`
`'
`
`I!
`
`DIAGNOSTIC AND STATISTIQZ-AL .
`MANUAL OF
`g
`MENTAL DISORDERS
`
`'
`
`FOURTH ED|T|ON
`
`DSM-IV—TRTM
`
`
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` DIAGNOSTIC AND STATISTICAL
`
`
`MANUAL OF
`
`MENTAL DISORDERS
`
`FOURTH EDITION
`
`
`
`§ I EI Eg I
`
`DSM-IV-TRTM
`
`
`
` 4Lugr‘fibmmmw
`
`
`Published by the
`American Psychiatric Association
`Washin ton, DC
`wooos ME ORIAL LIBRARY
`19 PLEASANT STREET
`BARRE Mix 01005-0489
`
`f
`i
`L
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`f"
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`Copyright © 2000 American Psychiatric Association
`
`DSM, DSM—IV, and DSM-IV—TR 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 ap-
`plies to unauthorized uses or reproductions in any form, including electronic applications.
`Correspondence regarding copyright permissions should be directed to the DSM Permissions,
`Office of Publishing Operations, American Psychiatric Association, 1400 K Street, N.W., Wash-
`ington, DC 20005.
`
`Manufactured in the United States of America on acid-free paper.
`ISBN 0-89042~024-6 1st Printing May 2000
`
`ISBN 0-89042-025-4 3rd Printing September 2002
`American Psychiatric Association
`1400 K Street, N.W., Washington, DC 20005
`www.psych.org
`
`
`
`The correct citation for this book is American Psychiatric Association: Diagnostic and Statistical
`Manual ofMental Disorders, Fourth Edition, Text Revision. Washington, DC, American Psychi—
`atric Association, 2000.
`
`Library of Congress Cataloging-in-Publication Data
`Diagnostic and statistical manual of mental disorders : DSM—IV.—4th ed., text revision.
`p.
`; cm.
`
`Prepared by the Task Force on DSM~IV and other committees and work groups of the Amer-
`ican Psychiatric Association.
`Includes index.
`
`ISBN 0-89042-024—6 (casebound : alk. paper)~ISBN 0-89042—025-4 (pbk. : alk. paper)
`1. Mental illness~—Classification—Handbooks, manuals, etc. 2. Mental illness—Diagnosis—
`Handbooks, manuals, etc. I. Title: DSM—IV. II. American Psychiatric Association. III. American
`Psychiatric Association. Task Force on DSM-IV.
`[DNLM: 1. Mental Disorders—classification. 2. Mental Disorders——diagnosis.
`WM 15 D536 2000]
`RC455.2.C4 D536 2000
`616.89’075—~dc21
`
`00—024852
`
`British Library Cataloguing in Publication Data
`A CIP record is available from the British Library.
`Text Design—Anne Barnes
`Manufacturing—R. R. Donnelley & Sons Company
`
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`fl
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`a man for all seasons
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`)ciation. Use
`)ciation.
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`'ohibition ap-
`)lications.
`
`Permissions,
`N.W.,Wash-
`
`nd Statistical
`
`rican Psychi—
`
`'ision.
`
`of the Amer-
`
`1per)
`Diagnosis—
`]. American
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`Contents
`
`Task Force on DSM-IV .................................... xi
`
`Work Groups for the DSM-lV—TR Text Revision ............... xv
`
`Acknowledgments for DSM—lV—TR ......................... xix
`
`Acknowledgments for
`DSM-lV Text Revision ................................... xxi
`
`Introduction ......................................... xxiii
`
`Cautionary Statement ................................ xxxvii
`UseoftheManual....................,....., ............ 1
`DSM—lV—TR Classification ................................. 13
`
`Multiaxial Assessment ................................... 27
`
`Disorders Usually First Diagnosed in
`infancy, Childhood, or Adolescence ........................ 39
`
`Delirium, Dementia, and Amnestic and
`
`Other Cognitive Disorders ............................... 135
`
`Mental Disorders Due to a General Medical Condition ........ 181
`
`Substance—Related Disorders ............................. 191
`
`Schizophrenia and
`
`Other Psychotic Disorders ............................... 297
`
`Mood Disorders ....................................... 345
`
`Anxiety Disorders ...................................... 429
`
`Somatoform Disorders .................................. 485
`
`Z
`
`Factitious Disorders .................................... 513
`Dissociative Disorders ................................... 519
`
`Sexual and Gender Identity Disorders ...................... 535
`
`1
`
`?
`g
`
`‘@494?“me
`
`9
`
`1
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`i5
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`1
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`% P
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`Eating Disorders ....................................... 583
`
`Sleep Disorders ........................................ 597
`
`Impulse-Control Disorders Not Elsewhere Classified .......... 663
`
`- Adjustment Disorders .................................. 679
`
`Personality Disorders ................................... 685
`
`_ bther Conditions That May Be a
`Focus of Clinical Attention ...... ‘........................ 731
`
`Additional Codes ...................................... 743
`
`Appendix A
`
`Decision Trees for Differential Diagnosis ................... 745
`
`Appendix B
`
`Criteria Sets and Axes Provided for Further Study ............ 759
`
`Appendix C
`
`Glossary of Technical Terms .............................. 819
`
`Conditions and Medication—induced Disorders .............. 867
`
`Appendix D
`
`Highlights of Changes in
`DSM—IV Text Revision ................................... 829
`
`Appendix E
`
`Alphabetical Listing of
`DSM-lV—TR Diagnoses and Codes ......................... 845
`
`Appendix F
`
`Numerical Listing of
`DSM-lV-TR Diagnoses and Codes ......................... 857
`
`Appendix G
`
`ICD-9-CM Codes for Selected General Medical
`
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`...... 583
`
`...... 597
`
`...... 663
`
`...... 679
`
`...... 685
`
`....... 731
`
`....... 743
`
`
`
`,
`Appendix H
`DSM—IV Classification
`
`(With lCD—1O Codes) .................................... 883
`
`Appendix I
`Outline for Cultural Formulation and
`
`Glossary of Culture—Bound Syndromes ..................... 897
`
`Appendix J
`
`DSM-IV Contributors ................................... 905
`
`Appendix K
`DSM-lV Text Revision Advisers ............................ 929
`
`
`
`
`
`
`
`
`
`
`....... 745
`
`Index ................................................ 933
`
`....... 7S9
`
`WMkfifiwfiWVWSufiI
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`raw/meawszeiéma»mamoxmweasWfimmmmvzmxmna‘ne’aWmamwaemmmwwwwmwmnmwWMKWAWWKWWXQWWWMW.2
`
`
`
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`
`TASK FORCE ON DSM-IV
`
`ALLEN FRANCES, MD.
`Chairperson
`
`HAROLD ALAN PINCUS, MD.
`Vice-Chairperson
`
`MICHAEL B. FIRST, MD.
`Editor, Text and Criteria
`
`9
`
`Nancy Coover Andreasen, M.D., PhD.
`David H. Barlow, PhD.
`
`Chester W. Schmidt, MD.
`Marc Alan Schuckit, MD.
`
`Magda Campbell, MD.
`Dennis P. Cantwell, MD.
`Ellen Frank, PhD.
`Judith H. Gold, MD.
`John Gunderson, M.D.
`Robert E. Hales, MD.
`
`Kenneth S. Kendler, MD.
`
`David J. Kupfer, MD.
`Michael R. Liebowitz, MD.
`
`Juan Enrique Mezzich, M.D., PhD.
`
`Peter 3 Nathan, Ph-D-
`
`Roger Peele, M'D'
`Darrel A. Regier, MD, MPH-
`A. John Rush, MD.
`
`David Shaffer, MD.
`Robert L. Spitzer, MD.
`Special Adviser
`Gary 1- Tucker, MD.
`B. Timothy Walsh, M.D.
`Thomas A. Widiger, PhD.
`Research Coordinator
`
`Janet B. W. Williams, D.S.W.
`
`John C. Urbaitis, MD.
`Assembly Liaison
`
`James J. Hudziak, MD.
`Resident Fellow (19904993)
`
`Junius Gonzales, MD.
`Resident Fellow (19884990)
`
`Ruth Ross, M.A.
`Science Editor
`
`Nancy E. Vettorello, M.U.P.
`Administrative Coordinator
`
`Wendy Wakefield Davis, Ed.M.
`Editorial Coordinator
`
`Cindy D. Jones
`Administrative Assistant
`
`‘ Nancy Sydnor—Greenberg, M.A.
`Administrative Consultant
`
`Myriam Kline, MS.
`Focused Field—Trial Coordinator
`
`James W. Thompson, M.D., M.P.H.
`Videotape Field-Trial Coordinator
`
`The DSM—IV Text Revision Work Groups are listed on pp. xv—xvii.
`
`Ki
`
`
`
`
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`DSM-lV Work Groups
`
`Anxiety Disorders Work Group
`
`Michael R. Liebowitz, MD.
`Chairperson
`
`David H. Barlow, PhD.
`
`Vice—Chairperson
`
`James C. Ballenger, MD.
`Jonathan Davidson, MD.
`
`Edna Foa, PhD.
`
`Abby Fyer, MD.
`
`Delirium, Dementia, and Amnestic and}
`Other Cognitive Disorders Work Group
`
`Gary J. Tucker, MD.
`Chairperson
`
`Michael Popkin, MD.
`Vice~Chairperson
`
`Eric Douglas Caine, MD.
`
`Marshall Folstein, MD.
`
`Gary Lloyd Gottlieb, MD.
`
`Igor Grant, MD.
`
`Benjamin Liptzin, MD.
`
`
`
`Disorders Usually First Diagnosed During infancy,
`Childhood, or Adolescence Work Group
`
`David Shaffer, MD.
`
`Co—Chairperson
`
`Magda Campbell, MD.
`Co-Chairperson
`
`Susan J. Bradley, MD.
`Dennis P. Cantwell, MD.
`
`Gabrielle A. Carlson, MD.
`
`Donald Jay Cohen, MD.
`
`Barry Garfinkel, MD.
`
`Rachel Klein, PhD.
`
`Benjamin Lahey, PhD.
`Rolf Loeber, PhD.
`
`Jeffrey Newcorn, MD.
`Rhea Paul, PhD.
`
`Judith H. L. Rapoport, MD.
`Sir Michael Rutter, MD.
`
`Fred Volkmar, MD.
`
`John S. Werry, MD.
`
`Eating Disorders Work Group
`
`B. Timothy Walsh, MD.
`Chairperson
`Paul Garfinkel, MD.
`
`Katherine A. Halmi, MD.
`
`James Mitchell, MD.
`
`G. Terence Wilson, PhD.
`
`Mood Disorders Work Group
`
`David Dunner, MD.
`
`Ellen Frank, PhD.
`
`Donald F. Klein, MD.
`
`A. John Rush, MD.
`Chairperson
`Martin B. Keller, MD.
`
`Vice—Chairperson
`Mark S. Bauer, MD.
`
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`l/ Work Groups
`
`
`
`Multiaxial Issues Work Group
`
`
` DSM-IV Work Groups
`
`
`
`
`Juan Enrique Mezzich. MD, Ph.D.
`Janet B. W. Williams, D.S.W.
`Roger Peele, MD.
`Chairperson
`
`
`Stephen Setterberg, MD.
`Howard H. Goldman, MD., Ph.D.
`
`
`
` Vice—Chairperson
`Andrew Edward Skodol II, MD.
`
`
`Alan M. Gruenberg, MD.
`
`
`Personality Disorders Work Group
`‘
`
`
`
`
`
`
`
`
`Iohn Gunderson, MD.
`
`Chairperson
`
`Robert M. A. Hirschfeld, M.D.
`Vice—Chairperson
`Roger Blashfield, Ph.D.
`Susan lean Fiester, MD.
`
`Theodore Millon, Ph.D.
`
`Bruce Pfohl, MD.
`
`Tracie Shea, Ph.D.
`Larry Siever, MD.
`Thomas A. Widiger, Ph.D.
`
`
`
`
`
`
`
`
`I cy,
`
`
`
`
`
`
`
`Premenstrual Dysphoric Disorder Work Group
`
`Judith H. Gold, MD.
`Chairperson
`Jean Endicott, Ph.D.
`Barbara Parry, MD.
`
`'
`
`Sally Severino, MD.
`Nada Logan Stotland, MD.
`Ellen Frank, Ph.D.
`
`
`
`
`
`
`
`Consultant Psychiatric Systems interface Disorders
`
`
`
`(Adjustment, Dissociative, Factitious, Impulse-Control, and
`Somatoform Disorders and Psychological Factors Affecting
`Medical Conditions) Work Group
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`Joe P. Fagan, MD.
`Michael G. Wise, MD.
`
`
`Robert E. Hales, MD.
`Chairperson
`0 Robert Cloninger, M'D-
`Vice-Chairperson
`Jonathan F. Borus, MD.
`
`Jack Denning Burke, In, MD., M.P.H.
`
`Steven A. King, MD.
`Ronald L. Martin, MD.
`Katharine Anne Phillips, MD.
`
`David Spiegel, MD.
`Alan Stoudemire, MD.
`
`James I. Strain, MD.
`
`
`
`
`
`
`Schizophrenia and Other Psychotic Disorders Work Group
`
`Nancy Coover Andreasen, MD., PhD.
`Chairperson
`John'M. Kane, MD'
`Vice—Chairperson
`
`Samuel Keith, MD.
`Kenneth S. Kendler, MD.
`Thomas McGlashan, MD.
`
`
`
`
`
`
`
`
`
`
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`
`DSM-IV Work Groups
`
`Sexual Disorders Work Group
`
`Chester W. Schmidt, MD.
`Chairperson
`
`Raul Schiavi, MD.
`
`Leslie Schover, PhD.
`
`Taylor Seagraves, MD.
`
`Thomas Nathan Wise‘, MD.
`
`
`
`
`
`Sleep Disorders Work Group
`
`David]. Kupfer, MD.
`Chairperson
`Charles F. Reynolds 11L MD-
`Vice—Chairperson
`Daniel Buysse, MD.
`
`3
`Roger Peele, MD.
`Quentin Regestein, MD.
`Michael Sateia, MD.
`Michael Thorpy, MD.
`
`Substance-Related Disorders Work Group
`
`Marc Alan Schuckit, MD.
`Chairperson
`10h“ 13' Helzer, M‘D'
`Vice-Chairperson
`
`Linda B. Cottler, PhD.
`Thomas Crowley, MD.
`Peter E. Nathan, PhD.
`George E. Woody, MD.
`
`Committee on Psychiatric Diagnosis and Assessment
`
`Layton McCurdy, MD.
`Chairperson (1987—1994)
`
`Jerry M. Lewis, MD.
`Consultant (1988—1994)
`
`Kenneth Z. Altshuler, MD. (1987—1992)
`Thomas F. Anders, MD. (1988—1994)
`
`Daniel]. Luchins, MD.
`Consultant (1987-1991)
`
`Susan Jane Blumenthal, MD. (1990—
`1993)
`
`Katharine Anne Phillips, MD-
`Consultant (1992—1994)
`
`Leah Joan Dickstein, MD. (1988—1991)
`Lewis J. Judd, MD. (1988—1994)
`Gerald L. Klerman, MD. (deceased)
`(1988—1991)
`St
`tC.Y d
`M.
`.1 2—1
`u OfSky’
`”fir
`D ( 99
`Jack D. Blaine, MD.
`1
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`
`994)
`
`Cynthia Pearl Rose, MD
`consultant (19904994)
`LOZIS A12? Moench,1l\9/:1D.1994
`ssem y zazson(
`—
`Steven K. Dobscha MD.
`’
`Resident Fellow (1990—1992)
`Mark Zimmerman MD.
`’
`Resident Fellow (1992—1994)
`
`)
`
`Joint Committee of the Board of Trustees and
`
`Assembly of District Branches on
`Issues Related to DSM—IV
`
`Ronald A. Shellow, MD.
`Chairperson
`Harvey Bluestone, MD.
`
`Leah Joan Dickstein, MD.
`Arthur John Farley, MD.
`Carol Ann Bernstein, MD.
`
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`-lV Work Groups
`
`
`
`
`
`
`
`‘
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`
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`
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`
`WORK GROUPS FOR THE DSM-IV TEXT REVISION
`
`MICHAEL B. FIRST, MD.
`Co—Chaz'rperson and Editor
`
`HAROLD ALAN PINCUS, M.D.
`Co~Chairperson
`
`Laurie E. McQueen, M.S.S.W.
`DSM Project Manager
`
`Yoshie Satake, B.A.
`DSM Program Coordinator
`
`Anxiety Disorders Text Revision Work Group
`
`Murray B. Stein, MD.
`
`Chairperson
`Jonathan Abramowitz, PhD.
`Gordon Asmundson, PhD.
`Jean C- Beckham, ””1
`Timothy Brown, Ph.D., PsyD.
`
`Michelle Craske, PhD.
`
`Edna Foa, PhD.
`Thomas Mellman, MD.
`Ron Norton PhD.
`Franklin Schneier, MD.
`Richard Zinbarg, PhD.
`
`Delirium, Dementia, and Amnestic and
`Other Cognitive Disorders and Mental Disorders
`Due to a General Medical Condition Text Revision Work Group
`
`Eric Douglas Caine, MD.
`Jesse Fann, M.D., MPH.
`
`Jeffrey M. Lyness, MD.
`Anton P. Porsteinsson, MD.
`
`Disorders Usually First Diagnosed During Infancy,
`Childhood, or Adolescence Text Revision Work Group
`David Shaffer, MD.
`Ami Klin, PhD.
`Chairperson
`’
`Daniel Pine, MD.
`Donald]. Cohen, MD.
`Mark A. Riddle, MD.
`Stephen Hinshawr Ph-D-
`Fred R. Volkmar, MD.
`Rachel G- Klein, Ph~D~
`Charles Zeanah, MD.
`
`Eating Disorders Text Revision Work Group
`Katharine L. Loeb, PhD.
`B. Timoth Walsh, MD.
`Y
`
`.
`.
`.
`Medication—Induced Movement Disorders
`Text Revision Work Group
`Alan Gelenberg, MD.
`Gerard Addonizio, MD.
`James Jefferson, MD.
`Lenard Adler, MD.
`Dilip Jeste, MD.
`Burton Angrist, MD.
`Daniel Casey, MD.
`Peter Weiden, MD.
`
`are
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`DSM—IV—TR Work Groups
`
`Mood Disorders Text Revision Work Group
`
`Mark S. Bauer, M.D‘
`Patricia Suppes, M.D., PhD.
`
`, Michael E. Thase, MD.
`
`Muitiaxiai Text Revision Work Group
`
`Alan M. Gruenberg, MD.
`
`Personality Disorders Text Revision Work Grdup
`
`Bruce Pfohl, MD.
`
`Thomas A. Widiger, PhD.
`
`Premenstrual Dysphoric Disorder Text Revision Work Group
`Sally Severino, MD.
`
`Psychiatric System Interface Disorders (Adjustment, Dissociative,
`Factitious, Impulse-Control, and Somatoform Disorders and
`Psychological Factors Affecting MedicaIConditions)
`Text Revision Work Group
`
`Azquvmvmwmwn
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`
`Marc Alan Schuckit, MD.
`
`Mitchell Cohen, MD.
`Marc Feldman, MD.
`Eric Hollander, MD.
`Steven A. King, MD.
`James Levenson, MD.
`Ronald L. Martin, MD. (deceased)
`Jeffrey Newcorn, MD.
`
`Russell Noyes, Jr., MD.
`Katharine Anne Phillips. MD.
`Eyal Shemesh, MD.
`David Spiegel, MD.
`James J. Strain, MD.
`Sean H. Yutzy, MD.
`
`Schizophrenia and Other Psychotic Disorders
`Text Revision Work Group
`
`Michael Flaum, MD.
`Co-Chairperson
`
`Xavier Amador, PhD.
`Co-Chairperson
`
`Sexual and Gender Identity Disorders Text Revision Work Group
`Chester W. Schmidt, MD.
`Thomas Nathan Wise, MD.
`R. Taylor Segraves, MD.
`Kenneth J. Zucker, PhD.
`
`Sleep Disorders Text Revision Work Group
`
`Daniel Buysse, MD.
`
`Peter Nowell, MD.
`
`Substance—Related Disorders Text Revision Work Group
`
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`
`
`DSM—iV—TR Work Groups
`
`an we
`
`American Psychiatric Association
`Committee on Psychiatric Diagnosis and Assessment
`
`David J. Kupfer, MD.
`Chair
`
`James Leckman, MD.
`Member
`
`Katharine Anne Phillips, MD.
`Member
`
`A. John Rush, MD.
`Member
`
`Daniel Winstead, MD.
`Member
`
`Bonnie Zima, MD., Ph.D,
`Member
`
`Barbara Kennedy, MD., PhD.
`Consultant
`
`Janet B. W. Williams, D.S.W.
`Consultant
`
`Louis Alan Moench, MD.
`Assembly Liaison
`Jack Barchas, MD.
`
`Corresponding Member
`
`Herbert W. Harris, MD., PhD.
`Corresponding Member
`Charles Kaelber, MD.
`
`Corresponding Member
`
`Jorge A. Costa e Silva, MD.
`Corresponding Member
`T. Bedirhan Ustun, MD.
`
`Corresponding Member
`Yeshuschandra Dhaibar, MD.
`APA/Glaxo—Wellcome Fellow
`
`
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`
`
`Acknowledgments for DSM—Iv
`
`
`
`SM—IV was a team effort. More than 1,000 people (and numerqus professional
`organizations) have helped us in the preparation of this document. Members of the
`Task Force on DSM-IV and DSM-IV Staff are listed on p. xi, members of the DSM-IV
`Work Groups are listed on pp. xii~xiv, and a list of other participants is included in
`Appendix J.
`The major responsibility for the content of DSM-IV rests with the Task Force on
`DSM-IV and members of the DSM—IV Work Groups. They have worked (often much
`harder than they bargained for) with a dedication and good cheer that has been inspi-
`rational to us. Bob Spitzer has our special thanks for his untiring efforts and unique per-
`spective. Norman Sartorius, Darrel Regier, Lewis Judd, Fred Goodwin, and Chuck
`Kaelber were instrumental in facilitating a mutually productive interchange between
`the American Psychiatric Association and the World Health Organization that has
`improved both DSM—IV and ICD-10, and increased their compatibility. We are grate—
`ful to Robert Israel, Sue Meads, and Amy Blum at the National Center for Health
`Statistics and Andrea Albaum—Feinstein at the American Health Information Man—
`agement Association for suggestions on the DSM-IV coding system. Denis Prager,
`Peter Nathan, and David Kupfer helped us to develop a novel data reanalysis strate-
`gy that has been supported with funding from the John D. and Catherine T. Mac—
`Arthur Foundation.
`Many individuals within the American Psychiatric Association deserve recogni—
`tion. Mel Sabshin’s special wisdom and grace made even the most tedious tasks seem
`worth doing. The American Psychiatric Association Committee on Psychiatric Diag-
`nosis and Assessment (chaired by Layton McCurdy) provided valuable direction and
`counsel. We would also like to thank the American Psychiatric Association Presidents
`(Drs. Fink, Pardes, Benedek, Hartmann, English, and McIntyre) and Assembly Speak-
`ers (Drs. Cohen, Flamm, Hanin, Pfaehler, and Shellow) who helped with the planning
`of our work. Carolyn Robinowitz and Jack White, and their respective staffs in the
`American Psychiatric Association Medical Director’s Office and the Business Admin~
`istration Office, have provided valuable assistance in the organization of the project.
`Several other individuals have our special gratitude. Wendy Davis, Nancy Vet—
`torello, and Nancy Sydnor-Greenberg developed and implemented an organizational
`structure that has kept this complex project from spinning out of control. We have
`also been blessed with an unusually able administrative staff, which has included
`Elisabeth Fitzhugh, Willa Hall, Kelly McKinney, Gloria Miele, Helen Stayna, Sarah
`Tilly, Nina Rosenthal, Susan Mann, Joanne Mas, and, especially, Cindy Jones. Ruth
`Ross, our tireless Science Editor, has been responsible for improving the clarity of ex—
`pression and organization of DSM—IV. Myriam Kline (Research Coordinator for the
`NIH-funded DSM—IV Focused Field Trials), Jim Thompson (Research Coordinator for
`
`Mx
`
`ix
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`Allen Frances, MD.
`
`Chairperson, Task Force on DSM-IV
`Harold Alan Pincus, MD.
`
`Vice—Chairperson, Task Force on DSM—IV
`Michael B. First, M.D.
`Editor, DSM—IV Text and Criteria
`
`Thomas A. Widiger, PhD.
`Research Coordinator
`
`am
`
`Acknowledgments for DSM—lV
`
`the MacArthur Foundation—funded Videotape Field Trial), and Sandy Ferris (Assis—
`tant Director for the Office of Research) have made many valuable contributions. We
`would also like to acknowledge all the other staff persons at the American Psychiatric
`Association who have helped with this project. Ron McMillen, Claire Reinburg, Pam
`Harley, and Jane Davenport of American Psychiatric Press have provided expert pro~
`duction assistance.
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`nents for DSM-IV
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`.ndy Ferris (Assis-
`contributions. We
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`Lerican Psychiatric
`ire Reinburg, Pam
`)vided expert pro—
`
`Acknowledgments for
`DSM—IV Text Revision .
`
`
`
`he effort to revise the DSM—IV text was also a team effort. We are especially in-
`debted to the tireless efforts of the DSM—IV Text Revision Work Groups (listed on
`pp. xv—xvii), who did the lion’s share of the work in the preparation of this revision.
`We would also like to acknowledge the contribution of the various advisers to the
`Work Groups (see Appendix K, p. 929), who provided their perspective on whether
`the proposed Changes were justified. Finally, we would like to thank the American
`Psychiatric Association’s Committee on Psychiatric Diagnosis and Assessment (listed
`on p. xvii), who provided helpful guidance and oversight during the process as well
`as approval of the final document. Special gratitude goes to committee members
`Katharine A. Phillips and Janet B. W. Williams, for their meticulously careful review
`of the text revision. Of course, none of this could have happened without the invalu-
`able organizational and administrative assistance provided by the DSM—IV staff,
`Laurie McQueen and Yoshie Satake, and production assistance provided by Anne
`Barnes, Pam Harley, Greg Kuny, Claire Reinburg, and Ron McMillen at American
`Psychiatric Press.
`
`Michael B. First, M.D.
`
`Co-Chm'rpe'rson and Editor
`Harold Alan Pincus, MD.
`
`Co-Chairpe-rson
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`
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`9i;
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`
`his is the fourth edition of the American Psychiatric Association’s Diagnostic and
`Statistical Manual ofMental Disorders, or DSM-IV. The utility and credibility of DSM-IV
`
`require that it focus on its clinical, research, and educational purposes and be support—
`ed by an extensive empirical foundation. Our highest priority has been to provide a
`
`helpful guide to clinical practice. We hoped to make DSM-IV practical and useful for
`
`clinicians by striving for brevity of criteria sets, clarity of language, and explicit state-
`ments of the constructs embodied in the diagnostic criteria. An additional goal was to
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`facilitate research and improve communication among clinicians and researchers. We
`
`were also mindful of the use of DSM—IV for improving the collection of clinical infor—
`
`mation and as an educational tool for teaching psychopathology.
`
`An official nomenclature must be applicable in a wide diversity of contexts. DSM-IV
`
`is used by clinicians and researchers of many different orientations (e.g., biological,
`psychodynamic, cognitive, behavioral, interpersonal, family/systems). It is used by
`
`
`psychiatrists, other physicians, psychologists, social workers, nurses, occupational and
`
`rehabilitation therapists, counselors, and other health and mental health profession-
`als. DSM-IV must be usable across settings—inpatient, outpatient, partial hospital,
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`consultation-liaison, clinic, private practice, and primary care, and with community
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`populations. It is also a necessary tool for collecting and communicating accurate ‘
`public health statistics. Fortunately, all these many uses are compatible with one
`
`another.
`DSM—IV was the product of 13 Work Groups (see Appendix I), each of which had
`
`primary responsibility for a section of the manual. This organization was designed to
`
`increase participation by experts in each of the respective fields. We took a number of
`
`precautions to ensure that the Work Group recommendations would reflect the
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`breadth of available evidence and opinion and not just the views of the specific mem-
`bers. After extensive consultations with experts and clinicians in each field, we select-
`
`ed Work Group members who represented a wide range of perspectives and
`
`experiences. Work Group members were instructed that they were to participate as
`
`consensus scholars and not as advocates of previously held views. Furthermore, we
`established a formal evidence—based process for the Work Groups to follow.
`
`The Work Groups reported to the Task Force on DSM—IV (see p. xi), which consist—
`ed of 27 members, many of whom also chaired a Work Group. Each of the 13 Work
`
`Groups was composed of 5 (or more) members whose reviews were critiqued by
`
`between 50 and 100 advisers, who were also Chosen to represent diverse clinical and
`research expertise, disciplines, backgrounds, and settings. The involvement of many
`
`international experts ensured that DSM-IV had available the widest pool of informa-
`tion and would be applicable across cultures. Conferences and workshops were held
`
`to provide conceptual and methodological guidance for the DSM—IV effort. These
`MM
`tsrtiii
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`Introduction
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`included a number of consultations between the developers of DSM—IV and the de-
`velopers of ICD—lO conducted for the purpose of increasing compatibility between
`the two systems. Also held were methods conferences that focused on cultural factors
`in the diagnosis of mental disorder, on geriatric diagnOSiS, and on psychiatric diag—
`nosis in primary care settings.
`To maintain open and extensive lines of communication, the Task Force on DSM-IV
`established a liaison with many other components within the American Psychiatric
`Association and with more than 60 organizations and associations interested in the
`development of DSM-IV (e.g., American Health Information Management Associa—
`tion, American Nurses’ Association, American Occupational Therapy Association,
`American Psychoanalytic Association, American Psychological Association, Ameri—
`can Psychological Society, Coalition for the Family, Group for the Advancement of
`Psychiatry, National Association of Social Workers, National Center for Health Sta-
`tistics, World Health Organization). We attempted to air issues and empirical evi—
`dence early in the process in order to identify potential problems and differences in
`interpretation. Exchanges of information were also made possible through the distri-
`bution of a semiannual newsletter (the DSM~IV Update), the publication of a regular
`column on DSM-IV in Hospital and Community Psychiatry, frequent presentations at
`national and international conferences, and numerous journal articles.
`Two years before the publication of DSM-IV, the Task Force published and widely
`distributed the DSM~IV Options Book. This volume presented a comprehensive sum-
`mary of the alternative proposals that were being considered for inclusion in DSM-IV
`in order to solicit opinion and additional data for our deliberations. We received ex-
`tensive correspondence from interested individuals who shared with us additional
`data and recommendations on the potential impact of the possible changes in DSM-IV
`on their clinical practice, teaching, research, and administrative work. This breadth of
`discussion helped us to anticipate problems and to attempt to find the best solution
`among the various options. One year before the publication of DSM-IV, a near-final
`draft of the proposed criteria sets was distributed to allow for one last critique.
`In arriving at final DSM—IV decisions, the Work Groups and the Task Force re-
`viewed all of the extensive empirical evidence and correspondence that had been
`gathered. It is our belief that the major innovation of DSM-IV lies not in any of its spe-
`cific content changes but rather in the systematic and explicit process by which it was
`constructed and documented. More than any other nomenclature of mental disor~
`ders, DSM—IV is grounded in empirical evidence.
`
`
`
`
`
`awamvwmm
`
`Historical Background
`The need for a classification of mental disorders has been clear throughout the history
`of medicine, but there has been little agreement on which disorders should be includ—
`ed and the optimal method for their organization. The many nomenclatures that have
`been developed during the past two millennia have differed in their relative empha-
`sis on phenomenology, etiology, and course as defining features. Some systems have
`included only a handful of diagnostic categories; others have included thousands.
`Moreover, the various systems for categorizing mental disorders have differed with
`respect to whether their principle objective was for use in clinical, research, or statis-
`tical settings. Because the history of classification is too extensive to be summarized
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`Introduction
`
`
`
`Introduction
`mm;
`
`
`
`
`[-IV and the de-
`
`tibility between
`I cultural factors
`
`vsychiatric diag—
`
`orce on DSM-IV
`
`ican Psychiatric
`nterested in the
`
`;ement Associa—
`py Association,
`)ciation, Ameri—
`xdvancement of
`* for Health Sta-
`
`1 empirical evi-
`.d differences in
`
`Tough the distri—
`:ion of a regular
`presentations at
`s.
`
`ihed and widely
`irehensive sum-
`Lsion in DSM—IV
`We received ex—
`th us additional
`
`nges in DSM—IV
`. This breadth of
`he best solution
`
`-IV, a near-final
`
`5t critique.
`: Task Force re-
`s that had been
`
`in any of its spe—
`by which it was
`)f mental disor-
`
`
`
`
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`
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`
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`
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`
`
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`
`
`
`hout the history
`iould be includ~
`atures that have
`
`relative empha-
`1e systems have
`.ded thousands.
`re' differed with
`
`search, or statis-
`be summarized
`
`
`
`
`
`
`
`
`
`here, we focus briefly only on those aspects that have led directly to the development
`of the Diagnostic and Statistical Manual of Mental Disorders (DSM) and to the “Mental
`Disorders” sections in the various editions of the International Classy‘ication 0f Diseases
`(1CD).
`In the United States, the initial impetus for developing a classification of mental
`disorders was the need to collect statistical information. What might be considered
`the first official attempt to gather information about mental illness in the United
`States was the recording of the frequency of one category-”idiocy/insanity” in the
`1840 census. By the 1880 census, seven categories of mental illness were distin—
`guished—wmania, melancholia, monomania, paresis, dementia, dipsomania, and epi—
`lepsy. In 1917, the Committee on Statistics of the American Psychiatric Association
`(at that time called the American Medico-Psychological Association [the name was
`changed in 1921]), together with the National Commission on Mental Hygiene, for-
`mulated a plan that was adopted by the Bureau of the Census for gathering uniform
`statistics across mental hospitals. Although this system devoted more attention to
`clinical utility than did previous systems, it was still primarily a statistical classifica-
`tion. The American Psychiatric Association subsequently collaborated with the New
`York Academy of Medicine to develop a nationally acceptable psychiatric nomen~
`clature that would be incorporated within the first edition of the American Medical
`Association’s Standard Classified Nomenclature of Disease. This nomenclature was
`
`designed primarily for diagnosing inpatients with severe psychiatric and neurologi—
`cal disorders.
`
`A much broader nomenclature was later developed by the US. Army (and modi—
`fied by the Veterans Administration) in order to better incorporate the outpatient pre—
`sentations of World War II servicemen and veterans (e.g., psychophysiological,
`personality, and acute disorders). Contemporaneously, the World Health Organi—
`zation (WHO) published the sixth edition of ICD, which, for the first time, included
`a section for mental disorders. ICD—6 was heavily influenced by the Veterans Admin-
`istration nomenclature and included 10 categories for psychoses, 9 for psychoneuro-
`ses, and 7 for disorders of character, behavior, and intelligence.
`The American Psychiatric Association Committee on Nomenclature and Statistics
`developed a variant of the ICD-6 that was published in 1952 as the first edition of the
`Diagnostic and Statistical Manual: Mental Disorders (DSM-I). DSM-I contained a glossa-
`ry of descriptions of the diagnostic categories and was the first official manual of
`mental disorders to focus on clinical utility. The use of the term reaction throughout
`DSM—I reflected the