The DSM-5-TR was released in 2022. While there was only one new disorder listed, there were numerous changes in terminology and updates to some disorders. We summarise them here.
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Introduction
Well, it has arrived: all 1142 pages of it, for a paltry $170 USD ($268 AUD on Amazon) for the paperback version, or $220 USD and $349 AUD for the hard cover. Nine years after the DSM-5 came out, its latest iteration, the DSM-5-TR is here, and awaits your perusal. But just in case your schedule might preclude speedily getting through all those pages, this article highlights the main areas of difference between the DSM-5 and its “text revision”. The context for the revision is that it represents “a compilation of iterative changes that have been made online on a rolling basis since the DSM-5 was first published in 2013” (Ault, 2022). Some 200 experts across a variety of working groups made recommendations for changes based on a comprehensive literature review. There are clarifying modifications for over 70 disorders, but there is not that much that is technically “new”, as not that many therapeutic advances have been made (Ault, 2022). Here are the main categories of differences that we’ll highlight:
- New: prolonged grief disorder
- Changes in language/terminology
- A new category and some new codes
- Assorted key updates to the disorders
- New and/or renewed criticism about the direction in which psychological diagnosis is heading
New: prolonged grief disorder
This is the only new disorder, in that others were already listed in the DSM-5 and have undergone “revisions”. To understand its emergence, we need to know a bit of the context for it. In the DSM-III and DSM-IV, a person who was depressed because they had recently lost a loved one could avoid a diagnosis of “MDD” (major depressive disorder) if they had depressive symptoms, because they would be “excluded” from that diagnosis based on the fact that they were grieving. When the DSM-5 came along in 2013, that exclusion was removed, so since 2013, people who are grieving and have particular symptoms can, after two weeks, receive a diagnosis of MDD.
In the DSM-5, the forerunner of prolonged grief disorder, persistent complex bereavement disorder (PCBD), was listed as a “condition for further study”. After a 2019 workshop to get consensus for diagnosis criteria, the APA board approved the new prolonged grief disorder in October 2020, and the APA assembly approved the new disorder in November 2020. If we think back to what was happening globally towards the end of 2020, our mind runs to the COVID-19 pandemic, and the million or more deaths in America alone, plus another five million globally. In this sense, perhaps, the zeitgeist was right for having a new disorder which, for the first time, centred on the death of a loved one, but still, we must recognise the movement toward pathologising grief.
For tools and guidelines to effectively work with clients who are experiencing loss and grief, head to this page.
The diagnostic criteria for PCBD include:
- The development of a persistent grief response (longer than a year for adults and 6 months for children and adolescents) characterised by one or both of the following symptoms, which have been present most days to a clinically significant degree, and have occurred nearly every day for at least the last month: intense yearning/longing for the deceased person; preoccupation with thoughts or memories of the deceased person.
- The bereaved person has to have experienced three of eight symptoms daily in the past 30 days related to the death, including feeling as if part of oneself has died, disbelief, avoidance of reminders, intense emotional pain, interpersonal difficulties, emotional numbness, feelings of life being meaningless, and/or intense loneliness.
- The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
- The duration and severity of the bereavement reaction must clearly exceed expected social, cultural, or religious norms for the individual’s culture and context.
- The symptoms are not better explained by another mental disorder, such as major depressive disorder (MDD) or posttraumatic stress disorder, and are not attributable to the physiological effects of a substance or another medical condition (Ault, 2022; Singer, 2022).
Proponents cheer billing possibility without MDD or PTSD diagnosis
Proponents of this change have noted that if anything makes it possible for therapists to bill for grief-related treatments without diagnosing their clients with a depressive or posttraumatic stress disorder, it is potentially helpful. This camp argues that the criteria for prolonged grief disorder are constructed in such a way as to exclude people who are going through a normal grieving process, and that the criteria – hopefully! – will distinguish between what anyone goes through when they lose a loved one and the prolonged grieving process without end that affects a much smaller number of people but which really can be crippling for them.
Critics fear stigmatisation and overtreatment
Critics, however, note that, at least in the DSM-III and DSM-IV, people had an opportunity to grieve without being stigmatised, mislabelled, or overtreated with medication. The new disorder, they maintain, doesn’t solve anything. Rather, it is said to add to the confusion and stigmatisation, becoming part of a creeping pathologising of everyday life, where most things need to have a mental disorder label. The adherents to this way of thinking argue that grief is not a mental illness, and that to be told we are disordered when we are feeling our most vulnerable and overwhelmed (as in grief) leads to us not trusting ourselves and our emotions, which, they add, is a very dangerous and short-sighted move (Ault, 2022; Singer, 2022).
Changes in language/terminology (reflecting a review of the impact of racism, gender, and other discrimination on mental health disorders)
Gender issues
There was problematic terminology in the Gender Dysphoria chapter of the DSM-5, which has been changed to preferred terminology. This includes changing terms such as:
- “Natal sex” to “birth-assigned gender”
- “Natal male/female” to “individual assigned male/female at birth”
- “Gender reassignment treatments” to “gender-affirming treatments”
- “Cross-sex medical procedure” to “gender-affirming medical procedure”
- “Desired gender” to “experienced gender”
The word “cisgender” wasn’t used in the DSM-5. Now in the DSM-5-TR, there has been a relatively sweeping move, not only including a definition of cisgender, but also preferring the term “non-transgender” as a way of centring not on cisgender folk, but on transgender people. The DSM-5-TR has a post-transition specifier for Gender Dysphoria.
The controversy concerning this aspect of the text revision revolves around the existence of gender dysphoria as a diagnosis. Some in the transgender community argue that there shouldn’t be anything about it in the manual – full stop! – because it’s not a psychiatric issue. As with the issue of grief, however, proponents contend that, if there is a diagnosis, people can receive treatment that they would not be able to get without a diagnosis. Those in the middle probably shrug and say that there is no right answer for such a dilemma.
Race and racial discrimination
The DSM-5-TR, as the DSM-5 before it, continues to acknowledge that race is a social construct: obvious to those of us who work in helping professions where there is a focus broader than the individual’s physical self (perhaps we may exclude some classes of doctors here, on the grounds that they are taught to view people primarily as biological beings). For the full text revision, the Work Group on Ethnoracial Equity and Inclusion (convened for the first time) attempted to ensure sufficient attention to risk factors such as the experience of racism and discrimination and their effect on mental health, as well as to safeguard the use of non-stigmatising language. Examples here include:
- The use of “Latinx”
- The term “racialized” instead of “racial” to highlight the socially-constructed nature of race
- The avoidance of “minority” and “non-white” on the grounds that “whiteness” should not continue to be the perspective from which racial bias and discrimination is viewed or centred
- Intellectual disorders and neuro-diverse conditions
Changes in terminology and criteria for intellectual development disorder and neuro-diverse conditions
The years since the 2013 publication of the DSM-5 have seen changes in the conversation of certain community groups, and notably some of these focus on intellectual disability and neuro-diverse conditions. Thus, we see some of the following:
- A change in terminology from “intellectual disability” (which in itself was a change from the prior “mental retardation”) to “intellectual developmental disorder”, which has a different code for each of “mild”, “moderate”, “severe”, and “profound”
- Criteria tightened for diagnoses such as attention deficit hyperactivity disorder and autism spectrum disorder
“Normality” shrinks
The result, say some critics, is an ongoing pattern of taking behaviours and symptoms of behaviours that are on the border with normality and expanding the definition of mental disorder, with the result that the realm of normality shrinks. Again, as with the aspects noted above, the advantage of such moves is that someone may get a diagnosis that they need, which heralds the beginning of a much better life. The downside is that, when the diagnosis is either unnecessary or just plain wrong, it can lead to too much treatment, the wrong treatment, and stigmatisation: becoming more harmful than helpful.
A new category and some new codes
During some time periods, no new disorders may emerge which require diagnosis, yet the focus of clinical attention can change, with some conditions being given greater importance than what they were deemed to deserve earlier. Thus, there is a new category for “Other Conditions That May Be a Focus of Clinical Attention”; it examines suicidal behaviour and non-suicidal self-injury (NSSI). A clinician would want to know about these, pay attention to them, and factor them into treatment planning, but at the same time acknowledge that they are behaviours which cross over multiple diagnostic categories. Correspondingly, there are now codes for the initial encounter of someone with suicidal ideation or attempt, for subsequent encounters, and for a history of (but not current) suicidal behavior. Moreover, there are codes for current NSSI and for a history of (but not current) NSSI. Codes can be useful in that they provide a systematic way of ascertaining the incidence and prevalence of the behaviours coded. Interestingly, even though the DSM-5-TR includes codes for suicidal behavior and NSSI, they kept Suicidal Behavior Disorder and NSSI Disorder in the section “Conditions for Further Study”.
Assorted key updates to the disorders
The APA has put out a list of 25 “fact sheets” highlighting a few other updates to the disorders. You can find that at: DSM-5-TR Fact Sheets (psychiatry.org).
These note differences such as the following examples:
- Bipolar I and Bipolar II. There are mood changes and sometimes psychotic features with bipolar disorder, but the DSM-5 language made it difficult to distinguish these from the psychotic disorders, such as schizoaffective. This has been clarified. For tools and guidelines to effectively work with clients with bipolar disorder, head to this page.
- Persistent depressive disorder. The holdover term “dysthymia” (to do with any DSM-5 diagnosis) from the DSM-IV’s dysthymic disorder has been removed; only two specifiers, “anxious distress” and “atypical”, remain.
- Social anxiety disorder. This has had “social phobia” removed, given that the helping fields have completely adopted the term “social anxiety disorder”, so “social phobia” is no longer clinically useful. For tools and guidelines to effectively work with clients with anxiety disorders, head to this page.
- Attenuated psychosis syndrome. The DSM-5 used to have the phrase “with relatively intact reality testing”. What? A diagnosis of core psychotic processes talking about intact reality? The confusion has been removed.
- Autism spectrum disorder. Criterion A for ASD in the DSM-5 had the phrase “as manifested by the following”, followed by three deficits in social communication and social interaction. Some clinicians thought that any one of the three was sufficient for the criterion to be met, but the DSM-5-TR clarifies that all three deficits must be present to meet Criterion A.
Criticism and support for the DSM-5-TR
We have flagged in several of the categories above the ever-present danger of pathologising some of life’s experiences that we will all go through if we live long enough, such as grieving the loss of a loved one. We have pointed out proponents’ argument that a diagnosis is useful, because then the treatment can begin to flow for an unhappy client who may be engaging maladaptive behaviours. We have likewise noted the critics’ point that – given the huge increase in numbers of possible disorders over the last few years – there is the ever-present tendency for providers of services to see their clients as merely their diagnosis: i.e., “my bipolar”, with the concomitant danger of stigma and the pathologising of aspects of life that are not genuinely mental health disorders. At the end of the day, who’s to say, for example, how long it is “normal” to grieve the loss of a cherished other?
A further criticism of the text revision is that it is just a “money spinner” for the APA, one which many institutions – who must be up-to-date – are then forced to buy. At the very least, we as helping professionals should understand how the DSM works and how it can best be used, so that we can optimally serve our clients. As one counselling trainer observed, some clients like a diagnosis. A diagnosis is a name, and as such it has limits. It helps the client to understand what they are not dealing with, and there is comfort in that. For others, the potential for stigma and all that happens going down the road of an incorrect diagnosis is agony, at least, and probably harm as well.
The DSM-5-TR is a massive tome and worth the expenditure if you don’t have the DSM-5 and are looking for a quick fix for your insomnia. If you do have the DSM-5, however, you may be able to look up specific revisions to the text published online since the DSM-5-TR has come out and go from there.
Key takeaways
- The newly-released DSM-5-TR has only prolonged grief disorder as a “new” condition, but there are numerous changes in language/terminology.
- There is a new category and new codes for suicidal behaviour and non-suicidal self-injury (NSSI) under “Other Conditions That May Be a Focus of Clinical Attention.”
- APA fact sheets highlight key updates to other disorders.
- There is criticism, both new and continuing, about the direction in which psychological diagnosis is heading.
References:
- American Psychiatric Association. (2022). DSM-5-TR Fact sheets. Psychiatry.org. Retrieved on 4 April 2022, from: DSM-5-TR Fact Sheets (psychiatry.org)
- Ault, A. (2022). DSM update: What’s new? Medscape. Retrieved on 4 April 2022, from: DSM-5 Update: What’s New? (medscape.com)
- Singer, J. (2022). Special report on DSM-5-TR – What social workers need to know. The New Social Worker. Retrieved on 4 April 2022, from: Special Report on DSM-5-TR—What Social Workers Need To Know – SocialWorker.com