Also from James Morrison

Diagnosis Made Easier:
Principles and Techniques for Mental Health Clinicians, Second Edition

The First Interview, Fourth Edition

When Psychological Problems Mask Medical Disorders:

A Guide for Psychotherapists

For more information, see www.guilford.com/morrison

2

DSM-5® Made Easy
The Clinician’s Guide to Diagnosis

James Morrison

THE GUILFORD PRESS
New York London

3

Epub Edition ISBN: 9781462515448; Kindle Edition ISBN: 9781462515455

© 2014 The Guilford Press
A Division of Guilford Publications, Inc.
72 Spring Street, New York, NY 10012
www.guilford.com

All rights reserved

No part of this book may be reproduced, translated, stored in a retrieval system, or transmitted, in any form
or by any means, electronic, mechanical, photocopying, microfilming, recording, or otherwise, without
written permission from the publisher.

Last digit is print number: 9 8 7 6 5 4 3 2 1

The author has checked with sources believed to be reliable in his effort to provide information that is
complete and generally in accord with the standards of practice that are accepted at the time of publication.
However, in view of the possibility of human error or changes in behavioral, mental health, or medical
sciences, neither the author, nor the editor and publisher, nor any other party who has been involved in the
preparation or publication of this work warrants that the information contained herein is in every respect
accurate or complete, and they are not responsible for any errors or omissions or the results obtained from
the use of such information. Readers are encouraged to confirm the information contained in this book with
other sources.

Library of Congress Cataloging-in-Publication Data

Morrison, James R., author.
DSM-5 made easy : the clinician’s guide to diagnosis / James Morrison.
p.; cm.
Includes bibliographical references and index.
ISBN 978-1-4625-1442-7 (hardcover : alk. paper)
I. Title.
[DNLM: 1. Diagnostic and statistical manual of mental disorders. 5th ed 2. Mental Disorders—

diagnosis—Case Reports. 3. Mental Disorders—classification—Case Reports. WM 141]
RC469
616.89’075—dc23

2014001109

DSM-5 is a registered trademark of the American Psychiatric Association. The APA has not participated in
the preparation of this book.

4

For Mary, still my sine qua non

5

About the Author

James Morrison, MD, is Affiliate Professor of Psychiatry at Oregon Health and
Science University in Portland. He has extensive experience in both the private
and public sectors. With his acclaimed practical books—including, most recently,
Diagnosis Made Easier, Second Edition, and The First Interview, Fourth Edition—
Dr. Morrison has guided hundreds of thousands of mental health professionals
and students through the complexities of clinical evaluation and diagnosis. His
website (www.guilford.com/jm) offers additional discussion and resources related
to psychiatric diagnosis and DSM-5.

6

Acknowledgments

Many people helped in the creation of this book. I want especially to thank my
wife, Mary, who has provided unfailingly excellent advice and continual support.
Chris Fesler was unsparing with his assistance in organizing my web page.

Others who read portions of the earlier version of this book, DSM-IV Made
Easy, in one stage or another included Richard Maddock, MD, Nicholas
Rosenlicht, MD, James Picano, PhD, K. H. Blacker, MD, and Irwin Feinberg,
MD. I am grateful to Molly Mullikin, the perfect secretary, who contributed
hours of transcription and years of intelligent service in creating the earlier
version of this book. I am also profoundly indebted to the anonymous reviewers
who provided input; you know who you are, even if I don’t.

My editor, Kitty Moore, a keen and wonderful critic, helped develop the
concept originally, and has been a mainstay of the enterprise for this new edition.
I also deeply appreciate the many other editors and production people at The
Guilford Press, notably Editorial Project Manager Anna Brackett, who helped
shape and speed this book into print. I would single out Marie Sprayberry, who
went the last mile with her thoughtful, meticulous copyediting. David Mitchell
did yeoman service in reading the manuscript from cover to cover to root out
errors. I am indebted to Ashley Ortiz for her intelligent criticism of my web page,
and to Kyala Shea, who helped get it web borne.

A number of clinicians and other professionals provided their helpful advice in
the final revision process. They include Alison Beale, Ray Blanchard, PhD, Dan
G. Blazer, MD, PhD, William T. Carpenter, MD, Thomas J. Crowley, MD,
Darlene Elmore, Jan Fawcett, MD, Mary Ganguli, MD, Bob Krueger, PhD,
Kristian E. Markon, PhD, William Narrow, MD, Peter Papallo, MSW, MS,
Charles F. Reynolds, MD, Aidan Wright, PhD, and Kenneth J. Zucker, PhD. To
each of these, and to the countless patients who have provided the clinical
material for this book, I am profoundly grateful.

7

Contents

Also from James Morrison

Title Page

Copyright Page

Dedication Page

About the Author

Acknowledgments

FREQUENTLY NEEDED TABLES

INTRODUCTION

CHAPTER 1 Neurodevelopmental Disorders

CHAPTER 2 Schizophrenia Spectrum and Other Psychotic Disorders

CHAPTER 3 Mood Disorders

CHAPTER 4 Anxiety Disorders

CHAPTER 5 Obsessive–Compulsive and Related Disorders

CHAPTER 6 Trauma- and Stressor-Related Disorders

CHAPTER 7 Dissociative Disorders

CHAPTER 8 Somatic Symptom and Related Disorders

CHAPTER 9 Feeding and Eating Disorders

CHAPTER 10 Elimination Disorders

CHAPTER 11 Sleep–Wake Disorders

CHAPTER 12 Sexual Dysfunctions

CHAPTER 13 Gender Dysphoria

CHAPTER 14 Disruptive, Impulse-Control, and Conduct Disorders

CHAPTER 15 Substance-Related and Addictive Disorders

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CHAPTER 16 Cognitive Disorders

CHAPTER 17 Personality Disorders

CHAPTER 18 Paraphilic Disorders

CHAPTER 19 Other Factors That May Need Clinical Attention

CHAPTER 20 Patients and Diagnoses

APPENDIX

Essential Tables

Global Assessment of Functioning (GAF) Scale

Physical Disorders That Affect Mental Diagnosis

Classes (or Names) of Medications That Can Cause Mental Disorders

INDEX

About Guilford Press

Discover Related Guilford Books

9

Frequently Needed Tables

TABLE 3.2 Coding for Bipolar I and Major Depressive Disorders

TABLE 3.3 Descriptors and Specifiers That Can Apply to Mood Disorders

TABLE 15.1 Symptoms of Substance Intoxication and Withdrawal

TABLE 15.2
ICD-10-CM Code Numbers for Substance Intoxication, Substance
Withdrawal, Substance Use Disorder, and Substance-Induced Mental
Disorders

TABLE 16.1 Coding for Major and Mild NCDs

Purchasers of this ebook can download copies of these tables from
www.guilford.com/morrison2-forms.

10

Introduction

The summer after my first year in medical school, I visited a friend at his home
near the mental institution where both of his parents worked. One afternoon,
walking around the vast, open campus, we fell into conversation with a staff
psychiatrist, who told us about his latest interesting patient.

She was a young woman who had been admitted a few days earlier. While
attending college nearby, she had suddenly become agitated—speaking rapidly
and rushing in a frenzy from one activity to another. After she impulsively sold
her nearly new Corvette for $500, her friends had brought her for evaluation.

“Five hundred dollars!” exclaimed the psychiatrist. “That kind of thinking,
that’s schizophrenia!”

Now my friend and I had had just enough training in psychiatry to recognize
that this young woman’s symptoms and course of illness were far more consistent
with an episode of mania than with schizophrenia. We were too young and
callow to challenge the diagnosis of the experienced clinician, but as we went on
our way, we each expressed the fervent hope that this patient’s care would be less
flawed than her assessment.

For decades, the memory of that blown diagnosis has haunted me, in part
because it is by no means unique in the annals of mental health lore. Indeed, it
wasn’t until many years later that the first diagnostic manual to include specific
criteria (DSM-III) was published. That book has since morphed into the
enormous fifth edition of the Diagnostic and Statistical Manual of Mental
Disorders (DSM-5), published by the American Psychiatric Association.

Everyone who evaluates and treats mental health patients must understand
the latest edition of what has become the world standard for evaluation and
diagnosis. But getting value from DSM-5 requires a great deal of concentration.
Written by a committee with the goal of providing standards for research as well
as clinical practice in a variety of disciplines, it covers nearly every conceivable
subject related to mental health. But you could come away from it not knowing
how the diagnostic criteria translate to a real live patient.

I wrote DSM-5 Made Easy to make mental health diagnosis more accessible to
clinicians from all mental health professions. In these pages, you will find
descriptions of every mental disorder, with emphasis on those that occur in
adults. With it, you can learn how to diagnose each one of them. With its careful

11

use, no one today would mistake that young college student’s manic symptoms
for schizophrenia.

WHAT HAVE I DONE TO MAKE DSM-5 EASY?

Quick Guides. Opening each chapter is a summary of the diagnoses addressed
therein—and other disorders that might afflict patients who complain about
similar problems. It also provides a useful index to the material in that chapter.

Introductory material. The section on each disorder starts out with a brief
description designed to orient you to the diagnosis. It includes a discussion of the
major symptoms, perhaps a little historical information, and some of the
demographics—who is likely to have this disorder, and in what circumstances.
Here, I’ve tried to state that which I would want to know myself if I were starting
out afresh as a student.

Essential Features. OK, that’s the name I’ve given them in in DSM-5 Made Easy,
but they’re also known as prototypes. I’ve used them in an effort to make the
DSM-5 criteria more accessible. For years, we working clinicians have known that
when we evaluate a new patient, we don’t grab a list of emotional and behavioral
attributes and start ticking off boxes. Rather, we compare the data we’ve gathered
to the picture we’ve formed of the various mental and behavioral disorders.
When the data fit an image, we have an “aha!” experience and pop that diagnosis
into our list of differential diagnoses. (From long experience and conversations
with countless other experienced clinicians, I can assure you that this is exactly
how it works.)

Very recently, a study of mood and anxiety disorders* has found that clinicians
who make diagnoses by rating their patients against prototypes perform at least as
well as, and sometimes better than, other clinicians who adhere to strict criteria.
That is, it can be shown that prototypes have validity even greater than that of
some DSM diagnostic criteria. Moreover, prototypes are reported to be usable by
clinicians with a relatively modest level of training and experience; you don’t have
to be coming off 20 years of clinical work to have success with prototypes. And
clinicians report that prototypes are less cumbersome and more clinically useful.
(However—and I hasten to underscore this point—the prototypes used in the
studies I have just mentioned were generated from the diagnostic criteria
inherent in the DSM criteria.) The bottom line: Sure, we need criteria, but we can
adapt them so they work better for us.

12

So once you’ve collected the data and read the prototypes, I recommend that
you assign a number to indicate how closely your patient fits the ideal of any
diagnoses you are considering. Here’s the accepted convention: 1 = little or no
match; 2 = some match (the patient has a few features of the disorder); 3 =
moderate match (there are significant, important features of the disorder); 4 =
good match (the patient meets the standard—the diagnosis applies); 5 = excellent
match (a classic case). Obviously, the vignettes I’ve provided will always match at
the 4 or 5 level (if not, why would I use them as illustrative examples?), so I
haven’t bothered to grade them on the 5-point scale. But you should do just that
with each new patient you interview.

Of course, there may be times you’ll want to turn to the official DSM-5
criteria. One is when you’re just starting out, so you can get a picture of the exact
numbers of each type of criteria that officially count the patient as “in.” Another
would be when you are doing clinical research, where you must be able to report
that participants were all selected according to scientifically studied, reproducible
criteria. And even as an experienced clinician, I return to the actual criteria from
time to time. Perhaps it’s just to have in my mind the complete information that
allows me to communicate with other clinicians; sometimes it is related to my
writing. But mostly, whether I am with patients or talking with students, I stick to
the prototype method—just like nearly every other working clinician.

The Fine Print. Most of the diagnostic material included in these sections is what
I call boilerplate. I suppose that sounds pejorative, but each Fine Print section
actually contains one or more important steps in the diagnostic process. Think of
it this way: The prototype is useful for purposes of inclusion, whereas the
boilerplate is useful largely for the also important exclusion of other disorders and
delimitation from normal. The boilerplate verbiage includes several sorts of
stereotyped phrases and warnings, which as an aid to memory I’ve dubbed the
D’s. (I started out by using “Don’t disregard the D’s” or similar phrases, but soon
got tired of all the typing; so, I eventually adopted “the D’s” as shorthand.)

Differential diagnosis. Here I list all the disorders to consider as alternatives
when evaluating symptoms. In most cases, this list starts off with substance use
disorders and general medical disorders, which despite their relative
infrequency you should always place first on the list of disorders competing for
your consideration. Next I put in those conditions that are most treatable, and
hence should be addressed early. Only at the end do I include those that have
a dismal prognosis, or that you can’t do very much to treat. I call this the safety
principle of differential diagnosis.

13

Distress or disability. Most DSM-5 diagnostic criteria sets require that the
patient experience distress or some form of impairment (in work, social
interactions, interpersonal relations, or something else). The purpose is to
ensure that we discriminate people who are patients from those who, while
normal, perhaps have lives with interesting aspects.

As best I can tell, distress receives one definition in all of DSM-5 (Campbell’s Psychiatric Dictionary
doesn’t even list it). The DSM-5 sections on trichotillomania and excoriation (skin-picking) disorder
both describe distress as including negative feelings such as embarrassment and forfeiture of control.
It’s unclear, however, whether the same definition is employed anywhere else, or what might be the
dominant thinking throughout the manual. But for me, some combination of lost pride, shame, and
control works pretty well as a definition. (DSM-IV didn’t define distress anywhere.)

Duration. Many disorders require that symptoms be present for a certain
minimum length of time before they can be diagnosed. Again, this is to ensure
that we don’t go around indiscriminately handing out diagnoses to everyone.
For example, nearly everyone will feel blue or down at one time or another; to
qualify for a diagnosis of a depressive disorder, it has to hang on for at least a
couple of weeks.

Demographics. A few disorders are limited to certain age groups or genders.

Coding Notes. Many of the Essential Features listings conclude with these notes,
which supply additional information about specifiers, subtypes, severity, and
other subjects relevant to the disorder in question.

Here you’ll find information about specifying subtypes and judging severity for
different disorders. I’ve occasionally put in a signpost pointing to a discussion of
principles you can use to determine that a disorder is caused by the use of
substances.

Sidebars. To underscore or augment what you need to know, I have sprinkled
sidebar information throughout the text (such as the one above). Some of these
merely highlight information that will help you make a diagnosis quickly. Some
contain historical information and other sidelights about diagnoses that I’ve
found interesting. Many include editorial asides—my opinions about patients, the
diagnostic process, and clinical matters in general.

Vignettes. I have based this book on that reliable device, the clinical vignette. As
a student, I found that I often had trouble keeping in mind the features of

14

diagnosis (such as it was back then). But once I had evaluated and treated a
patient, I always had a mental image to help me remember important points
about symptoms and differential diagnosis. I hope that the more than 130
patients I have described in DSM-5 Made Easy will do the same for you.

Evaluation. This section summarizes my thinking for every patient I’ve written
about. I explain how the patient fits the diagnostic criteria and why I think other
diagnoses are unlikely. Sometimes I suggest that additional history or medical or
psychological testing should be obtained before a final diagnosis is given. The
conclusions stated here allow you to match your thinking against mine. There are
two ways you can do this. One is by picking out from the vignette the Essential
Features I’ve listed for each diagnosis. But when you want to follow the thinking
of the folks who wrote the actual DSM-5, I’ve also included references (in
parentheses) to the individual criteria. If you disagree with any of my
interpretations, I hope you’ll e-mail me ([email protected]). And for updated
information, visit my website: www.guilford.com/jm.

Final diagnosis. Usually code numbers are assigned in the record room, and we
don’t have to worry too much about them. That’s fortunate, for they are
sometimes less than perfectly logical. But to tell the record room folks how to
proceed, we need to put all the diagnostic material that seems relevant into
verbiage that conforms to the approved format. My final diagnoses not only
explain how I’d code each patient; they also provide models to use in writing up
the diagnoses for your own patients.

Tables. I’ve included a number of tables to try to give you an overall picture of
various topics—the variety of specifiers that apply across different diagnoses, a list
of physical disorders that can produce emotional and behavioral symptoms.
Those that are of principal use in a given chapter I’ve included in that chapter. A
few, which apply more generally throughout the book, you’ll find in the
Appendix.

My writing. Throughout, I’ve tried to use language that is as simple as possible.
My goal has been to make the material sound as though it was written by a
clinician for use with patients, not by a lawyer for use in court. Wherever I’ve
failed, I hope you will e-mail me to let me know. At some point, I’ll try to put it
right, either in a future edition or on my website (or both).

15

STRUCTURE OF DSM-5 MADE EASY

The first 18 chapters* of this book contain descriptions and criteria for the major
mental diagnoses and personality disorders. Chapter 19 comprises information
concerning other terms that you may find useful. Many of these are Z-codes
(ICD-9 calls them V-codes), which are conditions that are not mental disorders
but may require clinical attention anyway. Most noteworthy are the problems
people with no actual mental disorder have in relating to one another.
(Occasionally, you might even list a Z-code/V-code as the reason a patient was
referred for evaluation.) Also described here are codes that indicate medications’
effects, malingering, and the need for more diagnostic information.

Chapter 20 contains a very brief description of diagnostic principles, followed
by some additional case vignettes, which are generally more complicated than
those presented earlier in the book. I’ve annotated these case histories to help you
to review the diagnostic principles and criteria covered previously. Of course, I
could include only a small fraction of all DSM-5 diagnoses in this section.

Throughout the book, I have tried to give you clinically relevant and accessible
information, written in simple, declarative sentences that describe what you need
to know in diagnosing a patient.

QUIRKS

Here are a few comments regarding some of my idiosyncrasies.

Abbreviations. I’ll cop to using some nonstandard abbreviations, especially for
the names of disorders. For example, BPsD (for brief psychotic disorder) isn’t
something you’ll read elsewhere, certainly not in DSM-5. I’ve used it and others
for the sake of shortening things up just a bit, and thus perhaps reducing ever so
slightly the amount of time it takes to read all this stuff. I use these ad hoc
abbreviations just in the sections about specific disorders, so don’t worry about
having to remember them longer than the time you’re reading about these
disorders. Indeed, I can think of two disorders that are sometimes abbreviated
CD and four that are sometimes abbreviated SAD, so always watch for context.

My quest for shortening has also extended to the chapter titles. In the service
of seeming inclusive, DSM-5 has sometimes overcomplicated these names, in my
view. So you’ll find that I’ve occasionally (not always—I’ve got my obsessive–
compulsive disorder under control!) shortened them up a bit for convenience.

16

You shouldn’t have any problem knowing where to turn for sleep disorders
(which DSM-5 calls sleep–wake disorders), mood disorders (bipolar and related
disorders plus depressive disorders), psychotic (schizophrenia spectrum and other
psychotic) disorders, cognitive (neurocognitive) disorders, substance (substance-
related and addictive) disorders, eating (feeding and eating) disorders, and
various other disorders from which I’ve simply dropped and related from the
official titles. Similarly, I’ve sometimes dropped the /medication from
substance/medication-induced [just about anything].

{Curly braces}. I’ve used these in the Essential Features and in some tables to
indicate when there are two mutually exclusive specifier choices, such as {with}
{without} good prognostic features. Again, it just shortens things up a bit.

Severity specifiers. One of the issues with DSM-5 is its use of complicated
severity specifiers that differ from one chapter to another, and sometimes from
one disorder to the next. Some of these are easier to use than others.

For example, for the psychoses, we are offered the Clinician-Rated Dimensions
of Psychosis Symptom Severity (CRDPSS?), which asks us to rate on a 5-point
scale, based on the past 7 days, each of eight symptoms (the five psychosis
symptoms of schizophrenia [p. 58] plus impaired cognition, depression, and
mania); there is no overall score, only the eight individual components, which we
are encouraged to rate again every few days. My biggest complaint about this
scale, apart from its complexity and the time required, is that it gives us no
indication as to overall functioning—only the degree to which the patient
experiences each of the eight symptoms. Helpfully, DSM-5 informs us that we are
allowed to rate the patient “without using this severity specifier,” an offer that
many clinicians will surely rush to accept.

Evaluating functionality. Whatever happened to the Global Assessment of
Functioning (GAF)? In use from DSM-III-R through DSM-IV-TR, the GAF was
a 100-point scale that reflected the patient’s overall occupational, psychological,
and social functioning—but not physical limitations or environmental problems.
The scale specified symptoms and behavioral guidelines to help us determine our
patients’ GAF scores. Perhaps because of the subjectivity inherent in this scale, its
greatest usefulness lay in tracking changes in a patient’s level of functioning across
time. (Another problem: It was a mash-up of severity, disability, suicidality, and
symptoms.)

However, the GAF is now G-O-N-E, eliminated for several reasons (as
described in a 2013 talk by Dr. William Narrow, research director for the DSM-5
Task Force). Dr. Narrow (accurately) pointed out that the GAF mixed concepts

17

(psychosis with suicidal ideas, for example) and that it had problems with
interrater reliability. Furthermore, what’s really wanted is a disability rating that
helps us understand how well a patient can fulfill occupational and social
responsibilities, as well as generally participate in society. For that, the Task Force
recommends the World Health Organization Disability Assessment Schedule,
Version 2.0 (WHODAS 2.0), which was developed for use with clinical as well as
general populations and has been tested worldwide. DSM-5 gives it on page 747;
it can also be accessed online (www.who.int/classifications/icf/whodasii/en/). It is
scored as follows: 1 = none, 2 = mild, 3 = moderate, 4 = severe, and 5 = extreme.
Note that scoring systems for the two measures are reciprocal; a high GAF score
more or less equates with a low WHODAS 2.0 rating.

After quite a bit of experimentation, I decided that the WHODAS 2.0 is so
heavily weighted toward physical abilities that it poorly reflects the qualities
mental health clinicians are interested in. Some of the most severely ill mental
patients received a only a moderate WHODAS 2.0 score; for example, Velma
Dean scored 20 on the GAF but 1.6 on the WHODAS 2.0. In addition,
calculation of the WHODAS 2.0 score rests on the answers given by the patient
(or clinician) to 36 questions—a burden of data collection that many busy
professionals will not be able to carry. And, because these answers cover
conditions over the previous month, the score cannot accurately represent
patients with rapidly evolving mental disorders. The GAF, on the other hand, is a
fairly simple (if subjective) way to estimate severity.

So, after much thought, I’ve decided not to recommend the WHODAS 2.0
after all. (Anyone who is interested in further discussion can write to me; I’ll be
happy to send along a chart that compares the GAF with the WHODAS 2.0 for
every patient mentioned in this book.) Rather, here’s my fix as regards evaluating
function and severity, and it’s the final quirk I’ll mention: Go ahead and use the
GAF. Nothing says that we can’t, and I find it sometimes useful for tracking a
patient’s progress through treatment. It’s quick, easy (OK, it’s also subjective), and
free. You can specify the patient’s current level of functioning, or the highest level
in any past time frame. You’ll find it in the Appendix of this book.

USING THIS BOOK

There are several ways in which you might use DSM-5 Made Easy.

Studying a diagnosis. Of course, you might go about this in several ways, but

18

here’s how I’d do it. Scan the introductory information for some background,
then read the vignette. Next, compare the information in the vignette to the
Essential Features, to assure yourself that you can pick out what’s important
diagnostically. If you want to see how well the vignettes fit the actual DSM-5
criteria, read through the vignette evaluations; there I’ve touched upon each
of the important diagnostic points. In each evaluation section, you’ll also find a
discussion of the differential diagnosis, as well as some other conditions often
found in association with the disorder in question.

Evaluating a patient whose diagnosis you think you know. Read through the
Essential Features, then check the information you have on this patient against
the prototype. Assign a 1–5 score, using the key given above (p. 3). Check
through the D’s to make sure you’ve considered all disqualifying information
and relevant alternative diagnoses. If all’s well and you’ve hit the mark, I’d
also read through the evaluation section of the relevant vignette, just to make
sure you’ve understood the criteria. Then you might want to read the
introductory material for background.

Evaluating a new patient. Follow the sequence given just above, with one
exception: After identifying one of several areas of clinical interest as a
diagnostic possibility—let’s say an anxiety disorder—you might want to start
with the Quick Guide in the relevant chapter. There you will find capsule
statements (too brief even to be …

DIAGNOSTIC AND STATISTICAL
MANUAL OF

MENTAL DISORDERS
F I F T H E D I T I O N

DSM-5TM

American Psychiatric Association

Officers 2012-2013
P residen t D ilip V. J este, M.D.

P resid en t-Elect J effrey A. Lieberm a n , M.D.
Tr ea su rer Da v id F a ssler, M.D.

Secreta ry R cxser Peele, M.D.

Assembly
Spea k er R. Sc o tt B en so n , M.D.

S peaker-Elect M elin da L. Yo u n g , M.D.

Board o f Trustees
Jeffrey A ka ka, M .D.

C aro l A. B ern stein, M.D.
B rL·̂ ̂C ro w ley, M.D.

An ita S. Everett, M.D.
J effrey G eller, M .D., M .P.H .

M ^ c D a v id G ra ff, M.D.
‘ J ^ e&A. G i^ eneVM.D.
Ju d ith F. Ka sh ta n , M.D.
M o lly K. M c Vo y, M .D.
J a m es E. N in in g er, M.D.
Jo h n M. O ldh a m , M .D.

A lan F. Sc h a tzberg , M.D.
A lik s . W id g e, M .D., P h .D.

E r ik R. V an d erlip, M .D .,
M em ber-in-T raining Tr u stee-E lect

DIAGNOSTIC AND STATISTICAL
MANUAL OF

MENTAL DISORDERS7
F I F T H E D I T I O N

DSM-5TM

New School Library

/«44

Amcriccin

O svch iatric

ADivi«ono(AmCT»MlVhijtiKAMod<tk>n

W ashin g ton , DC
Lon d on , E n gland

Copyright © 2013 American Psychiatric Association

DSM and DSM-5 are trademarks of the American Psychiatric Association. Use of these terms
is prohibited without permission of the American Psychiatric Association.

ALL RIGHTS RESERVED. Unless authorized in writing by the APA, no part of this book may
be reproduced or used in a manner inconsistent with the APA’s copyright. This prohibition
apphes to unauthorized uses or reproductions in any form, including electronic applications.

Correspondence regarding copyright permissions should be directed to DSM Permissions,
American Psychiatric Publishing, 1000 Wilson Boulevard, Suite 1825, Arlington, VA 22209­
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ISBN 978-0-89042-554-1 (Hardcover)

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The correct citation for this book is American Psychiatric Association: Diagnostic and Statisti­
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Library of Congress Cataloging-in-Publication Data
Diagnostic and statistical manual of mental disorders : DSM-5. — 5th ed.

p. ; cm.
DSM-5
DSM-V
Includes index.
ISBN 978-0-89042-554-1 (hardcover : alk. paper) — ISBN 978-0-89042-555-8 (pbk. : alk. paper)
I. American Psychiatric Association. II. American Psychiatric Association. DSM-5 Task Force,
m. Title: DSM-5. IV. Title: DSM-V.
[DNLM: 1. Diagnostic and statistical manual of mental disorders. 5th ed. 2. Mental Disorders—
classification. 3. Mental Disorders—diagnosis. WM 15]
RC455.2.C4
616.89Ό75—dc23

2013011061
British Library Cataloguing in Publication Data ^ n
A CIP record is available from the British Library. ^

Text Design—Tammy J. Cordova

Manufacturing—Edwards Brothers Malloy ^

cH

Contents

DSM-5 Classification…………………………………………………………xiii
Preface…………………………………………………………………………….. xli

Section I
DSM-5 Basics

Introduction……………………………………………………………………….. 5

Use of the M anual………………………………………………………………19

Cautionary Statement for Forensic Use of DSM-5………………… 25

Section II
Diagnostic Criteria and Codes

Neurodevelopmental Disorders………………………………………….. 31
Schizophrenia Spectrum and Other Psychotic Disorders……….87
Bipolar and Related Disorders………………………………………….. 123
Depressive Disorders………………………………………………………. 155
Anxiety Disorders………………………………………………………………189
Obsessive-Compulsive and Related Disorders………………….. 235
Trauma- and Stressor-Related Disorders…………………………… 265
Dissociative Disorders…………………………………………………….. 291
Somatic Symptom and Related Disorders…………………………. 309
Feeding and Eating Disorders………………………………………….. 329
Elimination Disorders………………………………………………………. 355
Sleep-Wake Disorders………………………………………………………. 361
Sexual Dysfunctions…………………………………………………………423
Gender Dysphoria…………………………………………………………….451

Disruptive, Impulse-Control, and Conduct Disorders…………..461
Substance-Related and Addictive Disorders……………………… 481
Neurocognitive Disorders…………………………………………………. 591
Personality Disorders………………………………………………………. 645
Paraphilic Disorders………………………………………………………… 685
Other Mental Disorders…………………………………………………… 707

Medication-Induced Movement Disorders
and Other Adverse Effects of M edication……………………….. 709

Other Conditions That May Be a Focus of Clinical Attention .. 715

Section III
Emerging Measures and Models

Assessment Measures…………………………………………………….. 733

Cultural Formulation………………………………………………………… 749

Alternative DSM-5 Model for Personality Disorders…………….761

Conditions for Further Study……………………………………………. 783

Appendix
Highlights of Changes From DSM-IV to DSM -5………………….. 809
Glossary of Technical Term s……………………………………………. 817
Glossary of Cultural Concepts of Distress…………………………. 833
Alphabetical Listing of DSM-5 Diagnoses and Codes

(ICD-9-CM and ICD-10-CM)……………………………………………. 839
Numerical Listing of DSM-5 Diagnoses and Codes

(ICD-9-CM)………………………………………………………………….. 863
Numerical Listing of DSM-5 Diagnoses and Codes

(ICD-10-CM)………………………………………………………………….877
DSM-5 Advisors and Other Contributors…………………………… 897

Index………………………………………………………………………………. 917

DSM-5 Task Force
D a vid J. K u pfer, M.D.

Task Force Chair
D a rrel A. R egier, M .D., M .P.H .

Task Force Vice-Chair
William E. Narrow, M.D.,

Research Director

Dan G. Blazer, M.D., Ph.D., M.P.H.
Jack D. Burke Jr., M.D., M.P.H.
William T. Carpenter Jr., M.D.
F. Xavier Castellanos, M.D.
Wilson M. Compton, M.D., M.P.E.
Joel E. Dimsdale, M.D.
Javier I. Escobar, M.D., M.Sc.
Jan A. Fawcett, M.D.
Bridget F. Grant, Ph.D., Ph.D. (2009-)
Steven E. Hyman, M.D. (2007-2012)
Dilip V. Jeste, M.D. (2007-2011)
Helena C. Kraemer, Ph.D.
Daniel T. Mamah, M.D., M.P.E.
James P. McNulty, A.B., Sc.B.
Howard B. Moss, M.D. (2007-2009)

Susan K. Schultz, M.D., Text Editor
Emily A. Kuhl, Ph.D., APA Text Editor

Charles P. O’Brien, M.D., Ph.D.
Roger Peele, M.D.
Katharine A. Phillips, M.D.
Daniel S. Pine, M.D.
Charles F. Reynolds III, M.D.
Maritza Rubio-Stipec, Sc.D.
David Shaffer, M.D.
Andrew E. Skodol II, M.D.
Susan E. Swedo, M.D.
B. Timothy Walsh, M.D.
Philip Wang, M.D., Dr.P.H. (2007-2012)
William M. Womack, M.D.
Kimberly A. Yonkers, M.D.
Kenneth J. Zucker, Ph.D.
Norman Sartorius, M.D., Ph.D., Consultant

APA Division of Research Staff on DSIVI-5
Darrel A. Regier, M.D., M.P.H.,

Director, Division o f Research
William E. Narrow, M.D., M.P.H.,

Associate Director
Emily A. Kuhl, Ph.D., Senior Science

Writer; Staff Text Editor
Diana E. Clarke, Ph.D., M.Sc., Research

Statistician

Lisa H. Greiner, M.S.S.A., DSM-5 Field
Trials Project Manager

Eve K. Moscicki, Sc.D., M.P.H.,
Director, Practice Research Network

S. Janet Kuramoto, Ph.D. M.H.S.,
Senior Scientific Research Associate,
Practice Research Network

Amy Porfiri, M.B.A.
Director o f Finance and Administration

Jennifer J. Shupinka, Assistant Director,
DSM Operations

Seung-Hee Hong, DSM Senior Research
Associate

Anne R. Hiller, DSM Research Associate
Alison S. Beale, DSM Research Associate
Spencer R. Case, DSM Research Associate

Joyce C. West, Ph.D., M.P.P.,
Health Policy Research Director, Practice
Research Network

Farifteh F. Duffy, Ph.D.,
Quality Care Research Director, Practice
Research Network

Lisa M. Countis, Field Operations
Manager, Practice Research Network

Christopher M. Reynolds,
Executive Assistant

APA Office of the IVIedlcal Director
Jam es H. S c u l l y Jr ., M.D.

Medical Director and CEO

Editorial and Coding Consultants
Michael B. First, M.D. Maria N. Ward, M.Ed., RHIT, CCS-P

DSM-5 Work Groups
ADHD and Disruptive Behavior Disorders

D a v id Sha ffer, M.D.
Chair

F. Xa v ier C a stella n o s, M.D.
Co-Chair

Paul J. Frick, Ph.D., Text Coordinator Luis Augusto Rohde, M.D., Sc.D.
Glorisa Canino, Ph.D. Rosemary Tannock, Ph.D.
Terrie E. Moffitt, Ph.D. Eric A. Taylor, M.B.
Joel T. Nigg, Ph.D. Richard Todd, Ph.D., M.D. (d. 2008)

Anxiety, Obsessive-Compulsive Spectrum, Posttraumatic,
and Dissociative Disorders

K a th a rin e A. Ph illips, M.D.
Chair

Michelle G. Craske, Ph.D., Text Scott L. Rauch, M.D.
Coordinator H. Blair Simpson, M.D., Ph.D.

J. Gavin Andrews, M.D. David Spiegel, M.D.
Susan M. Bögels, Ph.D. Dan J. Stein, M.D., Ph.D.
Matthew J. Friedman, M.D., Ph.D. Murray B. Stein, M.D.
Eric Hollander, M.D. (2007-2009) Robert J. Ursano, M.D.
Roberto Lewis-Fernandez, M.D., M.T.S. Hans-Ulrich Wittchen, Ph.D.
Robert S. Pynoos, M.D., M.P.H.

Childhood and Adolescent Disorders
D an iel S. Pin e, M.D.

Chair
Ronald E. Dahl, M.D. James F. Leckman, M.D.
E. Jane Costello, Ph.D. (2007-2009) Ellen Leibenluft, M.D.
Regina Smith James, M.D. Judith H. L. Rapoport, M.D.
Rachel G. Klein, Ph.D. Charles H. Zeanah, M.D.

Eating Disorders
B. T im o th y W alsh, M.D.

Chair
Stephen A. Wonderlich, Ph.D., Richard E. Kreipe, M.D.

Text Coordinator Marsha D. Marcus, Ph.D.
Evelyn Attia, M.D. James E. Mitchell, M.D.
Anne E. Becker, M.D., Ph.D., Sc.M. Ruth H. Striegel-Moore, Ph.D.
Rachel Bryant-Waugh, M.D. G. Terence Wilson, Ph.D.
Hans W. Hoek, M.D., Ph.D. Barbara E. Wolfe, Ph.D. A.P.R.N.

Mood Disorders
J a n a . F a w c e t t , M.D.

Chair
Ellen Frank, Ph.D., Text Coordinator
Jules Angst, M.D. (2007-2008)
William H. Coryell, M.D.
Lori L. Davis, M.D.
Raymond J. DePaulo, M.D.
Sir David Goldberg, M.D.
James S. Jackson, Ph.D.

Kenneth S. Kendler, M.D., Ph.D.
(2007-2010)

Mario Maj, M.D., Ph.D.
Husseini K. Manji, M.D. (2007-2008)
Michael R. Phillips, M.D.
Trisha Suppes, M.D., Ph.D.
Carlos A. Zarate, M.D.

Neurocognitive Disorders
D ilip V. Je s te , M .D. (2007-2011)

Chair Emeritus
D an G. Bla zer, M .D., P h .D., M.P.H.

Chair
R o n a l d C. P e te r s e n , M .D., Ph.D.

Co-Chair
Mary Ganguli, M.D., M.P.H.,

Text Coordinator
Deborah Blacker, M.D., Sc.D.
Warachal Faison, M.D. (2007-2008)

Igor Grant, M.D.
Eric J. Lenze, M.D.
Jane S. Paulsen, Ph.D.
Perminder S. Sachdev, M.D., Ph.D.

Neurodevelopmental Disorders
Su sa n E. Sw ed o , M.D.

Chair
Gillian Baird, M.A., M.B., B.Chir.,

Text Coordinator
Edwin H. Cook Jr., M.D.
Francesca G. Happé, Ph.D.
James C. Harris, M.D.
Walter E. Kaufmann, M.D.
Bryan H. King, M.D.

Catherine E. Lord, Ph.D.
Joseph Piven, M.D.
Sally J. Rogers, Ph.D.
Sarah J. Spence, M.D., Ph.D.
Fred Volkmar, M.D. (2007-2009)
Amy M. Wetherby, Ph.D.
Harry H. Wright, M.D.

Personality and Personality Disorders^
A n d rew E. Sk o d o l, M.D.

Chair
Joh n M. O l d h a m , M.D.

Co-Chair
Robert F. Krueger, Ph.D., Text

Coordinator
Renato D. Alarcon, M.D., M.P.H.
Carl C. Bell, M.D.
Donna S. Bender, Ph.D.

Lee Anna Clark, Ph.D.
W. John Livesley, M.D., Ph.D. (2007-2012)
Leslie C. Morey, Ph.D.
Larry J. Siever, M.D.
Roel Verheul, Ph.D. (2008-2012)

̂The members of the Personality and Personality Disorders Work Group are responsible for the
alternative DSM-5 model for personality disorders that is included in Section III. The Section II
personality disorders criteria and text (with updating of the text) are retained from DSM-IV-TR.

Psychotic Disorders
W illiam T. C arpen ter J r ., M.D.

Chair
Deanna M. Barch, Ph.D., Text Dolores Malaspina, M.D., M.S.P.H.

Coordinator Michael J. Owen, M.D., Ph.D.
Juan R. Bustillo, M.D. Susan K. Schultz, M.D.
Wolfgang Gaebel, M.D. Rajiv Tandon, M.D.
Raquel E. Gur, M.D., Ph.D. Ming T. Tsuang, M.D., Ph.D.
Stephan H. Heckers, M.D. Jim van Os, M.D.

Sexual and Gender Identity Disorders
K en n eth J. Zu c k er, Ph .D.

Chair
Lori Brotto, Ph.D., Text Coordinator Martin P. Kafka, M.D.
Irving M. Binik, Ph.D. Richard B. Krueger, M.D.
Ray M. Blanchard, Ph.D. Niklas Langström, M.D., Ph.D.
Peggy T. Cohen-Kettenis, Ph.D. Heino F.L. Meyer-Bahlburg, Dr. rer. nat.
Jack Drescher, M.D. Friedemann Pfäfflin, M.D.
Cynthia A. Graham, Ph.D. Robert Taylor Segraves, M.D., Ph.D.

Sleep-Wake Disorders
C h a rles F. Reyn o ld s III, M.D.

Chair
Ruth M. O’Hara, Ph.D., Text Coordinator Kathy P. Parker, Ph.D., R.N.
Charles M. Morin, Ph.D. Susan Redline, M.D., M.P.H.
Allan I. Pack, Ph.D. Dieter Riemann, Ph.D.

Somatic Symptom Disorders
J o el E. D im sd a le, M.D.

Chair
James L. Levenson, M.D., Text Michael R. Irwin, M.D.

Coordinator Francis J. Keefe, Ph.D. (2007-2011)
Arthur J. Barsky III, M.D. Sing Lee, M.D.
Francis Creed, M.D. Michael Sharpe, M.D.
Nancy Frasure-Smith, Ph.D. (2007-2011) Lawson R. Wulsin, M.D.

Substance-Related Disorders
C h a rles P. O ‘B rien, M .D., Ph .D.

Chair
Th o m a s J. C ro w ley, M.D.

Co-Chair
Wilson M. Compton, M.D., M.P.E., Thomas R. Kosten, M.D. (2007-2008)

Text Coordinator Walter Ling, M.D.
Marc Auriacombe, M.D. Spero M. Manson, Ph.D. (2007-2008)
Guilherme L. G. Borges, M.D., Dr .Sc. A. Thomas McLellan, Ph.D. (2007-2008)
Kathleen K. Bucholz, Ph.D. Nancy M. Petry, Ph.D.
Alan J. Budney, Ph.D. Marc A. Schuckit, M.D.
Bridget F. Grant, Ph.D., Ph.D. Wim van den Brink, M.D., Ph.D.
Deborah S. Hasin, Ph.D. (2007-2008)

DSM-5 Study Groups
Diagnostic Spectra and DSM/ICD Harmonization

Steven E. H ym a n , M.D.
Chair (2007-2012)

William T. Carpenter Jr., M.D. William E. Narrow, M.D., M.P.H.
Wilson M. Compton, M.D., M.P.E. Charles P. O’Brien, M.D., Ph.D.
Jan A. Fawcett, M.D. John M. Oldham, M.D.
Helena C. Kraemer, Ph.D. Katharine A. Phillips, M.D.
David J. Kupfer, M.D. Darrel A. Regier, M.D., M.P.H.

Lifespan Developmental Approaches
E ric J. L en ze, M.D.

Chair
Susa n K. Sc h u ltz, M.D.

Chair Emeritus
Dan iel S. P in e, M.D.

Chair Emeritus
Dan G. Blazer, M.D., Ph.D., M.P.H.
F. Xavier Castellanos, M.D.
Wilson M. Compton, M.D., M.P.E.

Daniel T. Mamah, M.D., M.P.E.
Andrew E. Skodol II, M.D.
Susan E. Swedo, M.D.

Gender and Cross-Cultural Issues
K im berly A. Yo n kers, M.D.

Chair
R oberto L ew is-Fern â n d ez, M .D., M .T.S.

Co-Chair, Cross-Cultural Issues
Renato D. Alarcon, M.D., M.P.H.
Diana E. Clarke, Ph.D., M.Sc.
Javier I. Escobar, M.D., M.Sc.
Ellen Frank, Ph.D.
James S. Jackson, Ph.D.
Spiro M. Manson, Ph.D. (2007-2008)
James P. McNulty, A.B., Sc.B.

Leslie C. Morey, Ph.D.
William E. Narrow, M.D., M.P.H.
Roger Peele, M.D.
Philip Wang, M.D., Dr.P.H. (2007-2012)
William M. Womack, M.D.
Kermeth J. Zucker, Ph.D.

Psychiatric/General Medical Interface
L a w so n R. W u lsin, M.D.

Chair
Ronald E. Dahl, M.D.
Joel E. Dimsdale, M.D.
Javier I. Escobar, M.D., M.Sc.
Dilip V. Jeste, M.D. (2007-2011)
Walter E. Kaufmann, M.D.

Richard E. Kreipe, M.D.
Ronald C. Petersen, Ph.D., M.D.
Charles F. Reynolds III, M.D.
Robert Taylor Segraves, M.D., Ph.D.
B. Timothy Walsh, M.D.

Impairment and Disability
J a n e S. P a u ls e n , Ph.D .

Chair
J. Gavin Andrews, M.D.
Glorisa Canino, Ph.D.
Lee Anna Clark, Ph.D.
Diana E. Clarke, Ph.D., M.Sc.
Michelle G. Craske, Ph.D.

Hans W. Hoek, M.D., Ph.D.
Helena C. Kraemer, Ph.D.
William E. Narrow, M.D., M.P.H.
David Shaffer, M.D.

Diagnostic Assessment Instruments
J a ck D. Burk e Jr ., M .D., M .P.H.

Chair
Lee Anna Clark, Ph.D.
Diana E. Clarke, Ph.D., M.Sc.
Bridget F. Grant, Ph.D., Ph.D.

Helena C. Kraemer, Ph.D.
William E. Narrow, M.D., M.P.H.
David Shaffer, M.D.

DSM-5 Research Group
W illiam E. N a rro w , M .D., M.P.H.

Chair
Jack D. Burke Jr., M.D., M.P.H.
Diana E. Clarke, Ph.D., M.Sc.
Helena C. Kraemer, Ph.D.

David J. Kupfer, M.D.
Darrel A. Regier, M.D., M.P.H.
David Shaffer, M.D.

Course Specifiers and Glossary
W o lfg a n g G a ebel, M.D.

Chair
Ellen Frank, Ph.D.
Charles P. O’Brien, M.D., Ph.D.
Norman Sartorius, M.D., Ph.D.,

Consultant
Susan K. Schultz, M.D.

Dan J. Stein, M.D., Ph.D.
Eric A. Taylor, M.B.
David J. Kupfer, M.D.
Darrel A. Regier, M.D., M.P.H.

Before each disorder name, ICD-9-CM codes are provided, followed by ICD-IO-CM codes
in parentheses. Blank lines indicate that either the ICD-9-CM or the ICD-IO-CM code is not
applicable. For some disorders, the code can be indicated only according to the subtype or
specifier.

ICD-9-CM codes are to be used for coding purposes in the United States through Sep­
tember 30,2014. ICD-IO-CM codes are to be used starting October 1,2014.

Following chapter titles and disorder names, page numbers for the corresponding text
or criteria are included in parentheses.

Note for all mental disorders due to another medical condition: Indicate the name of
the other medical condition in the name of the mental disorder due to [the medical condi­
tion]. The code and name for the other medical condition should be listed first immedi­
ately before the mental disorder due to the medical condition.

Neurodevelopm ental Disorders (31)

Intellectual Disabilities (33)
319 (___.__) Intellectual Disability (Intellectual Developmental Disorder) (33)

Specify current severity;
(F70) Mild
(F71) Moderate
(F72) Severe
(F73) Profound

315.8 (F88) Global Developmental Delay (41)

319 (F79) Unspecified Intellectual Disability (Intellectual Developmental
Disorder) (41)

Communication Disorders (41)
315.39 (F80.9) Language Disorder (42)

315.39 (F80.0) Speech Sound Disorder (44)

315.35 (F80.81) Childhood-Onset Fluency Disorder (Stuttering) (45)
Note: Later-onset cases are diagnosed as 307.0 (F98.5) adult-onset fluency

disorder.
315.39 (F80.89) Social (Pragmatic) Communication Disorder (47)

307.9 (F80.9) Unspecified Communication Disorder (49)

Autism Spectrum Disorder (50)
299.00 (F84.0) Autism Spectrum Disorder (50)

Specify if: Associated with a known medical or genetic condition or envi­
ronmental factor; Associated with another neurodevelopmental, men­
tal, or behavioral disorder

Specify current severity for Criterion A and Criterion B: Requiring very
substantial support. Requiring substantial support. Requiring support

Specify if: With or without accompanying intellectual impairment. With
or without accompanying language impairment. With catatonia (use
additional code 293.89 [F06.1])

Attention-Deficit/Hyperactivity Disorder (59)
___.__ (__ .__) Attention-Deficit/Hyperactivity Disorder (59)

Specify whether:
314.01 (F90.2) Combined presentation
314.00 (F90.0) Predominantly inattentive presentation
314.01 (F90.1) Predominantly hyperactive/impulsive presentation

Specify if: In partial remission
Specify current severity: Mild, Moderate, Severe

314.01 (F90.8) Other Specified Attention-Deficit/Hyperactivity Disorder (65)

314.01 (F90.9) Unspecified Attention-Deficit/Hyperactivity Disorder (66)

Specific Learning Disorder (66)
___.__ (___.__) Specific Learning Disorder (66)

Specify if:
315.00 (F81.0) With impairment in reading {specify if with word reading

accuracy, reading rate or fluency, reading comprehension)
315.2 (F81.81 ) With impairment in written expression {specify if with spelling

accuracy, grammar and punctuation accuracy, clarity or
organization of written expression)

315.1 (F81.2) With impairment in mathematics {specify if with number sense,
memorization of arithmetic facts, accurate or fluent
calculation, accurate math reasoning)

Specify current severity: Mild, Moderate, Severe

Motor Disorders (74)
315.4 (F82) Developmental Coordination Disorder (74)

307.3 (F98.4) Stereotypic Movement Disorder (77)
Specify if: With self-injurious behavior. Without self-injurious behavior
Specify if: Associated with a known medical or genetic condition, neuro­

developmental disorder, or environmental factor
Specify current severity: Mild, Moderate, Severe

Tic Disorders
307.23 (F95.2) Tourette’s Disorder (81)

307.22 (F95.1) Persistent (Chronic) Motor or Vocal Tic Disorder (81)
Specify if: With motor tics only. With vocal tics only

307.21 (F95.0) Provisional Tic Disorder (81)

307.20 (F95.8), Other Specified Tic Disorder (85)

307.20 (F95.9) Urispecified Tic Disorder (85)

Other Neurodevelopmental Disorders (86)
315.8 (FSB) Other Specified Neurodevelopmental Disorder (86)

315.9 (F89) Unspecified Neurodevelopmental Disorder (86)

Schizophrenia Spectrum
and Other Psychotic Disorders (87)

The following specifiers apply to Schizophrenia Spectrum and Other Psychotic Disorders
where indicated:
^Specify if: The following course specifiers are only to be used after a 1-year duration of the dis­

order: First episode, currently in acute episode; First episode, currently in partial remission;
First episode, currently in full remission; Multiple episodes, currently in acute episode; Mul­
tiple episodes, currently in partial remission; Multiple episodes, currently in full remission;
Continuous; Unspecified

^Specify if: With catatonia (use additional code 293.89 [F06.1])
^Specify current severity of delusions, hallucinations, disorganized speech, abnormal psycho­

motor behavior, negative symptoms, impaired cognition, depression, and mania symptoms

301.22 (F21)

297.1 (F22)

298.8 (F23)

295.40 (F20.81)

295.90 (F20.9)

295.70 (F25.0)
295.70 (F25.1)

293.81 (F06.2)
293.82 (F06.0)

Schizotypal (Personality) Disorder (90)

Delusional Disorder^’ ̂ (90)
Specify whether: Erotomanie type. Grandiose type. Jealous type. Persecu­

tory type. Somatic type. Mixed type. Unspecified type
Specify if: With bizarre content
Brief Psychotic Disorder^’ ̂ (94)
Specify if: With marked stressor(s). Without marked stressor(s). With

postpartum onset
Schizophreniform Disorder^’ ̂ (96)
Specify if: With good prognostic features. Without good prognostic fea­

tures
Schizophrenia^’ ̂ (99)

Schizoaffective Disorder^’ ̂ (105)
Specify whether:

Bipolar type
Depressive type

Substance/Medication-Induced Psychotic Disorder^ (110)
Note: See the criteria set and corresponding recording procedures for

substance-specific codes and ICD-9-CM and ICD-IO-CM coding.
Specify if: With onset during intoxication. With onset during withdrawal

Psychotic Disorder Due to Another Medical Condition^ (115)
Specify whether:

With delusions
With hallucinations

293.89 (F06.1) Catatonia Associated With Another Mental Disorder (Catatonia
Specifier) (119)

293.89 (F06.1) Catatonic Disorder Due to Another Medical Condition (120)

293.89 (F06.1) Unspecified Catatonia (121)
Note: Code first 781.99 (R29.818) other symptoms involving nervous and

musculoskeletal systems.
298.8 (F28) Other Specified Schizophrenia Spectrum and Other Psychotic

Disorder (122)

298.9 (F29) Unspecified Schizophrenia Spectrum and Other Psychotic
Disorder (122)

Bipolar and Related Disorders (123)
The following specifiers apply to Bipolar and Related Disorders where indicated:

Ŝpecify: With anxious distress (specify current severity: mild, moderate, moderate-severe, severe);
With mixed features; With rapid cycling; With melancholic features; With atypical features;
With mood-congruent psychotic features; With mood-incongruent psychotic features; With
catatonia (use additional code 293.89 [F06.1]); With péripartum onset; With seasonal pattem

296.41
296.42
296.43
296.44
296.45
296.46
296.40
296.40
296.45
296.46
296.40

296.51
296.52
296.53
296.54
296.55
296.56
296.50
296.7

(F31.11)
(F31.12)
(F31.13)
(F31.2)
(F31.73)
(F31.74)
(F31.9)
(F31.0)
(F31.73)
(F31.74)
(F31.9)

(F31.31)
(F31.32)
(F31.4)
(F31.5)
(F31.75)
(F31.76)
(F31.9)
(F31.9)

296.89 (F31.81)

Bipolar I Disorder® (123)
Current or most recent episode manic

Mild
Moderate
Severe
With psychotic features
In partial remission
In full remission
Unspecified

Current or most recent episode hypomanie
In partial remission
In kill remission
Unspecified

Current or most recent episode depressed
Mild
Moderate
Severe
With psychotic features
In partial remission
In full remission
Unspecified

Current or most recent episode unspecified

Bipolar II Disorder® (132)
Specify current or most recent episode: Hypomanie, Depressed
Specify course if full criteria for a mood episode are not currently met: In

partial remission. In full remission
Specify severity if full criteria for a mood episode are not currently met:

Mild, Moderate, Severe

301.13 (F34.0)
y

293.83 (__ ._ )

(F06.33)
(F06.33)
(F06.34)

296.89 (F31.89)

296.80 (F31.9)

Cyclothymic Disorder (139)
Specify if: With anxious distress

Substance/Medication-Induced Bipolar and Related Disorder (142)
Note: See the criteria set and corresponding recording procedures for

substance-specific codes and ICD-9-CM and ICD-IO-CM coding.
Specify if: With onset during intoxication. With onset during withdrawal

Bipolar and Related Disorder Due to Another Medical Condition
(145)

Specify if:
With manic features
With manic- or hypomanic-like episode
With mixed features

Other Specified Bipolar and Related Disorder (148)

Unspecified Bipolar and Related Disorder (149)

Depressive Disorders (155)
The following specifiers apply to Depressive Disorders where indicated:
^Specify: With anxious distress (specify current severity: mild, moderate, moderate-severe,

severe); With mixed features; With melancholic features; With atypical features; With mood-
congruent psychotic features; With mood-incongruent psychotic features; With catatonia
(use additional code 293.89 [F06.1]); With péripartum onset; With seasonal pattern

296.99 (F34.8) Disruptive Mood Dysregulation Disorder (156)

. ( _ ■ ) Major Depressive Disorder® (160)

. ( _ . ) Single episode
296.21 (F32.0) Mild
296.22 (F32.1) Moderate
296.23 (F32.2) Severe
296.24 (F32.3) With psychotic features
296.25 (F32.4) In partial remission
296.26 (F32.5) In full remission
296.20 (F32.9) Unspecified

. ( _ · ) Recurrent episode
296.31 (F33.0) Mild
296.32 (F33.1) Moderate
296.33 (F33.2) Severe
296.34 (F33.3) With psychotic features
296.35 (F33.41) In partial remission
296.36 (F33.42) In full remission
296.30 (F33.9) Unspecified
300.4 (F34.1) Persistent Depressive Disorder (Dysthymia)® (168)

Specify if: In partial remission. In full remission
Specify if: Early onset. Late onset
Specify if: With pure dysthymic syndrome; With persistent major depres­

sive episode; With intermittent major depressive episodes, with current

625.4 (N94.3)

(_ _ ■ _ )

293.83 (__ ._ )

(F06.31)
(F06.32)
(F06.34)

311 (F32.8)

311 (F32.9)

episode; With intermittent major depressive episodes, without current
episode

Specify current severity: Mild, Moderate, Severe
Premenstrual Dysphoric Disorder (171)

Substance/Medication-Induced Depressive Disorder (175)
Note: See the criteria set and corresponding recording procedures for

substance-specific codes and ICD-9-CM and ICD-IO-CM coding.
Specify if: With onset during intoxication. With onset during withdrawal

Depressive Disorder Due to Another Medical Condition (180)
Specify if:

With depressive features
With major depressive-like episode
With mixed features

Other Specified Depressive Disorder (183)

Unspecified Depressive Disorder (184)

Anxiety Disorders (189)
309.21 (F93.0)

312.23 (F94.0)

300.29 (__ ._ )

(F40.218)
(F40.228)
( _ · _ )
(F40.230)
(F40.231)
(F40.232)
(F40.233)
(F40.248)
(F40.298)

300.23 (F40.10)

300.01 (F41.0)

300.22 (F40.00)

300.02 (F41.1)

Separation Anxiety Disorder (190)

Selective Mutism (195)

Specific Phobia (197)
Specify if:

Animal
Natural environment
Blood-injection-injury

Fear of blood
Fear of injections and transfusions
Fear of other medical care
Fear of injury

Situational
Other

Social Anxiety Disorder (Social Phobia) (202)
Specify if: Performance only
Panic Disorder (208)

Panic Attack Specifier (214)

Agoraphobia (217)

Generalized Anxiety Disorder (222)

Substance/Medication-Induced Anxiety Disorder (226)
Note: See the criteria set and corresponding recording procedures for

substance-specific codes and ICD-9-CM and ICD-IO-CM coding.
Specify if: With onset during intoxication. With onset during withdrawal.

With onset after medication use

293.84 (F06.4) Anxiety Disorder Due to Another Medical Condition (230)

300.09 (F41.8) Other Specified Anxiety Disorder (233)

300.00 (F41.9) Unspecified Anxiety Disorder (233)

Obsessive-Compulsive and Related Disorders (235)
The following specifier applies to Obsessive-Compulsive and Related Disorders where indicated:
^Specify if: With good or fair insight. With poor insight. With absent insight/delusional beliefs

300.3 (F42)

300.7 (F45.22)

300.3 (F42)

312.39 (F63.2)

698.4 (L98.1)

(_._J

294.8 (F06.8)

300.3 (F42)

300.3 (F42)

Obsessive-Compulsive Disorder^ (237)
Specify if: Tic-related
Body Dysmorphic Disorder^ (242)
Specify if: With muscle dysmorphia
Hoarding Disorder^ (247)
Specify if: With excessive acquisition
Trichotillomania (Hair-Pulling …

How to Write a Diagnosis According to the DSM-5

An Aid for MSW Students

As you write a diagnosis, keep in mind that “[there] are specific recording protocols for
these diagnostic codes…to insure consistent, international recording” (American
Psychiatric Association, 2013, p. 23).

Writing a Diagnosis
A diagnosis is written as a simple list in order of priority to the current treatment needs.

F33.1 Major depressive disorder, moderate, recurrent, with seasonal pattern
F41.1 Generalized anxiety disorder
Z60.3 Acculturation difficulty

Each diagnosis needs an ICD code that is written before the name of the diagnosis.
The older (DSM-IV-TR) names of some disorders can sometimes be found after the
current name. However, to avoid confusion, only use the current name for the illness in
a diagnosis.

ICD Codes

The DSM-5 includes codes for the International Classification of Diseases. Both ICD-9
and ICD-10 are included in the DSM-5. Always ignore the ICD-9 codes and use only
the ICD-10-CM codes in diagnosis.

The ICD-10-CM codes are listed inside the parentheses in the screen shot below.

HOW TO CODE

For mental health conditions, codes always start with a letter (usually F), followed by 2–
6 digits. A code is not valid unless it has been coded to the full number of digits
required. A code with only the first three digits is used only if that condition is not further
subdivided within the DSM-5.

For example, for schizophrenia, there are no additional characters in spaces 4, 5, 6, and
7.

F20.9 Schizophrenia

In other cases, numbers must be added in the 4th, 5th, or 6th spaces to individualize a
condition. Spaces 4–6 provide greater detail of causes, location details, and severity.
For example, here are two codes for mania:

F30.10 Manic episode without psychotic symptoms, unspecified

F30.11 Manic episode without psychotic symptoms, mild 


Many disorders have more than one ICD code when there are common, clearly
identified subtypes to the illness. The diagnostic criteria box always tells you if a
code must be subdivided.

If you do not see a code at the top of the diagnostic criteria box, look for the correct
codes at the bottom of the box. Often the box prompts for further individualization by
saying “Specify if” or “Specify whether.” You may also be asked to set a severity level.

The wording “specify whether” tells you that the subtypes that follow are mutually
exclusive.

For example, here are two subtypes for schizoaffective disorder:

F25.0 Schizoaffective disorder, bipolar type
F25.1 Schizoaffective disorder, depressive type

Always check for coding notes for further directions. For example, in addition to our
subtypes for schizoaffective disorder, if catatonia is present, an additional code is found
in the coding note.

Now our diagnosis looks like this:

F25.0 Schizoaffective disorder, bipolar type
F06.1 Catatonia (associated with another mental disorder)

After the subtype for schizoaffective disorder is identified, the diagnostic box requires
even more individualization: “Specify if” is followed by “Specify current severity.”
These terms prompt the clinician to further detail the course of the illness and the way to
measure the severity of a presentation.

F25.0 Schizoaffective disorder, bipolar type, multiple episodes, currently in
acute episode, symptom severity
F06.1 Catatonia (associated with another mental disorder)

Some disorders such as the substance/medication-induced disorders have more
complex codes for their subtypes. When this happens, there is always a table and a
coding note found at the bottom of the diagnostic criteria box.

Be aware that some diagnoses use the same code because the ICD has limitations that
are already being updated for ICD-11. Always check the Centers for Medicare and

Medicaid Services (CMS) and the National Center for Health Statistics for updated
coding on those disorders that share a code.

HOW TO LIST MULTIPLE CODES

Formal DSM-5 diagnosis combines into one list all relevant mental disorders, including
personality disorders, disabilities, and other relevant medical diagnoses. The DSM-5
also expands the psychosocial stressors that a patient might be experiencing. These
are now called “other conditions that are a focus of treatment,” and most of them
begin with the letter “Z.” These conditions, which are critical to psychosocial
treatment (formerly known as the V codes), are found on p. 715 in the manual.

In a diagnostic list, always place the principal diagnosis first (the reason for the visit,
if in an outpatient setting). Other mental health co-morbid diagnoses follow in order of
priority to the treatment or focus of attention.

1. RULE A: In this diagnostic list, a mental disorder was the reason for the visit, with
the client experiencing an additional medical condition unrelated to the mental
disorder diagnosis. Other psychosocial factors relevant to the service are listed
after mental health conditions and physical conditions:

F40.00 Agoraphobia
K7030 Alcoholic cirrhosis of liver without ascites (by patient report)
Z60.3 Acculturation difficulty
Z72.0 Tobacco use disorder, mild (nicotine use)

The order of priority above is (a) principal mental health diagnosis, (b) medical
factors, and (c) psychosocial needs.

2. RULE B: If the client above has a clinical diagnosis of a mental health problem as

the principal diagnosis (all F codes), with the presence of a second, additional
mental disorder but without the medical problem of cirrhosis, the diagnosis looks
like this:

F40.00 Agoraphobia
F50.01 Anorexia nervosa, restricting subtype
Z60.3 Acculturation difficulty.
Z72.0 Tobacco use disorder, mild (nicotine use)

3. RULE C: An exception to rules A and B occurs only when the “other medical
condition” is thought to be causing the mental disorder. In such cases, the
medical condition should be listed first. Here, damage to the liver is also causing
a neurocognitive disorder.

K7030 Alcoholic cirrhosis of liver without ascites
F10.988 Mild neurocognitive disorder, without alcohol use

Z60.3 Acculturation difficulty
Z72.0 Tobacco use disorder, mild (nicotine use)

OTHER CONVENTIONS

In diagnosis, a clinician must first rule out if the condition is being caused by a physical
illness, then if it is caused by a substance use problem, and only then are mental
disorders investigated.

A diagnosis should only be provided once a comprehensive assessment has been
completed. The DSM-5 has online assessment measures to help in diagnosis.

In older diagnostics, clinicians used “diagnosis deferred” (799.9 in ICD-9) when they
were not ready to assign a diagnosis. There is no analogous code in the ICD-10;
instead, a clinician should use “provisional” or “other specified disorder,” when
appropriate.

A provisional diagnosis is preferred for mental health conditions, if the reason for
delaying diagnosis is that sufficient criteria to meet diagnostic category is not
documentable because of limited assessment. The APA (2013) tells clinicians to use a
provisional diagnosis “when you have a strong ‘presumption’ that the full criteria will
ultimately be met for a disorder but not enough information is available to make a firm
diagnosis” (p. 23). The word provisional simply follows the full diagnostic label:

F40.00 Agoraphobia, provisional

When symptoms are present but do not meet all the criteria needed for a diagnosis,
such as when symptoms are mixed or below the diagnostic threshold but are causing
significant distress, most chapters in the DSM-5 have an “Other Specified Disorder”
category. If used, the clinician then specifies the presentation according to specifiers
provided in the diagnostic box. For example, there are several options for F28 Other
Specified Schizophrenia Spectrum and Other Psychotic Disorder, one of example of
which is shown below:

F28 Other specified schizophrenia spectrum disorder, persistent
auditory hallucinations

While each chapter in the DSM-5 has an “UNSPECIFIED” code, clinicians are asked
not to use this in routine treatment situations. Insurance carriers have variable rules
about this label. The CMS actually designed the term for situations in which there is
insufficient information to make a diagnosis—for example, in settings like emergency
rooms. If you are using “UNSPECIFIED,” be prepared for many insurance carriers to
deny services and payments on the basis that there is no “medical necessity” present.

While all social workers need to know how to read and interpret diagnoses, state laws
determine if you can provide a direct diagnosis yourself. In most states, Licensed
Clinical Social Workers do assess and diagnose. Please look up your state laws.

References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental

disorders (5th ed.). Arlington, VA: Author.

American Psychiatric Association. (2018). DSM–5 frequently asked questions.

Retrieved from https://www.psychiatry.org/psychiatrists/practice/dsm/feedback-
and-questions/frequently-asked-questions

Centers for Disease Control and Prevention. (2017a). ICD-10-CM official guidelines for

coding and reporting: FY 2017 (October 1, 2016–September 30, 2017).
Retrieved from http://www.cdc.gov/nchs/data/icd/10cmguidelines_2017_final.pdf

Centers for Disease Control and Prevention. (2017b). International classification of

diseases, tenth revision, clinical modification (ICD-10-CM). Retrieved from
https://www.cdc.gov/nchs/icd/icd10cm.htm

Centers for Medicare and Medicaid Services. (2017). Provider resources. Retrieved

from https://www.cms.gov/Medicare/Coding/ICD10/ProviderResources.html

Material in this guide has been adapted from the referenced materials by Dr. Diane H.
Ranes, PhD, LCSW.

The utility of the DSM-5 Z-codes for clinical social work diagnosis
Joseph Walsh

School of Social Work, Virginia Commonwealth University, Richmond, Virginia, USA

ABSTRACT
The Diagnostic and Statistical Manual of Mental Disorders (DSM) is the stan-
dard reference text used by social workers for diagnosing mental disorders.
The social work profession has always had an uneasy relationship with the
DSM, but for 33 years there was an opportunity to note a client’s psychoso-
cial stressors on Axis IV. With the publication of the DSM-5, however, the
multiaxial diagnostic system was abandoned, and many social workers are
concerned that this change limits their ability to provide comprehensive
diagnoses. The purpose of this article is to consider an expanded use of
Z-codes as one way to continue including social work’s psychosocial per-
spective on human functioning in the diagnostic process.

KEYWORDS
Clinical social work; DSM-5;
mental health assessment;
mental health diagnosis;
Z-codes

The Diagnostic and Statistical Manual of Mental Disorders (originally published in 1952;
American Psychiatric Association [APA], 1952) has long been the standard reference text used
by social workers and other professions in the United States for diagnosing mental disorders. The
social work profession has always had an uneasy relationship with the DSM, given the psychiatry
profession’s bias toward a medical model of human functioning (Kutchins & Kirk, 1997;
Wakefield, 2013), but for 33 years there was an opportunity to note a client’s psychosocial
stressors on Axis IV and thus include the profession’s person-in-environment perspective in the
diagnostic process. With the publication of the latest edition of the DSM (referred to here as
DSM-5; APA, 2013), however, the multiaxial diagnostic system was abandoned. Many social
workers are rightfully concerned that this change limits their ability to provide comprehensive
diagnoses in that the deletion of Axis IV prohibits the formal inclusion of psychosocial stressors.
The purpose of this article is not to debate the merits and limitations of the new diagnostic
system (see Probst, 2014, for a critique), but to consider an expanded use of Z-codes as one way
to continue including social work’s psychosocial perspective on human functioning. Although an
expanded use of Z-codes does not alleviate the challenge to social work’s perspective created by
the deletion of Axis IV, it provides one way to constructively address this gap.

Axis IV and the social work perspective

The multiaxial diagnostic system was intended to facilitate a comprehensive client assessment by
addressing five domains of information: mental disorders, general medical conditions, psychosocial
and environmental problems, and overall level of functioning (APA, 1980). Axis IV was reserved for
reporting psychosocial and environmental problems that affected the diagnoses on Axis I and possibly
Axis II. Such problems included negative life events, environmental difficulties, familial or other
interpersonal stresses, inadequacies of social support or personal resources, and other problems
related to the client’s circumstances. As well as playing a contributing role in the development of a
mental disorder, psychosocial problems were also noted if they developed as a consequence of the

CONTACT Joseph Walsh [email protected] School of Social Work, Virginia Commonwealth University, 1000 Floyd Avenue,
Richmond, VA 23284-2027, USA.
© 2016 Taylor & Francis

JOURNAL OF HUMAN BEHAVIOR IN THE SOCIAL ENVIRONMENT
2016, VOL. 26, NO. 2, 149–153
http://dx.doi.org/10.1080/10911359.2015.1052913

primary diagnosis or constituted significant problems unrelated to the diagnosis. (When the Axis IV
problem was the primary focus of clinical attention, it was to be additionally recorded on Axis I with a
V-code.) The content of Axis IV evolved over the years, and DSM-IV (APA, 1994) included nine
possible psychosocial and environmental problems, including problems related to the client’s primary
support group and social environment; educational, occupational, housing, and economic problems;
problems related to access to health care and interaction with the legal system; and other psychosocial
and environmental problems.

The nature of the Z-codes

Appearing for the first time in DSM-III (APA, 1980), the V-codes, so named for their assigned code
numbers derived from the International Classification of Diseases (Buck, 2013), were listed in a
chapter for “conditions not attributable to a mental disorder that are a focus of attention or
treatment.” They were not considered to be diagnoses but were to be utilized in the following three
circumstances: when no disorder was found after an assessment, as a means of noting a client contact
when no diagnosis would be made, or when the person had a mental disorder but the intervention
would focus on the V-code condition. For example, a person might be assessed and diagnosed with
dysthymic disorder but want to work specifically on an unrelated parent-child problem (in which case
both issues would be noted on Axis I). Thirteen V-codes were listed in DSM-III and DSM-III-R (APA,
1980, 1987). It is worth noting that four of the Axis IV categories were represented in the list of
V-codes: academic problem, occupational problem, problems with primary support group (parent-
child problem, marital problem, other specified family circumstances), and social environment (other
interpersonal problems).

In DSM-IV and its later revision (APA, 1994, 2000) the V-codes were included in a chapter along
with several other conditions that may be a focus of clinical attention. Although the manual continued
to state that the V-codes were not diagnoses, a shift in its wording clouded the issue. This edition of
the manual stated that, in addition to the first two previously reported purposes of V-codes, they
could be used when “the individual has a mental disorder that is related to the problem (italics added),
but the problem is sufficiently severe to warrant independent clinical attention” (APA, 1994, p. 675).
The implication was that the V-code might in fact be related to the Axis I diagnosis as a causal
influence, which is what Axis IV notations had often implied. A child with oppositional defiant
disorder on Axis I could have an academic problem (as a V-code, Axis IV notation, or both)
contributing to the behaviors that supported the primary diagnosis. Axis IV is gone, of course, but
this example provides some evidence that the two types of codes overlapped. DSM-IV, by the way,
expanded the number of V-codes from 13 to 24, under the categories of “relational problems,”
“problems related to abuse or neglect,” and “additional conditions that may be a focus of clinical
attention.” Non-V-codes included in this chapter included six “psychological factors affecting medical
condition,” seven “medication-induced movement disorders,” and one “other medication-induced
mental disorder” (APA, 2000).

DSM-5 continues with the tradition of classifying the Z-codes (changed from V-codes to remain
consistent with ICD-10 coding, the manual from which they are drawn) as “other conditions that may
be a focus of clinical attention.” An introductory statement notes that these may “affect the diagnosis,
course, prognosis, or treatment” (APA, 2013, p. 715) of a disorder, even while also stating as before
that they are not mental disorders. The same wording from DSM-IV (APA, 1994) about using a
Z-code when the mental disorder is related to the problem is present, and the number of these codes
has increased almost fivefold. The Z-codes (some are labeled “T”-codes) are classified as “relational
problems” (n = 8), “abuse and neglect” of both children and adults (n = 71), “educational and
occupational problems” (n = 2), “housing and economic problems” (n = 9), “other problems related to
the social environment” (n = 6), “problems related to crime or interaction with the legal system”
(n = 5), “other health services encounters for counseling and medical advice” (n = 2) “problems
related to other psychological, personal, and environmental circumstances” (n = 8) and “other

150 J. WALSH

circumstances of personal history” (n = 7), which includes problems related to access to medical and
other health care. The number of available Z-codes has risen from 23 to 118, and they now cover all
areas formerly addressed in Axis IV.

There is a difference between having an official Axis IV designation of psychosocial stressors and
optional Z-codes that are considered to be largely unrelated to a diagnosis. Still, when one considers
that the APA has always attempted to separate both designations from the formal mental disorders, it
seems that the expanded list of Z-codes provides social workers with an opportunity to continue
listing significant psychosocial stressors on a regular basis. Even when the multiaxial system was in
use, the APA made it clear that it was sufficient to limit one’s diagnosis to the first three axes, giving
Axes IV and V a lesser status. The DSM-IV stated, “Clinicians who do not wish to use the multi-axial
format [italics added] may simply list the appropriate diagnoses.” They should “follow the general
ground rule of recording as many coexisting mental disorders, general medical conditions, and other
factors as are relevant to the care and treatment of the individual” (APA 1994, p. 35). None of the
three examples of this option in the manual included anything beyond the first three axes. It is
possible that social workers, given their person-in-environment perspective, took Axis IV more
seriously than some members of other professions. Still, because it is acknowledged that Axis IV
helped to individualize and detail a client’s problems and functioning status, social workers might
serve clients more comprehensively, and also help to educate members of other professions about the
relevance of environmental factors, by routinely using Z-codes in their diagnostic practices.

Examples

Five examples are included below to demonstrate how the Z-codes, most of which were not available
in previous editions of the DSM in these particular wordings, describe a psychosocial condition with
direct bearing on the onset or exacerbation of a primary diagnosis:

F20.9 Schizophrenia, multiple episodes, currently in acute episode
Z63.8 High expressed emotion level within family.

Expressed emotion is a concept that specifically refers to the amount of hostility, emotional over-
involvement, and criticism directed to an identified client by others in the family (Barrowclough &
Hooley, 2003). It was initially researched as a predictor of a relapse into an acute episode of
schizophrenia but has since been found applicable to a range of mental disorders. In DSM-IV
(APA, 1994) the corresponding Axis IV notation would have been “problems with primary support
group”:

F43.10 Posttraumatic stress disorder, with dissociative symptoms
Z62.810 Personal history of sexual abuse in childhood.

Many types of acute or persistent trauma can account for the onset of posttraumatic stress
disorder, and in this case the client’s history of childhood sexual abuse is identified as a major
causative factor. In DSM-IV (APA, 1994) there would have been no corresponding entry, because Axis
IV designations were limited to events that had occurred during the past year. A DSM-IV V-code of
“sexual abuse of child” would have been appropriate, although the newer designation clarifies that the
abuse, while critically significant to the client’s care, occurred longer ago:

F60.3 Borderline personality disorder
Z63.0 Relationship distress with intimate partner.

Clients with personality disorders by definition have persistent interpersonal problems, and in this
case such problems with an intimate partner are identified as either a causative or resulting factor. In

JOURNAL OF HUMAN BEHAVIOR IN THE SOCIAL ENVIRONMENT 151

the prior edition of the DSM a corresponding Axis IV coding would again have been “problems with
primary support group.” The V-code “partner relational problem” is, of course, quite similar to the
newer Z-code:

F43.23 Adjustment disorder with mixed anxiety and depressed mood
Z56.82 Problem related to current military deployment status

The above Z-code, which directly accounts for, or contributes to, the symptoms of the adjustment
disorder, is quite specific, far more so than any related code in prior editions of the DSM. On Axis IV
this might have been coded “problems related to the social environment” or “other psychosocial and
environmental problems,” either of which would be a far less clear descriptor given the circumstance:

F10.20 Alcohol use disorder, severe
292.69 Sickle cell disease
Z59.1 Inadequate housing
Z60.4 Social rejection

This example includes both a mental and medical disorder diagnosis and two Z-codes that may
have contributed to the onset of the mental disorder and have implications for the course of the
medical disorder. The first Z-code refers to overcrowding in the young client’s housing complex and is
almost identical in working to an Axis IV environmental stressor. The second Z-code refers to the
client’s experience of bullying and teasing and would have been coded as “problems related to the
social environment” on Axis IV. Neither of these codes has a corresponding descriptor in the DSM-IV
(APA, 1994) V-codes.

Summary

The publication of the DSM-5 has been met with criticism by members of the social work profession,
in part because of its elimination of Axis IV and the rest of the multiaxial system of diagnosis, which
reflects a devaluing of the profession’s person-in-environment perspective on human functioning.
Although such criticisms may be well founded, the availability in that manual of a much-expanded list
of Z-codes offers an alternative means for social workers to note psychosocial circumstances that are
relevant to the diagnosis. It remains to be seen if social workers will take advantage of this
opportunity, but clients will certainly be better served if these details of their lives are made evident
in the diagnostic statement.

References

American Psychiatric Association (APA). (1952) Diagnostic and statistical manual of mental disorders. Washington, DC:
Author.

American Psychiatric Association (APA). (1980) Diagnostic and statistical manual of mental disorders (3rd ed.).
Washington, DC: Author.

American Psychiatric Association (APA). (1987). Diagnostic and statistical manual of mental disorders (3rd ed, text
rev.). Washington, DC: Author.

American Psychiatric Association (APA). (1994). Diagnostic and statistical manual of mental disorders (4th ed.).
Washington, DC: Author.

American Psychiatric Association (APA). (2000). Diagnostic and statistical manual of mental disorders (4th ed, text rev.).
Washington, DC: Author.

American Psychiatric Association (APA). (2013). Diagnostic and statistical manual of mental disorders (5th ed.).
Arlington, VA: Author.

Barrowclough, C., & Hooley, J. M. (2003). Attributions and expressed emotion: A review. Clinical Psychology Review, 23,
849–880. doi:10.1016/S0272-7358(03)00075-8

Buck, C. J. (2013). 2014 ICD-9-CM for physicians (Vols. 1 and 2). New York, NY: Elsevier Health Services.

152 J. WALSH

Kutchins, H., & Kirk, S. A. (1997). Making us crazy: The psychiatric bible and the creation of mental disorders. New York,
NY: The Free Press.

Probst, B. (2014). The life and death of Axis IV: Caught in the quest for a theory of mental disorder. Research on Social
Work Practice, 24(1), 123–131. doi:10.1177/1049731513491326

Wakefield, J. (2013). DSM-5: An overview of changes and controversies. Clinical Social Work Journal, 41(2), 139–154.
doi:10.1007/s10615-013-0445-2

JOURNAL OF HUMAN BEHAVIOR IN THE SOCIAL ENVIRONMENT 153

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