Neurocognitive Disorsers And Disruptive, Impulse Control Disorder

are a group of conditions with onset in the developmental period. The disorders typically manifest early in development, often before the child enters grade school, and are characterized by developmental deficits that produce impairments of personal, social, academic, or occupational functioning. The range of developmental deficits varies from very specific limitations of learning or control of executive functions to global impairments of social skills or intelligence

is characterized by deficits in general mental abilities, such as reasoning, problem solving, planning, abstract thinking, judgment, academic learning, and learning from experience. The deficits result in impairments of adaptive functioning, such that the individual fails to meet standards of personal independence and social responsibility in one or more aspects of daily life, including communication, social participation, academic or occupational functioning, and personal independence at home or in community settings.

, as its name implies, is diagnosed when an individual fails to meet expected developmental milestones in several areas of intellectual functioning. The diagnosis is used for individuals who are unable to undergo systematic assessments of intellectual functioning, including children who are too young to participate in standardized testing. Intellectual disability may result from an acquired insult during the developmental period from, for example, a severe head injury, in which case a neurocognitive disorder also may be diagnosed

disorder is characterized by disturbances of the normal fluency and motor production of speech, including repetitive sounds or syllables, prolongation of consonants or vowel sounds, broken words, blocking, or words produced with an excess of physical tension. Like other neurodevelopmental disorders, communication disorders begin early in life and may produce lifelong functional impairments.

is characterized by persistent deficits in social communication and social interaction across multiple contexts, including deficits in social reciprocity, nonverbal communicative behaviors used for social interaction, and skills in developing, maintaining, and understanding relationships. In addition to the social communication deficits, the diagnosis of autism spectrum disorder requires the presence of restricted, repetitive patterns of behavior, interests, or activities. Because symptoms change with development and may be masked by compensatory mechanisms, the diagnostic criteria may be met based on historical information, although the current presentation must cause significant impairment.

is a neurodevelopmental disorder defined by impairing levels of inattention, disorganization, and/or hyperactivity-impulsivity. Inattention and disorganization entail inability to stay on task, seeming not to listen, and losing materials, at levels that are inconsistent with age or developmental level. Hyperactivity-impulsivity entails overactivity, fidgeting, inability to stay seated, intruding into other people’s activities, and inability to wait—symptoms that are excessive for age or developmental level. In childhood, ______ frequently overlaps with disorders that are often considered to be “externalizing disorders,” such as oppositional defiant disorder and conduct disorder. ADHD often persists into adulthood, with resultant impairments of social, academic and occupational functioning

is characterized by deficits in the acquisition and execution of coordinated motor skills and is manifested by clumsiness and slowness or inaccuracy of performance of motor skills that cause interference with activities of daily living

is diagnosed when an individual has repetitive, seemingly driven, and apparently purposeless motor behaviors, such as hand flapping, body rocking, head banging, selfbiting, or hitting. The movements interfere with social, academic, or other activities. If the behaviors cause self-injury, this should be specified as part of the diagnostic description.

, as the name implies, is diagnosed when there are specific deficits in an individual’s ability to perceive or process information efficiently and accurately. This neurodevelopmental disorder first manifests during the years of formal schooling and is characterized by persistent and impairing difficulties with learning foundational academic skills in reading, writing, and/or math. The individual’s performance of the affected academic skills is well below average for age, or acceptable performance levels are achieved only with extraordinary effort. ________ may occur in individuals identified as intellectually gifted and manifest only when the learning demands or assessment procedures (e.g., timed tests) pose barriers that cannot be overcome by their innate intelligence and compensatory strategies. For all individuals, ________ can produce lifelong impairments in activities dependent on the skills, including occupational performance

is a disorder with onset duringthe developmental period that includes both intellectual and adaptive functioning deficitsin conceptual, social, and practical domains. The following three criteria must be met:

A. Deficits in intellectual functions, such as reasoning, problem solving, planning, abstractthinking, judgment, academic learning, and learning from experience, confirmed byboth clinical assessment and individualized, standardized intelligence testing.

B. Deficits in adaptive functioning that result in failure to meet developmental and sociocultural standards for personal independence and social responsibility. Without ongoing support, the adaptive deficits limit functioning in one or more activities of daily life,such as communication, social participation, and independent living, across multipleenvironments, such as home, school, work, and community.

C. Onset of intellectual and adaptive deficits during the developmental period.Note: The diagnostic term intellectual disability is the equivalent term for the ICD-11 diagnosis of intellectual developmental disorders. Although the term intellectual disability isused throughout this manual, both terms are used in the title to clarify relationships withother classification systems. Moreover, a federal statute in the United States (Public Law111-256, Rosa’s Law) replaces the term mental retardation with intellectual disability, andresearch journals use the term intellectual disability. Thus, intellectual disability is theterm in common use by medical, educational, and other professions and by the lay publicand advocacy groups.

Specify current severity (see Table 1): 317 (F70) Mild

318.0 (F71) Moderate

318.1 (F72) Severe

318.2 (F73) Profound

This diagnosis is reserved for individuals under the age of 5 years when the clinical severity level cannot be reliably assessed during early childhood. This category is diagnosed when an individual fails to meet expected developmental milestones in several areas of intellectual functioning, and applies to individuals who are unable to undergo systematic assessments of intellectual functioning, including children who are too young to participate in standardized testing. This category requires reassessment after a period of time.

is the expressive production of sounds and includes an individual’s articulation, fluency, voice, and resonance quality

includes the form, function, and use of a conventional system of symbols (i.e., spoken words, sign language, written words, pictures) in a rule-governed manner for communication.

includes any verbal or nonverbal behavior (whether intentional or unintentional) that influences the behavior, ideas, or attitudes of another individual.

A. Persistent difficulties in the acquisition and use of language across modalities (i.e.,spoken, written, sign language, or other) due to deficits in comprehension or production that include the following:

1. Reduced vocabulary (word knowledge and use).

2. Limited sentence structure (ability to put words and word endings together to formsentences based on the rules of grammar and morphology).

3. Impairments in discourse (ability to use vocabulary and connect sentences to explain or describe a topic or series of events or have a conversation).

B. Language abilities are substantially and quantifiably below those expected for age, resulting in functional limitations in effective communication, social participation, academic achievement, or occupational performance, individually or in any combination.

C. Onset of symptoms is in the early developmental period.

D. The difficulties are not attributable to hearing or other sensory impairment, motor dysfunction, or another medical or neurological condition and are not better explained by intellectual disability (intellectual developmental disorder) or global developmental delay.

A. Persistent difficulty with speech sound production that interferes with speech intelligibility or prevents verbal communication of messages.

B. The disturbance causes limitations in effective communication that interfere with socialparticipation, academic achievement, or occupational performance, individually or inany combination.

C. Onset of symptoms is in the early developmental period.

D. The difficulties are not attributable to congenital or acquired conditions, such as cerebral palsy, cleft palate, deafness or hearing loss, traumatic brain injury, or other medical or neurological conditions.

A. Disturbances in the normal fluency and time patterning of speech that are inappropriate for the individual’s age and language skills, persist over time, and are characterizedby frequent and marked occurrences of one (or more) of the following:

1. Sound and syllable repetitions.

2. Sound prolongations of consonants as well as vowels.

3. Broken words (e.g., pauses within a word).

4. Audible or silent blocking (filled or unfilled pauses in speech).

5. Circumlocutions (word substitutions to avoid problematic words).

6. Words produced with an excess of physical tension.

7. Monosyllabic whole-word repetitions (e.g., “I-I-I-I see him”).

B. The disturbance causes anxiety about speaking or limitations in effective communication, social participation, or academic or occupational performance, individually or inany combination.

C. The onset of symptoms is in the early developmental period.

(Note: Later-onset casesare diagnosed as 307.0 [F98.5] adult-onset fluency disorder.)

D. The disturbance is not attributable to a speech-motor or sensory deficit, dysfluency associated with neurological insult (e.g., stroke, tumor, trauma), or another medical condition and is not better explained by another mental disorde

A. Persistent difficulties in the social use of verbal and nonverbal communication as manifested by all of the following:

1. Deficits in using communication for social purposes, such as greeting and sharinginformation, in a manner that is appropriate for the social context.

2. Impairment of the ability to change communication to match context or the needs ofthe listener, such as speaking differently in a classroom than on a playground, talking differently to a child than to an adult, and avoiding use of overly formal language.

3. Difficulties following rules for conversation and storytelling, such as taking turns inconversation, rephrasing when misunderstood, and knowing how to use verbal andnonverbal signals to regulate interaction.

4. Difficulties understanding what is not explicitly stated (e.g., making inferences) andnonliteral or ambiguous meanings of language (e.g., idioms, humor, metaphors,multiple meanings that depend on the context for interpretation).

B. The deficits result in functional limitations in effective communication, social participation, social relationships, academic achievement, or occupational performance, individually or in combination.

C. The onset of the symptoms is in the early developmental period (but deficits may notbecome fully manifest until social communication demands exceed limited capacities).

D. The symptoms are not attributable to another medical or neurological condition or to lowabilities in the domains of word structure and grammar, and are not better explained byautism spectrum disorder, intellectual disability (intellectual developmental disorder),global developmental delay, or another mental disorder.

A. Characterized by persistent deficits in social communication and social interaction across multiple contexts– Deficits in social-emotional reciprocity– Deficit in nonverbal communicative behaviors used for social interaction, – Deficit in skills in developing, maintaining, and understanding relationships.

B. Presence of restricted, repetitive patterns of behavior, interests, or activities (2)

C. Symptoms occur during the developmental period

D. Functional Impairment

E. Not better explained by other mental disorder

Specify if:

With or without accompanying intellectual impairment

With or without accompanying language impairment

Associated with a known medical or genetic condition or environmental factor

(Coding note: Use additional code to identify the associated medical or genetic condition.)

Associated with another neurodevelopmental, mental, or behavioral disorder

(Coding note: Use additional code[s] to identify the associated neurodevelopmental,mental, or behavioral disorder[s].)

With catatonia (refer to the criteria for catatonia associated with another mental disorder, pp. 119–120, for definition) (Coding note: Use additional code 293.89 [F06.1]catatonia associated with autism spectrum disorder to indicate the presence of the comorbid catatonia.)

A. Defined by impairing levels of inattention, disorganization, and/or hyperactivity-impulsivity.

1. Inattention and disorganization (6 out of 9 symptoms) entail inability to stay on task, seeming not to listen, and losing materials, at levels that are inconsistent with age or developmental level.

2.Hyperactivity-impulsivity (6 out of 9 symptoms)entails overactivity, fidgeting, inability to stay seated, intruding into other people's activities, and inability to wait

—symptoms that are excessive for age or developmental level.

B. Symptoms were present prior to age 12 years.

C. Symptoms are present in two or more settings

D. Functional interference

E. The symptoms do not occur exclusively during the course of schizophrenia or another psychotic disorder and are not better explained by another mental disorder

Specify whether:

314.01 (F90.2) Combined presentation: If both Criterion A1 (inattention) and Criterion A2 (hyperactivity-impulsivity) are met for the past 6 months.

314.00 (F90.0) Predominantly inattentive presentation: If Criterion A1 (inattention)is met but Criterion A2 (hyperactivity-impulsivity) is not met for the past 6 months.

314.01 (F90.1) Predominantly hyperactive/impulsive presentation: If Criterion A2 (hyperactivity-impulsivity) is met and Criterion A1 (inattention) is not met for the past 6 months.

Specify if:

In partial remission: When full criteria were previously met, fewer than the full criteriahave been met for the past 6 months, and the symptoms still result in impairment insocial, academic, or occupational functioning.

Specify current severity:

Mild: Few, if any, symptoms in excess of those required to make the diagnosis arepresent, and symptoms result in no more than minor impairments in social or occupational functioning.

Moderate: Symptoms or functional impairment between “mild” and “severe” are present.

Severe: Many symptoms in excess of those required to make the diagnosis, or severalsymptoms that are particularly severe, are present, or the symptoms result in markedimpairment in social or occupational functioning.

A. Difficulties learning and using academic skills, as indicated by the presence of at least one of the following symptoms that have persisted for at least 6 months, despite the provision of interventions that target those difficulties:

1. Inaccurate or slow and effortful word reading

2. Difficulty understanding the meaning of what is read

3. Difficulties with spelling

4. Difficulties with written expression

5. Difficulties mastering number sense, number facts, or calculation

6. Difficulties with mathematical reasoning

Specify if:

With impairment in reading: Formally known as dyslexia, reading disorder is characterized by an impaired ability to recognize words, poor comprehension, and slow and inaccurate reading.

With impairment in mathematics: Also known as dyscalculia. Child has difficulty with learning and remembering numerals, remembering and applying basic facts about numbers, and is slow and inaccurate in computation.

Witli impairment in written expression: Characterized by frequent grammatical and punctuation errors and poor spelling and handwriting skills

Specify current severity:

Mild 1-2 academic domains

Moderate 2+ academic domains

Severe several academic domains

A. The acquisition and execution of coordinated motor skills is substantially below that expected given the individual’s chronological age and opportunity for skill learning anduse. Difficulties are manifested as clumsiness (e.g., dropping or bumping into objects)as well as slowness and inaccuracy of performance of motor skills (e.g., catching anobject, using scissors or cutlery, handwriting, riding a bike, or participating in sports).

B. The motor skills deficit in Criterion A significantly and persistently interferes with activities of daily living appropriate to chronological age (e.g., self-care and self-maintenance) and impacts academic/school productivity, prevocational and vocationalactivities, leisure, and play.

C. Onset of symptoms is in the early developmental period.

D. The motor skills deficits are not better explained by intellectual disability (intellectual developmental disorder) or visual impairment and are not attributable to a neurological condition affecting movement (e.g., cerebral palsy, muscular dystrophy, degenerative disorder)

A. Repetitive, seemingly driven, and apparently purposeless motor behavior (e.g., handshaking or waving, body rocking, head banging, self-biting, hitting own body).

B. The repetitive motor behavior interferes with social, academic, or other activities andmay result in self-injury.

C. Onset is in the early developmental period.

D. The repetitive motor behavior is not attributable to the physiological effects of a substance or neurological condition and is not better explained by another neurodevelopmental or mental disorder (e.g., trichotillomania [hair-pulling disorder], obsessivecompulsive disorder).

Specify if:

With self-injurious behavior (or behavior that would result in an injury if preventivemeasures were not used)

Without self-injurious behavior

Specify if:

Associated with a known medical or genetic condition, neurodevelopmental disorder, or environmental factor (e.g., Lesch-Nyhan syndrome, intellectual disability[intellectual developmental disorder], intrauterine alcohol exposure)

Coding note: Use additional code to identify the associated medical or geneticcondition, or neurodevelopmental disorder.

Specify current severity:

Mild: Symptoms are easily suppressed by sensory stimulus or distraction.

Moderate: Symptoms require explicit protective measures and behavioral modification.

Severe: Continuous monitoring and protective measures are required to prevent serious injury.

A ____ is a sudden, rapid, recurrent, nonrhythmic motor movement or vocalization.

A. Both multiple motor and one or more vocal tics have been present at some time during the illness, although not necessarily concurrently. B. The tics may wax and wane in frequency but have persisted for more than 1 year since first tic onset. C. Onset is before age 18 years. D. The disturbance is not attributable to the physiological effects of a substance (e.g., cocaine) or another medical condition (e.g., Huntington’s disease, postviral encephalitis).

A. Single or multiple motor or vocal tics have been present during the illness, but not both motor and vocal. B. The tics may wax and wane in frequency but have persisted for more than 1 year since first tic onset. C. Onset is before age 18 years. D. The disturbance is not attributable to the physiological effects of a substance (e.g., cocaine) or another medical condition (e.g., Huntington’s disease, postviral encephalitis). E. Criteria have never been met for Tourette’s disorder. Specify if: With motor tics only With vocal tics only

A. Single or multiple motor and/or vocal tics.

B. The tics have been present for less than 1 year since first tic onset.

C. Onset is before age 18 years.

D. The disturbance is not attributable to the physiological effects of a substance (e.g., cocaine) or another medical condition (e.g., Huntington’s disease, postviral encephalitis).

E. Criteria have never been met for Tourette’s disorder or persistent (chronic) motor or vocal tic disorder.

include conditions involving problems in the self-control of emotions and behaviors. While other disorders in DSM- 5 may also involve problems in emotional and/or behavioral regulation, the disorders in this chapter are unique in that these problems are manifested in behaviors that violate the rights of others (e.g., aggression, destruction of property) and/or that bring the individual into significant conflict with societal norms or authority figures. The underlying causes of the problems in the self-control of emotions and behaviors can vary greatly across the disorders in this chapter and among individuals within a given diagnostic category.

A. A pattern of angry/irritable mood, argumentative/defiant behavior, or vindictiveness lastingat least 6 months as evidenced by at least four symptoms from any of the following categories, and exhibited during interaction with at least one individual who is not a sibling.

Angry/Irritable Mood

1. Often loses temper.

2. Is often touchy or easily annoyed.

3. Is often angry and resentful.

Argumentative/Defiant Behavior

4. Often argues with authority figures or, for children and adolescents, with adults.

5. Often actively defies or refuses to comply with requests from authority figures orwith rules.

6. Often deliberately annoys others.

7. Often blames others for his or her mistakes or misbehavior.Vindictiveness

8. Has been spiteful or vindictive at least twice within the past 6 months.

Note: The persistence and frequency of these behaviors should be used to distinguisha behavior that is within normal limits from a behavior that is symptomatic. For childrenyounger than 5 years, the behavior should occur on most days for a period of at least6 months unless otherwise noted (Criterion A8). For individuals 5 years or older, thebehavior should occur at least once per week for at least 6 months, unless otherwisenoted (Criterion A8). While these frequency criteria provide guidance on a minimal level of frequency to define symptoms, other factors should also be considered, such aswhether the frequency and intensity of the behaviors are outside a range that is normative for the individual’s developmental level, gender, and culture.

B. The disturbance in behavior is associated with distress in the individual or others in his orher immediate social context (e.g., family, peer group, work colleagues), or it impacts negatively on social, educational, occupational, or other important areas of functioning.

C. The behaviors do not occur exclusively during the course of a psychotic, substanceuse, depressive, or bipolar disorder. Also, the criteria are not met for disruptive mooddysregulation disorder.

Specify current severity:

Mild: Symptoms are confined to only one setting (e.g., at home, at school, at work, withpeers).

Moderate: Some symptoms are present in at least two settings.

Severe: Some symptoms are present in three or more settings.

A. Recurrent behavioral outbursts representing a failure to control aggressive impulses as manifested by either of the following:

1. Verbal aggression (e.g., temper tantrums, tirades, verbal arguments or fights) or physical aggression toward property, animals, or other individuals, occurring twice weekly, on average, for a period of 3 months. The physical aggression does not result in damage or destruction of property and does not result in physical injury to animals or other individuals.

2. Three behavioral outbursts involving damage or destruction of property and/or physical assault involving physical injury against animals or other individuals occurring within a 12-month period.

B. The magnitude of aggressiveness expressed during the recurrent outbursts is grossly out of proportion to the provocation or to any precipitating psychosocial stressors.

C. The recurrent aggressive outbursts are not premeditated (i.e., they are impulsive and/ or anger-based) and are not committed to achieve some tangible objective (e.g., money, power, intimidation).

D. The recurrent aggressive outbursts cause either marked distress in the individual or impairment in occupational or interpersonal functioning, or are associated with financial or legal consequences.

E. Chronological age is at least 6 years (or equivalent developmental level).

F. The recurrent aggressive outbursts are not better explained by another mental disorder (e.g., major depressive disorder, bipolar disorder, disruptive mood dysregulation disorder, a psychotic disorder, antisocial personality disorder, borderline personality disorder) and are not attributable to another medical condition (e.g., head trauma, Alzheimer’s disease) or to the physiological effects of a substance (e.g., a drug of abuse, a medication). For children ages 6–18 years, aggressive behavior that occurs as part of an adjustment disorder should not be considered for this diagnosis.

Note: This diagnosis can be made in addition to the diagnosis of attention-deficit/hyperactivity disorder, conduct disorder, oppositional defiant disorder, or autism spectrum disorder when recurrent impulsive aggressive outbursts are in excess of those usually seen in these disorders and warrant independent clinical attention.

A. A repetitive and persistent pattern of behavior in which the basic rights of others or major age-appropriate societal norms or rules are violated

1. Aggression to People or Animals

2. Destruction of Property

3. Deceitfulness or Theft

4. Serious violation of rules

B. Functional impairment

C. If the individual is age 18 years or older, criteria are not met for antisocial personality disorder

Specify whether:

312.81 (F91.1) Childhood-onset type: Individuals show at least one symptom characteristic of conduct disorder prior to age 10 years.

312.82 (F91.2) Adolescent-onset type: Individuals show no symptom characteristicof conduct disorder prior to age 10 years.

312.89 (F91.9) Unspecified onset: Criteria for a diagnosis of conduct disorder aremet, but there is not enough information available to determine whether the onset ofthe first symptom was before or after age 10 years.

Specify if:

With limited prosocial emotions: To qualify for this specifier, an individual must have displayed at least two of the following characteristics persistently over at least 12 months andin multiple relationships and settings. These characteristics reflect the individual’s typicalpattern of interpersonal and emotional functioning over this period and not just occasionaloccurrences in some situations. Thus, to assess the criteria for the specifier, multiple information sources are necessary. In addition to the individual’s self-report, it is necessary toconsider reports by others who have known the individual for extended periods of time(e.g., parents, teachers, co-workers, extended family members, peers).Lack of remorse or guilt: Does not feel bad or guilty when he or she does something wrong (exclude remorse when expressed only when caught and/or facingpunishment). The individual shows a general lack of concern about the negativeconsequences of his or her actions. For example, the individual is not remorsefulafter hurting someone or does not care about the consequences of breaking rules.

Callous—lack of empathy: Disregards and is unconcerned about the feelings ofothers. The individual is described as cold and uncaring. The person appears moreconcerned about the effects of his or her actions on himself or herself, rather thantheir effects on others, even when they result in substantial harm to others.Unconcerned about performance: Does not show concern about poor/problematic performance at school, at work, or in other important activities. The individualdoes not put forth the effort necessary to perform well, even when expectations areclear, and typically blames others for his or her poor performance.

Shallow or deficient affect: Does not express feelings or show emotions to others,except in ways that seem shallow, insincere, or superficial (e.g., actions contradict theemotion displayed; can turn emotions “on” or “off” quickly) or when emotional expressions are used for gain (e.g., emotions displayed to manipulate or intimidate others).

Specify current severity:

Mild: Few if any conduct problems in excess of those required to make the diagnosisare present, and conduct problems cause relatively minor harm to others (e.g., lying,truancy, staying out after dark without permission, other rule breaking).

Moderate: The number of conduct problems and the effect on others are intermediatebetween those specified in “mild” and those in “severe” (e.g., stealing without confronting a victim, vandalism).

Severe: Many conduct problems in excess of those required to make the diagnosis arepresent, or conduct problems cause considerable harm to others (e.g., forced sex, physicalcruelty, use of a weapon, stealing while confronting a victim, breaking and entering)

A. Deliberate and purposeful fire setting on more than one occasion.

B. Tension or affective arousal before the act.

C. Fascination with, interest in, curiosity about, or attraction to fire and its situational contexts (e.g., paraphernalia, uses, consequences).

D. Pleasure, gratification, or relief when setting fires or when witnessing or participatingin their aftermath.

E. The fire setting is not done for monetary gain, as an expression of sociopolitical ideology, to conceal criminal activity, to express anger or vengeance, to improve one’s livingcircumstances, in response to a delusion or hallucination, or as a result of impairedjudgment (e.g., in major neurocognitive disorder, intellectual disability [intellectual developmental disorder], substance intoxication).F. The fire setting is not better explained by conduct disorder, a manic episode, or antisocial personality disorder.

A. Recurrent failure to resist impulses to steal objects that are not needed for personaluse or for their monetary value.

B. Increasing sense of tension immediately before committing the theft.

C. Pleasure, gratification, or relief at the time of committing the theft.

D. The stealing is not committed to express anger or vengeance and is not in responseto a delusion or a hallucination.

E. The stealing is not better explained by conduct disorder, a manic episode, or antisocialpersonality disorder.

A. A pervasive pattern of disregard for and violation of the rights of others, occurring sinceage 15 years, as indicated by three (or more) of the following:

1. Failure to conform to social norms with respect to lawful behaviors, as indicated byrepeatedly performing acts that are grounds for arrest.

2. Deceitfulness, as indicated by repeated lying, use of aliases, or conning others forpersonal profit or pleasure.

3. Impulsivity or failure to plan ahead.

4. Irritability and aggressiveness, as indicated by repeated physical fights or assaults.

5. Reckless disregard for safety of self or others.

6. Consistent irresponsibility, as indicated by repeated failure to sustain consistentwork behavior or honor financial obligations.

7. Lack of remorse, as indicated by being indifferent to or rationalizing having hurt,mistreated, or stolen from another.

B. The individual is at least age 18 years.

C. There is evidence of conduct disorder with onset before age 15 years.

D. The occurrence of antisocial behavior is not exclusively during the course of schizophrenia or bipolar disorder.

• Presence of five or more of the following in many contexts beginning by early adulthood:

1. Frantic efforts to avoid abandonment

2. Unstable interpersonal relationships in which others are either idealized or devalued

3. Unstable sense of self

4. Self-damaging, impulsive behaviors in at least two areas, such as spending, sex, substance abuse, reckless driving, and binge eating

5. Recurrent suicidal behavior, gestures, or self-injurious behavior (e.g., cutting self)

6. Marked mood reactivity

7. Chronic feelings of emptiness– Recurrent bouts of intense or poorly controlled anger

8. During stress, a tendency to experience transient paranoid thoughts an dissociative symptoms

A pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following: 1. Frantic efforts to avoid real or imagined abandonment. (Note: Do not include suicidal or self-mutilating behavior covered in Criterion 5.) 2. A pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation. 3. Identity disturbance: markedly and persistently unstable self-image or sense of self. 4. Impulsivity in at least two areas that are potentially self-damaging (e.g., spending, sex, substance abuse, reckless driving, binge eating). (Note: Do not include suicidal or selfmutilating behavior covered in Criterion 5.) 5. Recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior. 6. Affective instability due to a marked reactivity of mood (e.g., intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days). 7. Chronic feelings of emptiness. 8. Inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights). 9. Transient, stress-related paranoid ideation or severe dissociative symptoms.