What Clinicians Need to Know About the DSM-5-TR Updates

In this Q&A, Michael B. First, MD, professor of clinical psychiatry, Columbia University, New York City, editor & co-chair, DSM-5-TR, answers questions about his panel presented at Psych Congress Elevate 2022, entitled "DSM-5 Text Revision (DSM-5-TR): What's New and What's Different."

Dr First reviews key changes to the "Introduction" and "Use" sections, explains new diagnoses that have been incorporated, and offers insights on how the updated text will aid clinicians in their practice. 

Meagan Thistle, Associate Digital Editor, Psych Congress Network: What key changes have been made to the “Introduction” and “Use of the Manual” sections of the DSM-5-TR?

Michael B. First, MD: New sections have been added for describing the various types of information included in the DSM-5-TR text, providing explanations for potentially confusing terms such as “substance/medication-induced disorders,” “independent mental disorders,” and “other medical condition”; and the difference between the terms “other specified disorder” and “unspecified disorder.” There is also a new section discussing the impact of racism and discrimination on psychiatric diagnosis.

Thistle: “Prolonged grief disorder” has been added to Section II. How is it defined?

Dr First: Prolonged grief disorder is characterized by intense, prolonged grief (intense yearning for the decreased or preoccupation with thoughts of the deceased) occurring nearly every day that persists beyond 12 months post-loss that causes clinically significant distress or impairment.  People suffering from this are essentially “stuck” in the grieving process and cannot move forward with their lives.

Thistle: How will the addition of this new diagnosis impact clinical practice?

Dr First: Individuals suffering from this condition are at risk for developing serious medical conditions, including cardiac disease, hypertension, cancer, and immunological deficiency, as well as having a reduced quality of life.  Recognizing the presence of this condition is a necessary step towards getting the proper treatment, namely targeted psychotherapeutic interventions as well as avoiding ineffective treatments, such as antidepressant medications which have not been demonstrated to be effective except if there is comorbid depression.

Thistle: While there are modifications to the diagnostic criteria for over 70 disorders, what are some of the most important to highlight that clinicians should know about?

Dr First: The most important change concerns the diagnostic criteria for Persistent Depressive Disorder.  The DSM-5 diagnostic criteria and text for persistent depressive disorder (depressed mood for more days than not lasting at least 2 years) gave contradictory guidance regarding how best to diagnose and code presentations with superimposed major depressive episodes (so-called “double depression”) as well as chronic episode lasting longer than 2 years: giving a single diagnosis (persistent depressive disorder) and diagnostic code (F34.1) along with the applicable course specifier (with pure dysthymic syndrome, with persistent major depressive episode, with intermittent major depressive episodes), or whether to also give an additional diagnosis of Major Depressive Disorder along with the applicable code (e.g., F33.3 Recurrent Major Depressive Disorder, with psychotic features). 

Giving 2 diagnoses has the clear advantage of allowing the clinician to indicate such important clinical features such as episode recurrence, the severity (mild, moderate, or severe), or presence of psychotic features of the current (or most recent) depressive episode. Consequently, the following note has been added to the diagnostic criteria for persistent depressive disorder:

Note: 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).

Thistle: How can the new codes for suicidal behavior and nonsuicidal behavior be used?

Dr First: Despite the importance of suicidal behavior in the management of patients, suicidal behavior appears in the diagnostic criteria sets for only two DSM-5 disorders—major depressive episode and borderline personality disorder—despite its common association with a wide variety of DSM disorders, such as schizophrenia and substance use disorders. DSM-5-TR now includes free-standing symptom codes to indicate current suicidal behavior as well as a history of suicidal behavior that can be given in addition to a psychiatric diagnosis (or even in the absence of a psychiatric diagnosis) to allow clinicians to highlight this important symptom. Symptoms codes for nonsuicidal self-injury have been added as well.

Thistle: Has anything notable been removed from the DSM-5-TR that would impact clinical practice?

Dr First: No.

Thistle: What else should clinicians know about the DSM-5 changes that you would like to discuss?

Dr First: Three diagnoses have been added to DSM-5-TR that are also notable. Prior editions recognized that chronic heavy use of three classes of substance (alcohol, inhalants, sedatives/hypnotics/anxiolytics) can cause persisting dementia. The replacement of the dementia category (which appeared in editions of DSM up to DSM-IV) with a dimensional neurocognitive disorder construct (i.e., mild neurocognitive disorder and major neurocognitive disorder) in DSM-5 allowed for neurocognitive disorders that were less severe that dementia to be diagnoses. Given that persistent use of stimulants such as methamphetamine and cocaine is known to cause neurocognitive impairment that can interfere with functioning to a certain degree, yet not so much so as to interfere with capacity for independence in everyday activities, stimulant-induced mild neurocognitive should have been added to DSM-5-TR.

Additionally, Unspecified Mood Disorder has been added for presentations of irritability and agitation, for which there is insufficient information to make a specific diagnosis, to give clinicians an alternative to having to decide between an unspecified bipolar or unspecified depressive disorder, especially since irritability may be indicative of either.

Finally, there are circumstances in which, after a psychiatric examination, the clinician concludes that there is no mental disorder, such as in the context of a workplace evaluation for fitness for duty.

Michael B. First, MD, is Professor of Clinical Psychiatry at Columbia University, Research Psychiatrist at the Department of Behavioral Health and Policy Research, New York State Psychiatric Institute, and maintains a d psychopharmacology practice in Manhattan, Dr. First is a nationally and internationally recognized expert on psychiatric diagnosis and assessment issues and conducts expert forensic psychiatric evaluations in both criminal and civil matters.

Dr. First is Editor and Co-chair of the DSM-5-TR, Editorial and Coding Consultant for DSM-5, a member of the DSM-5 Steering Committee, the chief technical and editorial consultant on the World Health Organization’s ICD-11 revision project, for the Mental, Behaviral, and Neurodevelopmentla disorders chpater. Dr. First was the Editor of the DSM-IV-TR, the Editor of Text and Criteria for DSM-IV and the American Psychiatric Association’s Handbook on Psychiatric Measures. He has co-authored and co-edited a number of booksm including the DSM-5 Handbook for Differential Diagnosis, the Structured Clinical Interview for DSM-5 (SCID-5), and Learning DSM-5 by Case Example.. He has trained thousands of clinicians and researchers in diagnostic assessment and differential diagnosis.