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1. Several discrete episodes of failure to resist aggressive impulses that result in serious assaultive acts or destruction of property.
2. The degree of aggressiveness expressed during the episodes is grossly out of proportion to any precipitating psychosocial stressors.
3. The aggressive episodes are not better accounted for by another mental disorder (e.g., antisocial personality disorder, borderline personality disorder, a psychotic disorder, a manic episode, conduct disorder, or attention-deficit/hyperactivity disorder) and are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., head trauma, Alzheimer's disease).

1. Recurrent failure to resist impulses to steal objects that are not needed for personal use or for their monetary value.
2. Increasing sense of tension immediately before committing the theft.
3. Pleasure, gratification, or relief at the time of committing the theft.
4. The stealing is not committed to express anger or vengeance and is not in response to a delusion or a hallucination.
5. The stealing is not better accounted for by conduct disorder, a manic episode, or antisocial personality disorder.

1. Deliberate and purposeful fire setting on more than one occasion.
2. Tension or affective arousal before the act.
3. Fascination with, interest in, curiosity about, or attraction to fire and its situational contexts (e.g., paraphernalia, uses, consequences).
4. Pleasure, gratification, or relief when setting fires, or when witnessing or participating in their aftermath.
5. The fire setting is not done for monetary gain, as an expression of sociopolitical ideology, to conceal criminal activity, to express anger or vengeance, to improve one's living circumstances, in response to a delusion or hallucination, or as a result of impaired judgment (e.g., in dementia, mental retardation, substance intoxication).
6. The fire setting is not better accounted for by conduct disorder, a manic episode, or antisocial personality disorder.

1. Persistent and recurrent maladaptive gambling behavior as indicated by five (or more) of the following:

   1. is preoccupied with gambling (e.g., preoccupied with reliving past gambling experiences, handicapping or planning the next venture, or thinking of ways to get money with which to gamble)
   2. needs to gamble with increasing amounts of money in order to achieve the desired excitement
   3. has repeated unsuccessful efforts to control, cut back, or stop gambling
   4. is restless or irritable when attempting to cut down or stop gambling
   5. gambles as a way of escaping from problems or of relieving a dysphoric mood (e.g., feelings of helplessness, guilt, anxiety, depression)
   6. after losing money gambling, often returns another day to get even (“chasing” one's losses)
   7. lies to family members, therapist, or others to conceal the extent of involvement with gambling
   8. has committed illegal acts such as forgery, fraud, theft, or embezzlement to finance gambling
   9. has jeopardized or lost a significant relationship, job, or educational or career opportunity because of gambling
   10. relies on others to provide money to relieve a desperate financial situation caused by gambling
2. The gambling behavior is not better accounted for by a manic episode.

1. Recurrent pulling out of one's hair resulting in noticeable hair loss.
2. An increasing sense of tension immediately before pulling out the hair or when attempting to resist the behavior.
3. Pleasure, gratification, or relief when pulling out the hair.
4. The disturbance is not better accounted for by another mental disorder and is not due to a general medical condition (e.g., a dermatological condition).
5. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

This category is for disorders of impulse control (e.g., skin picking) that do not meet the criteria for any specific impulse-control disorder or for another mental disorder having features involving impulse control described elsewhere in the manual (e.g., substance dependence, a paraphilia).

Pathological gambling

1. Two or more episodes of gambling occur over a period of at least 1 year.
2. These episodes do not have a profitable outcome for the individual but are continued despite personal distress and interference with personal functioning in daily living.
3. The individual describes an intense urge to gamble which is difficult to control and reports that he or she is unable to stop gambling by an effort of will.
4. The individual is preoccupied with thoughts or mental images of the act of gambling or the circumstances surrounding the act.

Pathological fire setting (pyromania)

1. There are two or more acts of fire setting without apparent motive.
2. The individual describes an intense urge to set fire to objects, with a feeling of tension before the act and relief afterward.
3. The individual is preoccupied with thoughts or mental images of fire setting or of the circumstances surrounding the act (e.g., abnormal interest in fire engines or in calling out the fire service).

Pathological stealing (kleptomania)

1. There are two or more thefts in which the individual steals without any apparent motive of personal gain or gain for another person.
2. The individual describes an intense urge to steal, with a feeling of tension before the act and relief afterward.

Trichotillomania

1. Noticeable hair loss is caused by the individual's persistent and recurrent failure to resist impulses to pull out hairs.
2. The individual describes an intense urge to pull out hairs, with mounting tension before the act and a sense of relief afterward.
3. There is no preexisting inflammation of the skin, and the hair pulling is not in response to a delusion or hallucination.

Other habit and impulse disorders
This category should be used for other kinds of persistently repeated maladaptive behaviors that are not secondary to a recognized psychiatric syndrome and in which it appears that there is repeated failure to resist impulses to carry out the behavior. There is a prodromal period of tension with a feeling of release at the time of the act.
Habit and impulse disorder, unspecified

1. Onset of symptoms must occur within 1 month of exposure to an identifiable psychosocial stressor, not of an unusual or catastrophic type.
2. The individual manifests symptoms or behavior disturbance of the types found in any of the affective disorders (except for delusions and hallucinations), any disorder in neurotic, stress-related, and somatoform disorders, and conduct disorders, but the criteria for an individual disorder are not fulfilled. Symptoms may be variable in both form and severity.


The predominant feature of the symptoms may be further specified.
Brief depressive reaction
A transient mild depressive state of a duration not exceeding 1 month.
Prolonged depressive reaction
A mild depressive state occurring in response to a prolonged exposure to a stressful situation but of a duration not exceeding 2 years.
Mixed anxiety and depressive reaction
Both anxiety and depressive symptoms are prominent, but at levels no greater than those specified for mixed anxiety and depressive disorder or other mixed anxiety disorders.
With predominant disturbance of other emotions
The symptoms are usually of several types of emotions, such as anxiety, depression, worry, tensions, and anger. Symptoms of anxiety and depression may meet the criteria for mixed anxiety and depressive disorder or for other mixed anxiety disorders, but they are not so predominant that other more specific depressive or anxiety disorders can be diagnosed. This category should also be used for reactions in children in whom regressive behavior such as bed-wetting or thumb-sucking is also present.
With predominant disturbance of conduct
The main disturbance is one involving conduct, e.g., an adolescent grief reaction resulting in aggressive or dissocial behavior.
With mixed disturbance of emotions and conduct
Both emotional symptoms and disturbances of conduct are prominent features.
With other specified predominant symptoms

3. Except in prolonged depressive reaction, the symptoms do not persist for more than 6 months after the cessation of the stress or its consequences. However, this should not prevent a provisional diagnosis being made if this criterion is not yet fulfilled.

1. The development of emotional or behavioral symptoms in response to an identifiable stressor(s) occurring within 3 months of the onset of the stressor(s).
2. These symptoms or behaviors are clinically significant as evidenced by either of the following:
   1. marked distress that is in excess of what would be expected from exposure to the stressor
   2. significant impairment in social or occupational (academic) functioning
3. The stress-related disturbance does not meet the criteria for another specific Axis I disorder and is not merely an exacerbation of a preexisting Axis I or Axis II disorder.
4. The symptoms do not represent bereavement.
5. Once the stressor (or its consequences) has terminated, the symptoms do not persist for more than an additional 6 months.

Specify if:
Acute: if the disturbance lasts less than 6 months
Chronic: if the disturbance lasts for 6 months or longer
Adjustment disorders are coded based on the subtype, which is selected according to the predominant symptoms. The specific stressor(s) can be specified on Axis IV.
With depressed mood
With anxiety
With mixed anxiety and depressed mood
With disturbance of conduct
With mixed disturbance of emotions and conduct
Unspecified

1. Disturbance of consciousness (i.e., reduced clarity of awareness of the environment) with reduced ability to focus, sustain, or shift attention.
2. A change in cognition (such as memory deficit, disorientation, language disturbance) or the development of a perceptual disturbance that is not better accounted for by a preexisting, established, or evolving dementia.
3. The disturbance develops over a short period of time (usually hours to days) and tends to fluctuate during the course of the day.
4. There is evidence from the history, physical examination, or laboratory findings that the disturbance is caused by the direct physiological consequences of a general medical condition.

Coding note: If delirium is superimposed on a preexisting vascular dementia, indicate the delirium by coding vascular dementia, with delirium.
Coding note: Include the name of the general medical condition on Axis I, e.g., Delirium due to hepatic encephalopathy; also code the general medical condition on Axis III.

1. Disturbance of consciousness (i.e., reduced clarity of awareness of the environment) with reduced ability to focus, sustain, or shift attention.
2. A change in cognition (such as memory deficit, disorientation, language disturbance) or the development of a perceptual disturbance that is not better accounted for by a preexisting, established, or evolving dementia.
3. The disturbance develops over a short period of time (usually hours to days) and tends to fluctuate during the course of the day.
4. There is evidence from the history, physical examination, or laboratory findings of either (1) or (2):
   1. the symptoms in Criteria A and B developed during substance intoxication
   2. medication use is etiologically related to the disturbance*
      Note: This diagnosis should be made instead of a diagnosis of substance intoxication only when the cognitive symptoms are in excess of those usually associated with the intoxication syndrome and when the symptoms are sufficiently severe to warrant independent clinical attention.
      *Note: The diagnosis should be recorded as substance-induced delirium if related to medication use.

Code (Specific substance) intoxication delirium:
(Alcohol; Amphetamine [or amphetaminelike substance]; Cannabis; Cocaine; Hallucinogen; Inhalant; Opioid; Phencyclidine [or phencyclidinelike substance]; Sedative, hypnotic, or anxiolytic; Other [or unknown] substance [e.g., cimetidine, digitalis, benztropine])

1. Disturbance of consciousness (i.e., reduced clarity of awareness of the environment) with reduced ability to focus, sustain, or shift attention.
2. A change in cognition (such as memory deficit, disorientation, language disturbance) or the development of a perceptual disturbance that is not better accounted for by a preexisting, established, or evolving dementia.
3. The disturbance develops over a short period of time (usually hours to days) and tends to fluctuate during the course of the day.
4. There is evidence from the history, physical examination, or laboratory findings that the symptoms in Criteria A and B developed during, or shortly after, a withdrawal syndrome.

Note: This diagnosis should be made instead of a diagnosis of substance withdrawal only when the cognitive symptoms are in excess of those usually associated with the withdrawal syndrome and when the symptoms are sufficiently severe to warrant independent clinical attention.
Code (Specific substance) withdrawal delirium:
(Alcohol; Sedative, hypnotic, or anxiolytic; Other [or unknown] substance)

1. Disturbance of consciousness (i.e., reduced clarity of awareness of the environment) with reduced ability to focus, sustain, or shift attention.
2. A change in cognition (such as memory deficit, disorientation, language disturbance) or the development of a perceptual disturbance that is not better accounted for by a preexisting, established, or evolving dementia.
3. The disturbance develops over a short period of time (usually hours to days) and tends to fluctuate during the course of the day.
4. There is evidence from the history, physical examination, or laboratory findings that the delirium has more than one etiology (e.g., more than one etiological general medical condition, a general medical condition plus substance intoxication or medication side effect).

Coding note: Use multiple codes reflecting specific delirium and specific etiologies, e.g., Delirium due to viral encephalitis; Alcohol withdrawal delirium.

This category should be used to diagnose a delirium that does not meet criteria for any of the specific types of delirium described in this section.
Examples include

1. A clinical presentation of delirium that is suspected to be due to a general medical condition or substance use but for which there is insufficient evidence to establish a specific etiology
2. Delirium due to causes not listed in this section (e.g., sensory deprivation)

1. There is clouding of consciousness, i.e., reduced clarity of awareness of the environment, with reduced ability to focus, sustain, or shift attention.
2. Disturbance of cognition is manifest by both:
   1. impairment of immediate recall and recent memory, with relatively intact remote memory;
   2. disorientation in time, place, or person.
3. At least one of the following psychomotor disturbances is present:
   1. rapid, unpredictable shifts from hypoactivity to hyperactivity;
   2. increased reaction time;
   3. increased or decreased flow of speech;
   4. enhanced startle reaction.
4. There is disturbance of sleep or of the sleep-wake cycle, manifest by at least one of the following:
   1. insomnia, which in severe cases may involve total sleep loss, with or without daytime drowsiness, or reversal of the sleep-wake cycle;
   2. nocturnal worsening of symptoms;
   3. disturbing dreams and nightmares, which may continue as hallucinations or illusions after awakening.
5. Symptoms have rapid onset and show fluctuations over the course of the day.
6. There is objective evidence from history, physical and neurological examination, or laboratory tests of an underlying cerebral or systemic disease (other than psychoactive substance-related) that can be presumed to be responsible for the clinical manifestations in Criteria A–D.

Comments
Emotional disturbances such as depression, anxiety or fear, irritability, euphoria, apathy, or wondering perplexity, disturbances of perception (illusions or hallucinations, often visual), and transient delusions are typical but are not specific indications for the diagnosis. A fourth character may be used to indicate whether or not the delirium is superimposed on dementia:
Delirium, not superimposed on dementia
Delirium, superimposed on dementia
Other delirium
Delirium, unspecified

1. The development of multiple cognitive deficits manifested by both

   1. memory impairment (impaired ability to learn new information or to recall previously learned information)
   2. one (or more) of the following cognitive disturbances:
      1. aphasia (language disturbance)
      2. apraxia (impaired ability to carry out motor activities despite intact motor function)
      3. agnosia (failure to recognize or identify objects despite intact sensory function)
      4. disturbance in executive functioning (i.e., planning, organizing, sequencing, abstracting)
2. The cognitive deficits in Criteria A1 and A2 each cause significant impairment in social or occupational functioning and represent a significant decline from a previous level of functioning.
3. The course is characterized by gradual onset and continuing cognitive decline.
4. The cognitive deficits in Criteria A1 and A2 are not due to any of the following:
   1. other central nervous system conditions that cause progressive deficits in memory and cognition (e.g., cerebrovascular disease, Parkinson's disease, Huntington's disease, subdural hematoma, normal-pressure hydrocephalus, brain tumor)
   2. systemic conditions that are known to cause dementia (e.g., hypothyroidism, vitamin B₁₂ or folic acid deficiency, niacin deficiency, hypercalcemia, neurosyphilis, HIV infection)
   3. substance-induced conditions
5. The deficits do not occur exclusively during the course of a delirium.
6. The disturbance is not better accounted for by another Axis I disorder (e.g., major depressive disorder, schizophrenia).

Code based on presence or absence of a clinically significant behavioral disturbance:
Without behavioral disturbance: if the cognitive disturbance is not accompanied by any clinically significant behavioral disturbance.
With behavioral disturbance: if the cognitive disturbance is accompanied by a clinically significant behavioral disturbance (e.g., wandering, agitation).
Specify subtype:
With early onset: if onset is at age 65 years or below
With late onset: if onset is after age 65 years
Coding note: Also code Alzheimer's disease on Axis III. Indicate other prominent clinical features related to the Alzheimer's disease on Axis I (e.g., Mood disorder due to Alzheimer's disease, with depressive features, and Personality change due to Alzheimer's disease, aggressive type).

1. The development of multiple cognitive deficits manifested by both

   1. memory impairment (impaired ability to learn new information or to recall previously learned information)
   2. one (or more) of the following cognitive disturbances:
      1. aphasia (language disturbance)
      2. apraxia (impaired ability to carry out motor activities despite intact motor function)
      3. agnosia (failure to recognize or identify objects despite intact sensory function)
      4. disturbance in executive functioning (i.e., planning, organizing, sequencing, abstracting)
2. The cognitive deficits in Criteria A1 and A2 each cause significant impairment in social or occupational functioning and represent a significant decline from a previous level of functioning.
3. Focal neurological signs and symptoms (e.g., exaggeration of deep tendon reflexes, extensor plantar response, pseudobulbar palsy, gait abnormalities, weakness of an extremity) or laboratory evidence indicative of cerebrovascular disease (e.g., multiple infarctions involving cortex and underlying white matter) that are judged to be etiologically related to the disturbance.
4. The deficits do not occur exclusively during the course of a delirium.

Code based on predominant features:
With delirium: if delirium is superimposed on the dementia
With delusions: if delusions are the predominant feature
With depressed mood: if depressed mood (including presentations that meet full symptom criteria for a major depressive episode) is the predominant feature. A separate diagnosis of mood disorder due to a general medical condition is not given.
Uncomplicated: if none of the above predominates in the current clinical presentation
Specify if:
With behavioral disturbance
Coding note: Also code cerebrovascular condition on Axis III.

1. The development of multiple cognitive deficits manifested by both

   1. memory impairment (impaired ability to learn new information or to recall previously learned information)
   2. one (or more) of the following cognitive disturbances:
      1. aphasia (language disturbance)
      2. apraxia (impaired ability to carry out motor activities despite intact motor function)
      3. agnosia (failure to recognize or identify objects despite intact sensory function)
      4. disturbance in executive functioning (i.e., planning, organizing, sequencing, abstracting)
2. The cognitive deficits in Criteria A1 and A2 each cause significant impairment in social or occupational functioning and represent a significant decline from a previous level of functioning.
3. There is evidence from the history, physical examination, or laboratory findings that the disturbance is the direct physiological consequence of a general medical condition other than Alzheimer's disease or cerebrovascular disease (e.g., HIV infection, traumatic brain injury, Parkinson's disease, Huntington's disease, Pick's disease, Creutzfeldt-Jakob disease, normal-pressure hydrocephalus, hypothyroidism, brain tumor, or vitamin B₁₂ deficiency).
4. The deficits do not occur exclusively during the course of a delirium.

Code based on presence or absence of a clinically significant behavioral disturbance:
Without behavioral disturbance: if the cognitive disturbance is not accompanied by any clinically significant behavioral disturbance.
With behavioral disturbance: if the cognitive disturbance is accompanied by a clinically significant behavioral disturbance (e.g., wandering, agitation).
Coding note: Also code the general medical condition on Axis III (e.g., HIV infection, head injury, Parkinson's disease, Huntington's disease, Pick's disease, Creutzfeldt-Jakob disease).

1. The development of multiple cognitive deficits manifested by both

   1. memory impairment (impaired ability to learn new information or to recall previously learned information)
   2. one (or more) of the following cognitive disturbances:
      1. aphasia (language disturbance)
      2. apraxia (impaired ability to carry out motor activities despite intact motor function)
      3. agnosia (failure to recognize or identify objects despite intact sensory function)
      4. disturbance in executive functioning (i.e., planning, organizing, sequencing, abstracting)
2. The cognitive deficits in Criteria A1 and A2 each cause significant impairment in social or occupational functioning and represent a significant decline from a previous level of functioning.
3. The deficits do not occur exclusively during the course of a delirium and persist beyond the usual duration of substance intoxication or withdrawal.
4. There is evidence from the history, physical examination, or laboratory findings that the deficits are etiologically related to the persisting effects of substance use (e.g., a drug of abuse, a medication).

Code (Specific substance)-induced persisting dementia:
   (Alcohol; Inhalant; Sedative, hypnotic, or anxiolytic; Other [or unknown] substance)

1. The development of multiple cognitive deficits manifested by both

   1. memory impairment (impaired ability to learn new information or to recall previously learned information)
   2. one (or more) of the following cognitive disturbances:
      1. aphasia (language disturbance)
      2. apraxia (impaired ability to carry out motor activities despite intact motor function)
      3. agnosia (failure to recognize or identify objects despite intact sensory function)
      4. disturbance in executive functioning (i.e., planning, organizing, sequencing, abstracting)
2. The cognitive deficits in Criteria A1 and A2 each cause significant impairment in social or occupational functioning and represent a significant decline from a previous level of functioning.
3. There is evidence from the history, physical examination, or laboratory findings that the disturbance has more than one etiology (e.g., head trauma plus chronic alcohol use, dementia of the Alzheimer's type with the subsequent development of vascular dementia).
4. The deficits do not occur exclusively during the course of a delirium.

Coding note: Use multiple codes based on specific dementias and specific etiologies e.g., Dementia of the Alzheimer's type, with late onset, without behavioral disturbance; Vascular dementia, uncomplicated.

This category should be used to diagnose a dementia that does not meet criteria for any of the specific types described in this section.
An example is a clinical presentation of dementia for which there is insufficient evidence to establish a specific etiology.

G1. There is evidence of each of the following:

1. A decline in memory, which is most evident in the learning of new information, although, in more severe cases, the recall of previously learned information may also be affected. The impairment applies to both verbal and nonverbal material. The decline should be objectively verified by obtaining a reliable history from an informant, supplemented, if possible, by neuropsychological tests or quantified cognitive assessments. The severity of the decline, with mild impairment as the threshold for diagnosis, should be assessed as follows:
   Mild. The degree of memory loss is sufficient to interfere with everyday activities, though not so severe as to be incompatible with independent living. The main function affected is the learing of new material. For example, the individual has difficulty in registering, storing, and recalling elements involved in daily living, such as where belongings have been put, social arrangements, or information recently imparted by family members.
   Moderate. The degree of memory loss represents a serious handicap to independent living. Only highly learned or very familiar material is retained. New information is retained only occasionally and very briefly. Individuals are unable to recall basic information about their own local geography, what they have recently been doing, or the names of familiar people.
   Severe. The degree of memory loss is characterized by the complete inability to retain new information. Only fragments of previously learned information remain. The individual fails to recognize even close relatives.
2. A decline in other cognitive abilities characterized by deterioration in judgment and thinking, such as planning and organizing, and in the general processing of information. Evidence for this should ideally be obtained from an informant and supplemented, if possible, by neuropsychological tests or quantified objective assessments. Deterioration from a previously higher level of performance should be established. The severity of the decline, with mild impairment as the threshold for diagnosis, should be assessed as follows:
   Mild. The decline in cognitive abilities causes impaired performance in daily living, but not to a degree that makes the individual dependent on others. Complicated daily tasks or recreational activities cannot be undertaken.
   Moderate. The decline in cognitive abilities makes the individual unable to function without the assistance of another in daily living, including shopping and handling money. Within the home, only simple chores can be performed. Activities are increasingly restricted and poorly sustained.
   Severe. The decline is characterized by an absence, or virtual absence, of intelligible ideation.

The overall severity of the dementia is best expressed as the level of decline in memory or other cognitive abilities, whichever is the more severe (e.g., mild decline in memory and moderate decline in cognitive abilities indicate a dementia of moderate severity).
G2. Awareness of the environment (i.e., absence of clouding of consciousness [as defined in delirium, not induced by alcohol and other psychoactive substances. Criterion A]) is preserved during a period sufficiently long to allow the unequivocal demonstration of the symptoms in Criterion G1. When there are superimposed episodes of delirium, the diagnosis of dementia should be deferred.
G3. There is a decline in emotional control or motivation, or a change in social behavior manifest as at least one of the following:

1. emotional lability
2. irritability
3. apathy
4. coarsening of social behavior

G4. For a confident clinical diagnosis, the symptoms in criterion G1 should have been present for at least 6 months; if the period since the manifest onset is shorter, the diagnosis can be only tentative.
Comments
The diagnosis is further supported by evidence of damage to other higher cortical functions, such as aphasia, agnosia, apraxia.
Judgment about independent living or the development of dependence (upon others) should take account of the cultural expectation and context.
Dementia is specified here as having a minimum duration of 6 months to avoid confusion with reversible states with identical behavioral syndromes, such as traumatic subdural hemorrhage, normal pressure hydrocephalus, and diffuse or focal brain injury.
A fifth character may be used to indicate the presence of additional symptoms: Dementia in Alzheimer's disease, vascular dementia, dementia in diseases classified elsewhere, unspecified dementia, as follows:
   Without additional symptoms
   With other symptoms, predominantly delusional
   With other symptoms, predominantly hallucinatory
   With other symptoms, predominantly depressive
   With other mixed symptoms
A sixth character may be used to indicate the severity of the dementia:
   Mild
   Moderate
   Severe
As mentioned above, the overall severity of the dementia depends on the level of memory or intellectual impairment, whichever is the more severe.

1. The general criteria for dementia G1–G4 must be met.
2. There is no evidence from the history, physical examination, or special investigations for any other possible cause of dementia (e.g., cerebrovascular disease, HIV disease, Parkinson's disease, Huntington's disease, normal pressure hydrocephalus), a systemic disorder (e.g., hypothyroidism, vitamin B₁₂ or folic acid deficiency, hypercalcemia), or alcohol or drug abuse.

Comments
The diagnosis is confirmed by postmortem evidence of neurofibrillary tangles and neuritic plaques in excess of those found in normal aging of the brain.
The following features support the diagnosis, but are not necessary elements: involvement of cortical functions as evidenced by aphasia, agnosia, or apraxia; decrease of motivation and drive, leading to apathy and lack of spontaneity; irritability and disinhibition of social behavior; evidence from special investigations that there is cerebral atrophy, particularly if this can be shown to be increasing over time. In severe cases there may be Parkinson-like extrapyramidal changes, logoclonia, and epileptic fits.
Specification of features for possible subtypes
Because of the possibility that subtypes exist, it is recommended that the following characteristics be ascertained as a basis for a further classification age at onset; rate of progression; configuration of the clinical features, particularly the relative prominence (or lack) of temporal, parietal or frontal lobe signs; any neuropathological or neurochemical abnormalities, and their pattern.
The division of Alzheimer's disease into subtypes can at present be accomplished in two ways: first by taking only the age of onset and labeling the disease as either early or late, with an approximate cutoff point at 65 years; or second, by assessing how well the individual conforms to one of the two putative syndromes, early- or late-onset type.
It should be noted that a sharp distinction between early- and late-onset types is unlikely. Early-onset type may occur in late life, just as late-onset type may occasionally have an onset before the age of 65. The following criteria may be used to differentiate dementia in Alzheimer's disease with early and late onset, but it should be remembered that the status of this subdivision is still controversial.
Dementia in Alzheimer's disease with early onset

1. The criteria for dementia in Alzheimer's disease must be met, and the age at onset must be below 65 years.
2. In addition, at least one of the following requirements must be met:
   1. evidence of a relatively rapid onset and progression;
   2. in addition to memory impairment, there must be aphasia (amnesic or sensory), agraphia, alexia, acalculia, or apraxia (indicating the presence of temporal, parietal, and/or frontal lobe involvement).

Dementia in Alzheimer's disease with late onset

1. The criteria for dementia in Alzheimer's disease must be met and the age at onset must be 65 years or more.
2. In addition, at least one of the following requirements must be met:
   1. evidence of a very slow, gradual onset and progression (the rate of the latter may be known only retrospectively after a course of 3 years or more);
   2. predominance of memory impairment G1(1), over intellectual impairment G1(2) (see general criteria for dementia).

Dementia in Alzheimer's disease, atypical or mixed type
This term and code should be used for dementias that have important atypical features or that fulfill criteria for both early- and late-onset types of Alzheimer's disease. Mixed Alzheimer's and vascular dementia are also included here.
Dementia in Alzheimer's disease, unspecified

G1.
The general criteria for dementia (G1–G4) must be met.

G2.
Deficits in higher cognitive functions are unevenly distributed, with some functions affected and others relatively spared. Thus, memory may be markedly affected while thinking, reasoning, and information processing may show only mild decline.

G3.
There is clinical evidence of focal brain damage, manifest as at least one of the following:

1. lateral spastic weakness of the limbs;
2. unilaterally increased tendon reflexes;
3. extensor plantar response;
4. pseudobulbar palsy.

G4.
There is evidence from the history, examination, or tests of a significant cerebrovascular disease, which may reasonably be judged to be etiologically related to the dementia (e.g., a history of stroke, evidence of cerebral infarction).

The following criteria may be used to differentiate subtypes of vascular dementia, but it should be remembered that the usefulness of this subdivision may not be generally accepted.

Vascular dementia of acute onset

1. The general criteria for vascular dementia must be met.
2. The dementia develops rapidly (i.e., usually within 1 month, but within no longer than 3 months) after succession of strokes or (rarely) after a single large infarction.

Multi-infarct dementia

1. The general criteria for vascular dementia must be met.
2. The onset of the dementia is gradual (i.e., within 3–6 months), following a number of minor ischemic episodes.

Comments
It is presumed that there is an accumulation of infarcts in the cerebral parenchyma. Between the ischemic episodes there may be period of actual clinical improvement.

Subcortical vascular dementia

1. The general criteria for vascular dementia must be met.
2. There is a history of hypertension.
3. There is evidence from clinical examination and special investigation of vascular disease located in the deep white matter of the cerebral hemispheres, with preservation of the cerebral cortex.

Mixed cortical and subcortical vascular dementia
Mixed cortical and subcortical components of the vascular dementia may be suspected from the clinical features, the results of investigation (including autopsy), or both.
Other vascular dementia
Vascular dementia, unspecified

Classified elsewhere
Dementia in Pick's disease

1. The general criteria for dementia (G1–G4) must be met.
2. Onset is slow with steady deterioration.
3. Predominance of frontal lobe involvement is evidenced by two or more of the following:
   1. emotional blunting;
   2. coarsening of social behavior;
   3. disinhibition;
   4. apathy or restlessness;
   5. aphasia
4. In the early stages, memory and parietal lobe functions are relatively preserved.

Dementia in Creutzfeldt-Jakob disease

1. The general criteria for dementia (G1–G4) must be met.
2. There is very rapid progression of the dementia, with disintegration of virtually all higher cerebral functions.
3. One or more of the following types of neurological symptoms and signs emerge, usually after or simultaneously with the dementia.
   1. pyramidal symptoms;
   2. extrapyramidal symptoms;
   3. cerebellar symptoms;
   4. aphasia;
   5. visual impairment.

Comments
An akinetic and mute state is the typical terminal stage. An amyotrophic variant may be seen, where the neurological signs precede the onset of the dementia. A characteristic electroencephalogram (periodic spikes against a slow and low voltage background), if present in association with the above clinical signs, increases the probability of the diagnosis. However, the diagnosis can be confirmed only by neuropathological examination (neuronal loss, astrocytosis, and spongiform changes). Because of the risk of infection, this should be carried out only under special protective conditions.
Dementia in Huntington's disease

1. The general criteria for dementia (G1–G4) must be met.
2. Subcortical functions are affected first and dominate the picture of dementia throughout; subcortical involvement is manifested by slowness of thinking or movement and personality alteration with apathy or depression.
3. There are involuntary choreiform movements, typically of the face, hands, or shoulders, or in the gait. The patient may attempt to conceal them by converting them into a voluntary action.
4. There is a history of Huntington's disease in one parent or a sibling, or a family history that suggests the disorder.
5. There are no clinical features that otherwise account for the abnormal movements.

Comments
In addition to involuntary choreiform movements, there may be development of extrapyramidal rigidity or of spasticity with pyramidal signs.
Dementia in Parkinson's disease

1. The general criteria for dementia (G1–G4) must be met.
2. A diagnosis of Parkinson's disease has been established.
3. None of the cognitive impairment is attributable to antiparkinsonian medication.
4. There is no evidence from the history, physical examination, or special investigations for any other possible cause of dementia, including other forms of brain disease, damage, or dysfunction (e.g., cerebrovascular disease, HIV disease, Huntington's disease, normal pressure hydrocephalus), a systemic disorder (e.g., hypothyroidism, vitamin B₁₂ or folic acid deficiency, hypercalcemia), or alcohol or drug abuse.

If criteria are also fulfilled for dementia in Alzheimer's disease with late onset, that category should be used in combination with Parkinson's disease.
Dementia in human immunodeficiency virus (HIV) disease

1. The general criteria for dementia (G1–G4) must be met.
2. A diagnosis of HIV infection has been established.
3. There is no evidence from the history, physical examination, or special investigations for any other possible cause of dementia, including other forms of brain disease, damage, or dysfunction (e.g., Alzheimer's disease, cerebrovascular disease, Parkinson's disease, Huntington's disease, normal pressure hydrocephalus), a systemic disorder (e.g., hypothyroidism, vitamin B₁₂ or folic acid deficiency, hypercalcemia), or alcohol or drug abuse.

Dementia in other specified diseases classified elsewhere
Dementia can occur as a manifestation or consequence of a variety of cerebral and somatic conditions. To specify the etiology the ICD-10 code for the underlying condition should be added.

1. The development of memory impairment as manifested by impairment in the ability to learn new information or the inability to recall previously learned information.
2. The memory disturbance causes significant impairment in social or occupational functioning and represents a significant decline from a previous level of functioning.
3. The memory disturbance does not occur exclusively during the course of a delirium or a dementia.
4. There is evidence from the history, physical examination, or laboratory findings that the disturbance is the direct physiological consequence of a general medical condition (including physical trauma).

1. The development of memory impairment as manifested by impairment in the ability to learn new information or the inability to recall previously learned information.
2. The memory disturbance causes significant impairment in social or occupational functioning and represents a significant decline from a previous level of functioning.
3. The memory disturbance does not occur exclusively during the course of a delirium or a dementia and persists beyond the usual duration of substance intoxication or withdrawal.
4. There is evidence from the history, physical examination, or laboratory findings that the memory disturbance is etiologically related to the persisting effects of substance use (e.g., a drug of abuse, a medication).

Code (Specific substance)-induced persisting amnestic disorder: (Alcohol; Sedative, hypnotic, or anxiolytic; Other [or unknown] substance)

This category should be used to diagnose an amnestic disorder that does not meet criteria for any of the specific types described in this section.
An example is a clinical presentation of amnesia for which there is insufficient evidence to establish a specific etiology (i.e., dissociative, substance induced, or due to a general medical condition).

1. There is memory impairment, manifest in both

   1. A defect of recent memory (impaired learning of new material) to a degree sufficient to interfere with daily living
   2. A reduced ability to recall past experiences
2. There is no
   1. Defect in immediate recall (as tested, for example, by the digit span)
   2. Clouding of consciousness and disturbance of attention. Delirium, not induced by alcohol and other psychoactive substances
   3. Global intellectual decline (dementia)
3. There is objective evidence (from physical and neurological examination, laboratory tests) and/or history of an insult to, or a disease of, the brain (especially involving bilaterally the diencephalic and medial temporal structures but other than alcohol encephalopathy) that can reasonably be presumed to be responsible for the clinical manifestations

Comments
Associated features, including confabulations, emotional changes (apathy, lack of initiative), and lack of insight are useful additional pointers to the diagnosis but are not invariably present.

1. Reading achievement, as measured by individually administered standardized tests of reading accuracy or comprehension, is substantially below that expected given the person's chronological age, measured intelligence, and age-appropriate education.
2. The disturbance in Criterion A significantly interferes with academic achievement or activities of daily living that require reading skills.
3. If a sensory deficit is present, the reading difficulties are in excess of those usually associated with it.

Coding note: If a general medical (e.g., neurological) condition or sensory deficit is present, code the condition on Axis III.

1. Mathematical ability, as measured by individually administered standardized tests, is substantially below that expected given the person's chronological age, measured intelligence, and age-appropriate education.
2. The disturbance in Criterion A significantly interferes with academic achievement or activities of daily living that require mathematical ability.
3. If a sensory deficit is present, the difficulties in mathematical ability are in excess of those usually associated with it.

1. Writing skills, as measured by individually administered standardized tests (or functional assessments of writing skills), are substantially below those expected given the person's chronological age, measured intelligence, and age-appropriate education.
2. The disturbance in Criterion A significantly interferes with academic achievement or activities of daily living that require the composition of written texts (e.g., writing grammatically correct sentences and organized paragraphs).
3. If a sensory deficit is present, the difficulties in writing skills are in excess of those usually associated with it.

Coding note: If a general medical (e.g., neurological) condition or sensory deficit is present, code the condition on Axis III.

This category is for disorders in learning that do not meet criteria for any specific learning disorder. This category might include problems in all three areas (reading, mathematics, written expression) that together significantly interfere with academic achievement even though performance on tests measuring each individual skill is not substantially below that expected given the person's chronological age, measured intelligence, and age-appropriate education.

Specific reading disorder

1. Either of the following must be present:
   1. A score on reading accuracy and/or comprehension that is at least 2 standard errors of prediction below the level expected on the basis of the child's chronological age and general intelligence, with both reading skills and IQ assessed on an individually administered test standardized for the child's culture and educational system.
   2. A history of serious reading difficulties, or test scores that met Criterion A(1) at an earlier age, plus a score on a spelling test that is at least 2 standard errors of prediction below the level expected on the basis of the child's chronological age and IQ.
2. The disturbance described in Criterion A significantly interferes with academic achievement or with activities of daily living that require reading skills.
3. The disorder is not the direct result of a defect in visual or hearing acuity, or of a neurological disorder.
4. School experiences are within the average expectable range (i.e., there have been no extreme inadequacies in educational experiences).
5. Most commonly used exclusion clause: IQ is below 70 on an individually administered standardized test.

1. The score on a standardized spelling test is at least 2 standard errors of prediction below the level expected on the basis of the child's chronological age and general intelligence.
2. Scores on reading accuracy and comprehension and on arithmetic are within the normal range (±2 standard deviations from the mean).
3. There is no history of significant reading difficulties.
4. School experience is within the average expectable range (i.e., there have been no extreme inadequacies in educational experiences).
5. Spelling difficulties have been present from the early stages of learning to spell.
6. The disturbance described in Criterion A significantly interferes with academic achievement or with activities of daily living that require spelling skills.
7. Most commonly used exclusion clause: IQ is below 70 on an individually administered standardized test.

1. The score on a standardized arithmetic test is at least 2 standard errors of prediction below the level expected on the basis of the child's chronological age and general intelligence.
2. Scores on reading accuracy and comprehension and on spelling are within the normal range (±2 standard deviations from the mean).
3. There is no history of significant reading or spelling difficulties.
4. School experience is within the average expectable range (i.e., there have been no extreme inadequacies in educational experiences).
5. Arithmetical difficulties have been present from the early stages of learning arithmetic.
6. The disturbance described in Criterion A significantly interferes with academic achievement or with activities of daily living that require arithmetical skills.
7. Most commonly used exclusion clause: IQ is below 70 on an individually administered standardized test.