DSM-5-TR: Salient Changes

The need to diagnose and classify mental disorders is not new. Hippocrates, a Greek physician and philosopher, who lived from 460 B.C. to 370 B.C., recognized the importance of correctly diagnosing and treating mental illnesses. Although diagnosing and treating mental disorders has changed, Hippocrates’ work on mental disorders was paramount to a successful diagnosis. Further, Hippocrates’ emphasis on competent diagnostic and medical principles resulted in the Hippocratic Oath which stressed, “do no harm” (Yapijakis, 2009). Although Hippocrates’ work occurred more than two thousand years ago, his work provided the foundation for later work focusing on diagnosis including the Diagnostic and Statistical Manual of Mental Disorders (DSM).

The DSM is widely respected and considered the most authoritative source for couple and family counselors in diagnosing mental disorders in the United States. Its stress on classification is summarized in its preface as:

The American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders is a classification of mental disorders associated with criteria designed to facilitate a more reliable diagnosis of disorders. With successful editions over the past 70 years, the DSM has become a standard reference for clinical practice in the mental health field. The DSM is intended to serve as a practical, functional, and flexible guide for organizing information that can aid in the accurate diagnosis and treatment of mental disorders. (American Psychiatric Association [APA], 2022b, p. xxiii)

The DSM is frequently used by couple and family counselors to diagnose mental disorders. The DSM covers categories for mental disorders for both adults and children. It not only covers categories for diagnosing mental health issues but it also contains statistics on such topics as typical age of onset, course of disorder, risks, and prognosis (APA, 2022b). The DSM is widely used for submitting a diagnosis to insurance companies for billing purposes. In fact, it is so widely recognized and accepted that Horwitz (2021) referred to the DSM as psychology's Bible.

The first DSM was published 70 years ago in 1952 (APA, 1952). Following its initial publication, the DSM has experienced several revisions with the most recent edition occurring in March 2022. This recent edition is titled the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text-Revision (DSM-5-TR) (APA, 2022b). The purpose of this article is to provide an overview of the development of the DSM with a special focus on the major changes present in the DSM-5-TR. This article will not only focus on the revised criteria for existing disorders but in addition, it will focus on a new diagnosis (Prolonged Grief Disorder) and changes occurring since the last edition of the DSM.

History of the DSM

As early as the 1840 U.S. Census, it was recognized that a need existed to collect data on mental health in the United States. In the 1880 U.S. Census, six categories (mania, melancholy, dementia, dipsomania, epilepsy, and paresis) of mental disorders were recognized and distinguished with additional data on mental illness being collected in mental hospitals (APA, 2022b). Following the end of World War II in 1945, additional attention was focused on classification and diagnosis. A more advanced, broader classification system was developed by the U.S. Army and later modified by the Veterans Administration to classify mental disorders experienced by service men and women and veterans from World War II. This classification was a parallel effort to the International Classification of Disease (ICD), initially published by the World Health Association (WHO) in 1948, which is now in its 10th edition (APA, 2022b).

DSM-1

Given the increasing need to classify and diagnose mental disorders, the first Diagnostic and Statical Manual (DSM-1) was published in 1952 (APA, 1952). Its purpose was to classify the various conditions that clinicians were observing in their clients. The definitions in the DSM-I were brief and general (Horwitz, 2014). In fact, the DSM-I consisted of only 132 pages (APA, 1952). It was 16 years later when the next edition of the DSM was published.

DSM-II

In 1968, the DSM-II was published. Although the number of diagnoses increased from 106 to 182, the diagnoses remained brief and general and were similar in format to the DSM-I. The DSM-II consisted of 134 pages (APA, 1968). Following the publication of the DSM-II, the APA experienced criticism because many mental health providers believed there was a need for a diagnostic system that was more uniform and based on research instead of assumptions present in previous editions of the DSM. Further, mental health providers posited that the more basic mental health disorders such as schizophrenia were not supported enough by diagnostic research (Fried et al., 2022). To address the criticism, the authors of the APA developed plans for a new DSM, the DSM-III.

DSM-III and DSM-III-R

The DSM-III was published in 1980 and contained 494 pages which was an increase of 360 pages from the previous DSM (APA, 1980). The DSM-III was more precise and more focused on a symptom-based classification instead of a perfunctory definition. Further, “its categories were based on more valid research and were organized into classifications buttressed by research in support of its classifications. The new direction of the DSM-III targeted the symptoms for specific mental disorders” (APA, 1980, p. 12). The DSM-III introduced a multiaxial system that was accepted by clinicians (Horwitz, 2021). Although Horwitz pointed to the positive features of the DMS-III, he concluded that the DSM-III had shortcomings because it needed a more congruent research standard that could be shared among clinicians and researchers.

The DSM-III-R was published in 1987 and consisted of 567 pages (APA, 1987). Because experience with the DSM-III revealed some inconsistencies, APA appointed a task force to review and correct the inconsistencies. A new term, sexual addiction was introduced and described under the more general diagnosis of sexual disorders-not otherwise specified (APA, 2022b).

DSM-IV and DSM-IV-TR

The DSM-IV was published in 1994 and consisted of 866 pages (APA, 1994). The goal of the DSM-IV was to formalize and regularize the terminology (APA, 2022b). According to the APA, the aim was to provide a clearer description to enhance a more uniform diagnosis. Striving to increase the uniformity in diagnoses, the DSM-IV-TR published in 2000, listed 293 disorders and consisted of 943 pages (APA, 2000). As with other editions, this edition of the DSM was closely aligned with the ICD-10 to increase congruence between the DSM and the ICD (APA, 2000). Like its predecessors, the DSM-IV-TR used a classification system to describe specific mental disorders with the intent of distinguishing one mental disorder from another mental disorder. The DSM-IV-TR continued the use of the multiaxial assessment to promote a more complete, accurate diagnosis (APA, 2022b).

DSM-5 and DSM-5-TR

In 2013, the DSM-5 was published (APA, 2013a). This edition consisted of 947 pages. A change occurred in the title as the number 5 symbol was used instead of the Roman numeral (V). Another change occurred with the multiaxial system which was omitted from the DSM-5 (APA, 2013b). The APA (2013b) reported:

changes were made with regard to the neurodevelopmental disorders, schizophrenia spectrum and other psychiatric disorders, bipolar and related disorders, depressive disorders, anxiety disorders, obsessive-compulsive and related disorders, trauma-and stressor-related disorders, dissociative disorders, somatic symptom and related disorders, feeding and eating disorders, sleep wake disorders, sexual dysfunction, gender dysphoria, disruptive impulse-control and conduct disorders, substance-related and addictive disorder, neurocognitive disorders, and paraphilic disorders. (pp. 2–18)

Although extensive changes were made in the DSM-5, APA decided to commission a revision, the DSM-5-TR (APA, 2022b). Many of the experts involved in the writing of the DSM-5 were contacted and asked to participate in the revision. A total of 200 experts were given the task of revising the DSM. This resulted in the publication of the DSM-5-TR in March 2022 which consists of 1,142 pages (APA, 2022b). In describing the DSM-5-TR, the members of the APA task force wrote:

Experts were given the task of conducting literature reviews covering the past nine years and reviewing text to identify out-of-date material. Four cross-cutting review groups (culture, sex and gender, suicide, forensics) reviewed all chapters. The text was also reviewed by a work group on ethnoracial equity and inclusion to ensure appropriate attention was given to risk factors such as racism and discrimination and the use of non-stigmatizing language. (p. 1)

In the following sections of this manuscript, the salient changes made to the DSM-5-TR will be described. These changes include such changes as a new diagnosis, disorder changes, and new coding updates.

New Diagnosis

A new diagnosis, Prolonged Grief Disorder (F 43.8) was added to the DSM-5-TR. This diagnosis was not developed to pathologize grief; instead, it was developed because people experiencing prolonged grief need and deserve to receive appropriate care (APA, 2022b). In describing Prolonged Grief Disorder, a diagnosis new to the DSM-5-TR, the authors wrote:

Prolonged grief disorder represents a prolonged maladaptive grief reaction that can be diagnosed only after at least 12 months (6 months in children and adolescent) have elapsed since the death of someone with whom the bereaved had a close relationship. Although the timeframe reliably discriminates normal grief that continues to be severe and impairing, the duration of adaptive grief may vary individually and cross-culturally. The condition involves the development of a persistent grief response characterized by an intense sorrow and frequent crying) or preoccupation with thoughts or memories of the deceased, although in children and adolescents, the preoccupation may focus on the circumstances of the death. (p. 323)

Further on pages 322–327 of the DSM-5-TR, the authors discuss the diagnostic criteria, diagnostic features, associated features, prevalence, development and cause, risk and prognostic factors, and culture-related diagnostic issues. Additionally, the authors address sex- and gender-related issues, associated with suicidal thoughts or behaviors, functional consequences of prolonged grief disorder, differential diagnosis, and comorbidity. They posit that persons experiencing a prolonged grief disorder experience it in a disabling way that differs from typical grief (APA, 2022b).

Additional Changes

The authors of the DSM-5-TR wrote many changes to the diagnostic criteria that appeared in the DSM-5 (APA, 2013a, 2022b). Although most of the changes in the diagnostic criteria of approximately 70 disorders are relatively minor, in the DSM-5-TR some of the changes significantly alter diagnostic conceptualizations and/or diagnostic criteria. Some of the diagnoses that were significantly revised include attenuated psychosis syndrome, autism spectrum disorder, bipolar 1 disorder, bipolar II disorder, manic episode, cyclothymic disorder, delirium, major depressive disorder, persistent depressive disorder, post-traumatic stress disorder in children six years and younger, and substance and medication mental disorders (First et al., 2022). This list is exemplary and not comprehensive of all the changes between volumes. Further, the DSM-5-TR includes updated notes on diagnoses and revised diagnostic and associated features as well as revised diagnostic criteria for many disorders. In the following sections, there is a brief overview of the differences between the DSM-5 and the DSM-5-TR regarding the diagnoses highlighted in this paragraph.

Attenuated Psychosis Syndrome

The DSM-5 and the DSM-5-TR both contain a section in their appendices labeled “conditions for further study.” These conditions have been identified as needing further study; therefore, they are viewed as a separate category from the other disorders in the manual. The attenuated psychosis syndrome is listed in both publications in their respective conditions for further study. Although criterion B-F remains the same in both the DSM-5 and the DSM-5-TR, the language for criterion A has been altered significantly from the DSM-5 which stated, “at least one of the following symptoms is present in attenuated form, with relatively intact reality testing, and is of sufficient severity or frequency to warrant clinical attention 1. Delusions, 2. Hallucinations, 3. Disorganized speech” (APA, 2013a, p. 783). In contrast, the DSM-5-TR criterion A has been modified as follows, “at least one of the following symptoms is present and is of sufficient severity or frequency to warrant clinical attention” (APA, 2022b, p. 903). This statement is followed in the DSM-5-TR by a list of three symptoms: attenuated delusions, attenuated hallucinations, and attenuated disorganized speech. Notably, this list does not include intact reality testing. Thus, the ability to engage in intact reality testing is no longer a requirement for the disorder.

Autism Spectrum Disorder

The diagnosis of autism spectrum disorder (ASD) is changed in the DSM-5-TR in criterion A. This change specifically pertains to persistent deficits in social communication and social interactions. The DSM-5-TR lists three areas of deficits (1–3), including deficits in (1) social–emotional reciprocity, (2) deficits in nonverbal communicative behaviors, and (3) deficits in developing, maintaining, and understanding relationships. Previously, the DSM-5 authors indicated that persistent deficits in items 1–3 of criteria A must be present to diagnose ASD (APA, 2013a, p. 50). In contrast, the DSM-5-TR authors revised the diagnostic criteria to indicate that ALL of the symptoms listed in 1–3 must be present in order to diagnose ASD (APA, 2022b, p. 56.) Thus, the language of the DSM-5-TR is clearer than the language in the DSM-5 regarding the required diagnostic criteria for ASD.

Bipolar I Disorder, Bipolar II Disorder, and Manic Episode

The DSM-5-TR authors revised the criterion for bipolar I disorder, bipolar II disorder, and manic episodes. Regarding manic episode diagnosis, criteria A-D of manic episode remains virtually the same between the DSM-5 and the DSM-5-TR. However, the language regarding the occurrence of a manic episode in bipolar I disorder, criterion B, has changed from “the occurrence of the manic and major depressive episode is not better explained by schizoaffective disorder, schizophrenia, schizophreniform disorder, delusional disorder, or other specified or unspecified schizophrenia spectrum and other psychotic disorder” (APA, 2013a, p. 126) to “at least one manic episode is not better explained by schizoaffective disorder and is not superimposed on schizophrenia, schizophreniform disorder, delusional disorder, or other specified or unspecified schizophrenia spectrum and other psychotic disorder” (APA, 2022b, p. 142). According to the APA (2022a), the language in the DSM-5-TR pertaining to manic episodes that are concurrent with a psychotic disorder can now be diagnosed with more clarity because the “better explained by” (APA, 2013a, p. 126) in the DSM-5 was ambiguous and difficult to understand.

Although the diagnostic criteria for bipolar II disorder do not contain changes in the criteria for the disorder, the language in the DSM-5 regarding the occurrence of the Hypomanic Episode is altered from “the occurrence of the hypomanic episode(s) is not better explained by…” (APA, 2013a, p. 134) to “at least one hypomanic episode and at least one major depressive episode are not better explained by…” (APA, 2022b, p. 152). This changed language indicates that the most recent manic episode may not be as influential in the diagnosis as the overall pattern of previous manic episodes and the presence of another psychotic disorder.

Cyclothymic Disorder

The diagnostic criteria for cyclothymic disorder remain similar in both the DSM-5 and the DSM-5-TR; however, the language for criterion B has been revised in the DSM-5-TR. Previously, in the DSM-5, criterion B required hypomanic and depressive periods to have been present for at least one-half of the time of a two-year period (one year for children and adolescents), and the individual had to be without symptoms for more than two months at a time (APA, 2013a). The DSM-5-TR's criteria B are now revised to reflect that criterion A symptoms must be present for at least half the time of at least two years (one year for children and adolescents) and the individual has not been without the symptoms for more than two months at a time. Specifically, DSM-5-TR criterion A symptoms now require that there have been numerous periods with hypomanic and depressive symptoms that do not meet the criteria for hypomania or major depressive episodes, respectively (APA, 2013a, 2022b). This slight alteration improves clarity regarding the diagnostic criteria of the disorder.

Delirium

The diagnostic criteria of delirium were revised in criterion A of the DSM-5-TR. The authors of the DSM-5-TR modified the language of the DSM-5 in criteria A very slightly; however, the slight modification provides more clarity for diagnosis. Specifically, the DSM-5 criteria stated that a disturbance in awareness occurred when a person had reduced orientation to their environment. The authors of the DSM-5-TR clarify this criterion to now state that a disturbance in awareness occurs when there is a “reduced awareness of the environment.” This slight alteration in language allows more clarity in diagnosis since criteria C, unchanged from the DSM-5 to the DSM-5-TR, also uses the term “disorientation” as an additional disturbance in cognition. Thus, there is now no redundancy between the diagnostic criteria because the DSM-5 phrase “reduced orientation to the environment” was ambiguous.

Major Depressive Disorder

The diagnostic criteria for A-C of major depressive disorder have not changed from the DSM-5 to the DSM-5-TR. However, criterion D has been revised regarding the diagnosis of a major depressive episode. Previously, the DSM-5 criteria stated that in order to diagnose a major depressive episode, the clinician had to differentiate the etiology of the episode to differentiate if “the occurrence of the major depressive episode is not better explained by…” (APA, 2013a, p. 161). Instead, the authors of the DSM-5-TR simply updated the language to “at least one major depressive episode is not better explained by…” (APA, 2022b, p. 183). This revision indicates that the pattern of major depressive episodes should be influential in the diagnosis. The new language also clarifies that a mood disorder can be diagnosed if the essential diagnostic components have been met. Further, the coding and recording procedures for major depressive disorders now have coding, which includes “the most recent episode if the major depressive disorder is in partial or full remission” (APA, 2022b, p. 184) and a specifier of “‘with seasonal pattern’ describing the pattern of recurrent major depressive episodes” (APA, 2022b, p. 184).

Persistent Depressive Disorder

The most significant change in the persistent depressive disorder diagnostic criteria in the DSM-5-TR is the removal of the clarifier in the title of the disorder (Dysthymia) (APA, 2013a, 168). Additionally, while criteria A-D and F-H have not changed from the DSM-5 to the DSM-5-TR, criterion E has been revised in the DSM-5-TR by omitting the phrase that the “criteria have never been met for cyclothymic disorder” (APA, 2013a, p. 168). Finally, the notes section following the diagnostic criteria for this disorder differs significantly between the DSM-5 and the DSM-5-TR. In the DSM-5, the note following diagnostic criteria stated:

Because the criteria for a major depressive episode include four symptoms that are absent from the symptom list for persistent depressive disorder (dysthymia), a very limited number of individuals will have depressive symptoms that have persisted longer than 2 years but will not meet criteria for persistent depressive disorder. If full criteria for a major depressive episode have been met at some point during the current episode of illness, they should be given a diagnosis of major depressive disorder. Otherwise, a diagnosis of other specified depressive disorder or unspecified depressive disorder is warranted. (APA, 2013a, pp. 168–169)

In contrast, in the DSM-5-TR, the note following diagnostic criteria for Persistent Depressive Disorder states:

If criteria are sufficient for a diagnosis of a major depressive episode at any time during the 2-year period of depressed mood, then a separate diagnosis of major depression should be made in addition to the diagnosis of persistent depressive disorder along with the relevant specifier (e.g., with intermittent major depressive episodes, with current episode). (APA, 2022b, p. 193)

This change added greater clarity to the distinctions between persistent depressive disorder and major depressive episodes.

Post-Traumatic Stress Disorder in Children Six Years and Younger

Although the criteria for post-traumatic stress disorder (PTSD) in children remain mostly unchanged between the DSM-5 and DSM-5-TR, there was one significant change that occurred regarding the removal of a note in criterion A. Specifically, this change was the omission of the phrase “witnessing does not include events that are witnessed only in electronic media, television, movies, or pictures” (APA, 2013a, p. 272). Thus, the removal of this qualifier indicates that a child under the age of six years old could be diagnosed with PTSD if they witnessed something traumatic through an electronic platform.

Substance/Medication-Induced Mental Disorders

The most significant change regarding substance/medication-induced mental disorders from the DSM-5 to the DSM-5-TR is the language in the diagnostic and associated features. Namely, the language in the DSM-5 referred to these diagnoses as “disorders” (APA, 2013a, p. 488). The DSM-5-TR's authors changed the language from “disorders” to “disturbances” (APA, 2022b, pp. 550–551). Additionally, while the diagnostic criteria of A and C-E remain the same in both the DSM-5 and the DSM-5-TR, the language for criterion B has been updated. The authors of the DSM-5-TR removed the terms “disorder” and “mental disorder” (APA, 2013a, p. 488). The DSM-5-TR language now refers to “the symptoms in criterion A” (APA, 2022b, p. 550), which include “a clinically significant presentation of symptoms characteristic of disorders in the relevant diagnostic class (that, sic) predominates in the clinical picture” (APA, 2022b, p. 550).

Suicide and Nonsuicidal Behaviors

First et al. (2022) discussed that Section II of the DSM-5-TR focuses on the need for clinicians to observe and differentiate between the presence or history of suicidal behavior in which the client's suicidal behavior is potentially self-injurious behavior involving an intent to die. In contrast, the author said the clinician should determine if the nonsuicidal behavior was intentional self-inflicted damage to the body that is likely to induce bleeding or bruising, although there is not suicidal intent. The codes allow for the clinician to observe and record these behaviors.

Unspecified Mood Disorder

Unspecified mood disorder has been added to the new DSM-5-TR and is described on pages 169 and 210 (APA, 2022b). This diagnosis is related to symptoms commonly found in the Bipolar-Related Disorders and/or Depressive-Related Disorders but is not listed with these disorders because it does not meet all of the criteria needed for bipolar or depressive disorders.

New Coding Updates

Neurocognitive and Substance Disorders have new coding updates in the DSM-5-TR. The neurocognitive updates are described on pages 669–671. The coding updates for substance use disorders are described on page 545. The new codes will provide improvements, better accuracy, and integration of research for clinicians.

Neurocognitive and Substance Use Disorders

In the DSM-5-TR, Neurocognitive and Substance Use Disorders have new coding updates. These new codes were provided to help clinicians to be more accurate in coding the disorders. The neurocognitive updates are described on pages 669 to 671 of the DSM. The coding updates for Substance Use Disorders are described on page 575.

Conclusion

Since the need to diagnose and classify mental disorders is salient to the work for family and couples’ counselors, especially counselors in private and agency practice, this article was developed. Specifically, the authors focused this article to help counselors become more aware of the changes in the most recent edition of the DSM, the DSM-5-TR, which was published in March 2022. The authors concluded that several changes were included in the DSM-5-TR. To help couple and family counselors to feel less overwhelmed and more informed about the DSM-5-TR, the authors described the changes occurring in the following: the history of the DSM, new diagnosis, additional changes, now coding updates, and neurocognitive and substance use disorders. In the section focusing on additional changes, the authors focused on changes involving the following: attenuated psychosis syndrome, autism spectrum disorder, bipolar 1 disorder, bipolar II disorder, manic episode, cyclothymic disorder, delirium, major depressive disorder, persistent depressive disorder, post-traumatic stress disorder in children six years and younger, and substance and medication mental disorders, suicide and nonsuicidal behaviors, and unspecified mood disorders. The authors informed couple and family counselors about the specific changes involved with each disorder as well as the page numbers in the DSM-5-TR in which the changes occurred. In this article, the authors described the major changes occurring in the new DSM-5-TR while simultaneously encouraging counselors to not only become aware of the changes but in addition, counselors were informed of the need to understand the changes. Another intent of the authors was to demystify the changes incorporated in the DSM-5-TR. Although space did not allow the authors to focus on all changes, the authors focused on the major changes.