explained by a communication disorder (e.g., stuttering) and does not occur exclusively during the course of autism spectrum disorder, schizophrenia, or another psychotic disorder.Associated Features
When encountering other individuals in social interactions, children with selective mutism do not initiate speech or reciprocally respond when spoken to by others. Lack of speech occurs in social interactions with children or adults. Children with selective mutism will speak in their home in the presence of immediate family members but often not even in front of close friends or second-degree relatives, such as grandparents or cousins. The disturbance is most often marked by high social anxiety. The lack of speech may interfere with social communication, although children with this disorder sometimes use nonspoken or nonverbal means (e.g., grunting, pointing, writing) to communicate and may be willing or eager to perform or engage in social encounters when speech is not required (e.g., nonverbal parts in school plays).

In clinical settings, children with selective mutism are almost always given an additional diagnosis of another anxiety disorder— most commonly, social anxiety disorder.Differential Diagnoses
Neurodevelopmental and psychotic disorders: Individuals with an autism spectrum disorder, schizophrenia or another psychotic disorder, or severe intellectual developmental disorder (intellectual disability) may have problems in social communication and be unable to speak appropriately in social situations. In contrast, selective mutism should be diagnosed only when a child has an established capacity to speak in some social situations (e.g., typically at home).

Social Anxiety Disorder: The social anxiety and social avoidance in social anxiety disorder may be associated with selective mutism. In such cases, both diagnoses may be given.Comorbid Disorders
The most common comorbid conditions are other anxiety disorders, most often social anxiety disorder, followed by separation anxiety disorder and specific phobia. In clinical settings, selective mutism and autism spectrum disorder have also been noted as frequently co-occurring conditions. Oppositional behaviors can be observed in a substantial minority of children with selective mutism, although this oppositional behavior may be limited to situations requiring speech. Communication delays or disorders also may appear in some children with selective mutism.←

Specific Phobia Diagnostic Criteria
A. Marked fear or anxiety about a specific object or situation.
B. The phobic object or situation almost always provokes immediate fear or anxiety.
C. The phobic object or situation is actively avoided or endured with intense fear or anxiety.
D. The fear or anxiety is out of proportion to the actual danger posed by the specific object or situation and to the sociocultural context.
E. The fear, anxiety, or avoidance is persistent, typically lasting for 6 months or more.
F. The fear, anxiety, or avoidance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
G. The disturbance is not better explained by the symptoms of another mental disorder, including fear, anxiety, and avoidance of situations associated with panic-like symptoms or other incapacitating symptoms (as in agoraphobia); objects or situations related to obsessions (as in obsessive-compulsive disorder); reminders of traumatic events (as in posttraumatic stress disorder); separation from home or attachment figures (as in separation anxiety disorder); or social situations (as in social anxiety disorder).Associated Features
It is common for individuals to have multiple specific phobias. The average individual with specific phobia fears three objects or situations, and approximately 75% of individuals with specific phobia fear more than one situation or object.

Specific phobia sometimes develops following a traumatic event, observation of others going through a traumatic event, an unexpected panic attack in the to be feared situation, or informational transmission. However, many individuals with specific phobia are unable to recall the specific reason for the onset of their phobias. Specific phobia usually develops in early childhood, with the majority of cases developing prior to age 10 years. Although most specific phobias develop in childhood and adolescence, it is possible for a specific phobia to develop at any age, often as the result of experiences that are traumatic. For example, phobias of choking almost always follow a near-choking event at any age.Differential Diagnoses
Agoraphobia: Situational specific phobia may resemble agoraphobia in its clinical presentation, given the overlap in feared situations (e.g., flying, enclosed places, elevators). If an individual fears only one of the agoraphobic situations, then specific phobia, situational, may be diagnosed. If two or more agoraphobic situations are feared, a diagnosis of agoraphobia is likely warranted. For example, an individual who fears airplanes and elevators (which overlap with the “public transportation” agoraphobic situation) but does not fear other agoraphobic situations would be
diagnosed with specific phobia, situational, whereas an individual who fears airplanes, elevators,
and crowds (which overlap with two agoraphobic situations, “using public transportation” and “standing in line or being in a crowd”) would be diagnosed with agoraphobia. Criterion B of agoraphobia (the situations are feared or avoided “because of thoughts that escape might be difficult or help might not be available in the event of developing panic-like symptoms or other incapacitating or embarrassing symptoms”) can also be useful in differentiating agoraphobia from specific phobia. If the situations are feared for reasons other than not being able to escape or get help, such as fear of being harmed directly by the object or situation (e.g., fear of the plane crashing, fear of the animal biting), a specific phobia diagnosis may be more appropriate.

Panic Disorder: Individuals with specific phobia may experience panic attacks when confronted with their feared situation or object. A diagnosis of specific phobia would be given if the panic attacks only occurred in response to the specific object or situation, whereas a diagnosis of panic disorder would be given if the individual also experienced panic attacks that were unexpected.

Trauma- and Stressor-Related Disorders: If the phobia develops following a traumatic event,
posttraumatic stress disorder (PTSD) should be considered as a diagnosis. However, traumatic events can precede the onset of PTSD and specific phobia. In this case, a diagnosis of specific phobia would be assigned only if all of the criteria for PTSD are not met.

Obsessive-Compulsive Disorder: If an individual’s primary fear or anxiety is of an object or situation as a result of obsessions (e.g., fear of blood due to obsessive thoughts about contamination from blood-borne pathogens; fear of driving due to obsessive images of harming others), and if other diagnostic criteria for obsessive-compulsive disorder are met, then obsessive-compulsive disorder should be diagnosed.

Psychotic Disorders: When the fear and avoidance are attributable to delusional thinking, a diagnosis of specific phobia is not warranted.

Eating Disorders: A diagnosis of specific phobia is not given if the avoidance behavior is exclusively limited to avoidance of food and food-related cues, in which case a diagnosis of anorexia nervosa or bulimia nervosa should be considered.Comorbid Disorders
Specific phobia is rarely seen in medical-clinical settings in the absence of other psychopathology and is more frequently seen in nonmedical mental health settings. Specific phobia is frequently associated with a range of other disorders. Because of early onset, specific phobia is typically the temporally primary disorder. Individuals with specific phobia are at increased risk for the development of other disorders, including other anxiety disorders, depressive and bipolar disorders, substance-related disorders, somatic symptom and related disorders, and personality disorders (particularly dependent personality disorder).←

Social Anxiety Disorder Diagnostic Criteria
A. Marked fear or anxiety about one or more social situations in which the individual is exposed to possible scrutiny by others. Examples include social interactions, being observed, and performing in front of others.
B. The individual fears that he or she will act in a way or show anxiety symptoms that will be negatively evaluated (i.e., will be humiliating or embarrassing; will lead to rejection or offend others).
C. The social situations almost always provoke fear or anxiety.
D. The social situations are avoided or endured with intense fear or anxiety.
E. The fear or anxiety is out of proportion to the actual threat posed by the social situation and to the sociocultural context.
F. The fear, anxiety, or avoidance is persistent, typically lasting for 6 months or more.
G. The fear, anxiety, or avoidance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
H. The fear, anxiety, or avoidance is not attributable to the physiological effects of a substance or another medical condition.
I. The fear, anxiety, or avoidance is not better explained by the symptoms of another mental disorder, such as panic disorder, body dysmorphic disorder, or autism spectrum disorder.
J. If another medical condition is present, the fear, anxiety, or avoidance is clearly unrelated or is excessive.Associated Features
Individuals with social anxiety disorder may be inadequately assertive or excessively submissive or, less commonly, highly controlling of the conversation. They may show overly rigid body posture or inadequate eye contact, or speak with an overly soft voice. These individuals may be shy or withdrawn, and they may be less open in conversations and disclose little about themselves. They may seek employment in jobs that do not require social contact.Differential Diagnoses
Normative shyness: Shyness (i.e., social reticence) is a common personality trait and is not by itself pathological. In some societies, shyness is even evaluated positively. However, when there is a significant adverse impact on social, occupational, and other important areas of functioning, a diagnosis of social anxiety disorder should be considered, and when full diagnostic criteria for social anxiety disorder are met, the disorder should be diagnosed.

Agoraphobia: Individuals with agoraphobia may fear and avoid social situations (e.g., going to a
movie) because escape might be difficult or help might not be available in the event of incapacitation or panic-like symptoms, whereas individuals with social anxiety disorder are most fearful of scrutiny by others. Moreover, individuals with social anxiety disorder are likely to be calm when left entirely alone, which is often not the case in agoraphobia.

Generalized Anxiety Disorder: Social worries are common in generalized anxiety disorder, but the focus is more on the nature of ongoing relationships rather than on fear of negative evaluation. Individuals with generalized anxiety disorder, particularly children, may have excessive worries about the quality of their social performance, but these worries also pertain to nonsocial performance and when the individual is not being evaluated by others. In social anxiety disorder, the worries focus on social performance and others’ evaluation.

Major Depressive Disorder: Individuals with major depressive disorder may be concerned about
being negatively evaluated by others because they feel they are bad or not worthy of being liked. In contrast, individuals with social anxiety disorder are worried about being negatively evaluated because of certain social behaviors or physical symptoms.

Body Dysmorphic Disorder: Individuals with body dysmorphic disorder are preoccupied with one
or more perceived defects or flaws in their physical appearance that are not observable or appear slight to others; this preoccupation often causes social anxiety and avoidance. If their social fears
and avoidance are caused only by their beliefs about their appearance, a separate diagnosis of social anxiety disorder is not warranted.

Autism Spectrum Disorder: Social anxiety and social communication deficits are hallmarks of autism spectrum disorder. Individuals with social anxiety disorder typically have adequate age-appropriate social relationships and social communication capacity, although they may appear to have impairment in these areas when first interacting with unfamiliar peers or adults.

Avoidant Personality Disorder: Individuals with avoidant personality disorder have a broader avoidance pattern and higher rates of impairment than those individuals with social anxiety disorder. Moreover, individuals with avoidant personality disorder have a strong and pervasively negative self-concept, a view of rejection as equating to a global evaluation of the self as being of little worth, and a sense of not fitting in socially that dates from early childhood. Nonetheless, social anxiety disorder is typically more comorbid with avoidant personality disorder than with any other personality disorder, and avoidant personality disorder is more comorbid with social anxiety disorder than with any other anxiety disorder.Comorbid Disorders
Social anxiety disorder is often comorbid with other anxiety disorders, major depressive disorder, and substance use disorders, and the onset of social anxiety disorder generally precedes that of the other disorders, except for specific phobia and separation anxiety disorder. Chronic social isolation in the course of social anxiety disorder may result in major depressive disorder. Comorbidity with depression is high also in older adults. Substances may be used as self-medication for social fears, but the symptoms of substance intoxication or withdrawal, such as trembling, may also be a source of (further) social fear. Social anxiety disorder is frequently comorbid with body dysmorphic disorder, and generalized social anxiety disorder is often comorbid with avoidant personality disorder.←

Panic Attack Criteria
An abrupt surge of intense fear or intense discomfort that reaches a peak within minutes, and during which time four (or more) of the following symptoms occur:
::::::::::::::1. Palpitations, pounding heart, or accelerated heart rate.
::::::::::::::2. Sweating.
::::::::::::::3. Trembling or shaking.
::::::::::::::4. Sensations of shortness of breath or smothering.
::::::::::::::5. Feelings of choking.
::::::::::::::6. Chest pain or discomfort.
::::::::::::::7. Nausea or abdominal distress
::::::::::::::8. Feeling dizzy, unsteady, light-headed, or faint.
::::::::::::::9. Chills or heat sensations.
::::::::::::::10. Paresthesias (numbness or tingling sensations).
::::::::::::::11. Derealization (feelings of unreality) or depersonalization (being detached from oneself).
::::::::::::::12. Fear of losing control or “going crazy."
::::::::::::::13. Fear of dyingPanic Disorder Diagnostic Criteria
A. Recurrent unexpected panic attacks.
B. At least one of the attacks has been followed by 1 month (or more) of one or both of the following:
::::::::::::::1. Persistent concern or worry about additional panic attacks or their consequences (e.g., losing control, having a heart attack, “going crazy”).
::::::::::::::2. A significant maladaptive change in behavior related to the attacks (e.g., behaviors designed to avoid having panic attacks, such as avoidance of exercise or unfamiliar situations).
C. The disturbance is not attributable to the physiological effects of a substance or another medical condition.
D. The disturbance is not better explained by another mental disorder (e.g., the panic attacks do not occur only in response to feared social situations, as in social anxiety disorder; in response to circumscribed phobic objects or situations, as in specific phobia; in response to obsessions, as in obsessive-compulsive disorder; in response to reminders of traumatic events, as in posttraumatic stress disorder; or in response to separation from attachment figures, as in separation anxiety disorder).Associated Features
In addition to worry about panic attacks and their consequences, many individuals with panic disorder report constant or intermittent feelings of anxiety that are more broadly related to health and mental health concerns. For example, individuals with panic disorder often anticipate a catastrophic outcome from a mild physical symptom or medication side effect (e.g., thinking that they may have heart disease or that a headache means presence of a brain tumor). Such individuals often are relatively intolerant of medication side effects. In addition, there may be pervasive concerns about abilities to complete daily tasks or withstand daily stressors, excessive use of drugs (e.g., alcohol, prescribed medications or illicit drugs) to control panic attacks, or extreme behaviors aimed at controlling panic attacks.Differential Diagnoses
Limited-symptom panic attacks: Panic disorder should not be diagnosed if full-symptom (unexpected) panic attacks have never been experienced. In the case of only limited-symptom unexpected panic attacks, an other specified anxiety disorder or unspecified anxiety disorder diagnosis should be considered.

Panic attacks occurring in other anxiety disorders: Panic attacks that occur as a symptom of other anxiety disorders are expected (e.g., triggered by social situations in social anxiety disorder, by phobic objects or situations in specific phobia or agoraphobia, by worry in generalized anxiety disorder, by separation from home or attachment figures in separation anxiety disorder) and thus would not meet criteria for panic disorder. (Note: Sometimes an unexpected panic attack is associated with the onset of another anxiety disorder, but then the attacks become expected, whereas panic disorder is characterized by recurrent unexpected panic attacks.) If the panic attacks occur only in response to specific triggers, then only the relevant anxiety disorder is assigned. However, if the individual experiences unexpected panic attacks as well and shows persistent concern and worry or behavioral change because of the attacks, then an additional diagnosis of panic disorder should be considered.Comorbid Disorders
The prevalence of panic disorder is elevated in individuals with other disorders, particularly other anxiety disorders (and especially agoraphobia), major depressive disorder, bipolar I and bipolar II disorder, and possibly mild alcohol use disorder. While panic disorder occasionally has an earlier age at onset than the comorbid disorder(s), onset often occurs after the comorbid disorder and may be seen as a severity marker of the comorbid illness.

Reported lifetime rates of comorbidity between major depressive disorder and panic disorder vary widely, ranging from 10% to 65% in individuals with panic disorder. In approximately one-third of individuals with both disorders, the depression precedes the onset of panic disorder. In the remaining two-thirds, depression occurs coincident with or following the onset of panic disorder. Comorbidity with other anxiety disorders and illness anxiety disorder is also common.←

Agoraphobia Diagnostic Criteria
A. Marked fear or anxiety about two (or more) of the following five situations:
::::::::::::::1. Using public transportation.
::::::::::::::2. Being in open spaces.
::::::::::::::3. Being in enclosed places.
::::::::::::::4. Standing in line or being in a crowd.
::::::::::::::5. Being outside of the home alone.
B. The individual fears or avoids these situations because of thoughts that escape might be difficult or help might not be available in the event of developing panic-like symptoms or other incapacitating or embarrassing symptoms.
C. The agoraphobic situations almost always provoke fear or anxiety.
D. The agoraphobic situations are actively avoided, require the presence of a companion, or are endured with intense fear or anxiety.
E. The fear or anxiety is out of proportion to the actual danger posed by the agoraphobic situations and to the sociocultural context.
F. The fear, anxiety, or avoidance is persistent, typically lasting for 6 months or more.
G. The fear, anxiety, or avoidance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
H. If another medical condition is present, the fear, anxiety, or avoidance is clearly excessive.
I. The fear, anxiety, or avoidance is not better explained by the symptoms of another mental disorder—for example, the symptoms are not confined to specific phobia, situational type; do not involve only social situations; and are not related exclusively to obsessions, perceived defects or flaws in physical appearance, reminders of traumatic events, or fear of separation.Associated Features
Avoidance can be behavioral (e.g., changing daily routines, choosing a job nearby to avoid using public transportation, arranging for food delivery to avoid entering shops and supermarkets) as
well as cognitive (e.g., using distraction to get through agoraphobic situations) in nature. The avoidance can become so severe that the individual is completely homebound. Often, an individual is better able to confront a feared situation when accompanied by a companion, such as a partner, friend, or health professional. Also, the individual may employ safety behaviors (e.g., sitting near exits when taking public transportation or at the movies) to better endure such situations.

In its most severe forms, agoraphobia can cause individuals to become completely homebound, unable to leave their home and dependent on others for services or assistance to provide even for basic needs. Demoralization and depressive symptoms, as well as abuse of alcohol and sedative
medication as inappropriate self-medication strategies, are common.Differential Diagnoses
Specific Phobia: Differentiating agoraphobia from situational specific phobia can be challenging in some cases, because these conditions share several symptom characteristics and criteria. Specific phobia, situational type, should be diagnosed versus agoraphobia if the fear, anxiety, or avoidance is limited to one of the agoraphobic situations. Requiring fears from two or more of the agoraphobic situations is a robust means for differentiating agoraphobia from specific phobias, particularly the situational subtype. Thus, if the situation is feared for reasons other than panic-like symptoms or other incapacitating or embarrassing symptoms (e.g., fears of being directly harmed by the situation itself, such as fear of the plane crashing for individuals who fear flying), then a diagnosis of specific phobia may be more appropriate.

Social Anxiety Disorder: Agoraphobia should be differentiated from social anxiety disorder based
primarily on the situational clusters that trigger fear, anxiety, or avoidance. In social anxiety disorder, the focus is on fear of being negatively evaluated.

Major Depressive Disorder: In major depressive disorder, the individual may avoid leaving home because of apathy, loss of energy, low self-esteem, and anhedonia. If the avoidance is unrelated to fears of panic-like or other incapacitating or embarrassing symptoms, then agoraphobia should not be diagnosed.Comorbid Disorders
About 90% of individuals with agoraphobia also have other mental disorders. The most frequent additional diagnoses are other anxiety disorders (e.g., specific phobias, panic disorder, social anxiety disorder), depressive disorders (major depressive disorder), PTSD, and alcohol use disorder. Whereas other anxiety disorders (e.g., separation anxiety disorder, specific phobias, panic disorder) frequently precede onset of agoraphobia, depressive disorders and substance use disorders typically occur secondary to agoraphobia.←

Generalized Anxiety Disorder Diagnostic Criteria
A. Excessive anxiety and worry (apprehensive expectation), occurring more days than not for at least 6 months, about a number of events or activities (such as work or school performance).
B. The individual finds it difficult to control the worry.
C. The anxiety and worry are associated with three (or more) of the following six symptoms (with at least some symptoms having been present for more days than not for the past 6 months):
::::::::::::::1. Restlessness or feeling keyed up or on edge.
::::::::::::::2. Being easily fatigued.
::::::::::::::3. Difficulty concentrating or mind going blank.
::::::::::::::4. Irritability.
::::::::::::::5. Muscle tension.
::::::::::::::6. Sleep disturbance (difficulty falling or staying asleep, or restless, unsatisfying sleep).
D. The anxiety, worry, or physical symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
E. The disturbance is not attributable to the physiological effects of a substance or another medical condition.
F. The disturbance is not better explained by another mental disorder.Associated Features
Several features distinguish generalized anxiety disorder from nonpathological anxiety. First, the worries associated with generalized anxiety disorder are excessive and typically interfere significantly with psychosocial functioning, whereas the worries of everyday life are not excessive and are perceived as more manageable and may be put off when more pressing matters arise. Second, the worries associated with generalized anxiety disorder are more pervasive, pronounced, and distressing; have longer duration; and frequently occur without precipitants. The greater the range of life circumstances about which a person worries, the more likely his or her symptoms are to meet criteria for generalized anxiety disorder. Third, everyday worries are much less likely to be accompanied by physical symptoms (e.g., restlessness or feeling keyed up or on edge). Individuals with generalized anxiety disorder report subjective distress as a result of constant worry and related impairment in social, occupational, or other important areas of functioning.Differential Diagnoses
Social Anxiety Disorder: Individuals with social anxiety disorder often have anticipatory anxiety that is focused on upcoming social situations in which they must perform or be evaluated by others, whereas individuals with generalized anxiety disorder worry, whether or not they are being evaluated.

Panic Disorder: Panic attacks that are triggered by worry in generalized anxiety disorder would
not qualify for panic disorder. However, if the individual experiences unexpected panic attacks as well and shows persistent concern and worry or behavioral change because of the attacks, then
an additional diagnosis of panic disorder should be considered.

OCD: Several features distinguish the excessive worry of generalized anxiety disorder from the obsessional thoughts of obsessive-compulsive disorder. In generalized anxiety disorder the focus of the worry is about forthcoming problems, and it is the excessiveness of the worry about future events that is abnormal. In obsessive-compulsive disorder, the obsessions are inappropriate ideas that take the form of intrusive and unwanted thoughts, urges, or images.

PTSD and Adjustment Disorder: Anxiety is invariably present in posttraumatic stress disorder. Generalized anxiety disorder is not diagnosed if the anxiety and worry are better explained by symptoms of posttraumatic stress disorder. Although anxiety may manifest in adjustment disorder, this residual category should be used only when the criteria are not met for any other mental disorder (including generalized anxiety disorder). Moreover, in adjustment disorders, the anxiety occurs in response to an identifiable stressor within 3 months of the onset of the stressor and does not persist for more than 6 months after the termination of the stressor or its consequences.Comorbid Disorders
Individuals whose presentation meets criteria for generalized anxiety disorder are likely to have met, or currently meet, criteria for other anxiety and unipolar depressive disorders. The negative affectivity (neuroticism) or emotional liability that underpins this pattern of comorbidity is associated with temperamental antecedents and genetic and environmental risk factors shared between these disorders, although independent pathways are also possible. Comorbidity with substance use, conduct, psychotic, neurodevelopmental, and neurocognitive disorders is less common.←

Other Specified Anxiety Disorder
This category applies to presentations in which symptoms characteristic of an anxiety disorder that cause clinically significant distress or impairment in social, occupational, or other important areas of functioning predominate but do not meet the full criteria for any of the disorders in the anxiety disorders diagnostic class, and do not meet criteria for adjustment disorder with anxiety or adjustment disorder with mixed anxiety and depressed mood. The other specified anxiety disorder category is used in situations in which the clinician chooses to communicate the specific reason that the presentation does not meet the criteria for any specific anxiety disorder.

Examples of presentations that can be specified using the “other specified” designation include:

1. Limited-symptom panic attacks.
2. Generalized anxiety occurring less often than “more days than not.”←

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Obsessive-Compulsive Disorder Diagnostic Criteria
A. Presence of obsessions, compulsions, or both.
:::::::Obsessions are defined by (1) and (2):
::::::::::::::1. Recurrent and persistent thoughts, urges, or images that are experienced, at some time during the disturbance, as intrusive and unwanted, and that in most individuals cause
marked anxiety or distress.
::::::::::::::2. The individual attempts to ignore or suppress such thoughts, urges, or images, or to neutralize them with some other thought or action (i.e., by performing a compulsion).
:::::::Compulsions are defined by (1) and (2):
::::::::::::::1. Repetitive behaviors (e.g., hand washing, ordering, checking) or mental acts (e.g., praying, counting, repeating words silently) that the individual feels driven to perform in response to an obsession or according to rules that must be applied rigidly.
::::::::::::::2. The behaviors or mental acts are aimed at preventing or reducing anxiety or distress, or preventing some dreaded event or situation; however, these behaviors or mental acts are not connected in a realistic way with what they are designed to neutralize or prevent, or are clearly excessive.
B. The obsessions or compulsions are time-consuming or cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
C. The obsessive-compulsive symptoms are not attributable to the physiological effects of a substance or another medical condition.
D. The disturbance is not better explained by the symptoms of another mental disorder (e.g., excessive worries, as in generalized anxiety disorder; preoccupation with appearance, as in body dysmorphic disorder; difficulty discarding or parting with possessions, as in hoarding disorder; hair pulling, as in trichotillomania [hair-pulling disorder]; skin picking, as in excoriation [skin-picking] disorder; stereotypies, as in stereotypic movement disorder; ritualized eating behavior, as in eating disorders; preoccupation with substances or gambling, as in substance-related and addictive disorders; preoccupation with having an illness, as in illness anxiety disorder; sexual urges or fantasies, as in paraphilic disorders; impulses, as in disruptive, impulse-control, and conduct disorders; guilty ruminations, as in major depressive disorder; thought insertion or delusional preoccupations, as in schizophrenia spectrum and other psychotic disorders; or repetitive patterns of behavior, as in autism spectrum disorder).OCD Specifiers
With good or fair insight: The individual recognizes that obsessive-compulsive disorder beliefs are definitely or probably not true or that they may or may not be true.
With poor insight: The individual thinks obsessive-compulsive disorder beliefs are probably true.
With absent insight/delusional beliefs: The individual is completely convinced that obsessive-compulsive disorder beliefs are true.Associated Features
Individuals with obsessive-compulsive disorder (OCD) vary in the degree of insight they have about the accuracy of the beliefs that underlie their obsessive-compulsive symptoms. Many individuals have good or fair insight (e.g., the individual believes that the house definitely will not, probably will not, or may or may not burn down if the stove is not checked 30 times). Some have poor insight (e.g., the individual believes that the house will probably burn down if the stove is not checked 30 times), and a few have absent insight/delusional beliefs (e.g., the individual is convinced that the house will burn down if the stove is not checked 30 times). Insight can vary within an individual over the course of the illness.

Individuals with OCD experience a range of affective responses when confronted with situations that trigger obsessions and compulsions. For example, many individuals experience marked anxiety that can include recurrent panic attacks. Others report strong feelings of disgust. While performing compulsions, some individuals report a distressing sense of “incompleteness” or uneasiness until things look, feel, or sound “just right.”

It is common for individuals with the disorder to avoid people, places, and things that trigger obsessions and compulsions. For example, individuals with contamination concerns might avoid public situations (e.g., restaurants, public restrooms) to reduce exposure to feared contaminants; individuals with intrusive thoughts about causing harm might avoid social interactions.

Many individuals with OCD have dysfunctional beliefs. These beliefs can include an inflated sense of responsibility and the tendency to overestimate threat; perfectionism and intolerance of uncertainty; and over-importance of thoughts (e.g., believing that having a forbidden thought is as bad as acting on it) and the need to control thoughts. These beliefs, however, are not specific to OCD. The involvement of family or friends in compulsive rituals, termed accommodation, can exacerbate or maintain symptoms and is an important target in treatment, especially in children.Differential Diagnoses
Anxiety Disorders: Recurrent thoughts, avoidant behaviors, and repetitive requests for reassurance can also occur in anxiety disorders. However, the recurrent thoughts that are present in generalized anxiety disorder (i.e., worries) are usually about real-life concerns, whereas the obsessions of OCD usually do not involve real-life concerns and can include content that is odd, irrational, or of a seemingly magical nature; moreover, compulsions are usually present and usually linked to the obsessions. Like individuals with OCD, individuals with specific phobia can have a fear reaction to specific objects or situations; however, in specific phobia the feared object is usually much more circumscribed, and rituals are not present. In social anxiety disorder, the feared objects or situations are limited to social interactions or performance situations, and avoidance or reassurance seeking is focused on reducing feelings of embarrassment.

Other obsessive-compulsive disorders: In body dysmorphic disorder, the obsessions and
compulsions are limited to concerns about physical appearance; and in trichotillomania (hair-pulling disorder), the compulsive behavior is limited to hair pulling in the absence of obsessions. Hoarding disorder symptoms focus exclusively on the persistent difficulty discarding or parting with possessions, marked distress associated with discarding items, and excessive accumulation
of objects. However, if an individual has obsessions that are typical of OCD (e.g., concerns about incompleteness or harm), and these obsessions lead to compulsive accumulation (e.g., acquiring
all objects in a set to attain a sense of completeness or not discarding old newspapers because they may contain information that could prevent harm), a diagnosis of OCD should be given instead.

Psychotic Disorders: Some individuals with OCD have poor insight or even delusional OCD beliefs. However, they have obsessions and compulsions (distinguishing their condition from delusional disorder) and do not have other features of schizophrenia or schizoaffective disorder (e.g., hallucinations or disorganized speech). For individuals whose OCD symptoms warrant the “with absent insight/delusional beliefs” specifier, these symptoms should not be diagnosed as a psychotic disorder.Comorbid Disorders
Individuals with OCD often have other psychopathology. Many adults with the disorder in the United States have a lifetime diagnosis of an anxiety disorder or a depressive or bipolar disorder; a lifetime diagnosis of an impulse-control disorder or a substance use disorder is also common. Onset of OCD is usually later than for most comorbid anxiety disorders (with the exception of separation anxiety disorder) and PTSD but often precedes that of depressive disorders.
:
Up to 30% of individuals with OCD also have a lifetime tic disorder. A comorbid tic disorder is most common in men with onset of OCD in childhood. These individuals tend to differ from those without a history of tic disorders in the themes of their OCD symptoms, comorbidity, course, and pattern of familial transmission. A triad of OCD, tic disorder, and attention-deficit/hyperactivity disorder can also be seen in children.←

Body Dysmorphic Disorders Diagnostic Criteria
A. Preoccupation with one or more perceived defects or flaws in physical appearance that are not observable or appear slight to others.
B. At some point during the course of the disorder, the individual has performed repetitive behaviors (e.g., mirror checking, excessive grooming, skin picking, reassurance seeking) or mental acts (e.g., comparing his or her appearance with that of others) in response to the appearance concerns.
C. The preoccupation causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
D. The appearance preoccupation is not better explained by concerns with body fat or weight in an individual whose symptoms meet diagnostic criteria for an eating disorder.Specifiers
With muscle dysmorphia: The individual is preoccupied with the idea that his or her body build is too small or insufficiently muscular. This specifier is used even if the individual is preoccupied with other body areas, which is often the case.

With good or fair insight: The individual recognizes that the body dysmorphic disorder beliefs are definitely or probably not true or that they may or may not be true.
With poor insight: The individual thinks that the body dysmorphic disorder beliefs are probably true.
With absent insight/delusional beliefs: The individual is completely convinced that the body dysmorphic disorder beliefs are true.Associated Features
Muscle dysmorphia, a form of body dysmorphic disorder, consists of preoccupation with the idea that one’s body is too small or insufficiently lean or muscular. Individuals with this form of the disorder actually have a normal-looking body or are even very muscular. They may also be preoccupied with other body areas, such as skin or hair. A majority (but not all) diet, exercise, and/or lift weights excessively, sometimes causing bodily damage. Some use potentially dangerous steroids and other substances to try to make their body bigger and more muscular.

Preoccupations can focus on one or many body areas, most commonly the skin (e.g., perceived acne, scars, lines, wrinkles, paleness), hair (e.g., “thinning” hair or “excessive” body or facial hair), or nose (e.g., size or shape). However, any body area can be the focus of concern (e.g., eyes, teeth, weight, stomach, breasts, legs, face size or shape, lips, chin, eyebrows, genitals). Some individuals are concerned about perceived asymmetry of body areas.

Many individuals with body dysmorphic disorder have ideas or delusions of reference, believing that other people take special notice of them or mock them because of how they look. Body dysmorphic disorder is associated with high levels of anxiety, social anxiety, social avoidance, depressed mood, negative affectivity (neuroticism), rejection sensitivity, and perfectionism as well as low extroversion and low self-esteem.Differential Diagnoses
Normal appearance concerns: Body dysmorphic disorder differs from normal appearance concerns in being characterized by excessive appearance-related preoccupations and repetitive behaviors that are time-consuming, are usually difficult to resist or control, and cause clinically significant distress or impairment in functioning. Physical defects that are clearly noticeable (i.e., not slight) are not diagnosed as body dysmorphic disorder. However, skin picking as a symptom of body dysmorphic disorder can cause noticeable skin lesions and scarring; in such cases, body dysmorphic disorder should be diagnosed.

Eating Disorders: In an individual with an eating disorder, concerns about being fat or overweight are considered a symptom of the eating disorder rather than body dysmorphic disorder. However, weight concerns may occur in body dysmorphic disorder. Eating disorders and body dysmorphic disorder can be comorbid, in which case both should be diagnosed.

Anxiety Disorders: Social anxiety and avoidance are common in body dysmorphic disorder. However, unlike social anxiety disorder, agoraphobia, and avoidant personality disorder, body dysmorphic disorder includes prominent appearance-related preoccupation, which may be delusional, and repetitive behaviors. In addition, the social anxiety and avoidance that are characteristic of body dysmorphic disorder are attributable to concerns about perceived appearance defects and the belief or fear that other people will consider these individuals ugly, ridicule them, or reject them because of their physical features. Unlike generalized anxiety disorder, anxiety and worry in body dysmorphic disorder focus on perceived appearance flaws

Psychotic Disorders: Many individuals with body dysmorphic disorder have delusional appearance beliefs (i.e., complete conviction that their view of their perceived defects is accurate), which is diagnosed as body dysmorphic disorder, with absent insight/delusional beliefs, not as delusional disorder. Appearance-related ideas or delusions of reference are common in body dysmorphic disorder (i.e., thinking that other people take special notice in a negative way because of the individual’s appearance). However, unlike schizophrenia or schizoaffective disorder, body dysmorphic disorder involves prominent appearance preoccupations and related repetitive behaviors; disorganized behavior and other psychotic symptoms are absent (except for appearance beliefs, which may be delusional). For individuals whose obsessive-compulsive and related disorder symptoms warrant the “with absent insight/delusional beliefs” specifier, these symptoms should not be diagnosed as a psychotic disorder.

Other disorders/symptoms: Body dysmorphic disorder should not be diagnosed if the preoccupation is limited to discomfort with or a desire to be rid of one’s primary and/or secondary sex characteristics in an individual with gender dysphoria. Nor should body dysmorphic disorder be diagnosed if the preoccupation focuses on the belief that one emits a foul or offensive body odor as in olfactory reference disorder (olfactory reference syndrome), which is an example of an other specified obsessive-compulsive and related disorder in DSM-5. Body integrity dysphoria (which is included in ICD-11 but not DSM-5) involves a persistent desire to become an amputee in order to correct a mismatch between the individual’s sense of how his or her body should be configured and his or her actual anatomical configuration. In contrast to body dysmorphic disorder, the individual does not feel that the limb to be amputated is ugly or defective in any way, just that it should not be there. Dysmorphic concern (which is not a DSM-5 disorder) is a broader construct that is similar to, but not equivalent to, body dysmorphic disorder. It involves symptoms reflecting an overconcern with slight or imagined flaws in appearance.Comorbid Disorders
Major depressive disorder is the most common comorbid disorder, with onset usually after that of body dysmorphic disorder. Comorbid social anxiety disorder, OCD, and substance-related disorders are also common.←

Hoarding Disorder Diagnostic Criteria
A. Persistent difficulty discarding or parting with possessions, regardless of their actual value.
B. This difficulty is due to a perceived need to save the items and to distress associated with discarding them.
C. The difficulty discarding possessions results in the accumulation of possessions that congest and clutter active living areas and substantially compromises their intended use. If living areas are uncluttered, it is only because of the interventions of third parties (e.g., family members).
D. The hoarding causes clinically significant distress or impairment in social, occupational, or other important areas of functioning (including maintaining a safe environment for self and others).
E. The hoarding is not attributable to another medical condition.
F. The hoarding is not better explained by the symptoms of another mental disorder.Specifiers
With excessive acquisition: If difficulty discarding possessions is accompanied by excessive acquisition of items that are not needed or for which there is no available space.

With good or fair insight: The individual recognizes that hoarding-related beliefs and behaviors (pertaining to difficulty discarding items, clutter, or excessive acquisition) are problematic.
With poor insight: The individual is mostly convinced that hoarding-related beliefs and behaviors (pertaining to difficulty discarding items, clutter, or excessive acquisition) are not problematic despite evidence to the contrary.
With absent insight/delusional beliefs: The individual is completely convinced that hoarding-related beliefs and behaviors (pertaining to difficulty discarding items, clutter, or excessive acquisition) are not problematic despite evidence to the contrary.Associated Features
Other common features of hoarding disorder include indecisiveness, perfectionism, avoidance, procrastination, difficulty planning and organizing tasks, and distractibility. Some individuals with hoarding disorder live in unsanitary conditions that may be a logical consequence of severely cluttered spaces and/or that are related to planning and organizing difficulties.Differential Diagnoses
Neurodevelopmental disorders: Hoarding disorder is not diagnosed if the accumulation of objects is judged to be a direct consequence of a neurodevelopmental disorder, such as autism spectrum disorder or intellectual developmental disorder.

Psychotic Disorders: Hoarding disorder is not diagnosed if the accumulation of objects is judged to be a direct consequence of delusions or negative symptoms in schizophrenia spectrum and other psychotic disorders.

Major Depressive Episode: Hoarding disorder is not diagnosed if the accumulation of objects is
judged to be a direct consequence of psychomotor symptoms, fatigue, or loss of energy during a major depressive episode.

OCD: Hoarding disorder is not diagnosed if the symptoms are judged to be a direct consequence of typical obsessions or compulsions, such as fears of contamination, harm, or feelings of incompleteness in OCD. Feelings of incompleteness (e.g., losing one’s identity, or having to document and preserve all life experiences) are the most frequent OCD symptoms associated with this form of hoarding. The accumulation of objects can also be the result of persistently avoiding onerous rituals (e.g., not discarding objects in order to avoid endless washing or checking rituals). In OCD, the behavior is generally unwanted and highly distressing, and the individual experiences no pleasure or reward from it. Excessive acquisition is usually not present; if excessive acquisition is present, items are acquired because of a specific obsession (e.g., the need to buy items that have been accidentally touched in order to avoid contaminating other people), not because of a genuine desire to possess the items. Individuals who hoard in the context of OCD are also more likely to accumulate bizarre items, such as trash, feces, urine, fingernail and toenail cuttings, hair, used diapers, or rotten food. Accumulation of such items is very unusual in hoarding disorder. When severe hoarding appears concurrently with other typical symptoms of OCD but is judged to be independent from these symptoms, both hoarding disorder and OCD may be diagnosed.Comorbid Disorders
Approximately 75% of individuals with hoarding disorder have a comorbid mood or anxiety disorder. The most common comorbid conditions are major depressive disorder, social anxiety disorder, and generalized anxiety disorder. Approximately 20% of individuals with hoarding disorder also have symptoms that meet diagnostic criteria for OCD. These comorbidities may often be the main reason for consultation, because individuals are unlikely to spontaneously report hoarding symptoms, and hoarding symptoms are often not asked about in routine clinical interviews.←

Trichotillomania Diagnostic Criteria
A. Recurrent pulling out of one’s hair, resulting in hair loss.
B. Repeated attempts to decrease or stop hair pulling.
C. The hair pulling causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
D. The hair pulling or hair loss is not attributable to another medical condition.
E. The hair pulling is not better explained by the symptoms of another mental disorder.Associated Features
Hair-pulling sites may vary over time. Hair pulling may occur in brief episodes scattered throughout the day or during less frequent but more sustained periods that can continue for hours, and such hair pulling may endure for months or years. The term distress includes negative affects that may be experienced by individuals with hair pulling, such as feeling a loss of control, embarrassment, and shame.

Hair pulling may be accompanied by a range of behaviors or rituals involving hair. Thus, individuals may search for a particular kind of hair to pull (e.g., hairs with a specific texture or color), may try to pull out hair in a specific way (e.g., so that the root comes out intact), or may visually examine or tactilely or orally manipulate the hair after it has been pulled (e.g., rolling the hair between the fingers, pulling the strand between the teeth, biting the hair into pieces, or swallowing the hair).

Hair pulling does not usually occur in the presence of other individuals, except immediate family members. Some individuals may deny their hair pulling to others. The majority of individuals with
trichotillomania also have one or more other body-focused repetitive behaviors, including skin picking, nail biting, and lip chewing.Differential Diagnoses
Hair removal or manipulation for cosmetic purposes: Trichotillomania should not be diagnosed when hair removal is performed solely for cosmetic reasons (i.e., to improve physical appearance). Many individuals twist and play with their hair, but this behavior does not usually qualify for a diagnosis of trichotillomania. Some individuals may bite rather than pull hair; again, this does not qualify for a diagnosis of trichotillomania.

Other obsessive-compulsive disorders: Individuals with OCD and symmetry concerns may pull out hairs as part of their symmetry rituals, and individuals with body dysmorphic disorder may remove body hair that they perceive as ugly, asymmetrical, or abnormal; in such cases a diagnosis of trichotillomania is not given.

Stereotypic Movement Disorder: Stereotypic movement disorder can sometimes involve hair-
pulling behavior. For example, a child with intellectual developmental disorder or autism spectrum disorder may engage in stereotypic head banging, hand or arm biting, and hair pulling when frustrated or angry, and sometimes when excited. This behavior, if impairing, would be diagnosed as stereotypic movement disorder (co-occurring with intellectual developmental disorder or autism spectrum disorder) rather than trichotillomania.Comorbid Disorders
Trichotillomania is often accompanied by other mental disorders, most commonly major depressive disorder and excoriation (skin-picking) disorder. Repetitive body-focused symptoms other than hair pulling or skin picking (e.g., nail biting) occur in the majority of individuals with trichotillomania and may deserve an additional diagnosis of other specified obsessive-compulsive and related disorder (i.e., other body-focused repetitive behavior disorder).←

Excoriation Disorder Diagnostic Criteria
A. Recurrent skin picking resulting in skin lesions.
B. Repeated attempts to decrease or stop skin picking.
C. The skin picking causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
D. The skin picking is not attributable to the physiological effects of a substance or another medical condition.
E. The skin picking is not better explained by symptoms of another mental disorder.Associated Features
The most commonly picked sites are the face, arms, and hands, but many individuals pick from multiple body sites. Individuals may pick at healthy skin, at minor skin irregularities, at lesions such as pimples or calluses, or at scabs from previous picking. Most individuals pick with their fingernails, although many use tweezers, pins, or other objects. In addition to skin picking, there may be skin rubbing, squeezing, lancing, and biting. Individuals with excoriation disorder often spend significant amounts of time on their picking behavior, sometimes several hours per day, and such skin picking may endure for months or years.

Skin picking may be accompanied by a range of behaviors or rituals involving skin or scabs. Thus, individuals may search for a particular kind of scab to pull, and they may examine, play with, or mouth or swallow the skin after it has been pulled. Skin picking may also be preceded or accompanied by various emotional states. Skin picking may be triggered by feelings of anxiety or boredom, may be preceded by an increasing sense of tension (either immediately before picking the skin or when attempting to resist the urge to pick), and may lead to gratification, pleasure, or a sense of relief when the skin or scab has been picked. Some individuals report picking in response to a minor skin irregularity or to relieve an uncomfortable bodily sensation.Differential Diagnoses
Other obsessive-compulsive disorders: Excessive washing compulsions in response to
contamination obsessions in individuals with OCD may lead to skin lesions, and skin picking may occur in individuals with body dysmorphic disorder who pick their skin because of appearance concerns; in such cases, excoriation disorder should not be diagnosed. The description of other body-focused repetitive behavior disorder in other specified obsessive-compulsive and related disorder excludes individuals whose symptoms meet diagnostic criteria for excoriation disorder.

Neurodevelopmental Disorders: While stereotypic movement disorder may be characterized by repetitive self-injurious behavior, onset is in the early developmental period. While tics in individuals with Tourette’s disorder may lead to self-injury, the behavior is not tic-like in excoriation disorder.Comorbid Disorders
Excoriation disorder is often accompanied by other mental disorders. Such disorders include OCD and trichotillomania (hair-pulling disorder), as well as major depressive disorder. Repetitive body-focused symptoms other than skin picking and hair pulling (e.g., nail biting) occur in many individuals with excoriation disorder and may deserve an additional diagnosis of other specified obsessive-compulsive and related disorder (i.e., other body-focused repetitive behavior disorder).←

Other Specified Obsessive-Compulsive and Related Disorder
This category applies to presentations in which symptoms characteristic of an obsessive-compulsive and related disorder that cause clinically significant distress or impairment in social, occupational, or other important areas of functioning predominate but do not meet the full criteria for any of the disorders in the obsessive-compulsive and related disorders diagnostic class. The other specified obsessive-compulsive and related disorder category is used in situations in which the clinician chooses to communicate the specific reason that the presentation does not meet the criteria for any specific obsessive-compulsive and related disorder.

Examples of presentations that can be specified using the “other specified” designation include:

1. Body dysmorphic–like disorder with actual flaws: This is similar to body dysmorphic disorder except that the defects or flaws in physical appearance are clearly observable by others (i.e., they are more noticeable than “slight”). In such cases, the preoccupation with these flaws is clearly excessive and causes significant impairment or distress.
2. Body dysmorphic–like disorder without repetitive behaviors: Presentations that meet body dysmorphic disorder except that the individual has never performed repetitive behaviors or mental acts in response to the appearance concerns.
3. Other body-focused repetitive behavior disorder: Presentations involving recurrent body-focused repetitive behaviors other than hair pulling and skin picking (e.g., nail biting, lip biting, cheek chewing) that are accompanied by repeated attempts to decrease or stop the behaviors and that cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
4. Obsessional jealousy: This is characterized by non-delusional preoccupation with a partner’s perceived infidelity. The preoccupations may lead to repetitive behaviors or mental acts in response to the infidelity concerns; they cause clinically significant distress or impairment in social,
occupational, or other important areas of functioning; and they are not better explained by another mental disorder such as delusional disorder, jealous type, or paranoid personality disorder.
5. Olfactory reference disorder (olfactory reference syndrome): This is characterized by the individual’s persistent preoccupation with the belief that they are emitting a foul or offensive body odor that is unnoticeable or only slightly noticeable to others; in response to this preoccupation, these individuals often engage in repetitive and excessive behaviors such as repeatedly checking for body odor, excessive showering, or seeking reassurance, as well as excessive attempts to camouflage the perceived odor. These symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.←

you picked... trauma- and stressor-related disorders!

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PTSD Diagnostic Criteria
A. Exposure to actual or threatened death, serious injury, or sexual violence in one (or more) of the following ways:
::::::::::::::1. Directly experiencing the traumatic event(s).
::::::::::::::2. Witnessing, in person, the event(s) as it occurred to others.
::::::::::::::3. Learning that the traumatic event(s) occurred to a close family member or close friend. In cases of actual or threatened death of a family member or friend, the event(s) must have been violent or accidental.
::::::::::::::4. Experiencing repeated or extreme exposure to aversive details of the traumatic event(s) in a work-related context.
B. Presence of one (or more) of the following intrusion symptoms associated with the traumatic event(s), beginning after the traumatic event(s) occurred:
::::::::::::::1. Recurrent, involuntary, and intrusive distressing memories of the traumatic event(s).
::::::::::::::2. Recurrent distressing dreams in which the content and/or affect of the dream are related to the traumatic event(s).
::::::::::::::3. Dissociative reactions (e.g., flashbacks) in which the individual feels or acts as if the traumatic event(s) were recurring. (Such reactions may occur on a continuum, with the most extreme expression being a complete loss of awareness of present surroundings.)
::::::::::::::4. Intense or prolonged psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event(s).
::::::::::::::5. Marked physiological reactions to internal or external cues that symbolize or resemble an aspect of the traumatic event(s).
C. Persistent avoidance of stimuli associated with the traumatic event(s), beginning after the traumatic event(s) occurred, as evidenced by one or both of the following:
::::::::::::::1. Avoidance of or efforts to avoid distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s).
::::::::::::::2. Avoidance of or efforts to avoid external reminders (people, places, conversations, activities, objects, situations) that arouse distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s).
D. Negative alterations in cognitions and mood associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred, as evidenced by two (or more) of the following:
::::::::::::::1. Inability to remember an important aspect of the traumatic event(s) (typically due to dissociative amnesia and not to other factors such as head injury, alcohol, or drugs).
::::::::::::::2. Persistent and exaggerated negative beliefs or expectations about oneself, others, or the world (e.g., “I am bad,” “No one can be trusted,” “The world is completely dangerous,” “My whole nervous system is permanently ruined”).
::::::::::::::3. Persistent, distorted cognitions about the cause or consequences of the traumatic event(s) that lead the individual to blame himself/herself or others.
::::::::::::::4. Persistent negative emotional state (e.g., fear, horror, anger, guilt, or shame).
::::::::::::::5. Markedly diminished interest or participation in significant activities.
::::::::::::::6. Feelings of detachment or estrangement from others.
::::::::::::::7. Persistent inability to experience positive emotions (e.g., inability to experience happiness, satisfaction, or loving feelings).
E. Marked alterations in arousal and reactivity associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred, as evidenced by two (or more) of the following:
::::::::::::::1. Irritable behavior and angry outbursts (with little or no provocation) typically expressed as verbal or physical aggression toward people or objects.
::::::::::::::2. Reckless or self-destructive behavior.
::::::::::::::3. Hypervigilance.
::::::::::::::4. Exaggerated startle response.
::::::::::::::5. Problems with concentration.
::::::::::::::6. Sleep disturbance (e.g., difficulty falling or staying asleep or restless sleep).
F. Duration of the disturbance (Criteria B, C, D, and E) is more than 1 month.
G. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
H. The disturbance is not attributable to the physiological effects of a substance or another medical condition.Associated Features
The essential feature of posttraumatic stress disorder (PTSD) is the development of characteristic symptoms following exposure to one or more traumatic events. The clinical presentation of PTSD varies. In some individuals, fear-based reexperiencing, emotional, and behavioral symptoms may predominate. In others, anhedonic or dysphoric mood states and negative cognitions may be most prominent. In some other individuals, arousal and reactive-externalizing symptoms are prominent, while in yet others, dissociative symptoms predominate. Finally, some individuals exhibit combinations of these symptom patterns. A significant subgroup of individuals with PTSD experience persistent dissociative symptoms of either depersonalization (detachment from their bodies) or derealization (detachment from the world around them).

The traumatic events in Criterion A all involve actual or threatened death, serious injury, or sexual violence in some way but differ in how the individual is exposed to them, which can be through directly experiencing the traumatic event, witnessing in person the event as it occurred to others, learning that the event occurred to a family member or a close friend, or indirect exposure in the course of occupational duties, through being exposed to grotesque details of an event. The disorder may be especially severe or long lasting when the stressor is interpersonal and intentional.

Auditory pseudo-hallucinations, such as having the sensory experience of hearing one’s thoughts spoken in one or more different voices, as well as paranoid ideation, can be present. Following prolonged, repeated, and severe traumatic events (e.g., childhood abuse, torture), the individual may additionally experience difficulties in regulating emotions or maintaining stable interpersonal relationships, or dissociative symptoms. When the traumatic event involves the violent death of someone with whom the individual had a close relationship, symptoms of both prolonged grief
disorder and PTSD may be present.

In adjustment disorders, the stressor can be of any severity or type rather than a stressor involving exposure to actual or threatened death, serious injury, or sexual violence as required by PTSD Criterion A. The diagnosis of an adjustment disorder is used when the response to a stressor that meets PTSD Criterion A does not meet all other PTSD criteria. An adjustment disorder is also diagnosed when the symptom pattern of PTSD occurs in response to a stressor that does not meet PTSD Criterion A.Differential Diagnoses
Adjustment Disorder: In adjustment disorders, the stressor can be of any severity or type rather than a stressor involving exposure to actual or threatened death, serious injury, or sexual violence as required by PTSD Criterion A. The diagnosis of an adjustment disorder is used when the response to a stressor that meets PTSD Criterion A does not meet all other PTSD criteria (or criteria for another mental disorder). An adjustment disorder is also diagnosed when the symptom pattern of PTSD occurs in response to a stressor that does not meet PTSD Criterion A (e.g., spouse leaving, being fired).

Other posttraumatic disorders and conditions: Not all psychopathology that occurs in individuals exposed to an extreme stressor should necessarily be attributed to PTSD. The PTSD diagnosis requires that trauma exposure precede the onset or exacerbation of pertinent symptoms. If the symptom response pattern to the extreme stressor meets criteria for another mental disorder, these diagnoses should be given instead of, or in addition to, PTSD. Other diagnoses and conditions are excluded if they are better explained by PTSD (e.g., symptoms of panic disorder that occur only after exposure to traumatic reminders). If severe, symptom response patterns to the extreme stressor that meet criteria for another mental disorder may warrant a separate diagnosis (e.g., dissociative amnesia) in addition to PTSD.

Acute Stress Disorder: Acute stress disorder is distinguished from PTSD because the symptom pattern in acute stress disorder is restricted to a duration of 3 days to 1 month following exposure to the traumatic event.

Dissociative disorders: Dissociative amnesia, dissociative identity disorder, and depersonalization/derealization disorder may or may not be preceded by exposure to a traumatic event or may or may not have co-occurring PTSD symptoms. When full PTSD criteria are also met, however, the PTSD “with dissociative symptoms” subtype should be considered.Comorbid Disorders
Individuals with PTSD are more likely than those without PTSD to have symptoms that meet diagnostic criteria for at least one other mental disorder, such as depressive, bipolar, anxiety, or substance use disorders. PTSD is also associated with increased risk of major neurocognitive disorder.←

Acute Stress Disorder Diagnostic Criteria
A. Exposure to actual or threatened death, serious injury, or sexual violence in one (or more) of the following ways:
::::::::::::::1. Directly experiencing the traumatic event(s).
::::::::::::::2. Witnessing, in person, the event(s) as it occurred to others.
::::::::::::::3. Learning that the traumatic event(s) occurred to a close family member or close friend. In cases of actual or threatened death of a family member or friend, the event(s) must have been violent or accidental.
::::::::::::::4. Experiencing repeated or extreme exposure to aversive details of the traumatic event(s) in a work-related context.
B. Presence of nine (or more) of the following symptoms from any of the five categories of intrusion, negative mood, dissociation, avoidance, and arousal, beginning or worsening after the traumatic event(s) occurred:
:::::::Intrusion
::::::::::::::1. Recurrent, involuntary, and intrusive distressing memories of the traumatic event(s).
::::::::::::::2. Recurrent distressing dreams in which the content and/or affect of the dream are related to the traumatic event(s).
::::::::::::::3. Dissociative reactions (e.g., flashbacks) in which the individual feels or acts as if the traumatic event(s) were recurring. (Such reactions may occur on a continuum, with the most extreme expression being a complete loss of awareness of present surroundings.)
::::::::::::::4 Intense or prolonged psychological distress or marked physiological reactions in response to internal or external cues that symbolize or resemble an aspect of the traumatic event(s).
:::::::Negative Mood
::::::::::::::5. Persistent inability to experience positive emotions (e.g., inability to experience happiness, satisfaction, or loving feelings).
:::::::Dissociative Symptoms
::::::::::::::6. An altered sense of the reality of one’s surroundings or oneself (e.g., seeing oneself from another’s perspective, being in a daze, time slowing).
::::::::::::::7. Inability to remember an important aspect of the traumatic event(s) (typically due to dissociative amnesia and not to other factors such as head injury, alcohol, or drugs).
:::::::Avoidance Symptoms
::::::::::::::8. Efforts to avoid distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s).
::::::::::::::9. Efforts to avoid external reminders (people, places, conversations, activities, objects, situations) that arouse distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s).
:::::::Arousal Symptoms
::::::::::::::10. Sleep disturbance (e.g., difficulty falling or staying asleep or restless sleep).
::::::::::::::11. Irritable behavior and angry outbursts (with little or no provocation) typically expressed as verbal or physical aggression toward people or objects.
::::::::::::::12. Hypervigilance.
::::::::::::::13. Problems with concentration.
::::::::::::::14. Exaggerated startle response.
C. Duration of the disturbance (symptoms in Criterion B) is 3 days to 1 month after trauma exposure.
D. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
E. The disturbance is not attributable to the physiological effects of a substance or another
medical condition and is not better explained by brief psychotic disorder.Associated Features
Individuals with acute stress disorder commonly engage in catastrophic or extremely negative thoughts about their role in the traumatic event, their response to the traumatic experience, or the likelihood of future harm. For example, an individual with acute stress disorder may feel excessively guilty about not having prevented the traumatic event or about not adapting to the experience more successfully. Individuals with acute stress disorder may also interpret their symptoms in a catastrophic manner, such that flashback memories or emotional numbing may be interpreted as a sign of diminished mental capacity. It is common for individuals with acute stress disorder to experience panic attacks in the initial month after trauma exposure that may be triggered by trauma reminders or may apparently occur spontaneously. Additionally, individuals with acute stress disorder may display chaotic or impulsive behavior. For example, individuals may drive recklessly, make irrational decisions, or gamble excessively.Differential Diagnoses
Adjustment Disorder: In adjustment disorders, the stressor can be of any severity rather than of
the severity and type required by Criterion A of acute stress disorder. The diagnosis of an adjustment disorder is used when the response to a Criterion A event does not meet the criteria for acute stress disorder (or another specific mental disorder) and when the symptom pattern of acute stress disorder occurs in response to a stressor that does not meet Criterion A for exposure to actual or threatened death, serious injury, or sexual violence (e.g., spouse leaving, being fired). For example, severe stress reactions to life-threatening illnesses that may include some acute stress disorder symptoms may be more appropriately described as an adjustment disorder. Some forms of acute stress response do not include acute stress disorder symptoms and may be characterized by anger, depression, or guilt. These responses are more appropriately described as primarily an adjustment disorder. Depressive or anger responses in an adjustment disorder may involve rumination about the traumatic event, as opposed to involuntary and intrusive distressing memories in acute stress disorder.

Posttraumatic Stress Disorder: Acute stress disorder is distinguished from PTSD because the symptom pattern in acute stress disorder must resolve within 1 month of the traumatic event. If the symptoms persist for more than 1 month and meet criteria for PTSD, the diagnosis is changed from acute stress disorder to PTSD.←

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

Posttraumatic Stress Disorder: In adjustment disorders, the stressor can be of any severity rather than of the severity and type required by Criterion A of acute stress disorder and posttraumatic stress disorder (PTSD). In distinguishing adjustment disorders from these two posttraumatic diagnoses, there are both timing and symptom profile considerations. Adjustment disorders can be diagnosed immediately and persist up to 6 months after exposure to the traumatic event, whereas acute stress disorder can only occur between 3 days and 1 month of exposure to the stressor, and PTSD cannot be diagnosed until at least 1 month has passed since the occurrence of the traumatic stressor. The required symptom profiles for PTSD and acute stress disorder differentiate them from the adjustment disorders. With regard to symptom profiles, an adjustment disorder may be diagnosed following a traumatic event when an individual exhibits symptoms of either acute stress disorder or PTSD that do not meet or exceed the diagnostic threshold for either disorder. Because adjustment disorder cannot persist for more than 6 months after termination of the stressor or its consequences, cases in which symptoms occurring in response to a traumatic event that fall short of the diagnostic threshold for PTSD and that persist for longer than 6 months should be diagnosed as other specified trauma- and stressor-related disorder. An adjustment disorder should also be diagnosed for individuals who have not been exposed to a traumatic event meeting Criterion A for PTSD, but who otherwise exhibit the full symptom profile of either acute stress disorder or PTSD.

Personality Disorders: With regard to personality disorders, some personality features may be
associated with a vulnerability to situational distress that may resemble an adjustment disorder.
The lifetime history of personality functioning will help inform the interpretation of distressed
behaviors to aid in distinguishing a long-standing personality disorder from an adjustment disorder. In addition to some personality disorders incurring vulnerability to distress, stressors may also exacerbate personality disorder symptoms. In the presence of a personality disorder, if the symptom criteria for an adjustment disorder are met, and the stress-related disturbance exceeds what may be attributable to maladaptive personality disorder symptoms (i.e., Criterion C is met), then the diagnosis of an adjustment disorder should be made.Comorbid Disorders
Adjustment disorders can accompany most mental disorders and any medical condition. Adjustment disorders can be diagnosed in addition to another mental disorder only if the latter does not explain the particular symptoms that occur in reaction to the stressor. For example, an individual may develop an adjustment disorder, with depressed mood, after losing a job and at the same time have a diagnosis of obsessive-compulsive disorder. Or, an individual may have a depressive or bipolar disorder and an adjustment disorder as long as the criteria for both are met.←

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

Other Specified Trauma- and Stressor-Related Disorder
This category applies to presentations in which symptoms characteristic of a trauma- and stressor-related disorder that cause clinically significant distress or impairment in social, occupational, or other important areas of functioning predominate but do not meet the full criteria for any of the disorders in the trauma- and stressor-related disorders diagnostic class. The other specified trauma- and stressor-related disorder category is used in situations in which the clinician chooses to communicate the specific reason that the presentation does not meet the criteria for any specific trauma- and stressor-related disorder.

Examples of presentations that can be specified using the “other specified” designation include:

1. Adjustment-like disorders with delayed onset of symptoms that occur more than 3 months after the stressor.
2. Adjustment-like disorders with prolonged duration of more than 6 months without prolonged duration of stressor.
3. Persistent response to trauma with PTSD-like symptoms (i.e., symptoms occurring in response to a traumatic event that fall short of the diagnostic threshold for PTSD and that persist for longer than 6 months, sometimes referred to as “subthreshold/partial PTSD”).←

you picked... dissociative disorders!

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Dissociative Identity Disorder Diagnostic Criteria
A. Disruption of identity characterized by two or more distinct personality states: The disruption in identity involves marked discontinuity in sense of self and sense of agency, accompanied by related alterations in affect, behavior, consciousness, memory, perception, cognition, and/or sensory-motor functioning. These signs and symptoms may be observed by others or reported by the individual.
B. Dissociative amnesia: Recurrent gaps in the recall of everyday events, important personal information, and/or traumatic events that are inconsistent with ordinary forgetting.
C. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
D. The disturbance is not a normal part of a broadly accepted cultural or religious practice.
E. The symptoms are not attributable to the physiological effects of a substance or another medical condition.Associated Features
The overtness or covertness of these personality states varies as a function of psychological motivation, current level of stress, cultural context, internal conflicts and dynamics, and emotional resilience, among other factors. Sustained periods of identity confusion/alteration may occur when psychosocial pressures are severe and/or prolonged. In those cases of dissociative identity disorder that present as the individual being possessed by external identities (possession-form dissociative identity disorder), and in a small proportion of non-possession-form cases, manifestations of alternate identities are readily observable. Most individuals with non-possession-form dissociative identity disorder do not overtly display, or only subtly display, their discontinuity of identity, and only a minority present to clinical attention with discernible alternation of identities. The elaboration of dissociative personality states with different names, wardrobes, hairstyles, handwriting, accents, and so forth, occurs in only a minority of individuals with the non-possession-form dissociative identity disorder and is not essential to diagnosis. In those cases where alternate personality states cannot be directly observed, the presence of distinct personality states can be identified by sudden alterations or discontinuities in the individual’s sense of self and sense of agency, and recurrent dissociative amnesia.
Possession-form identities in dissociative identity disorder typically manifest behaviorally as if a “spirit,” supernatural being, or outside person has taken control, with the individual speaking or acting in a distinctly different manner. The identities that arise during possession-form dissociative identity disorder present recurrently, are unwanted and involuntary, and cause clinically significant distress or impairment.

Criterion A symptoms are related to discontinuities of experience that can affect any aspect of an individual’s functioning. Individuals with dissociative identity disorder may report the feeling that they have suddenly become depersonalized observers of their own speech and actions, which they may feel powerless to stop. These individuals may also report perceptions of voices (e.g., a child’s voice, voices commenting on the individual’s thoughts or behavior, persecutory voices and command hallucinations). In some cases, hearing voices is specifically denied, but the individual reports multiple, perplexing, independent thought streams over which the individual experiences no control. Strong emotions, impulses, thoughts, and even speech or other actions may suddenly materialize, without a sense of personal ownership or control. Conversely, thoughts and emotions may unexpectedly vanish, and speech and actions are abruptly inhibited. These experiences are frequently reported as ego-dystonic and puzzling. Attitudes, outlooks, and personal preferences (e.g., about food, activities, gender identity) may suddenly shift. Individuals may report that their bodies feel different (e.g., like a small child, the opposite gender, different ages simultaneously). Alterations in sense of self and agency may be accompanied by a feeling that attitudes, emotions, and behaviors—even the individual’s own body—are “not mine” or are “not under my control.”

In most individuals with dissociative identity disorder, switching/shifting of states is subtle and may occur with only subtle changes in overt presentation. State switching may be more overt in the possession form of dissociative identity disorder. In general, the individual with dissociative identity disorder experiences themself as multiple, simultaneously overlapping and interfering states.

Dissociative amnesia manifests in several major domains: 1) gaps in any aspect of autobiographical memory (e.g., important life events like getting married or giving birth, lack of recall of all school experiences before high school); 2) lapses in memory of recent events or well-learned skills (e.g., how to do one’s job, use a computer, cook or drive); and 3) discovery of possessions that the individual has no recollection of ever owning (e.g., clothing, weapons, tools, writings or drawings that he or she must have created). Dissociative fugues, with amnesia for travel, are common. Individuals may report suddenly finding themselves in another city, at work, or even at home: in the closet, under the bed, or running out of the house. Amnesia in individuals with dissociative identity disorder is not limited to stressful or traumatic events; it can involve everyday events as well. Individuals may report major gaps in ongoing memory (e.g., experiencing “time loss,” “blackouts,” or “coming to” in the midst of doing something). Individuals with dissociative identity disorder often conceal, or are not fully aware of, disruptions in consciousness, amnesia, or other dissociative symptoms. Many individuals with dissociative identity disorder report dissociative flashbacks during which they experience a sensory reliving of a previous event as though it were occurring in the present, often with a change of identity, a partial or complete loss of contact with or disorientation to current reality during the flashback, and a subsequent amnesia for the content of the flashback.

The disorder may first manifest at almost any age from early childhood to late life. Overt identity alteration/confusion may be triggered by many factors, such as later traumatic experiences (e.g., sexual assault), or even seemingly inconsequential stressors, like a minor motor vehicle accident. The experience of other major or cumulative life stressors may also worsen symptoms, including life events such as the individual’s children reaching the same age at which the individual was significantly abused or traumatized. The death of, or the onset of a fatal illness in, the individual’s abuser(s) is another example of an event that may worsen symptoms.

In the context of family and attachment pathology, early life trauma (e.g., neglect and physical, sexual, and emotional abuse, usually before ages 5–6 years) represents a risk factor for dissociative identity disorder. In studies from diverse geographic regions, about 90% of the individuals with the disorder report multiple types of early neglect and childhood abuse, often extending into late adolescence. Some individuals report that maltreatment primarily occurred outside the family, in school, church, and/or neighborhoods, including being bullied severely. Other forms of repeated early-life traumatic experiences include multiple, painful childhood medical and surgical procedures; war; terrorism; or being trafficked beginning in childhood. Onset has also been described after prolonged and often transgenerational exposure to dysfunctional family dynamics (e.g., overcontrolling parenting, insecure attachment, emotional abuse) in the absence of clear neglect or sexual or physical abuse.Differential Diagnoses
Dissociative Amnesia: Both dissociative identity disorder and dissociative amnesia are
characterized by gaps in the recall of everyday events, important personal information, or traumatic events that are inconsistent with ordinary forgetting. Dissociative identity disorder is distinguished from dissociative amnesia by the additional presence of identity disruption characterized by two or more distinct personality states.

Depersonalization/Derealization Disorder: The essential feature of depersonalization/derealization disorder is persistent or recurrent episodes of depersonalization, derealization, or both. Individuals with depersonalization/derealization disorder do not experience the presence of personality/identity states with alterations of self and agency, nor do they typically report dissociative amnesia.

Bipolar Disorder: Dissociative identity disorder is commonly misdiagnosed as bipolar disorder, typically bipolar II disorder, with mixed features. The relatively rapid shifts in behavioral state in
individuals with dissociative identity disorder—usually within minutes or hours—are atypical for even the most rapid-cycling individuals with bipolar disorders. These state alterations are due to rapidly shifting dissociative states and/or fluctuating posttraumatic intrusions. Sometimes these shifts are accompanied by rapid changes in levels of activation, but these usually last minutes to
hours, not days, and are associated with activation of specific identity states. Elevated or depressed mood may be experienced as loculated in specific identities, through overlap/interference phenomena. Usually, the individual with dissociative identity disorder does not have a classic bipolar sleep disturbance, instead suffering from chronic, severe nightmares and nocturnal flashbacks that interrupt sleep.

Posttraumatic Stress Disorder: A majority of individuals with dissociative identity disorder will have symptoms that meet diagnostic criteria for comorbid PTSD. Dissociative symptoms characteristic of dissociative identity disorder should be differentiated from the dissociative amnesia, dissociative flashbacks, and depersonalization/derealization characteristic of acute stress disorder, PTSD, or the dissociative subtype of PTSD. Dissociative amnesia in PTSD typically manifests only for specific traumatic events or aspects of traumatic events, as opposed to the chronic, complex dissociative amnesia characteristic of dissociative identity disorder. Depersonalization/derealization symptoms in the dissociative subtype of PTSD are related to specific posttraumatic reminders. Depersonalization/derealization symptoms in dissociative identity disorder may occur not only in response to posttraumatic reminders, but also in an ongoing fashion in daily life, including in response to stressful interpersonal interactions and when there is overlap/interference between states.

Psychotic Disorders: Individuals with dissociative identity disorder may experience symptoms that can superficially appear similar to those of psychotic disorders. These include auditory hallucinations and symptoms characteristic of intrusions of personality states into the individual’s awareness; these symptoms can seemingly resemble some of the Schneiderian first-rank symptoms formerly considered indicative of schizophrenia (e.g., thought broadcasting, thought insertion, thought withdrawal, hearing voices keeping up a running commentary about the individual). For example, hearing different personality states discussing the individual can resemble auditory hallucinations of voices arguing in schizophrenia. The individual with dissociative identity disorder may also experience the thoughts or emotions of an intruding personality state, which can resemble thought insertion in schizophrenia, as well as experience the sudden disappearance of these thoughts or emotions, which can resemble thought withdrawal. Such experiences in an individual with schizophrenia are usually accompanied by delusional beliefs about the cause of those symptoms (i.e., thoughts being inserted by an outside force), whereas individuals with dissociative identity disorder typically experience these symptoms as ego-alien and frightening. Individuals with dissociative identity disorder may also report a range of visual, tactile, olfactory, gustatory, and somatic hallucinations, which are usually related to auto-hypnotic, posttraumatic, and dissociative factors, such as partial flashbacks, in contrast to individuals with schizophrenia, whose hallucinations are primarily auditory and less commonly visual. Dissociative identity disorder and psychotic disorders are therefore distinguished by symptoms characteristic of one of these conditions and not the other (e.g., dissociative amnesia in dissociative identity disorder and not in psychotic disorders). Finally, individuals with schizophrenia have low hypnotic capacity, whereas
individuals with dissociative identity disorder have the highest hypnotic capacity among all clinical groups.

Personality Disorders: Individuals with dissociative identity disorder often present identities that
appear to encapsulate a variety of severe personality disorder features, suggesting a differential diagnosis of personality disorder, especially of the borderline type. Importantly, however, the individual’s longitudinal variability in personality style (attributable to inconsistency among
identities) differs from the pervasive and persistent dysfunction in affect management and interpersonal relationships typical of those with personality disorders.Comorbid Disorders
Disorders that are comorbid with dissociative identity disorder include PTSD, depressive disorders, substance-related disorders, feeding and eating disorders, obsessive-compulsive disorder, antisocial personality disorder, and other specified personality disorder with avoidant, obsessive-compulsive, or borderline personality traits. The most common forms of functional neurological symptom disorder include nonepileptic seizures, gait disturbances, and paralyses. Most commonly, nonepileptic seizures resemble grand mal seizures or complex partial seizures with temporal lobe foci; others may mimic absence or partial seizures.←

Dissociative Amnesia Diagnostic Criteria
A. An inability to recall important autobiographical information, usually of a traumatic or stressful nature, that is inconsistent with ordinary forgetting.
B. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
C. The disturbance is not attributable to the physiological effects of a substance or a neurological or other medical condition.
D. The disturbance is not better explained by dissociative identity disorder, posttraumatic stress disorder, acute stress disorder, somatic symptom disorder, or major or mild neurocognitive disorder.Associated Features
A variety of types of dissociative amnesia may manifest. In general, the memory deficit in dissociative amnesia is retrograde and, except in rare cases, is not associated with ongoing amnesia for contemporary life events. Retrospective memory impairments include not only lost memories of traumatic experiences but also lost memories of everyday life during which no trauma occurred. Most commonly, individuals with dissociative amnesia report localized amnesia—a failure to recall events during a circumscribed period of time; and/or selective amnesia—the individual can recall some, but not all, of the events during a circumscribed period of time. In systematized amnesia the individual fails to recall a specific category of important information (e.g., fragmentary recall of home growing up, but continuous memory for school; no recall of a violent older sibling; lack of recall of a specific room in the individual’s childhood home). Individuals rarely overtly complain of symptoms of these forms of dissociative amnesia and attempt to minimize and rationalize the memory loss.

Generalized dissociative amnesia involves a complete loss of memory for most or all of the individual’s life history. Individuals with generalized amnesia may forget personal identity, lose previous knowledge about the world, and less commonly lack access to well-learned skills. Generalized dissociative amnesia has an acute onset; the perplexity, disorientation, and purposeless wandering of individuals with generalized amnesia usually bring them to the attention of the police or psychiatric emergency services.

Individuals with dissociative amnesia are frequently unaware (or only partially aware) of their memory problems. They may recall some traumatic events, or parts of traumatic events, but not others of the same type. Many, especially those with localized amnesia, minimize the importance of their memory loss and may become uncomfortable when prompted to address it.Differential Diagnoses
Dissociative Identity Disorder: Recurrent episodes of dissociative amnesia may be attributable to dissociative identity disorder. Individuals with dissociative amnesia may report depersonalization and auto-hypnotic symptoms, as do individuals with dissociative identity disorder. Individuals with dissociative identity disorder report pervasive discontinuities in sense of self and agency, accompanied by many other dissociative symptoms. Amnesias in dissociative identity disorder, in addition to retrospective autobiographical memory deficits, include ongoing amnesia (“time loss”) for everyday events and interpersonal interactions; finding unexplained possessions; perplexing major fluctuations in skills and knowledge; and frequent, brief amnesic gaps during interpersonal interactions.

Posttraumatic Stress Disorder: Some individuals with PTSD cannot recall part or all of a specific traumatic event (e.g., a rape victim who cannot recall most events for the entire day of the rape). When that amnesia extends to events beyond the immediate time of the trauma, a comorbid diagnosis of dissociative amnesia may be warranted. Individuals with the dissociative subtype of PTSD may also report dissociative amnesia in addition to depersonalization/derealization.

Other Specified Dissociative Disorder: The acute dissociative reactions to stressful events example of other specified dissociative disorder is characterized by a combination of dissociative symptoms that occur together acutely in response to stressful events and typically last less than 1 month. Amnestic episodes that occur as part of these reactions are accompanied by other prominent dissociative symptoms, have a short duration (hours or days), and tend to be circumscribed to limited periods or events in a person’s life (micro-amnesias).Comorbid Disorders
As is common in individuals with a history of trauma, many comorbidities co-occur with dissociative amnesia, particularly as dissociative amnesia begins to remit. A wide variety of affective phenomena may surface, including dysphoria, grief, rage, shame, guilt, and psychological conflict and turmoil. Individuals may engage in self-injury and other high-risk behaviors. These individuals may have symptoms that meet diagnostic criteria for persistent depressive disorder, major depressive disorder, or subthreshold depression (other specified depressive disorder). Many individuals with dissociative amnesia develop PTSD at some point during their life, especially when the traumatic antecedents of their amnesia are brought into conscious awareness. Many of these individuals may show symptoms of the dissociative subtype of PTSD. Many individuals with dissociative amnesia have symptoms that meet diagnostic criteria for a comorbid somatic symptom and related disorder (and vice versa), particularly functional neurological symptom disorder (conversion disorder). Substance-related and addictive disorders may be comorbid with dissociative amnesia, as well as feeding and eating disorders and sexual dysfunctions. The most common comorbid personality disorder is other specified personality disorder (with mixed personality disorder features), which often includes avoidant, obsessive-compulsive, dependent, and borderline features.←

Depersonalization/Derealization Disorder Diagnostic Criteria
A. The presence of persistent or recurrent experiences of depersonalization, derealization, or both:
::::::::::::::1. Depersonalization: Experiences of unreality, detachment, or being an outside observer with respect to one’s thoughts, feelings, sensations, body, or actions (e.g., perceptual alterations, distorted sense of time, unreal or absent self, emotional and/or physical numbing).
::::::::::::::2. Derealization: Experiences of unreality or detachment with respect to surroundings (e.g., individuals or objects are experienced as unreal, dreamlike, foggy, lifeless, or visually distorted).
B. During the depersonalization or derealization experiences, reality testing remains intact.
C. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
D. The disturbance is not attributable to the physiological effects of a substance or another medical condition.
E. The disturbance is not better explained by another mental disorder, such as schizophrenia, panic disorder, major depressive disorder, acute stress disorder, posttraumatic stress disorder, or another dissociative disorder.Associated Features
Individuals with depersonalization/derealization disorder may have difficulty describing their symptoms and may think they are “crazy” or “going crazy.” Another common experience is the fear of irreversible brain damage. A commonly associated symptom is a subjectively altered sense of time (i.e., too fast or too slow), as well as a subjective difficulty in vividly recalling past memories and owning them as personal and emotional. Vague somatic symptoms, such as head fullness, tingling, or lightheadedness, are not uncommon. Individuals may experience extreme rumination or obsessional preoccupation (e.g., constantly obsessing about whether they really exist, or checking their perceptions to determine whether they appear real). Varying degrees of anxiety and depression are also common associated features.

The presence of intact reality testing specifically regarding the depersonalization/derealization symptoms is essential to differentiating depersonalization/derealization disorder from psychotic disorders. Rarely, positive-symptom schizophrenia can pose a diagnostic challenge when nihilistic delusions are present. For example, an individual may complain that he or she is dead or the world is not real; this could be either a subjective experience that the individual knows is not true or a delusional conviction.Differential Diagnoses
Other Dissociative disorders: In order to diagnose depersonalization/derealization disorder, the symptoms should not occur in the context of another dissociative disorder, such as dissociative identity disorder. Differentiation from dissociative amnesia and functional neurological symptom disorder is simpler, as the symptoms of these disorders do not overlap with those of depersonalization/derealization disorder.

Major Depressive Disorder: Feelings of numbness, deadness, apathy, and being in a dream are not uncommon in major depressive episodes. However, in depersonalization/derealization disorder, such symptoms are associated with further symptoms of the disorder. If the depersonalization/derealization clearly precedes the onset of a major depressive episode or clearly continues after its resolution, the diagnosis of depersonalization/derealization disorder applies.

Panic attacks: Depersonalization/derealization is one of the symptoms of panic attacks, increasingly common as panic attack severity increases. Therefore, depersonalization/derealization disorder should not be diagnosed when the symptoms occur only during panic attacks that are part of panic disorder, social anxiety disorder, or specific phobia. In addition, it is not uncommon for depersonalization/derealization symptoms to first begin in the context of new-onset panic attacks or as panic disorder progresses and worsens. In such presentations, the diagnosis of depersonalization/derealization disorder can be made if 1) the depersonalization/derealization component of the presentation is very prominent from the start, clearly exceeding in duration and intensity the occurrence of actual panic attacks; or 2) the depersonalization/derealization continues after panic disorder has remitted or has been successfully treated.

Psychotic Disorders: The presence of intact reality testing specifically regarding the
depersonalization/derealization symptoms is essential to differentiating depersonalization/derealization disorder from psychotic disorders. Rarely, positive-symptom schizophrenia can pose a diagnostic challenge when nihilistic delusions are present. For example, an individual may complain that he or she is dead or the world is not real; this could be either a subjective experience that the individual knows is not true or a delusional conviction.Comorbid Disorders
In a convenience sample of adults recruited for a number of depersonalization research studies, lifetime comorbidities were high for unipolar depressive disorder and for any anxiety disorder, with a significant proportion of the sample having both disorders. Comorbidity with posttraumatic stress disorder was low. The three most commonly co-occurring personality disorders were avoidant, borderline, and obsessive-compulsive.←

Other Specified Dissociative Disorder
This category applies to presentations in which symptoms characteristic of a dissociative disorder that cause clinically significant distress or impairment in social, occupational, or other important areas of functioning predominate but do not meet the full criteria for any of the disorders in the dissociative disorders diagnostic class. The other specified dissociative disorder category is used in situations in which the clinician chooses to communicate the specific reason that the presentation does not meet the criteria for any specific dissociative disorder.

Examples of presentations that can be specified using the “other specified” designation include:

1. Chronic and recurrent syndromes of mixed dissociative symptoms: This category includes identity disturbance associated with less-than-marked discontinuities in sense of self and agency, or alterations of identity or episodes of possession in an individual who reports no dissociative amnesia.
2. Identity disturbance due to prolonged and intense coercive persuasion: Individuals who have been subjected to intense coercive persuasion (e.g., brainwashing, thought reform, indoctrination while captive, torture, long-term political imprisonment, recruitment by sects/cults or by terror organizations) may present with prolonged changes in, or conscious questioning of, their identity.
3. Acute dissociative reactions to stressful events: This category is for acute, transient conditions that typically last less than 1 month, and sometimes only a few hours or days. These conditions are characterized by constriction of consciousness; depersonalization; derealization; perceptual disturbances (e.g., time slowing, macropsia); microamnesias; transient stupor; and/or alterations in sensory-motor functioning (e.g., analgesia, paralysis).
4. Dissociative trance: This condition is characterized by an acute narrowing or complete loss of awareness of immediate surroundings that manifests as profound unresponsiveness or insensitivity to environmental stimuli. The unresponsiveness may be accompanied by minor stereotyped behaviors (e.g., finger movements) of which the individual is unaware and/or that he or she cannot control, as well as transient paralysis or loss of consciousness. The dissociative trance is not a normal part of a broadly accepted collective cultural or religious practice.←

you picked... somatic symptom and related disorders!

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

Illness Anxiety Disorder Diagnostic Criteria
A. Preoccupation with having or acquiring a serious illness.
B. Somatic symptoms are not present or, if present, are only mild in intensity. If another medical condition is present or there is a high risk for developing a medical condition (e.g., strong family history is present), the preoccupation is clearly excessive or disproportionate.
C. There is a high level of anxiety about health, and the individual is easily alarmed about personal health status.
D. The individual performs excessive health-related behaviors (e.g., repeatedly checks his or her body for signs of illness) or exhibits maladaptive avoidance (e.g., avoids doctor appointments and hospitals).
E. Illness preoccupation has been present for at least 6 months, but the specific illness that is feared may change over that period of time.
F. The illness-related preoccupation is not better explained by another mental disorder, such as somatic symptom disorder, panic disorder, generalized anxiety disorder, body dysmorphic disorder, obsessive-compulsive disorder, or delusional disorder, somatic type.Associated Features
Illness concerns assume a prominent place in the individual’s life, affecting daily activities, and may even result in invalidism. Illness becomes a central feature of the individual’s identity and self-image, a frequent topic of social discourse, and a characteristic response to stressful life events. Individuals with the disorder often examine themselves repeatedly (e.g., examining one’s throat in the mirror). They research their suspected disease excessively and repeatedly seek reassurance from family, friends, or physicians.Differential Diagnoses
Anxiety Disorders: In generalized anxiety disorder, individuals worry about multiple events, situations, or activities, only one of which may involve health. In panic disorder, the individual may be concerned that the panic attacks reflect the presence of a medical illness; however, although these individuals may have health anxiety, their anxiety is typically very acute and episodic. In illness anxiety disorder, the health anxiety and fears are more persistent and enduring. Individuals with illness anxiety disorder may experience panic attacks that are triggered by their illness concerns.

Obsessive-Compulsive Related Disorders: Individuals with illness anxiety disorder may have intrusive thoughts about having a disease and also may have associated compulsive behaviors (e.g., seeking reassurance). However, in illness anxiety disorder, the preoccupations are usually
focused on having a disease, whereas in obsessive-compulsive disorder (OCD), the thoughts are
intrusive and are usually focused on fears of getting a disease in the future. Most individuals with
OCD have obsessions or compulsions involving other concerns in addition to fears about contracting disease. In body dysmorphic disorder, concerns are limited to the individual’s physical appearance, which is viewed as defective or flawed.

Psychotic Disorders: Individuals with illness anxiety disorder are not delusional and can
acknowledge the possibility that the feared disease is not present. Their ideas do not attain the rigidity and intensity seen in the somatic delusions occurring in psychotic disorders (e.g., schizophrenia; delusional disorder, somatic type; major depressive disorder, with psychotic features). True somatic delusions are generally more bizarre (e.g., that an organ is rotting or dead) than the concerns seen in illness anxiety disorder. The concerns seen in illness anxiety disorder, though not founded in reality, are plausible.Comorbid Disorders
Illness anxiety disorder co-occurs with anxiety disorders (in particular, generalized anxiety disorder and panic disorder), OCD, and depressive disorders. Approximately two-thirds of individuals with illness anxiety disorder are likely to have at least one other comorbid major mental disorder. Individuals with illness anxiety disorder may have an elevated risk for personality disorders.←

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you picked... sleep-wake disorders!

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you picked... disruptive, impuslse-control, & cognitive disorders!

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you picked... personality disorders!

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