By Katherine Biles, CHCP^a; Joshua Schechtel, MD, MPH^b; and Hailing Zhang, MD^c

In light of Mental Health Awareness Month, it is important that all professionals working in the health education field are aware of key updates within therapeutic areas they may be involved with, including those regarding mental health.

In March 2022, the American Psychiatric Association made updates to its authoritative source of information on mental health disorders, “The Diagnostic and Statistical Manual of Mental Health Disorders, publishing its Fifth Edition, Text Revision (DSM-5-TR™).” It had been nine years since its previous revision.

“Clinicians use DSM to diagnose disorders affecting mood accurately and consistently, personality, identity, cognition and more. The manual does not address treatment, including use of medications. The DSM has been updated several times since its first release in 1952. It standardizes diagnoses by psychiatrists, psychologists, social workers, nurses and other health and mental health professionals, but it also informs research, public health policy, education, reimbursement systems and forensic science.²”

Some of the recent changes include the addition of prolonged grief disorder and the inclusion of symptom codes for suicidal behavior and nonsuicidal self-injury.¹ The update also includes refinement of criteria and comprehensive literature-based updates to the text.¹

In “DSM-5-TR™,” the diagnostic criteria for many individual disorders were refined based on scientific advances. Changes are clear from its new table of contents, which depicts how various conditions may relate to each other and the occurrence of mental disorders across the lifespan — both of which may actually influence care. Another goal for the manual’s framework is to help clinicians make more accurate and consistent diagnoses, which can also lead to better treatments for patients.

As stated, the “DSM-5-TR™” is sequentially organized to follow the developmental lifespan. Every chapter reflects this organization. Within individual diagnostic categories, disorders typically diagnosed in childhood are presented first, followed by those in adolescence, adulthood and later life.² Disorders that were previously discussed in one single “infancy, childhood and adolescence” chapter are now integrated throughout the textbook.³

“APA and American Psychiatric Association Publishing are proud to offer ‘DSM-5-TR’ as an essential reference for all mental health professionals,” APA CEO and Medical Director Saul Levin, M.D., M.P.A., says to Psychiatry News.¹ “The updated manual reflects evolving research and clinical experience and will be of enormous benefit to practitioners, researchers, academic institutions and health systems.”¹

“DSM is widely regarded as the most authoritative source of information about most aspects of mental disorders except treatment,” Michael B. First, M.D., co-chair of the Revision Subcommittee and “DSM-5-TR” editor, says to Psychiatric News. “This information, encapsulated in the DSM text, is continually evolving. Consequently, it is crucial for the text to be kept up to date based on evolving psychiatric literature. ‘DSM-5’ text sections on ‘Risk and Prognostic Factors’ and ‘Diagnostic Markers’ contain information more susceptible to becoming outdated because of scientific advances. Nine years have elapsed since publication of ‘DSM-5’ in 2013, longer than historical revisions to DSM after five to seven years.”¹

The most extensively updated sections of the manual were Prevalence, Risk and Prognostic Factors, Culture-Related Diagnostic Issues, Sex- and Gender-Related Diagnostic Issues, Association With Suicidal Thoughts or Behavior, and Comorbidity.⁴ In addition, the entire DSM text has been reviewed and revised by the Ethnoracial Equity and Inclusion Work Group to ensure appropriate attention to risk factors such as the experience of racism and discrimination, as well as to the use of non-stigmatizing language.¹

Most significant is the addition of a new disorder, prolonged grief disorder. This addition is the result of years of research and clinical experience showing that many people experience a persistent inability to move past grief over the loss of a loved one and that these symptoms are severe enough to affect day-to-day functioning.¹ It is estimated that following the nonviolent loss of a loved one, 1 in 10 bereaved adults is at risk for developing prolonged grief disorder, First told Psychiatry News. ¹ (See information below for the criteria for prolonged grief disorder.)

Interestingly, there has been some backlash to this addition, as critics have argued with categorizing grief as a mental disorder for fear of “pathologizing a fundamental aspect of the human experience.”⁴ Others like Dr. Joanne Cacciatore, an associate professor of social work at Arizona State University, completely disagrees with the addition, stating, “When … an expert tells us we are disordered and we are feeling very vulnerable and feeling overwhelmed, we no longer trust ourselves and our emotions. To me, that is an incredibly dangerous move and short sighted.”⁴ But researchers like Dr. M. Katherine Shear, a psychiatry professor at Columbia University, view grief as distinct from depression and more closely associated with disorders like PTSD.⁴ Currently, there is research undergoing that pharmaceutical treatments like naltrexone, a drug used to help treat addiction, could be used to treat prolonged grief disorder.⁴

Diagnostic Criteria for Prolonged Grief Disorder (F43.8)

Appropriately, “DSM-5-TR™” includes new symptom codes that allow clinicians to indicate the presence or history of suicidal behavior and nonsuicidal self-injury.¹

The suicidal behavior symptom code can be applied to individuals who have participated in some potentially self-injurious behavior with at least some intent to die because of the act. Evidence of intent to end their life can be explicit or inferred from the behavior or circumstances.¹

Additionally, the category “Unspecified Mood Disorder” was restored in “DSM-5-TR™,” after deletion from the previous edition, for mixed mood presentations that do not meet criteria for a bipolar or depressive disorder.

There have also been significant updates to the terminology to describe gender dysphoria. The term “desired gender” is now “experienced gender,” the term “cross-sex medical procedure” is now “gender-affirming medical procedure” and the term “natal male”/“natal female” is now “individual assigned male/female at birth.”⁵

Diagnostic Criteria Revisions in the 5th Edition

Additionally, there are changes to the specifier definitions for several disorders. These include changes to the severity specifiers for manic episode, the mood congruent/mood incongruent specifier for bipolar disorder, the mixed features specifier for major depressive disorder, the acute/persistent specifier for adjustment disorder, narcolepsy specifiers and the post-transition specifier for gender dysphoria.⁵

Two disorders have been renamed to adopt more current usage: Intellectual disability is now intellectual developmental disorder, and conversion disorder is now functional neurological symptom disorder.¹

During the development of the “DSM-5-TR™,” reviewers were eager to address the impact of culture, racism and discrimination on psychiatric diagnosis in the text of the disorder chapters.⁶ A Cross-Cutting Review Committee on Cultural Issues, composed of U.S.-based and international experts in cultural psychiatry, psychology and anthropology, reviewed the texts for cultural influences on disorder characteristics, incorporating relevant information in the sections on culture-related diagnostic issues. Importantly, a separate Ethnoracial Equity and Inclusion Work Group, composed of 10 mental health practitioners from diverse ethnic and racialized backgrounds with expertise in disparity-reduction practices, reviewed references to race, ethnicity and related concepts to avoid perpetuating stereotypes or including discriminatory clinical information.⁶

‘DSM-5-TR™’s’ Challenges to Use of Language Viewing Races as Discrete Natural Entities  

The “DSM-5-TR^TM” contains descriptions, symptoms and other criteria for diagnosing mental disorders. This update provides a common language for healthcare providers to communicate with and about their patients and creates consistent diagnoses that can be used in research on mental disorders. The long-standing psychiatric manual provides a common language for researchers to study the criteria for potential future revisions and to aid in the development of medications and other treatments.

As May 2022 is Mental Health Awareness Month, it is so important that professionals working in the health education field remain up to date on any and all new developments in important therapeutic areas such as mental health. The “DSM-5-TR^TM” update in March presents the Almanac with a wonderful opportunity to keep our readers abreast of such important updates.

^a Katherine Biles is currently a contractor for EVR Consulting with Takeda Pharmaceuticals; ^b Dr. Joshua Schechtel is a senior medical director for Physicians’ Education Resource^®, LLC (PER); ^cDr. Hailing Zhang is a psychiatrist practicing in Bridgewater, New Jersey.

References

1. Moran, M. Updated DSM-5 Text Revisions to Be Released in March. Psychiatric News. Published Online:28 Dec 2021https://doi.org/10.1176/appi.pn.2022.1.20Related
2. American Psychiatric Association. 2022. From Planning to Publication: Developing DSM-5-TR.
3. American Psychiatric Association. The Organization of DSM-5. 2022. https://www.psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/DSM-5-TR/APA-DSM5TR-TheOrganizationofDSM.pdf Accessed May 2, 2022.
4. Barry, E. How Long Should It Take to Grieve? Psychiatry Has Come Up with an Answer. The New York Times. Published in print March 19, 2022, Section A, Page 1 as Prolonged Grief Is Declared a Mental Disorder. Updated March 25, 2022. https://www.nytimes.com/2022/03/18/health/prolonged-grief-disorder.html?smid=url-share Accessed May 3, 2022.
5. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Text Revision DSM-5-TR 5th Edition. March 2022.
6. American Psychiatric Association. How Were Race/Ethnicity Issues Discussed in DMS-5-TR? 2022. https://www.psychiatry.org/psychiatrists/practice/dsm/frequently-asked-questions#4101 Accessed May 2, 2022.
7. American Psychiatric Association. Attention to Culture, Racism and Discrimination in the DSM-5. https://psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/DSM-5-TR/APA-DSM5TR-AttentiontoCultureRacismandDiscrimination.pdf Accessed May 2, 2022.