Diagnostic and Statistical Manual of Mental Disorders

1. Mental Disorders: A Spectrum of Experiences

Although DSM-5 remains a categorical classification of separate disorders, we recognize that mental disorders do not always fit completely within the boundaries of a single disorder.

Beyond Categories. The DSM-5 acknowledges that mental disorders aren't always clear-cut categories. Instead, they often exist on a spectrum, with overlapping symptoms and shared vulnerabilities. This means that individuals may experience symptoms that span multiple diagnostic categories, reflecting the complexity of mental health.

Clinical Utility. The DSM-5 is designed to be a practical guide for clinicians, providing a common language for diagnosis and treatment. It aims to organize information in a way that is useful for clinical practice, education, and research. The manual is intended to be a tool for clinicians, an essential educational resource for students and practitioners, and a reference for researchers in the field.

Harmonization with ICD. The DSM-5 is harmonized with the World Health Organization’s International Classification of Diseases (ICD), ensuring that the DSM criteria define disorders identified by ICD diagnostic names and code numbers. This harmonization facilitates communication and research across different settings and countries.

2. Neurodevelopmental Disorders: Early Life Challenges

The neurodevelopmental disorders are a group of conditions with onset in the developmental period.

Early Onset. Neurodevelopmental disorders manifest early in life, often before a child enters school. These conditions are characterized by developmental deficits that impact personal, social, academic, or occupational functioning. The range of deficits varies from specific learning limitations to global impairments in social skills or intelligence.

Spectrum of Conditions. This category includes intellectual disabilities, communication disorders, autism spectrum disorder, attention-deficit/hyperactivity disorder (ADHD), specific learning disorder, and motor disorders. These disorders often co-occur, highlighting the complex interplay of developmental factors. For example:

• Autism spectrum disorder is characterized by deficits in social communication and interaction, along with restricted, repetitive behaviors.
• ADHD is defined by impairing levels of inattention, disorganization, and/or hyperactivity-impulsivity.
• Specific learning disorder is diagnosed when there are specific deficits in an individual’s ability to perceive or process information efficiently and accurately.

Lifelong Impact. Neurodevelopmental disorders can have a lifelong impact on an individual's functioning. Early identification and intervention are crucial for improving outcomes and supporting individuals in reaching their full potential.

3. Schizophrenia Spectrum: Beyond Reality

Although DSM-5 remains a categorical classification of separate disorders, we recognize that mental disorders do not always fit completely within the boundaries of a single disorder.

Psychotic Symptoms. Schizophrenia spectrum and other psychotic disorders are defined by abnormalities in one or more of five key domains: delusions, hallucinations, disorganized thinking (speech), grossly disorganized or abnormal motor behavior (including catatonia), and negative symptoms. These symptoms can significantly alter an individual's perception of reality.

Spectrum of Disorders. This category includes schizotypal personality disorder, delusional disorder, brief psychotic disorder, schizophreniform disorder, schizophrenia, schizoaffective disorder, substance/medication-induced psychotic disorder, and psychotic disorder due to another medical condition. These disorders are organized along a spectrum of severity and duration. For example:

• Schizophrenia is characterized by a combination of positive and negative symptoms that persist for at least 6 months.
• Schizophreniform disorder has a similar symptom presentation to schizophrenia but lasts less than 6 months.
• Brief psychotic disorder is characterized by psychotic symptoms that last for more than 1 day but less than 1 month.

Catatonia. Catatonia, a state of marked psychomotor disturbance, can occur in the context of various mental disorders, including psychotic disorders. It is characterized by a range of symptoms, from resistance to instructions to a complete lack of verbal and motor responses.

4. Bipolar and Depressive Disorders: The Rollercoaster of Mood

Bipolar and depressive disorders are the most commonly diagnosed conditions in psychiatry.

Mood Extremes. Bipolar and related disorders are characterized by fluctuations in mood, ranging from periods of elevated or irritable mood (mania or hypomania) to periods of depressed mood. Depressive disorders, on the other hand, are characterized by persistent feelings of sadness, emptiness, or irritability.

Bipolar Spectrum. This category includes bipolar I disorder, bipolar II disorder, and cyclothymic disorder. Bipolar I disorder is characterized by manic episodes, while bipolar II disorder is characterized by hypomanic episodes and major depressive episodes. Cyclothymic disorder involves less severe mood fluctuations. For example:

• Bipolar I disorder is characterized by manic episodes, which may be accompanied by depressive episodes.
• Bipolar II disorder is characterized by hypomanic episodes and major depressive episodes.
• Cyclothymic disorder involves less severe mood fluctuations that do not meet the criteria for mania, hypomania, or major depression.

Depressive Disorders. This category includes disruptive mood dysregulation disorder, major depressive disorder, persistent depressive disorder (dysthymia), and premenstrual dysphoric disorder. Major depressive disorder is characterized by discrete episodes of at least 2 weeks’ duration involving changes in affect, cognition, and neurovegetative functions. Persistent depressive disorder (dysthymia) is a more chronic form of depression that lasts for at least 2 years in adults or 1 year in children.

5. Anxiety, Trauma, and Stress: Navigating Fear and Distress

Although DSM-5 remains a categorical classification of separate disorders, we recognize that mental disorders do not always fit completely within the boundaries of a single disorder.

Fear and Anxiety. Anxiety disorders are characterized by excessive fear and anxiety, along with related behavioral disturbances. Fear is the emotional response to a real or perceived imminent threat, while anxiety is the anticipation of future threat.

Trauma and Stress. Trauma- and stressor-related disorders are characterized by exposure to a traumatic or stressful event. These disorders include reactive attachment disorder, disinhibited social engagement disorder, posttraumatic stress disorder (PTSD), acute stress disorder, and adjustment disorders. For example:

• PTSD is characterized by re-experiencing, avoidance, negative cognitions and mood, and alterations in arousal and reactivity following exposure to a traumatic event.
• Acute stress disorder is similar to PTSD but lasts for a shorter duration (3 days to 1 month).
• Adjustment disorders are characterized by emotional or behavioral symptoms in response to an identifiable stressor.

Variety of Presentations. The disorders in this chapter differ in the types of objects or situations that induce fear, anxiety, or avoidance behavior, and the associated cognitive ideation. They also differ in the types of symptoms that are most prominent, ranging from anxiety and fear to dysphoria, anger, and dissociation.

6. Obsessive-Compulsive and Related Disorders: The Grip of Repetitive Thoughts and Behaviors

Although DSM-5 remains a categorical classification of separate disorders, we recognize that mental disorders do not always fit completely within the boundaries of a single disorder.

Obsessions and Compulsions. Obsessive-compulsive and related disorders are characterized by the presence of obsessions (recurrent and persistent thoughts, urges, or images) and/or compulsions (repetitive behaviors or mental acts). These disorders also include conditions characterized by preoccupations and repetitive behaviors or mental acts in response to the preoccupations.

Spectrum of Disorders. This category includes obsessive-compulsive disorder (OCD), body dysmorphic disorder, hoarding disorder, trichotillomania (hair-pulling disorder), excoriation (skin-picking) disorder, and substance/medication-induced obsessive-compulsive and related disorder. For example:

• OCD is characterized by obsessions and/or compulsions that are time-consuming or cause significant distress or impairment.
• Body dysmorphic disorder is characterized by preoccupation with perceived defects or flaws in physical appearance.
• Hoarding disorder is characterized by persistent difficulty discarding or parting with possessions.
• Trichotillomania (hair-pulling disorder) is characterized by recurrent pulling out of one’s hair.
• Excoriation (skin-picking) disorder is characterized by recurrent picking of one’s skin.

Insight and Specifiers. The disorders in this chapter are often accompanied by varying degrees of insight into the accuracy of the beliefs that underlie the symptoms. Specifiers are used to indicate the level of insight, as well as other relevant features, such as tic-related symptoms.

7. Feeding, Eating, Elimination, and Sleep-Wake Disorders: Disruptions of Basic Needs

These diverse needs and interests were taken into consideration in planning DSM-5.

Basic Functions. This chapter includes disorders that involve disruptions in basic functions such as eating, elimination, and sleep. These disorders can have a significant impact on physical health and psychosocial functioning.

Feeding and Eating Disorders. This category includes pica, rumination disorder, avoidant/restrictive food intake disorder, anorexia nervosa, bulimia nervosa, and binge-eating disorder. These disorders are characterized by a persistent disturbance of eating or eating-related behavior that results in the altered consumption or absorption of food. For example:

• Anorexia nervosa is characterized by restriction of energy intake, intense fear of gaining weight, and a disturbance in self-perceived weight or shape.
• Bulimia nervosa is characterized by recurrent episodes of binge eating and inappropriate compensatory behaviors to prevent weight gain.
• Binge-eating disorder is characterized by recurrent episodes of binge eating without compensatory behaviors.

Elimination Disorders. This category includes enuresis (repeated voiding of urine) and encopresis (repeated passage of feces) into inappropriate places. These disorders are usually first diagnosed in childhood or adolescence.

Sleep-Wake Disorders. This category includes insomnia disorder, hypersomnolence disorder, narcolepsy, breathing-related sleep disorders, circadian rhythm sleep-wake disorders, non-rapid eye movement (NREM) sleep arousal disorders, nightmare disorder, rapid eye movement (REM) sleep behavior disorder, restless legs syndrome, and substance/medication-induced sleep disorder. These disorders are characterized by dissatisfaction regarding the quality, timing, and amount of sleep.

8. Sexual Dysfunctions and Gender Dysphoria: Exploring Identity and Intimacy

Although the benefits of a more dimensional approach to personality disorders have been identified in previous editions, the transition from a categorical diagnostic system of individual disorders to one based on the relative distribution of personality traits has not been widely accepted.

Sexual Response. Sexual dysfunctions are characterized by a clinically significant disturbance in a person’s ability to respond sexually or to experience sexual pleasure. These disorders can affect various aspects of the sexual response cycle, including desire, arousal, and orgasm.

Gender Identity. Gender dysphoria is characterized by distress that may accompany the incongruence between one’s experienced or expressed gender and one’s assigned gender. This diagnosis is not limited to a desire to be of the other gender, but may include a desire to be of an alternative gender.

Spectrum of Disorders. This chapter includes delayed ejaculation, erectile disorder, female orgasmic disorder, female sexual interest/arousal disorder, genito-pelvic pain/penetration disorder, male hypoactive sexual desire disorder, premature (early) ejaculation, and gender dysphoria. These disorders are often influenced by a complex interplay of biological, sociocultural, and psychological factors.

9. Disruptive, Impulse-Control, and Conduct Disorders: Challenges in Self-Regulation

The neurodevelopmental disorders are a group of conditions with onset in the developmental period.

Self-Control. Disruptive, impulse-control, and conduct disorders are characterized by problems in the self-control of emotions and behaviors. These problems are manifested in behaviors that violate the rights of others and/or that bring the individual into conflict with societal norms or authority figures.

Spectrum of Disorders. This category includes oppositional defiant disorder, intermittent explosive disorder, conduct disorder, antisocial personality disorder, pyromania, and kleptomania. For example:

• Oppositional defiant disorder is characterized by a pattern of angry/irritable mood, argumentative/defiant behavior, or vindictiveness.
• Conduct disorder is characterized by a repetitive and persistent pattern of behavior in which the basic rights of others or major age-appropriate societal norms or rules are violated.
• Intermittent explosive disorder is characterized by recurrent behavioral outbursts representing a failure to control aggressive impulses.

Early Onset. These disorders tend to have first onset in childhood or adolescence. They are more common in males than in females, and they often co-occur with other mental disorders, such as substance use disorders and antisocial personality disorder.

10. Substance-Related and Addictive Disorders: The Pull of Compulsion

The categories of substance abuse and substance dependence have been eliminated and replaced with an overarching new category of substance use disorders—with the specific substance used defining the specific disorders.

Reward System Activation. Substance-related and addictive disorders are characterized by the use of substances that directly activate the brain reward system, leading to compulsive drug-seeking behavior and continued use despite negative consequences. This category includes both substance use disorders and substance-induced disorders.

Substance Use Disorders. These disorders are characterized by a cluster of cognitive, behavioral, and physiological symptoms indicating that the individual continues using the substance despite significant substance-related problems. The diagnosis can be applied to all 10 classes of substances, including alcohol, caffeine, cannabis, hallucinogens, inhalants, opioids, sedatives, hypnotics, anxiolytics, stimulants, and tobacco.

Substance-Induced Disorders. These disorders include intoxication, withdrawal, and other substance/medication-induced mental disorders (e.g., psychotic disorders, bipolar and related disorders, depressive disorders, anxiety disorders, obsessive-compulsive and related disorders, sleep disorders, sexual dysfunctions, delirium, and neurocognitive disorders).

Non-Substance-Related Disorders. This category includes gambling disorder, reflecting evidence that gambling behaviors activate reward systems similar to those activated by drugs of abuse.

11. Neurocognitive Disorders: The Decline of Cognitive Function

Enhanced specificity for major and mild neurocognitive disorders.

Acquired Cognitive Decline. Neurocognitive disorders (NCDs) are characterized by a decline in cognitive function that is acquired rather than developmental. These disorders represent a decline from a previously attained level of functioning.

Spectrum of Disorders. This category includes delirium, major NCD, mild NCD, and their etiological subtypes. The subtypes are based on the underlying pathology, such as Alzheimer’s disease, frontotemporal lobar degeneration, Lewy body disease, vascular disease, traumatic brain injury, substance/medication use, HIV infection, prion disease, Parkinson’s disease, Huntington’s disease, another medical condition, multiple etiologies, and unspecified. For example:

• Major NCD is characterized by significant cognitive decline that interferes with independence in everyday activities.
• Mild NCD is characterized by modest cognitive decline that does not interfere with independence in everyday activities.
• Delirium is characterized by a disturbance in attention and awareness that develops over a short period of time and tends to fluctuate in severity.

Cognitive Domains. The criteria for NCDs are based on defined cognitive domains, including complex attention, executive function, learning and memory, language, perceptual-motor, and social cognition.

12. Personality Disorders: Enduring Patterns of Maladaptive Behavior

Although the benefits of a more dimensional approach to personality disorders have been identified in previous editions, the transition from a categorical diagnostic system of individual disorders to one based on the relative distribution of personality traits has not been widely accepted.

Inflexible Patterns. Personality disorders are characterized by enduring patterns of inner experience and behavior that deviate markedly from cultural expectations, are inflexible and pervasive, have an onset in adolescence or early adulthood, are stable over time, and lead to distress or impairment.

Categorical Approach. The DSM-5 retains a categorical approach to personality disorders, with 10 specific disorders grouped into three clusters:

• Cluster A (odd or eccentric): paranoid, schizoid, and schizotypal personality disorders.
• Cluster B (dramatic, emotional, or erratic): antisocial, borderline, histrionic, and narcissistic personality disorders.
• Cluster C (anxious or fearful): avoidant, dependent, and obsessive-compulsive personality disorders.

Alternative Model. An alternative “hybrid” model has been proposed in Section III to guide future research that separates interpersonal functioning assessments and the expression of pathological personality traits for six specific disorders. A more dimensional profile of personality trait expression is also proposed for a trait-specified approach.

Last updated: January 24, 2025