Paraphilic Disorders

Paraphilic Disorders
paraphilic disorders are unusual sexual behaviors or interests that can cause distress to the
person or harm to others. Some examples of these behaviors include:
1. Voyeuristic disorder: Spying on others while they are in private activities, like
changing or bathing.
2. Exhibitionistic disorder: Exposing genitals to strangers.
3. Frotteuristic disorder: Touching or rubbing against someone without their consent.
4. Sexual masochism disorder: Enjoying being hurt or humiliated during sexual

activities.
5. Sexual sadism disorder: Gaining sexual pleasure from hurting or humiliating others.
6. Pedophilic disorder: Having a sexual interest in children.
7. Fetishistic disorder: Having a strong sexual focus on non-living objects (like shoes) or
non-genital body parts (like feet).
8. Transvestic disorder: Becoming sexually aroused by dressing in clothes typically worn

by the opposite gender.
Not everyone who has these interests has a disorder. It becomes a "paraphilic disorder"
when it causes the person distress or leads to actions that harm others. For example, if
someone has these interests but they don't act on them in harmful ways or don't feel upset
about them, they might not need a diagnosis or treatment.
Voyeuristic Disorder involves a person becoming sexually aroused by

watching someone who is naked, changing clothes, or engaged in sexual activity without
that person knowing. To be diagnosed with this disorder, the following criteria must be met:
1. Duration: The person experiences intense sexual arousal from secretly watching
others for at least 6 months.
2. Actions or distress: The person has either acted on these urges with non-
consenting people or the urges cause them significant distress or problems in their
daily life (like work or relationships).
3. Age: The person must be at least 18 years old. This is to avoid confusing this
disorder with normal sexual curiosity during adolescence.
Key Features:
 In a controlled environment: This means the person is in a place, like a hospital or

prison, where they can't easily engage in voyeurism.
 In full remission: This means the person has not acted on their urges and has had
no distress for at least 5 years, even in a normal environment where they would have
opportunities.
Prevalence and Development:
 Voyeuristic behavior is quite common, especially in males, with an estimated 12% of

men and 4% of women engaging in it at some point in life.
 The disorder often starts in adolescence, but it can only be diagnosed after the age of
18.
 Voyeuristic disorder can develop due to factors like childhood abuse, hypersexuality,
or substance abuse, though the exact causes aren't clear.
Risk Factors:
 Temperament: People with strong voyeuristic tendencies are at higher risk of

developing the disorder.
 Environment: Early sexual trauma or misuse of substances can increase the risk.
The disorder can cause distress or harm, especially if it leads to spying on non-consenting
individuals, which can be both a psychological and legal issue.
Exhibitionistic Disorder is characterized by intense sexual arousal from

exposing one’s genitals to an unsuspecting person, which causes either distress or
impairment in functioning, or the individual has acted on these urges with a non-consenting
person. The diagnostic criteria are as follows:
Diagnostic Criteria:
1. Duration: For at least 6 months, the individual experiences recurrent and intense
sexual arousal from exposing their genitals to an unsuspecting person. This arousal
may be expressed through fantasies, urges, or behaviors.
2. Actions or distress: The person has either acted on these urges with a non-
consenting individual, or their urges or fantasies cause them significant distress or
impairment in important areas of life (social, occupational, etc.).
3. Specify: The individual may be:
o Aroused by exposing genitals to prepubescent children,
o Aroused by exposing genitals to physically mature individuals,
o Aroused by exposing genitals to both prepubescent children and mature

individuals.
Additional Specifiers:
 In a controlled environment: For individuals in institutional settings where their

ability to expose their genitals is restricted.
 In full remission: The person has not acted on these urges, nor experienced
distress or impairment for at least 5 years, even in a setting where opportunities to
expose themselves exist.
Key Features:
 Disclosers vs. Nondisclosers: Some individuals may openly admit to this behavior
and its associated distress. Others may deny any sexual attraction or arousal despite
clear evidence of recurrent behavior.
 Recurrent: This usually means multiple victims, but the criteria can still be met with
fewer victims if the behavior is repeated with the same person or there's a clear
preference for genital exposure.
 Threshold for Diagnosis: The sexual interest in exposing oneself must persist for at
least 6 months, but the time frame is flexible, especially if the behavior is recurrent.
Prevalence:
 The highest estimated prevalence in males is between 2% and 4%, while it's believed
to be much lower in females.
Development and Course:
 The disorder typically begins in adolescence or early adulthood, later than the
development of typical sexual interests.
 As the person ages, exhibitionistic behaviors may decrease, but the course of the
disorder varies.
Risk Factors:
 Temperamental: People with a history of antisocial personality disorder, alcohol

misuse, or pedophilic interests are at a higher risk.
 Environmental: Childhood sexual or emotional abuse and hypersexuality are

potential risk factors, though the exact relationship to the disorder is unclear.
Exhibitionistic Disorder is differentiated from normal sexual curiosity by its persistence over
time, the distress it causes, or the fact that the individual acts on these urges with non-
consenting individuals.
Frotteuristic Disorder involves recurrent and intense sexual arousal

from touching or rubbing against a nonconsenting person, causing distress or impairment, or
the person acts on these urges. Below is a summary of the diagnostic criteria, features, and
other relevant aspects of the disorder:
1. Duration: For at least 6 months, the individual experiences recurrent and intense
sexual arousal from touching or rubbing against a nonconsenting person, as
expressed through fantasies, urges, or behaviors.
2. Actions or distress: The person has either acted on these urges with a
nonconsenting individual, or these urges or fantasies cause significant distress or
impairment in social, occupational, or other areas of functioning.
Specifiers:
 In a controlled environment: This applies to individuals living in institutional

settings where opportunities to touch or rub against nonconsenting persons are
restricted.
 In full remission: The person has not acted on these urges with nonconsenting
individuals, nor experienced distress or impairment for at least 5 years, even when
not in a controlled environment.
 Time Frame: The 6-month criterion is a guideline, not a strict rule, and can be
fulfilled with clear evidence of recurrent behavior over a shorter period.
Prevalence:
 Frotteuristic acts, such as uninvited sexual touching or rubbing, may occur in up to

30% of adult males in the general population.
 In outpatient clinical settings for paraphilic disorders, approximately 10% to 14% of

adult males meet the diagnostic criteria for frotteuristic disorder. The exact
population prevalence is unknown but likely lower than these clinical rates.
 Most adult males with the disorder report becoming aware of their sexual interest in
this behavior during late adolescence or early adulthood.
 Children and adolescents may engage in similar behaviors without necessarily

meeting the criteria for frotteuristic disorder. Differentiating this from non-sexual
conduct issues in younger individuals can be difficult.
 Over time, factors such as subjective distress, psychiatric comorbidity, sexual

impulsivity, and psychosocial impairment may influence the course of the disorder,
though advancing age is often associated with a decline in frotteuristic behaviors.
Risk and Prognostic Factors:
 Temperamental: Antisocial behavior, hypersexuality, and sexual impulsivity may

serve as nonspecific risk factors. However, frotteurism itself is a necessary
precondition for frotteuristic disorder.
Gender-Related Diagnostic Issues:
 Frotteuristic disorder is far more common in males than in females, with significantly
fewer women exhibiting this behavior.
Frotteuristic Disorder, like other paraphilias, is diagnosed based on

persistent behavior or distress resulting from urges to touch nonconsenting individuals, and
it significantly impairs the individual’s functioning.
Sexual Masochism Disorder involves an individual's intense sexual arousal from being
humiliated, beaten, bound, or made to suffer. Below is an overview of the diagnostic criteria
and relevant details:
Diagnostic Criteria (302.83 F65.51):
1. Duration: For at least 6 months, the person experiences recurrent and intense
sexual arousal from being humiliated, beaten, bound, or made to suffer, as evidenced
by fantasies, urges, or behaviors.
2. Distress or Impairment: These fantasies, urges, or behaviors cause clinically

significant distress or impairment in important areas of functioning such as social,
occupational, or personal life.
Specifiers:
 With Asphyxiophilia: If the person achieves sexual arousal by restricting breathing.
 In a Controlled Environment: This applies to individuals living in institutional

settings where opportunities to engage in masochistic sexual behavior are restricted.
 In Full Remission: No distress or impairment has been observed for at least 5 years
while in an uncontrolled environment.
Diagnostic Features:
 Individuals who are diagnosed with Sexual Masochism Disorder typically

acknowledge their intense sexual arousal from humiliation or suffering and report
psychosocial difficulties due to these urges.
 If there is no distress or impairment (e.g., no feelings of guilt or shame), the person

may have masochistic sexual interest but would not meet the criteria for a full
disorder diagnosis.
Associated Features Supporting Diagnosis:
 Extensive use of pornography that involves being humiliated, beaten, bound, or

made to suffer is sometimes associated with the disorder.
Prevalence:
 The exact prevalence is unknown. However, a study in Australia estimated that 2.2%
of males and 1.3% of females had engaged in activities such as bondage and
discipline, sadomasochism, or dominance and submission within the past year.
 The mean age of onset for masochistic fantasies is typically 19.3 years, though
some report earlier onset during puberty or childhood.
 The course of Sexual Masochism Disorder can vary and is influenced by factors
such as subjective distress (e.g., guilt, shame), psychiatric comorbidities,
hypersexuality, sexual impulsivity, and psychosocial impairment.
 Advancing age tends to reduce sexual masochistic preferences, as it does with other
sexual behaviors.
Functional Consequences:
 The direct functional consequences of Sexual Masochism Disorder are unclear,

but individuals who practice asphyxiophilia or other dangerous autoerotic behaviors
are at risk of accidental death.
This disorder is characterized by distress and impairment caused by sexual arousal related
to suffering and humiliation, and poses potential physical risks, particularly with extreme
behaviors like asphyxiophilia.
Sexual Sadism Disorder is characterized by intense sexual arousal

from the physical or psychological suffering of another person, which may be associated
with significant distress or impairment in functioning. Below is a detailed overview of the
disorder:
1. Duration: Over at least 6 months, the individual experiences recurrent and intense
sexual arousal from the physical or psychological suffering of another person, as
shown through fantasies, urges, or behaviors.
2. Behavior and Consequences: The individual has acted on these sexual urges with
a nonconsenting person, or the sexual urges/fantasies cause significant distress or
impairment in social, occupational, or other important areas of functioning.
Specifiers:
 In a Controlled Environment: This applies to individuals living in settings like

institutions, where opportunities to engage in sadistic behaviors are restricted.
 In Full Remission: The person has not acted on their sadistic urges with a
nonconsenting person, nor experienced distress or impairment for at least 5 years in
an uncontrolled environment.
 The diagnostic criteria apply to individuals who either openly admit to having sadistic
sexual interests or those who deny such interests despite objective evidence.
 Admitting individuals: If they report distress or impairment from their sexual

interests in inflicting pain or suffering, they may be diagnosed with Sexual Sadism
Disorder. If they deny distress but acknowledge their sexual interest without acting
on it, they may not meet the full criteria.
 Nondisclosing individuals: Those who have inflicted pain or suffering on multiple

victims but deny any sadistic urges or fantasies may still be diagnosed if their
behavior aligns with the disorder’s criteria.
 Extensive use of pornography that depicts the infliction of pain or suffering may be
associated with Sexual Sadism Disorder.
Prevalence:
 The prevalence in the general population is unknown and primarily based on forensic
samples. Estimates vary widely depending on the context. Among civilly committed
sexual offenders in the U.S., fewer than 10% meet criteria for Sexual Sadism
Disorder. However, among those who have committed sexually motivated homicides,
rates range from 37% to 75%.
 Sexual Sadism typically emerges in young adulthood. Males report an average onset
age of around 19.4 years, though some cases have been reported earlier. Females
with sadomasochistic orientations have been noted to become aware of their
preferences in early adulthood.
 While sexual sadism itself is likely a lifelong characteristic, Sexual Sadism
Disorder may fluctuate over time based on the individual’s subjective distress or
propensity to harm nonconsenting others.
 Advancing age generally reduces sexual sadistic behaviors, similar to other paraphilic
and normophilic sexual behaviors.
 Sexual Sadism Disorder may result in legal consequences, relational problems, or

occupational difficulties, particularly when nonconsenting individuals are involved,
leading to significant harm to others and distress to the perpetrator.
This disorder involves dangerous behaviors toward others, often escalating to significant
harm or criminal actions, particularly in nonconsensual contexts. The progression and
intensity of the disorder can fluctuate, especially in the absence of distress or external
constraints.
Pedophilic Disorder involves recurrent, intense sexual urges, fantasies,

or behaviors focused on prepubescent children, typically aged 13 years or younger. It differs
from mere sexual interest in children because it also includes distress, dysfunction, or
actions involving a non-consenting child. Below is a detailed explanation of the disorder:
1. Duration: For at least 6 months, the individual experiences recurrent, intense

sexually arousing fantasies, sexual urges, or behaviors involving sexual activity with
a prepubescent child or children (generally under 13 years old).
2. Behavior and Consequences: The individual has acted on these sexual urges, or
they cause significant distress or interpersonal difficulties.
3. Age Requirement: The individual must be at least 16 years old and at least 5 years
older than the child or children in Criterion A.
o Note: This excludes individuals in late adolescence who are involved in

consensual sexual relationships with a 12- or 13-year-old.
Specifiers:
 Exclusive Type: Attracted only to children.
 Nonexclusive Type: Attracted to both children and physically mature individuals.
 Sexual Attraction: To males, females, or both.
 Limited to Incest: When sexual attraction is limited to related children.
 Admitting Individuals: These individuals acknowledge a strong sexual interest in

children and may even express that this interest is stronger or equal to their interest
in adults. If they report distress or difficulties due to their attraction to children, they
may be diagnosed with Pedophilic Disorder.
 Non-Admitting Individuals: These individuals deny sexual interest in children

despite clear evidence of behavior or urges. For example, they may have approached
multiple children for sexual purposes or may admit to past sexual encounters with
children but deny ongoing sexual attraction. They can still be diagnosed if their
behaviors fit the criteria.
The duration requirement (at least 6 months) ensures that the sexual attraction to children
is not a transient condition. However, a shorter duration may suffice if there is clear clinical
evidence.
 Pornography Use: Extensive use of pornography featuring prepubescent children is

often a strong indicator of Pedophilic Disorder. Individuals may gravitate toward this
kind of material because it matches their sexual interests.
Prevalence:
 The population prevalence of Pedophilic Disorder is unknown. Estimates suggest that

up to 3-5% of the male population may have pedophilic tendencies, while the
prevalence in females is likely much lower. Pedophilic disorder in women is extremely
rare and poorly understood.
 Awareness: Many adult males with Pedophilic Disorder report becoming aware of
their sexual interest in children around the time of puberty, similar to the
development of sexual interest in mature individuals.
 Age Considerations: Pedophilia may manifest early, but diagnosing it in

adolescence is difficult due to the challenges of distinguishing it from age-appropriate
sexual interest in peers. This is why Criterion C requires the individual to be at least
16 years old and at least 5 years older than the prepubescent children they are
attracted to.
 Lifelong Condition: Pedophilia is thought to be a lifelong condition, but Pedophilic

Disorder may fluctuate depending on distress, psychosocial factors, or the propensity
to act out. Advancing age generally reduces the frequency of both normophilic and
paraphilic behaviors.
Risk and Prognostic Factors:
 Temperamental Factors: An interaction between pedophilia and antisocial

tendencies increases the likelihood that males with both traits will act on their sexual
urges. Antisocial Personality Disorder is thus considered a risk factor.
 Environmental Factors: Many males with Pedophilic Disorder report childhood

sexual abuse, though it is unclear whether this is a causal factor.
 Genetic/Physiological Factors: Neurodevelopmental issues in utero may increase

the likelihood of developing pedophilia, which in turn increases the risk of Pedophilic
Disorder.
Pedophilic Disorder poses significant challenges due to its potential for harm to children and
the distress it can cause for the individual experiencing these urges, especially if acted
upon. Treatment focuses on managing urges and preventing harmful behaviors.
Fetishistic Disorder involves recurrent and intense sexual arousal from the use of
nonliving objects or a focus on specific, non-genital body parts, which causes significant
distress or impairment. Below are the details for the diagnosis:
A. Over at least 6 months, the individual experiences recurrent and intense sexual arousal
from nonliving objects or a highly specific focus on nongenital body parts, as manifested by
fantasies, urges, or behaviors. B. These fantasies, urges, or behaviors cause clinically
significant distress or impairment in social, occupational, or other important areas of
functioning. C. The fetish objects are not limited to articles of clothing used in cross-dressing
(as in transvestic disorder) or devices specifically designed for genital stimulation (e.g.,
vibrators).
Specifiers:
 Body part(s): If the fetish focuses on a specific part of the body (e.g., feet, hair).
 Nonliving object(s): If the fetish focuses on an inanimate object (e.g., shoes,

underwear).
 Other: Other specific fetishes that do not fit into the categories above.
 In a controlled environment: This applies to individuals who live in institutional

settings where opportunities to engage in fetishistic behaviors are restricted.
 In full remission: The individual has not experienced distress or impairment related
to the fetish for at least 5 years in an uncontrolled environment.
 The key feature of Fetishistic Disorder is the persistent use of nonliving objects (e.g.,
clothing, footwear) or an intense focus on nongenital body parts (e.g., feet, hair) for
sexual arousal.
 The disorder must also cause significant distress or impair functioning in major areas
of life (social, occupational, etc.).
 The focus of arousal must not be limited to objects used in cross-dressing or sexual
devices like vibrators.
 Partialism: A form of fetishism where sexual arousal is focused exclusively on body

parts, such as feet or hair.
 Individuals may engage with their fetish objects during sexual activity by rubbing,
holding, tasting, or smelling the objects, or by having a partner use them.
 Many individuals with Fetishistic Disorder collect large numbers of fetish objects.
 Fetishes often begin in adolescence, and once developed, the disorder tends to
persist throughout life, though the intensity and frequency of urges can fluctuate.
 Some individuals experience an onset of fetishistic interest even before puberty.
 Fetishistic behaviors may become more pronounced or diminish over time, depending
on individual circumstances.
Cultural-Related Diagnostic Issues:
 Cultural norms surrounding sexual behavior play a role in determining whether a

behavior is considered clinically abnormal or socially acceptable. Understanding
these norms is essential for diagnosis.
Gender-Related Diagnostic Issues:
 Fetishistic Disorder is reported almost exclusively in males. It is rarely reported in

females in clinical settings.
Functional Consequences of Fetishistic Disorder:
 Sexual dysfunction in relationships may arise when the fetish object or body part is
unavailable during sexual activity. Some individuals prefer solitary sexual activities
centered on their fetish, even when in a relationship.
 In some cases, individuals with Fetishistic Disorder may steal or collect their desired
fetish objects (e.g., shoes, underwear), leading to nonsexual criminal behaviors like
theft or burglary.
While Fetishistic Disorder is relatively uncommon, the disorder can lead to significant
challenges, especially in romantic relationships or in cases where fetishistic behavior leads
to legal trouble. Treatment may involve managing distress and reducing the impact on
functioning.
Transvestic Disorder involves recurrent and intense sexual arousal from cross-dressing,
causing significant distress or impairment. Below are the diagnostic details:
A. Over at least 6 months, the individual experiences recurrent and intense sexual arousal
from cross-dressing, as manifested by fantasies, urges, or behaviors. B. These fantasies,
urges, or behaviors cause clinically significant distress or impairment in social, occupational,
or other important areas of functioning.
Specifiers:
 With fetishism: If sexually aroused by fabrics, materials, or garments.
 With autogynephilia: If sexually aroused by thoughts or images of oneself as

female.
 In a controlled environment: Applies to individuals living in institutional or other

settings where opportunities to cross-dress are restricted.
 In full remission: No distress or impairment in functioning for at least 5 years while

in an uncontrolled environment.
 The diagnosis applies to individuals whose cross-dressing or thoughts of cross-
dressing are frequently accompanied by sexual excitement and who experience
distress or functional impairment (social or interpersonal). Cross-dressing may
involve partial (e.g., undergarments) or complete outfits, and for men, often includes
wigs and makeup.
 In many cases, cross-dressing is followed by masturbation or sexual activity. Younger

individuals may remove clothing after ejaculation, while older individuals might avoid
stimulation to prolong the cross-dressing experience.
 Autogynephilia is often seen, where a male is sexually aroused by the thought or

image of himself as a woman. Fantasies may include engaging in stereotypical
female behaviors or having female anatomy (e.g., breasts).
Prevalence:
 Transvestic Disorder is rare, primarily reported in males. Less than 3% of males report
sexual arousal from dressing in women’s attire at any point in their lives. It is even
rarer in females.
 Most individuals with this disorder identify as heterosexual, though some may have
occasional sexual interactions with males, particularly when cross-dressed.
 The onset often occurs in childhood, starting with a fascination with specific items of
women’s clothing. Cross-dressing produces pleasurable excitement before puberty
and begins to elicit sexual arousal at puberty, sometimes leading to masturbation
and ejaculation.
 In some cases, sexual excitement linked to cross-dressing diminishes with age, but
the desire to cross-dress may persist or increase, bringing feelings of comfort or well-
being.
 The course may be continuous or episodic. Cross-dressing behavior may temporarily

abate during romantic relationships but tends to return, causing distress when it
interferes with conventional heterosexual roles.
 Some individuals with Transvestic Disorder may develop gender dysphoria, seeking
to feminize their bodies or live in the female role for longer periods. This can reduce
or eliminate the sexual arousal initially tied to cross-dressing.
 The behavior can strain or interfere with heterosexual relationships, especially for
those trying to maintain traditional marriages or partnerships with women. This often
causes distress when cross-dressing conflicts with their desires for conventional
family life.
Transvestic Disorder often involves deep personal conflict, especially when it intersects with
romantic relationships or traditional gender expectations. The progression to gender
dysphoria in some cases adds complexity, requiring careful clinical attention.
Obsessive-Compulsive and Related Disorders
Obsessive-compulsive and related disorders include a range of conditions characterized by
repetitive thoughts, behaviors, or urges that can cause significant distress or impair
everyday functioning. Here’s a breakdown of these disorders:
1. Obsessive-Compulsive Disorder (OCD)
 Obsessions: Recurrent, intrusive, and unwanted thoughts, urges, or images that

cause distress (e.g., contamination fears, aggressive or taboo thoughts).
 Compulsions: Repetitive behaviors (e.g., washing, checking) or mental acts (e.g.,

counting, repeating) that individuals feel compelled to perform to relieve the anxiety
caused by obsessions.
 Common symptom dimensions include cleaning, symmetry, taboo thoughts, and

harm obsessions.
 Tic-related specifier: Used when an individual has a current or past history of tic
disorders.
2. Body Dysmorphic Disorder (BDD)
 Preoccupation with perceived defects in physical appearance that others may

not notice or that seem slight.
 Repetitive behaviors such as mirror checking, grooming, skin picking, or seeking

reassurance, or mental acts like comparing one’s appearance with others.
 Muscle Dysmorphia is a subtype where the individual feels that their body is too
small or lacks muscle.
3. Hoarding Disorder
 Persistent difficulty in discarding possessions, regardless of their value, due to a

perceived need to save them.
 Results in cluttered living areas, making spaces unusable.
 Often accompanied by excessive acquisition through buying, collecting, or even

stealing items.
4. Trichotillomania (Hair-Pulling Disorder)
 Recurrent pulling out of one’s hair leading to noticeable hair loss.
 Repeated attempts to stop the behavior are often unsuccessful.
 The behavior may be accompanied by emotional states like anxiety or boredom, and
can lead to relief when hair is pulled.
5. Excoriation (Skin-Picking Disorder)
 Recurrent picking of the skin, resulting in skin lesions.
 Individuals often try but fail to stop the behavior.

 Similar to hair-pulling, this can be driven by emotional tension and lead to
gratification or relief.
6. Substance/Medication-Induced Obsessive-Compulsive and Related Disorder
 Symptoms of obsessive-compulsive behaviors caused by substance use,

intoxication, or withdrawal, or as a result of medication effects.
7. Obsessive-Compulsive and Related Disorder Due to Another Medical Condition
 Symptoms are directly tied to the pathophysiological consequences of a medical

disorder.
8. Other Specified and Unspecified Obsessive-Compulsive and Related Disorders
 Includes conditions that don’t fully meet the criteria for specific disorders but involve
obsessions, compulsions, or related behaviors.
o Examples include body-focused repetitive behavior disorder (such as

nail-biting, lip-biting) and obsessional jealousy (unrelenting jealousy based
on imagined or exaggerated fears).
Insight Specifiers for Obsessive-Compulsive Disorders
 Good or fair insight: The individual recognizes that their beliefs are probably not
true.
 Poor insight: They think their beliefs are probably true.
 Absent insight/delusional beliefs: They are completely convinced that their

beliefs are true.
Relationships with Anxiety and Other Disorders
 These disorders are closely related to anxiety disorders, with OCD sharing many
overlapping features.
 They can be distinguished from normal preoccupations and behaviors by their

excessiveness or their persistence beyond developmentally appropriate stages.
In summary, obsessive-compulsive and related disorders encompass a broad spectrum of

conditions, each involving repetitive thoughts or behaviors that create distress or impair
daily life. These disorders are treated differently based on their specific characteristics, but
all share the common feature of being beyond normal, everyday rituals or concerns.
Body Dysmorphic Disorder (BDD) - Diagnostic Criteria and Features
Diagnostic Criteria (300.7 F45.22)
A. Preoccupation with perceived defects or flaws
 The individual has a preoccupation with one or more perceived defects or flaws in
their physical appearance that are either not observable or appear slight to others.
B. Repetitive behaviors or mental acts
 At some point, the individual has performed repetitive behaviors (e.g., mirror
checking, excessive grooming, skin picking, reassurance seeking) or mental acts
(e.g., comparing their appearance with that of others) in response to their
appearance concerns.
C. Clinically significant distress or impairment
 The preoccupation causes clinically significant distress or impairment in social,

occupational, or other important areas of functioning.
D. Exclusion of eating disorder concerns
 The appearance preoccupation is not better explained by concerns about body fat or
weight in individuals whose symptoms meet diagnostic criteria for an eating disorder.
Specify If:
1. With Muscle Dysmorphia
 The individual is preoccupied with the idea that their body build is too small or
insufficiently muscular, even if they are preoccupied with other body areas.
2. Degree of Insight
 With good or fair insight: The individual recognizes that the beliefs related to BDD
are probably not true.
 With poor insight: The individual believes that the BDD-related beliefs are probably
true.
 With absent insight/delusional beliefs: The individual is completely convinced

that the beliefs are true.
Diagnostic Features
 Perceived Defects: Individuals are preoccupied with perceived flaws that they
believe are ugly, unattractive, or deformed. Common concerns include the skin
(acne, scars), hair (thinning or excessive hair), and features like the nose, but any
body part can be affected.
 Intrusive and Time-Consuming: The preoccupations are intrusive, unwanted, and

can consume 3-8 hours per day, leading to significant distress and difficulty in daily
functioning.
 Repetitive Behaviors: Individuals often engage in behaviors such as:
o Checking mirrors or reflective surfaces.
o Excessive grooming (combing, styling).
o Camouflaging perceived defects with clothing or makeup.
o Seeking reassurance from others about their appearance.
o Compulsively exercising or undergoing cosmetic procedures.
Associated Features Supporting Diagnosis

 Social Anxiety: Many individuals with BDD experience high levels of anxiety and
social avoidance, often believing that others mock them because of their
appearance.
 Comorbid Conditions: High levels of depression, neuroticism, and perfectionism,

coupled with low self-esteem and low extroversion, are common.
 Treatment Seeking: A significant number seek cosmetic treatments, though such

treatments often lead to dissatisfaction and can exacerbate symptoms.
Prevalence
 Point prevalence among U.S. adults is 2.4% (2.5% in females, 2.2% in males).
 Current prevalence is around 1.7%-1.8% in Germany, with higher rates (9%-15%)

among dermatology and cosmetic surgery patients.
Development and Course
 Age of Onset: Mean onset is 16-17 years, with the most common age being 12-13
years.
 Chronic Nature: The disorder is often chronic, although evidence-based treatments

can lead to improvement. The course appears similar in children/adolescents and
adults.
Risk and Prognostic Factors
 Environmental: High rates of childhood neglect and abuse are associated with BDD.
 Genetic and Physiological: There is an elevated prevalence in first-degree

relatives of individuals with OCD.
Conclusion
Body Dysmorphic Disorder is a serious mental health condition marked by an individual's

distorted perception of their appearance, leading to significant distress and impairment.
Understanding its diagnostic criteria, features, and implications is essential for effective
treatment and support. If you suspect someone may be suffering from BDD, encouraging
them to seek professional help is crucial.
Hoarding Disorder
Diagnostic Criteria 300.3 (F42)
A. Persistent difficulty discarding or parting with possessions, regardless of their actual

value.
B. This difficulty is due to a perceived need to save the items and distress associated with
discarding them.
C. The difficulty discarding possessions results in the accumulation of possessions that
congest and clutter active living areas, substantially compromising their intended use. If
living areas are uncluttered, it is only because of the interventions of third parties (e.g.,
family members, cleaners, authorities).
D. The hoarding causes clinically significant distress or impairment in social, occupational, or

other important areas of functioning (including maintaining a safe environment for self and
others).
E. The hoarding is not attributable to another medical condition (e.g., brain injury,
cerebrovascular disease, Prader-Willi syndrome).
F. The hoarding is not better explained by the symptoms of another mental disorder (e.g.,
obsessions in obsessive-compulsive disorder, decreased energy in major depressive
disorder, delusions in schizophrenia or another psychotic disorder, cognitive deficits in major
neurocognitive disorder, restricted interests in autism spectrum disorder).
Specify if:
With excessive acquisition: If difficulty discarding possessions is accompanied by

excessive acquisition of items that are not needed or for which there is no available space.
With good or fair insight: The individual recognizes that hoarding-related beliefs and
behaviors (pertaining to difficulty discarding items, clutter, or excessive acquisition) are
problematic.
With poor insight: The individual is mostly convinced that hoarding-related beliefs and
behaviors (pertaining to difficulty discarding items, clutter, or excessive acquisition) are not
problematic despite evidence to the contrary.
With absent insight/delusional beliefs: The individual is completely convinced that

hoarding-related beliefs and behaviors (pertaining to difficulty discarding items, clutter, or
excessive acquisition) are not problematic despite evidence to the contrary.
Diagnostic Features
The essential feature of hoarding disorder is persistent difficulties discarding or parting

with possessions, regardless of their actual value (Criterion A). This persistent nature
indicates long-standing difficulty rather than more transient life circumstances leading to
excessive clutter.
Individuals often cite perceived utility, aesthetic value, or sentimental attachment to

possessions as reasons for their difficulty in discarding items. Commonly saved items include
newspapers, magazines, old clothing, bags, books, mail, and paperwork. Individuals may
also hoard valuable items, often in disorganized piles mixed with less valuable objects.
Hoarding results in the accumulation of items that fill and clutter active living areas,
impairing their intended use (Criterion C). Living areas may not be usable for their intended
purpose, such as cooking, sleeping, or sitting. If areas appear uncluttered, this is usually due
to third-party interventions.
The hoarding must cause clinically significant distress or impairment in social,
occupational, or other important areas of functioning (Criterion D).
Common features of hoarding disorder include:
 Indecisiveness
 Perfectionism
 Avoidance
 Procrastination
 Difficulty planning and organizing tasks
 Distractibility
Individuals with hoarding disorder often live in unsanitary conditions as a result of clutter.
Animal hoarding can occur, defined by the accumulation of a large number of animals and
failure to provide proper care and sanitation. This may be a special manifestation of
hoarding disorder.
Prevalence
Nationally representative prevalence studies are limited, but community surveys estimate
the point prevalence of clinically significant hoarding in the U.S. and Europe to be
approximately 2%-6%. While hoarding affects both genders, some studies report a greater
prevalence among males, contrasting with clinical samples, which are predominantly female.
Hoarding symptoms appear to be almost three times more prevalent in older adults
(ages 55-94 years) compared to younger adults (ages 34-44 years).
Hoarding symptoms often emerge in early life, around ages 11-15, and may start
interfering with daily functioning by the mid-20s, causing significant impairment by the mid-
30s. The severity of hoarding symptoms tends to increase with age, often becoming chronic.
Pathological hoarding in children can be differentiated from typical saving and collecting
behaviors. In younger individuals, the potential intervention of third parties (e.g., parents)
should be considered when diagnosing hoarding disorder.
Trichotillomania (Hair-Pulling Disorder)
Diagnostic Criteria 312.39 (F63.2)
A. Recurrent pulling out of one’s hair, resulting in hair loss.
B. Repeated attempts to decrease or stop hair pulling.

C. The hair pulling causes clinically significant distress or impairment in social, occupational,
D. The hair pulling or hair loss is not attributable to another medical condition (e.g., a
dermatological condition).
E. The hair pulling is not better explained by the symptoms of another mental disorder (e.g.,
attempts to improve a perceived defect or flaw in appearance in body dysmorphic disorder).
Diagnostic Features
The essential feature of trichotillomania is recurrent pulling out of one's hair (Criterion
A). Hair pulling can occur from any area of the body with hair, commonly from the scalp,
eyebrows, and eyelids, and less commonly from areas such as axillary, facial, pubic, and
peri-rectal regions. The specific sites may vary over time, and hair pulling can occur in brief
episodes throughout the day or during longer, sustained periods lasting hours, sometimes
enduring for months or years.
Criterion A requires that hair pulling leads to hair loss. Individuals may pull hair in a widely
distributed pattern, making hair loss less visible, or they may conceal it using makeup,
scarves, or wigs.
Individuals with trichotillomania make repeated attempts to decrease or stop hair

pulling (Criterion B). Distress related to hair pulling may include feelings of loss of control,
embarrassment, and shame, leading to significant impairment in various areas of
functioning (Criterion C).
Individuals may engage in behaviors or rituals surrounding hair pulling, such as:
 Searching for specific types of hair to pull (e.g., those with particular textures or
colors).
 Attempting to pull hair out in a certain way (e.g., ensuring the root comes out intact).
 Manipulating the pulled hair (e.g., rolling it between fingers, pulling it between teeth,
biting, or swallowing it).
Hair pulling may be preceded or accompanied by various emotional states, often triggered
by anxiety or boredom. It may involve an increasing sense of tension before pulling and lead
to relief or gratification once hair is pulled.
Some individuals experience an "itch-like" or tingling sensation in the scalp, relieved by

hair pulling. Pain is typically not associated with the behavior.
Hair loss patterns can vary significantly, with areas of complete alopecia and regions of
thinned hair density being common. Specific patterns, like "tonsure trichotillomania," may
present with nearly complete baldness except for a narrow perimeter around the scalp,
particularly at the nape of the neck. Eyebrows and eyelashes may also be absent.
Hair pulling usually does not occur in front of others, except immediate family members.
Some individuals may feel urges to pull hair from others, pets, dolls, or fibrous materials
(e.g., sweaters, carpets). Denial about hair pulling is common, and many individuals with
trichotillomania may also engage in other body-focused repetitive behaviors, such as skin
picking or nail biting.
Prevalence
The 12-month prevalence estimate for trichotillomania in adults and adolescents is 1%-2%.
The condition affects females more frequently than males, with a ratio of approximately
10:1. This gender ratio may reflect both the true prevalence and differences in treatment-
seeking behavior based on gender. Among children, the gender representation is more
equal.
Hair pulling may be observed in infants but typically resolves during early development. The
onset of trichotillomania most commonly coincides with or follows the onset of puberty. Hair
pulling sites may vary, and the course of trichotillomania is usually chronic, with some
waxing and waning if untreated. Symptoms in females may worsen with hormonal changes
(e.g., menstruation, perimenopause).
For some individuals, the disorder may come and go over weeks, months, or years. A
minority may experience remission without relapse within a few years of onset.
Excoriation (Skin-Picking) Disorder
Diagnostic Criteria 698.4 (L98.1)
A. Recurrent skin picking resulting in skin lesions.
B. Repeated attempts to decrease or stop skin picking.
C. The skin picking causes clinically significant distress or impairment in social,

occupational, or other important areas of functioning.
D. The skin picking is not attributable to the physiological effects of a substance (e.g.,
cocaine) or another medical condition (e.g., scabies).
E. The skin picking is not better explained by symptoms of another mental disorder (e.g.,
delusions or tactile hallucinations in a psychotic disorder, attempts to improve a perceived
defect or flaw in appearance in body dysmorphic disorder, stereotypies in stereotypic
movement disorder, or intention to harm oneself in nonsuicidal self-injury).
Diagnostic Features
The essential feature of excoriation (skin-picking) disorder is recurrent picking at one's

own skin (Criterion A). Common sites for skin picking include the face, arms, and hands,
although individuals may pick at multiple body sites. Individuals may target healthy skin,
minor irregularities, lesions (like pimples or calluses), or scabs from previous picking. Picking
is typically done with fingernails, but some individuals may use tweezers, pins, or other
objects.
In addition to skin picking, individuals may engage in related behaviors such as skin rubbing,
squeezing, lancing, or biting. Many spend significant amounts of time on picking, sometimes
several hours per day, which may last for months or years. Criterion A requires that skin
picking leads to skin lesions, and individuals often attempt to conceal these lesions using
makeup or clothing.
Individuals with excoriation disorder have made repeated attempts to decrease or stop
skin picking (Criterion B). The behavior can cause clinically significant distress or impairment
in social, occupational, or other important areas of functioning (Criterion C). Distress may
manifest as feelings of loss of control, embarrassment, and shame, leading to
significant impairment in various areas, such as social and occupational functioning.
Skin picking may involve a variety of accompanying behaviors or rituals, such as:
 Searching for specific types of scabs to pick.
 Examining, playing with, or swallowing the skin after it has been picked.
Skin picking can be triggered by feelings of anxiety or boredom and may be preceded by an
increasing sense of tension, resulting in relief or gratification once the skin or scab is picked.
Some individuals may also pick in response to minor skin irregularities or to alleviate
uncomfortable bodily sensations.
Pain is not typically reported alongside skin picking. The behavior can vary between more
focused picking (with preceding tension and subsequent relief) and more automatic
picking (occurring without full awareness). Skin picking usually does not occur in front of
others, except for immediate family members, although some individuals may report picking
the skin of others.
Prevalence
In the general population, the lifetime prevalence of excoriation disorder in adults is about
1.4% or higher. It is more commonly reported in females, with three-quarters or more of
affected individuals being women. This gender ratio likely reflects the true prevalence of the
condition and potential differences in treatment-seeking behavior based on gender and
cultural attitudes toward appearance.
Excoriation disorder may present at various ages, but it most often begins during
adolescence, commonly coinciding with the onset of puberty. The disorder frequently starts
following a dermatological condition, such as acne. Sites of skin picking may vary over time.
The usual course of the disorder is chronic, with symptoms potentially waxing and waning if
left untreated. For some individuals, the disorder may fluctuate over weeks, months, or
years.
Genetic and Physiological Factors: Excoriation disorder is more prevalent among

individuals with obsessive-compulsive disorder (OCD) and their first-degree relatives
than in the general population.
Feeding and Eating Disorders Overview

Feeding and eating disorders are characterized by persistent disturbances in eating or
eating-related behaviors that lead to altered food consumption or absorption, significantly
impairing physical health or psychosocial functioning. The diagnostic criteria include several
disorders: pica, rumination disorder, avoidant/restrictive food intake disorder, anorexia
nervosa, bulimia nervosa, and binge-eating disorder.
These disorders are classified in a mutually exclusive manner, meaning that during a single
episode, only one diagnosis can be assigned among rumination disorder, avoidant/restrictive
food intake disorder, anorexia nervosa, bulimia nervosa, and binge-eating disorder. This
classification is based on their distinct clinical courses, outcomes, and treatment needs.
However, a diagnosis of pica can be made alongside any other feeding and eating disorder.
Some individuals with these disorders report eating-related symptoms similar to those
observed in substance use disorders, such as cravings and patterns of compulsive use,
suggesting potential overlap in the neural systems involved in self-regulation and reward.
Yet, the relative contributions of shared and unique factors in the development of eating and
substance use disorders remain poorly understood.
It is also important to note that obesity is not classified as a mental disorder in DSM-5.
It results from a long-term energy intake excess compared to expenditure, influenced by
genetic, physiological, behavioral, and environmental factors. However, there are strong
associations between obesity and several mental disorders, including binge-eating disorder,
depressive disorders, and schizophrenia. Certain psychotropic medications can contribute to
obesity, which may also act as a risk factor for developing some mental disorders.
Pica
Diagnostic Criteria
A. Persistent eating of nonnutritive, nonfood substances over a period of at least 1 month.
B. The eating of nonnutritive, nonfood substances is inappropriate to the developmental

level of the individual.
C. The eating behavior is not part of a culturally supported or socially normative practice.
D. If the eating behavior occurs in the context of another mental disorder (e.g., intellectual
disability, autism spectrum disorder, schizophrenia) or medical condition (including
pregnancy), it is sufficiently severe to warrant additional clinical attention.
Coding Note:
 ICD-9-CM code for pica: 307.52 (used for children or adults).
 ICD-10-CM codes for pica: F98.3 (children) and F50.8 (adults).
Specify if:
 In remission: After full criteria for pica were previously met, the criteria have not
been met for a sustained period of time.
Diagnostic Features
The essential feature of pica is the persistent eating of one or more nonnutritive,
nonfood substances for at least 1 month (Criterion A), requiring clinical attention due to
severity. Typical ingested substances vary by age and might include items like:
 Paper
 Soap
 Cloth
 Hair
 String
 Wool
 Soil
 Chalk
 Talcum powder
 Paint
 Gum
 Metal
 Pebbles
 Charcoal or coal
 Ash
 Clay
 Starch
 Ice
The term "nonnutritive" is significant as pica does not apply to the ingestion of diet products
with minimal nutritional content. Generally, there is no aversion to food.
The eating of nonnutritive substances must be developmentally inappropriate (Criterion

B) and not culturally supported or normative (Criterion C). A minimum age of 2 years is
suggested for diagnosis to exclude normal mouthing of objects in infants. If the behavior
occurs exclusively within the context of another mental disorder, a separate diagnosis of
pica should only be made if it is severe enough to require additional clinical attention
(Criterion D).
Deficiencies in vitamins or minerals (e.g., zinc, iron) have been reported in some cases,
though no specific biological abnormalities are typically found. Pica often comes to clinical
attention due to medical complications, which can include:
 Mechanical bowel problems
 Intestinal obstruction (e.g., from a bezoar)
 Intestinal perforation
 Infections (e.g., from ingesting feces or dirt)
 Poisoning (e.g., from lead-based paint ingestion)
Prevalence
The prevalence of pica is unclear. Among individuals with intellectual disability, the
prevalence of pica appears to increase with the severity of the condition.
Pica can onset during childhood, adolescence, or adulthood, but it is most commonly
reported in childhood. In adults, pica is more likely to occur alongside intellectual
disability or other mental disorders. The behavior may also manifest during pregnancy,
with specific cravings (e.g., for chalk or ice). However, diagnosing pica during pregnancy is
only appropriate if such cravings lead to ingestion of nonnutritive substances that pose
medical risks.
The course of pica can be prolonged and may lead to medical emergencies, including:
 Intestinal obstruction
 Acute weight loss
 Poisoning
The disorder can be potentially fatal, depending on the substances ingested.
Environmental Factors: Neglect, lack of supervision, and developmental delay can

increase the risk of developing pica.
Rumination Disorder
Diagnostic Criteria (ICD-10-CM: 307.53 / F98.21)
A. Repeated regurgitation of food over a period of at least 1 month. The regurgitated food
may be re-chewed, re-swallowed, or spit out.
B. The repeated regurgitation is not attributable to an associated gastrointestinal or other

medical condition (e.g., gastroesophageal reflux, pyloric stenosis).
C. The eating disturbance does not occur exclusively during the course of anorexia
nervosa, bulimia nervosa, binge-eating disorder, or avoidant/restrictive food intake disorder.
D. If the symptoms occur in the context of another mental disorder (e.g., intellectual
disability or another neurodevelopmental disorder), they are sufficiently severe to warrant
additional clinical attention.
Specify if:
 In remission: After full criteria for rumination disorder were previously met, the
criteria have not been met for a sustained period of time.
Diagnostic Features
The essential feature of rumination disorder is the repeated regurgitation of food, which
occurs after feeding or eating for at least 1 month (Criterion A). This behavior is
characterized by:
 Previously swallowed food, possibly partially digested, being brought back into the
mouth without apparent nausea, involuntary retching, or disgust.
 The regurgitated food may be re-chewed and either ejected or re-swallowed.
 Regurgitation should be frequent, occurring at least several times per week,

typically daily.
The behavior cannot be better explained by an associated gastrointestinal or medical

condition (Criterion B) and should not occur exclusively during episodes of other eating
disorders (Criterion C). If symptoms arise alongside another mental disorder (Criterion D),
they should be sufficiently severe to require additional clinical attention, representing a
primary aspect of the individual’s presentation needing intervention.
Rumination disorder can be diagnosed across the lifespan, particularly in individuals with
intellectual disabilities. Clinicians may observe individuals directly engaging in this behavior,
or diagnosis may rely on self-reports or corroborative information from parents or caregivers.
Individuals may describe the behavior as habitual or outside of their control.
 Infants: Infants with rumination disorder often display a characteristic posture,

including straining and arching the back with the head held back, while making
sucking movements with their tongue. They may appear satisfied by the activity and
may be irritable and hungry between regurgitation episodes.
 Weight Issues: Weight loss and failure to gain expected weight are common in
infants with this disorder. Malnutrition may occur despite apparent hunger and the
intake of relatively large amounts of food, especially in severe cases where
regurgitation follows each feeding.
 Older Children and Adults: Malnutrition can also be seen in older children and
adults, particularly if regurgitation is accompanied by food intake restrictions.
Adolescents and adults might try to hide their regurgitation behavior by covering
their mouth or coughing and may avoid eating with others due to the social
undesirability of the behavior.
Prevalence
Prevalence data for rumination disorder are inconclusive, but it is often reported to be higher
among certain groups, particularly individuals with intellectual disabilities.
 Onset: Rumination disorder can begin in infancy, childhood, adolescence, or

adulthood, with onset in infants typically occurring between 3 and 12 months.
 Course: In infants, the disorder frequently remits spontaneously, but it can also have
a prolonged course leading to medical emergencies, such as severe malnutrition, and
may potentially be fatal, particularly in infancy.
 The disorder can occur episodically or continuously until treated. For infants and older
individuals with intellectual disabilities or other neurodevelopmental disorders, the
regurgitation and rumination may serve a self-soothing or self-stimulating function,
akin to other repetitive behaviors.
Environmental Factors: Psychosocial issues such as lack of stimulation, neglect, stressful

life situations, and parent-child relationship problems may predispose infants and young
children to develop rumination disorder.
Functional Consequences of Rumination Disorder
 Malnutrition: Secondary to repeated regurgitation, malnutrition can lead to growth

delays and negatively impact development and learning potential.
 Weight Issues: Older individuals may intentionally restrict food intake due to the
social undesirability of regurgitation, resulting in weight loss or low weight.
 Social Functioning: Social functioning is more likely to be adversely affected in

older children, adolescents, and adults, especially as they may avoid social eating
situations.
Avoidant/Restrictive Food Intake Disorder

Diagnostic Criteria (ICD-10-CM: 307.59 / F50.8)
A. An eating or feeding disturbance (e.g., apparent lack of interest in eating or food;
avoidance based on the sensory characteristics of food; concern about aversive
consequences of eating) as manifested by persistent failure to meet appropriate nutritional
and/or energy needs associated with one (or more) of the following:
1. Significant weight loss (or failure to achieve expected weight gain or faltering
growth in children).
2. Significant nutritional deficiency.
3. Dependence on enteral feeding or oral nutritional supplements.
4. Marked interference with psychosocial functioning.
B. The disturbance is not better explained by lack of available food or by an associated

culturally sanctioned practice.
C. The eating disturbance does not occur exclusively during the course of anorexia
nervosa or bulimia nervosa, and there is no evidence of a disturbance in the way one’s body
weight or shape is experienced.
D. The eating disturbance is not attributable to a concurrent medical condition or better

explained by another mental disorder. When the eating disturbance occurs in the context of
another condition or disorder, the severity of the eating disturbance exceeds what is
routinely associated with that condition and warrants additional clinical attention.
Specify if:
 In remission: After full criteria for avoidant/restrictive food intake disorder were
previously met, the criteria have not been met for a sustained period of time.
Diagnostic Features
Avoidant/restrictive food intake disorder replaces and extends the DSM-IV diagnosis of
feeding disorder of infancy or early childhood. The main diagnostic feature is:
 Avoidance or restriction of food intake (Criterion A) that leads to a clinically

significant failure to meet nutritional requirements or insufficient energy intake
through oral food consumption.
Key features must include:
1. Significant weight loss: Determined by clinical judgment; instead of losing weight,

children and adolescents may fail to maintain expected weight or height growth.
2. Significant nutritional deficiency: Clinical assessment methods (dietary intake

assessment, physical exams, laboratory testing) can help determine this.
3. Dependence on enteral feeding or oral nutritional supplements: Requires

supplementary feeding to sustain adequate intake (e.g., nasogastric tube feeding,
complete oral nutrition supplements).
4. Marked interference with psychosocial functioning: Inability to participate in

normal social activities, like eating with others.
The disorder does not include food avoidance or restriction due to the lack of food
availability, cultural practices (e.g., religious fasting), or developmentally normal behaviors
(e.g., picky eating in toddlers, reduced intake in older adults). The disturbance cannot be
better explained by excessive concern about body weight or shape (Criterion C) or
concurrent medical or mental conditions (Criterion D).
Food avoidance may arise from sensory characteristics (e.g., extreme sensitivity to
appearance, smell, texture) or as a conditioned negative response due to past aversive
experiences (e.g., choking, trauma).
Several associated features may accompany food avoidance or reduced intake:
 Lack of interest in eating or food, leading to weight loss or faltering growth.
 Infants may appear too sleepy, distressed, or agitated to feed and might not engage
with caregivers during feeding.
 Older children and adolescents may exhibit generalized emotional difficulties not
meeting criteria for other anxiety or mood disorders, often referred to as "food
avoidance emotional disorder."
 Common Onset: Food avoidance or restriction typically develops in infancy or early

childhood but may persist into adulthood. Sensory-related avoidance often arises in
the first decade of life.
 Persistence: Long-term outcomes suggest stability in food avoidance based on

sensory aspects, but in adulthood, such behaviors may not severely impact
functioning.
 Irritability: Infants may be difficult to console during feeding and may have poor
interactions with caregivers. Nutritional inadequacies can exacerbate associated
features, including irritability and developmental delays.
 Temperamental: Risk factors include anxiety disorders, autism spectrum disorder,

obsessive-compulsive disorder, and attention-deficit/hyperactivity disorder.
 Environmental: Family history of anxiety or higher feeding disturbances in children

of mothers with eating disorders.
 Genetic and Physiological: A history of gastrointestinal conditions,

gastroesophageal reflux disease, and vomiting may be linked to feeding behaviors
characteristic of this disorder.
Cultural and Gender-Related Diagnostic Issues

 Cultural: Avoidant/restrictive food intake disorder should not be diagnosed if
avoidance of food is solely related to cultural practices.
 Gender: The disorder is equally common in males and females during early
childhood but is more prevalent in males when comorbid with autism spectrum
disorder.
Diagnostic Markers
Diagnostic markers include:
 Malnutrition
 Low weight
 Growth delays
 The need for artificial nutrition in the absence of clear medical conditions other than
poor intake.
These features should guide clinicians in assessing and diagnosing avoidant/restrictive food
intake disorder accurately.
Anorexia Nervosa: Overview and Diagnostic

Criteria
Diagnostic Criteria
1. A. Energy Intake Restriction:
o The individual restricts energy intake relative to requirements, leading to a

significantly low body weight. This low weight is defined as less than
minimally normal or, for children and adolescents, less than what is minimally
expected.
2. B. Intense Fear:
o There is an intense fear of gaining weight or becoming fat, or persistent

behaviors that interfere with weight gain, even when at a significantly low
weight.
3. C. Disturbance in Body Image:
o There is a disturbance in the perception of body weight or shape, an undue

influence of body weight or shape on self-evaluation, or a persistent lack of
recognition of the seriousness of the current low body weight.
Coding Note
 ICD-9-CM Code: 307.1 (assigned regardless of subtype)
 ICD-10-CM Codes:
o (F50.01) Restricting type: No episodes of binge eating or purging in the last 3
months.
o (F50.02) Binge-eating/purging type: Recurrent episodes of binge eating or

purging in the last 3 months.
Specify Remission Status
 In Partial Remission: Criteria A not met for a sustained period; either B or C still
met.
 In Full Remission: None of the criteria have been met for a sustained period.
Specify Current Severity (based on BMI)
 Mild: BMI > 17 kg/m²
 Moderate: BMI 16-16.99 kg/m²
 Severe: BMI 15-15.99 kg/m²
 Extreme: BMI < 15 kg/m²
Subtypes
 Binge-eating/purging type: Engages in binge eating and purging behaviors.
 Restricting type: Primarily engages in dieting, fasting, or excessive exercise.
Diagnostic Features
 Persistent Energy Intake Restriction: Weight below minimally normal levels.
 Intense Fear of Weight Gain: Fear remains even with significant weight loss.
 Disturbance in Self-Perception: Distorted body image and self-esteem linked to

weight and shape.
 Medical complications due to malnutrition (e.g., amenorrhea, vital sign

abnormalities).
 Possible depressive symptoms and obsessive-compulsive features.
 Risk factors include anxiety disorders, cultural factors valuing thinness, and family
history.
Prevalence
 12-Month Prevalence: Approximately 0.4% in young females; much lower in males

(10:1 ratio).
 Common onset during adolescence or young adulthood, often triggered by stressful

life events.
 Variable course: some recover fully, others experience chronic patterns or fluctuating
symptoms.
 Temperamental: Childhood anxiety and obsessional traits.
 Environmental: Cultural pressures valuing thinness.
 Genetic and Physiological: Family history and potential brain abnormalities.
Culture-Related Diagnostic Issues
 Cross-cultural variation in prevalence and presentation, with higher incidence in post-

industrialized countries.
 Differences in expressed fear of weight gain across cultural contexts.
Diagnostic Markers
 Laboratory abnormalities may support diagnosis.
Suicide Risk
 Elevated suicide risk; assessment of suicidal ideation and behaviors is essential.
Bulimia Nervosa: Overview and Diagnostic Criteria

Diagnostic Criteria (ICD-10: 307.51 / DSM-5: F50.2)
1. Recurrent Episodes of Binge Eating:
o Defined as eating a significantly larger amount of food in a discrete period

(e.g., within 2 hours) compared to what most individuals would eat under
similar circumstances.
o Accompanied by a sense of lack of control over eating during the episode.
2. Recurrent Inappropriate Compensatory Behaviors:
o Behaviors include self-induced vomiting, misuse of laxatives, diuretics, fasting,

or excessive exercise to prevent weight gain.
3. Frequency and Duration:
o Binge eating and compensatory behaviors must occur, on average, at least

once a week for 3 months.
4. Influence on Self-Evaluation:
o Self-evaluation is unduly influenced by body shape and weight.
5. Exclusion of Anorexia Nervosa:
o The disturbance does not occur exclusively during episodes of anorexia

nervosa.
Specifiers
 In Partial Remission: Some criteria met for a sustained period.

 In Full Remission: None of the criteria have been met for a sustained period.
Current Severity
 Mild: 1-3 episodes of inappropriate compensatory behaviors per week.
 Moderate: 4-7 episodes.
 Severe: 8-13 episodes.
 Extreme: 14 or more episodes.
Diagnostic Features
 Binge Eating Episodes:
o Episodes are characterized by excessive food intake in a short time and a

sense of loss of control.
o Often occur in secrecy and can be triggered by negative emotions or stress.
 Compensatory Behaviors:
o Most commonly include vomiting, but may also involve laxative misuse or
excessive exercise.
o Individuals may become skilled at inducing vomiting or may misuse various

medications.
 Self-Evaluation:
o Body shape and weight heavily influence self-esteem and self-worth.
Associated Features
 Weight Range:
o Individuals are typically within the normal weight or overweight range (BMI >
18.5 and < 30).
 Physical Symptoms:
o May include menstrual irregularities, gastrointestinal issues, and potential for

severe medical complications.
Prevalence
 General Population:
o 12-month prevalence among young females is approximately 1%-1.5%.
o Less common in males, with a female-to-male ratio of about 10:1.
 Age of Onset:
o Typically begins in adolescence or young adulthood.
 Course:
o Symptoms may be chronic or intermittent, with periods of remission often
alternating with recurrences.
Risk Factors
 Temperamental:
o Weight concerns, low self-esteem, depressive symptoms, and social anxiety.
 Environmental:
o Internalization of a thin body ideal and experiences of childhood trauma.
 Genetic:
o Family history of eating disorders may increase risk.
Diagnostic Markers
 Laboratory Abnormalities:
o May include fluid and electrolyte imbalances, elevated serum amylase, and
signs of dental erosion due to purging behaviors.
Suicide Risk
 Elevated Risk:
o Individuals with bulimia nervosa have an increased risk of suicidal ideation

and attempts, necessitating comprehensive evaluation and monitoring.
Binge-Eating Disorder Overview

Diagnostic Criteria (307.51, F50.8)
1. Recurrent Episodes of Binge Eating:
o Definition: Eating a large amount of food within a discrete period (e.g., 2

hours).
o Control: Feeling a lack of control overeating during the episode.
2. Associated Features:
o Three or more of the following:
1. Eating more rapidly than normal.
2. Eating until feeling uncomfortably full.
3. Eating large amounts of food when not hungry.
4. Eating alone due to embarrassment.
5. Feeling disgusted, depressed, or guilty afterward.
3. Distress: Marked distress regarding binge eating.
4. Frequency: Binge eating occurs at least once a week for 3 months.

5. Exclusion: Not associated with inappropriate compensatory behaviors (e.g., bulimia
nervosa) and does not occur exclusively during bulimia nervosa or anorexia nervosa.
Remission and Severity
 Specify if:
o In Partial Remission: Binge eating occurs less than once a week for a
sustained period.
o In Full Remission: None of the criteria have been met for a sustained period.
 Current Severity:
o Mild: 1-3 episodes per week.
o Moderate: 4-7 episodes per week.
o Severe: 8-13 episodes per week.
o Extreme: 14 or more episodes per week.
Diagnostic Features
 Essential Feature: Recurrent episodes of binge eating at least once a week for 3
months.
 Context: The definition of a binge is relative to the individual's typical eating

patterns; what is excessive for one might be normal for another in different contexts
(e.g., celebrations).
 Loss of Control: A key aspect is the inability to stop eating or control the amount
consumed, sometimes described as dissociation during episodes.
 Food Variety: The types of food consumed can vary greatly, characterized more by
quantity than craving.
 Demographics: Occurs in normal-weight, overweight, and obese individuals, often

leading to greater functional impairment and psychiatric comorbidities compared to
those without the disorder.
 Prevalence:
o 12-month prevalence in U.S. adults: 1.6% in females, 0.8% in males.
o More prevalent in individuals seeking weight-loss treatment.

 Onset: Typically begins in adolescence or young adulthood but can start later in life.
 Dieting Relationship: Many individuals develop binge eating following dieting,

contrasting with bulimia nervosa, where dysfunctional dieting often precedes binge
eating.
 Remission Rates: Higher than for bulimia nervosa or anorexia nervosa, but binge-
eating disorder can be persistent.
 Genetic and Physiological: Family history may suggest genetic influences, and
certain biological factors could increase risk.
This overview encapsulates the diagnostic criteria, features, and understanding of binge-
eating disorder, which is essential for recognition and treatment in clinical practice.
Elimination Disorders Overview
Elimination disorders involve inappropriate elimination of urine or feces, typically diagnosed

in childhood or adolescence. This includes enuresis (inappropriate voiding of urine) and
encopresis (inappropriate passage of feces). They can occur voluntarily or involuntarily and
may happen separately or together.
Enuresis
1. Repeated Voiding:
o Involuntary or intentional voiding of urine into bed or clothes.
2. Clinical Significance:
o Occurs at least twice a week for at least 3 consecutive months, or causes

significant distress/impairment in social, academic, or other important areas.
3. Age Requirement:
o Chronological age of at least 5 years (or equivalent developmental level).
4. Exclusion:
o Not due to physiological effects of substances (e.g., diuretics, antipsychotic

medication) or other medical conditions (e.g., diabetes, spina bifida, seizure
disorder).
Specify Subtypes
1. Nocturnal Only: Passage of urine only during nighttime sleep.

2. Diurnal Only: Passage of urine during waking hours.
3. Nocturnal and Diurnal: Combination of both subtypes.
Diagnostic Features
 Essential Feature: Repeated voiding of urine, occurring at least twice a week for 3
months.
 Involuntary Voiding: Most often, but can occasionally be intentional.
 Age: Must have reached an age of expected continence (≥5 years).
 Exclusion of Medical Causes: The incontinence is not due to medical issues.
 Nocturnal Enuresis: Often occurs during REM sleep; the child may recall dreams of
urination.
 Diurnal Enuresis: Often involves deferring voiding until incontinence occurs,

sometimes due to social anxiety or preoccupation with activities.
Prevalence
 5%-10% among 5-year-olds.
 3%-5% among 10-year-olds.
 Approximately 1% among individuals aged 15 and older.
 Types:
o Primary Enuresis: Never established urinary continence.
o Secondary Enuresis: Develops after a period of established continence.
 Onset of Secondary Enuresis: Most common between ages 5-8 years.
 Spontaneous Remission: Occurs in 5%-10% per year after age 5.
 Persistence into Adulthood: Occurs in about 1% of cases.
 Environmental Factors: Delayed or lax toilet training, psychosocial stress.
 Genetic Factors: Family history increases risk; heritability shown in family and twin
studies.
 Physiological Factors: Associated with circadian rhythm delays in urine production
and bladder capacity issues.
Culture-Related Issues
 Enuresis is reported across various cultures, with similar prevalence rates and
developmental trajectories. High rates are found in orphanages and residential
institutions due to toilet training environments.
Gender-Related Issues
 Nocturnal Enuresis: More common in males.
 Diurnal Incontinence: More common in females.
 Parental Influence: Greater risk in children of previously enuretic fathers compared

to mothers.
Functional Consequences of Enuresis
 Impairment due to enuresis can affect social activities (e.g., ineligibility for camps),
self-esteem, social ostracism, and can result in anger or rejection from caregivers.
This overview of elimination disorders, particularly enuresis, highlights the diagnostic

criteria, prevalence, developmental aspects, and associated features, crucial for
understanding and managing these conditions.
Encopresis Overview
Encopresis is an elimination disorder characterized by the repeated passage of feces into

inappropriate places, such as clothing or the floor. This condition can be either involuntary or
intentional and is typically diagnosed in children.
1. Repeated Passage of Feces:
o Involuntary or intentional passage into inappropriate places.
2. Frequency:
o At least one occurrence each month for at least 3 months.
3. Age Requirement:
o Chronological age of at least 4 years (or equivalent developmental level).
4. Exclusion of Medical Causes:

o The behavior is not due to the physiological effects of a substance (e.g.,
laxatives) or another medical condition, except when involving constipation.
Specify Subtypes
1. With Constipation and Overflow Incontinence:
o Evidence of constipation is present, often leading to poorly formed stools and

leakage occurring mostly during the day.
2. Without Constipation and Overflow Incontinence:
o No evidence of constipation; feces may be of normal consistency, and soiling

is intermittent.
Diagnostic Features
 Essential Feature: Involuntary or intentional passage of feces into inappropriate

places (Criterion A).
 Frequency: Must occur at least once a month for 3 months (Criterion B).
 Age: The child must be at least 4 years old (Criterion C).
 Exclusion of Medical Causes: Fecal incontinence cannot be solely attributed to a

medical condition except through constipation (Criterion D).
 Shame and Avoidance: Children may feel ashamed and avoid situations leading to
embarrassment, such as school or camps.
 Impact on Self-Esteem: The disorder can significantly affect the child’s self-esteem
and may result in social ostracism.
 Deliberate Smearing: This behavior may occur during attempts to clean or hide
involuntarily passed feces, potentially indicating oppositional defiant disorder or
conduct disorder.
 Comorbidity with Enuresis: Many children with encopresis also exhibit symptoms
of enuresis and may experience urinary reflux.
Prevalence
 Approximately 1% of 5-year-olds are estimated to have encopresis, with a higher

prevalence in males compared to females.

 Age of Diagnosis: Encopresis is diagnosed after the age of 4 years.
 Predisposing Factors: Inconsistent toilet training and psychosocial stressors (e.g.,

school transition, birth of a sibling) can contribute.
 Types of Course:
o Primary: The child has never established fecal continence.
o Secondary: The disturbance arises after a period of established continence.
 Persistence: Encopresis can persist with intermittent exacerbations for years.
 Genetic and Physiological Factors: Painful defecation can lead to a cycle of

withholding behaviors, increasing the likelihood of encopresis.
 Medication Effects: Some medications (e.g., anticonvulsants) may contribute to

constipation, raising the risk of encopresis.
Diagnostic Markers
 Physical Examination: Assessing for retained stool and gas in the colon.
 Imaging: Gastrointestinal imaging (e.g., abdominal radiograph) may help, and

further tests (e.g., barium enema) can rule out conditions like Hirschsprung's disease.
Differential Diagnosis
 Encopresis is diagnosed only if fecal incontinence is linked to constipation that cannot

be explained by other medical conditions. Conditions like chronic diarrhea or anal
stenosis would not qualify for a DSM-5 diagnosis of encopresis.
Comorbidity
 Urinary Tract Infections: These are more common in females and may occur
alongside encopresis.
Insomnia Disorder Overview

Diagnostic Criteria
 ICD-10 Code: 780.52 (G47.00)
A. Sleep Complaints
 Predominant dissatisfaction with sleep quantity or quality, with one or more of the
following symptoms:
1. Difficulty Initiating Sleep: Difficulty falling asleep at bedtime. In children,
this may require caregiver intervention.
2. Difficulty Maintaining Sleep: Frequent awakenings or trouble returning to

sleep after awakenings. In children, may require caregiver help.
3. Early-Morning Awakening: Waking up too early and unable to return to

sleep.
B. Impact on Functioning
 Sleep disturbance causes clinically significant distress or impairment in social,

occupational, educational, academic, behavioral, or other important areas.
C. Frequency
 Sleep difficulty occurs at least 3 nights per week.
D. Duration
 Sleep difficulty has been present for at least 3 months.
E. Opportunity for Sleep
 Sleep difficulties occur despite adequate opportunity for sleep.
F. Exclusion of Other Sleep Disorders
 Insomnia is not better explained by other sleep-wake disorders (e.g., narcolepsy,

circadian rhythm disorders).
G. Substance Influence
 Not attributable to the physiological effects of a substance (e.g., drug abuse,

medication).
H. Coexisting Conditions
 Coexisting mental disorders and medical conditions do not adequately explain the
predominant complaint of insomnia.
Specifiers
 With non-sleep disorder mental comorbidity (including substance use

disorders).
 With other medical comorbidity.
 With other sleep disorder.
Coding Note
 The code 780.52 (G47.00) applies to all three specifiers. Code the relevant associated
mental disorder, medical condition, or other sleep disorder immediately after the
code for insomnia disorder.
Severity Specifiers
 Episodic: Symptoms last at least 1 month but less than 3 months.

 Persistent: Symptoms last 3 months or longer.
 Recurrent: Two or more episodes within the space of 1 year.
Acute and Short-term Insomnia
 Symptoms lasting less than 3 months but meeting other criteria should be coded as
an other specified insomnia disorder.
Diagnostic Features
 Essential feature: dissatisfaction with sleep quantity or quality.
 Common types of insomnia:
o Sleep-onset insomnia: Difficulty falling asleep.
o Sleep maintenance insomnia: Frequent awakenings during the night.
o Late insomnia: Early morning awakenings without returning to sleep.
Associated Features
 Physiological and cognitive arousal factors may interfere with sleep.
 Complaints of nonrestorative sleep can accompany insomnia.
 Daytime impairments include fatigue, cognitive performance issues, and mood

disturbances.
Prevalence
 About one-third of adults report insomnia symptoms; 10-15% experience daytime

impairments.
 More prevalent among females than males (ratio approximately 1.44:1).
 Commonly occurs in conjunction with other medical or mental disorders.
 Onset can occur at any life stage; first episodes often happen in young adulthood.
 Insomnia can be situational (acute), persistent, or recurrent.
 Chronicity rates for insomnia vary between 45%-75% across 1-7 year follow-ups.
Risk Factors
 Temperamental: Anxiety-prone personality, heightened arousal.
 Environmental: Noise, temperature extremes.
 Genetic and Physiological: Higher incidence in females and older adults; familial
predisposition.
Gender-Related Issues
 Insomnia complaints are more common in females, often linked to life events such as
childbirth or menopause.
 Polysomnographic studies indicate older females may experience better sleep quality
compared to older males.
Conclusion
Insomnia disorder is complex, with varying causes, impacts, and courses. Treatment
approaches should address both insomnia and any coexisting conditions to improve overall
functioning and quality of life.
Hypersomnolence Disorder Overview

Diagnostic Criteria: 780.54 (G47.10)
A. Symptoms:
 Self-reported excessive sleepiness despite a main sleep period of at least 7 hours,

with at least one of the following:
1. Recurrent periods of sleep or lapses into sleep during the day.
2. A prolonged main sleep episode lasting more than 9 hours that is

nonrestorative.
3. Difficulty being fully awake after abrupt awakening.
B. Frequency:
 Hypersomnolence occurs at least three times a week for at least 3 months.
C. Impairment:
 Symptoms cause significant distress or impairment in cognitive, social, occupational,

D. Exclusions:
 The hypersomnolence is not better explained by another sleep disorder (e.g.,

narcolepsy, breathing-related sleep disorder, circadian rhythm sleep-wake disorder,
or a parasomnia).
E. Substance Effects:
 Not attributable to the physiological effects of a substance (e.g., drug abuse,

medications).
F. Other Disorders:
 Coexisting mental and medical disorders do not adequately explain the predominant
complaint of hypersomnolence.
Specifiers
 With mental disorder: Including substance use disorders.
 With medical condition.
 With another sleep disorder.

Duration:
 Acute: Less than 1 month.
 Subacute: 1-3 months.
 Persistent: More than 3 months.
Severity Levels
 Mild: Difficulty maintaining alertness 1-2 days/week.
 Moderate: Difficulty maintaining alertness 3-4 days/week.
 Severe: Difficulty maintaining alertness 5-7 days/week.
Diagnostic Features
 Symptoms of Hypersomnolence:
o Excessive sleep quantity (long nocturnal sleep or daytime sleep).
o Poor wakefulness quality (difficulty awakening).
o Sleep inertia (impaired performance post-awakening).
 Individuals may exhibit quick sleep onset and good sleep efficiency (>90%), but
struggle to wake up. Confusion or combativeness can occur during the awakening
process, which may also happen after daytime naps.
 Automatic Behaviors:
o Individuals may engage in automatic behaviors, performing routine activities

without awareness (e.g., driving).
 Sleep Patterns:
o Major sleep episodes may last 9 hours or more but are often nonrestorative.
Daytime naps may last over an hour but also feel unrefreshing.
 Subjective sleep quality can vary, and sleepiness tends to build gradually, rather than
appearing suddenly.
Associated Features
 Nonrestorative sleep, automatic behavior, difficulty waking, and sleep inertia are
common.
 About 80% report nonrestorative sleep; 36%-50% experience sleep inertia.
Prevalence
 5%-10% of individuals in sleep disorder clinics may be diagnosed with

hypersomnolence disorder.
 About 1% of the general population may experience sleep inertia.

 Symptoms typically manifest in late adolescence or early adulthood (mean age 17-
24), with a diagnosis often occurring 10-15 years after symptom onset.
 Hypersomnolence has a progressive course, with episodes potentially lasting up to 20

hours.
 Environmental Factors: Temporary increases can occur with stress or alcohol use;
viral infections may precede hypersomnolence in some cases.
 Genetic Factors: May have a familial pattern, potentially inherited in an autosomal

dominant manner.
Diagnostic Markers
 Polysomnography Findings:
o Normal to prolonged sleep duration, short sleep latency, normal to increased

sleep continuity, and mostly greater than 90% sleep efficiency.
o Mean sleep latency typically less than 10 minutes, with occasional sleep-onset
REM periods.
Narcolepsy Diagnostic Criteria
A. Recurrent periods of sleep:
 Occurrence of lapses into sleep or napping at least three times per week over the
past 3 months.
B. Presence of at least one of the following:
1. Episodes of cataplexy:
o (a) In individuals with long-standing disease: brief (seconds to minutes)

episodes of sudden bilateral loss of muscle tone with maintained
consciousness, typically triggered by laughter or joking.
o (b) In children or within 6 months of onset: spontaneous grimaces, jaw-

opening episodes, tongue thrusting, or global hypotonia without obvious
emotional triggers.
2. Hypocretin deficiency:
o Measured via cerebrospinal fluid (CSF) hypocretin-1 immunoreactivity values:

less than or equal to one-third of healthy subject values or less than or equal
to 110 pg/mL.
o Must not be associated with acute brain injury, inflammation, or infection.
3. Polysomnography findings:
o Rapid eye movement (REM) sleep latency of less than or equal to 15 minutes,
or a multiple sleep latency test showing mean sleep latency less than or equal
to 8 minutes with two or more sleep-onset REM periods.
Specify the Diagnosis
 347.00 (G47.419): Narcolepsy without cataplexy but with hypocretin deficiency.
 347.01 (G47.411): Narcolepsy with cataplexy but without hypocretin deficiency.
 347.00 (G47.419): Autosomal dominant cerebellar ataxia, deafness, and narcolepsy.
 347.00 (G47.419): Autosomal dominant narcolepsy, obesity, and type 2 diabetes.
 347.10 (G47.429): Narcolepsy secondary to another medical condition.
Severity Specification
 Mild: Infrequent cataplexy (less than once per week), naps only once or twice per
day, and less disturbed nocturnal sleep.
 Moderate: Cataplexy once daily or every few days, disturbed nocturnal sleep, need
for multiple naps daily.
 Severe: Drug-resistant cataplexy with multiple attacks daily, nearly constant

sleepiness, and disturbed nocturnal sleep.
Subtypes and Diagnostic Features
 Narcolepsy without cataplexy but with hypocretin deficiency: Symptoms may

not be triggered by emotions and may be unusually long-lasting. Confirm diagnosis
with repeated testing if initial results are negative.
 Narcolepsy with cataplexy but without hypocretin deficiency: May require

HLA DQBl*06:02 testing. Exclude seizures and functional neurological disorders.
 Narcolepsy secondary to another medical condition: May show positive HLA

DQBl*06:02 due to autoimmune processes triggered by underlying conditions.
Diagnostic Characteristics
 Essential features include recurrent daytime sleepiness occurring at least three times
a week.
 Cataplexy often manifests as brief, sudden loss of muscle tone due to emotional
triggers. Differentiate from weakness in athletic contexts or stress-induced weakness.
 Confirmatory tests include nocturnal polysomnography and MSLT, assessing REM

sleep latency and sleep onset REM periods.
Associated Features
 Automatic behaviors may occur when sleepiness is severe.
 Vivid hallucinations (hypnagogic or hypnopompic) are common, along with sleep

paralysis, nightmares, and REM sleep behavior disorder.
 Individuals may show signs of sleepiness during examinations, with typical features
observed during cataplexy.
Prevalence and Course
 Affects approximately 0.02%-0.04% of the population, with a slight male

predominance.
 Onset typically occurs in adolescence or early adulthood, with a possibility of abrupt
or progressive onset.
 Cataplexy usually appears within 1 year of sleepiness onset, with other symptoms
developing thereafter.
 The condition is lifelong, with symptom exacerbation often linked to medication

noncompliance or concurrent sleep disorders.
Management
 A regular schedule and adequate sleep hygiene are crucial in managing symptoms,
especially as individuals age or retire, allowing for more napping opportunities.
Breathing-Related Sleep Disorders Overview
Categories:
1. Obstructive Sleep Apnea Hypopnea
2. Central Sleep Apnea
3. Sleep-Related Hypoventilation
Obstructive Sleep Apnea Hypopnea (OSAHS)
Diagnostic Criteria (327.23 - G47.33):
 A. Either (1) or (2):
1. Polysomnography evidence of:
 At least five obstructive apneas or hypopneas per hour with:
 Nocturnal breathing disturbances (snoring, gasping, pauses) or
 Daytime sleepiness or fatigue not explained by other

conditions.
2. 15 or more obstructive apneas/hypopneas per hour, regardless of symptoms.
Severity:
 Mild: Apnea-hypopnea index (AHI) < 15.
 Moderate: AHI 15-30.
 Severe: AHI > 30.
Specifiers:
 Severity determined by the AHI and accompanying symptoms, such as oxygen

desaturation levels and sleep fragmentation.
 Characterized by repeated upper airway obstructions during sleep (apneas and
hypopneas).
 Apnea: total absence of airflow; Hypopnea: reduction in airflow.
 Symptoms include snoring, daytime sleepiness, fatigue, and others.
Diagnostic Approach:
 Diagnosis based on polysomnographic findings and associated symptoms.
 Risk factors include obesity, gender, and physical characteristics.
Associated Features:
 Other symptoms can include insomnia, heartburn, nocturia, morning headaches, and
erectile dysfunction.
 Hypertension occurs in over 60% of cases.
Prevalence:
 Affects 1-2% of children, 2-15% of middle-aged adults, and over 20% of older adults.
 Higher prevalence in males, older adults, and certain ethnic groups.
 Follows a J-shaped distribution, peaking in ages 3-8 due to enlarged tonsils, with
reductions in prevalence during later childhood.
 Increases again in midlife due to obesity and post-menopausal effects.
Risk Factors:
 Genetic and Physiological: Obesity, male gender, structural issues (e.g.,

retrognathia), adenotonsillar hypertrophy, and menopause.
 Cultural Differences: Variations in reporting symptoms across cultures; some

cultures may view snoring as normal.
Diagnostic Markers:
 Polysomnography is essential for quantifying respiratory disturbances and associated

oxygen levels.
 Arterial blood gas measurements while awake are typically normal, but some
individuals may exhibit hypoxemia or hypercapnia.
Central Sleep Apnea (CSA)
 A. Evidence from polysomnography of 5 or more central apneas per hour of

sleep.
 B. The disorder is not better explained by another current sleep disorder.
Specify the Type:
1. Idiopathic Central Sleep Apnea (327.21/G47.31)
o Characterized by episodes of apneas and hypopneas caused by variability in

respiratory effort without airway obstruction.
2. Cheyne-Stokes Breathing (786.04/R06.3)
o Periodic crescendo-decrescendo variation in tidal volume resulting in central

apneas and hypopneas (≥5 events/hour) with frequent arousals.
3. Central Sleep Apnea Comorbid with Opioid Use (780.57/G47.37)
o Attributed to the effects of opioids on respiratory rhythm generators.
Severity Specifiers:
 Graded based on the frequency of breathing disturbances, oxygen desaturation, and

sleep fragmentation.
Subtypes
 Idiopathic CSA and Cheyne-Stokes Breathing show increased gain in the

ventilatory control system.
 CSA with Opioid Use is linked to respiratory control impairment due to opioids.
Diagnostic Features
 Characterized by repeated episodes of apneas and hypopneas due to variability in

respiratory effort.
 Associated with conditions like heart failure, stroke, or renal failure, leading to
Cheyne-Stokes Breathing.
Associated Features
 Symptoms may include sleepiness, insomnia, and fragmented sleep; some

individuals may be asymptomatic.
Prevalence
 Idiopathic CSA is rare; prevalence of Cheyne-Stokes Breathing increases with heart

failure (up to 20% in those with ejection fraction <45%).
 CSA comorbid with opioid use occurs in ~30% of chronic opioid users.

 Cheyne-Stokes Breathing often develops with heart failure; its clinical significance
post-stroke is uncertain.
 CSA comorbid with opioid use typically occurs after prolonged use.
Risk Factors
 Includes older age, male gender, and conditions like heart failure and stroke.
Diagnostic Markers
 Physical findings related to heart failure (e.g., jugular venous distension) and
polysomnography used for characterization.
Functional Consequences
 May lead to disrupted sleep and associated symptoms like fatigue and excessive
sleepiness.
Differential Diagnosis
 CSA is differentiated from obstructive sleep apnea based on the ratio of central to
obstructive events.
 Cheyne-Stokes breathing is distinguished by predisposing conditions and

characteristic breathing patterns.
Here’s a concise summary of the key points regarding Sleep-Related Hypoventilation:
Sleep-Related Hypoventilation (SRH)
 A. Polysomnography shows episodes of decreased respiration associated with

elevated CO2 levels. Persistent low hemoglobin oxygen saturation may also indicate
hypoventilation.
 B. The disturbance is not better explained by another current sleep disorder.
Specify the Type:
1. Idiopathic Hypoventilation (327.24/G47.34)
o Not attributable to any readily identified condition.
2. Congenital Central Alveolar Hypoventilation (327.25/G47.35)
o A rare congenital disorder presenting in the perinatal period with shallow

breathing or cyanosis during sleep.
3. Comorbid Sleep-Related Hypoventilation (327.26/G47.36)
o Occurs as a consequence of conditions like:
 Pulmonary Disorders (e.g., COPD)
 Neuromuscular Disorders (e.g., muscular dystrophies)

 Medications (e.g., benzodiazepines, opioids)
 Obesity Hypoventilation Disorder: Characterized by BMI >30 and

hypercapnia during wakefulness (PCO2 >45).
Specify Current Severity:
 Graded based on hypoxemia and hypercarbia during sleep, with end-organ

impairment (e.g., right-sided heart failure) indicating greater severity.
Subtypes
 The prevalence of obesity hypoventilation disorder is thought to be increasing

alongside rising obesity rates.
Diagnostic Features
 Sleep-related hypoventilation can occur independently or comorbidly with other

medical/neurological disorders. Symptoms may include excessive daytime
sleepiness, frequent arousals, morning headaches, and insomnia.
 Individuals may experience:
o Insomnia or excessive sleepiness.
o Orthopnea (difficulty breathing while lying flat).
o Headaches upon awakening.
o Coexistence with obstructive sleep apnea or central sleep apnea.
o Consequences like pulmonary hypertension, cor pulmonale, or neurocognitive

dysfunction.
Prevalence
 Idiopathic Sleep-Related Hypoventilation is uncommon; Congenital Central

Alveolar Hypoventilation is rare. Comorbid Sleep-Related Hypoventilation is
more prevalent, particularly associated with COPD, neuromuscular disorders, or
obesity.
 Idiopathic SRH is typically a slowly progressive disorder. When comorbid with other
conditions, severity reflects the underlying condition's progression.
 Congenital Central Alveolar Hypoventilation often manifests at birth but can

also appear in later childhood/adulthood due to variable gene mutation penetrance
(e.g., PHOX2B).
Complications
 May lead to pulmonary hypertension, cor pulmonale, cardiac dysrhythmias,

polycythemia, and neurocognitive dysfunction with worsening respiratory failure.
This summary captures the essential aspects of Sleep-Related Hypoventilation, including its
diagnostic criteria, types, features, and implications. Let me know if you need further details
or have specific questions!

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Paraphilic Disorders

2. Exhibitionistic disorder: Exposing genitals to strangers.

3. Frotteuristic disorder: Touching or rubbing against someone without their consent.

4. Sexual masochism disorder: Enjoying being hurt or humiliated during sexual

6. Pedophilic disorder: Having a sexual interest in children.

8. Transvestic disorder: Becoming sexually aroused by dressing in clothes typically worn

Voyeuristic Disorder involves a person becoming sexually aroused by

 In a controlled environment: This means the person is in a place, like a hospital or

Prevalence and Development:

 Voyeuristic behavior is quite common, especially in males, with an estimated 12% of

 Temperament: People with strong voyeuristic tendencies are at higher risk of

Exhibitionistic Disorder is characterized by intense sexual arousal from

3. Specify: The individual may be:

o Aroused by exposing genitals to prepubescent children,

o Aroused by exposing genitals to physically mature individuals,

o Aroused by exposing genitals to both prepubescent children and mature

 In a controlled environment: For individuals in institutional settings where their

Development and Course:

 Temperamental: People with a history of antisocial personality disorder, alcohol

 Environmental: Childhood sexual or emotional abuse and hypersexuality are

Frotteuristic Disorder involves recurrent and intense sexual arousal

 In a controlled environment: This applies to individuals living in institutional

 Frotteuristic acts, such as uninvited sexual touching or rubbing, may occur in up to

 In outpatient clinical settings for paraphilic disorders, approximately 10% to 14% of

Development and Course:

 Children and adolescents may engage in similar behaviors without necessarily

 Over time, factors such as subjective distress, psychiatric comorbidity, sexual

Risk and Prognostic Factors:

 Temperamental: Antisocial behavior, hypersexuality, and sexual impulsivity may

Gender-Related Diagnostic Issues:

Frotteuristic Disorder, like other paraphilias, is diagnosed based on

Diagnostic Criteria (302.83 F65.51):

2. Distress or Impairment: These fantasies, urges, or behaviors cause clinically

 With Asphyxiophilia: If the person achieves sexual arousal by restricting breathing.

 In a Controlled Environment: This applies to individuals living in institutional

 Individuals who are diagnosed with Sexual Masochism Disorder typically

 If there is no distress or impairment (e.g., no feelings of guilt or shame), the person

Associated Features Supporting Diagnosis:

 Extensive use of pornography that involves being humiliated, beaten, bound, or

Development and Course:

 The direct functional consequences of Sexual Masochism Disorder are unclear,

Sexual Sadism Disorder is characterized by intense sexual arousal

Diagnostic Criteria (302.84 F65.52):

 In a Controlled Environment: This applies to individuals living in settings like

 Admitting individuals: If they report distress or impairment from their sexual

 Nondisclosing individuals: Those who have inflicted pain or suffering on multiple

Associated Features Supporting Diagnosis:

Development and Course:

 Sexual Sadism Disorder may result in legal consequences, relational problems, or

Pedophilic Disorder involves recurrent, intense sexual urges, fantasies,

Diagnostic Criteria (302.2 F65.4):

1. Duration: For at least 6 months, the individual experiences recurrent, intense

o Note: This excludes individuals in late adolescence who are involved in

 Exclusive Type: Attracted only to children.

 Nonexclusive Type: Attracted to both children and physically mature individuals.

 Sexual Attraction: To males, females, or both.

 Limited to Incest: When sexual attraction is limited to related children.

 Admitting Individuals: These individuals acknowledge a strong sexual interest in

 Non-Admitting Individuals: These individuals deny sexual interest in children