The Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5) has been the official U.S. diagnositic guide since 2013. This March (March 18, 2022), the American Psychiatric Association (APA) released the Diagnostic and Statistical Manual of Mental Disorders (5th ed., text rev.; DSM-5-TR), an updated and revised version of the DSM-5. The DSM-5-TR is now the federal government's official manual for the diagnosis and reporting of mental disorders and "other conditions that may be the focus of clinical attention" (abbreviated in this guide as "other conditions"). The major revisions and changes in the DSM-5-TR include the narrative text for each disorder, changes in codes, new mental disorders and other conditions, changes in names and terms used to describe the disorders, revised criteria sets, and additions and revisions to specifiers.
All mental health professionals have the task of quickly becoming familiar with the use of the DSM-5-TR for diagnosis. This overview and summary of the DSM-5-TR revisions is focused on commonly diagnosed mental disorders and other conditions and serves as a guide and resource for counselors preparing for NBCC's national counseling examinations. This overview is organized in sections, one for each of the revised DSM-5-TR components. At the end of each section is a section on suggested strategies to learn and recall these revisions of the DSM-5-TR are provided, labeled "Learning Strategy."
The Diagnostic and Statistical Manual of Mental Disorders can be considered two books in one, as it contains both the diagnostic criteria sets and ICD-10 codes for each mental disorder and is a written resource about each mental disorder covering diagnostic features, prevalence, development and course, risk factors, sex- and gender-related and cultural-related diagnostic issues, association with suicide, differential diagnosis, and comorbidity.
Only the DSM-5-TR Manual contains the text sections. The much smaller DSM-5-TR Desk Reference provides only the diagnostic criteria, specifiers, and codes for each mental disorder. If counselors don't have personal copies of the manual, it is essential that they have easy access to the DSM-5-TR Manual to learn and apply the new information about each common mental disorder provided in the text portions plus the Section III chapters "Assessment Measures" and "Culture and Psychiatric Diagnosis."
The text portions in the DSM-5-TR have been revised to:
A new chapter titled "Culture and Psychiatric Diagnosis" (DSM-5-TR, Section III, pp. 859-879) was added. This chapter contains basic information on integrating cultural concepts in diagnoses, including a Cultural Formulation Interview to use as part of the counseling intake interview.
Counselors need to read and familiarize themselves with the current evidence-based knowledge in the text sections of common, frequently diagnosed mental disorders. The DSM-5-TR consists of 982 pages excluding the preface, lists of advisors, and index! Rather than trying to sit down and read large sections of the DSM-5-TR and retain the information, apply the adult learning strategy of relevance. Adults learn best when they have immediate need for the information. Every time you diagnose a new client, read the complete text for the mental disorder(s) you identified. For example, after the clinical interview, you identify that the client probably has ADHD. Before making the diagnosis, read the full text for Attention-Deficit/Hyperactivity Disorder and consider if indeed your client's symptoms and history fit this diagnosis. Do the same for every mental disorder as you diagnose it. Soon you will have learned and updated yourself to a number of common mental disorders!
Since October 1, 2015, the official coding system in the United States has been the World Health Organization's International Classification of Diseases (10th ed.; clinical modification; ICD-10-CM). CM stands for clinical modification. Each country member of the WHO is required to use the same codes but may change the disorder name and diagnostic criteria based on the country's health care approaches and culture. For the United States, the National Center for Health Statistics (NCHS) manages and provides the permissible ICD codes for mental disorders.
The DSM-5 was published in 2013 with the ICD-9 numeric and projected ICD-10 alpha-numeric ICD codes. After the ICD-10-CM became required in 2015, the NCHS continued to change individual code numbers to better align with the ICD-10 on a yearly basis. As codes were revised each year, APA published the new codes as an addendum titled DSM-5 Update posted on the APA DSM-5 Library website at dsm.psychiatryonline.org. Essentially, the mental health professional had to download the update and write the code changes in their copy of the DSM-5 manual or desk reference.
The DSM-5-TRManual and DSM-5-TRDesk Reference contain the correct ICD-10 codes for specific mental disorders and other conditions official as of December 2021. Directions for the coding procedure for any specific diagnosis follow the criteria set in a text section "Recording Procedures" or "Coding Notes." The ICD-10 codes provided in the DSM-5-TR for each diagnosis should be the code used to report the diagnoses for all clients in the counselor's active caseload regardless of the code in effect when these clients were first diagnosed.
Be aware that the World Health Organization released the ICD-11 in January 2022 and over 30 nations are already using it. It is speculated that the U.S. government will switch to the use of the ICD-11 for diagnosis no earlier than 2025.
Rather than try to remember which diagnoses have a new ICD-10 code, the counselor just needs to know the most efficient way to locate the correct ICD code for a diagnosis. To identify the ICD-10 code of a particular diagnosis for a new client, look at the coding notes following the criteria set for the specific diagnosis. To determine if the ICD codes are changed for the diagnoses of continuing clients, the most efficient approach is to use the "DSM-5-TR Classification," a list of all mental disorders and their ICD-10 code(s), grouped by their DSM-5-TR diagnostic chapters (see DSM-5-TR Manual, pages xxvii-lxix). This list is the only place in the manual that displays all the disorders and codes together along with the specifiers that can be applied. Note also that the manual page number is provided for the location of each disorder's criteria set, for example, "F91.3 Oppositional Defiant Disorder (522)."
F43.8 Prolonged Grief Disorder is a new mental disorder added to the category of Trauma- and Stressor-Related Disorders (DSM-5-TR, pp. 322-327). Prolonged Grief Disorder (PGD) is a maladaptive grief reaction present for adults at least 12 months or for children and adolescents, 6 months after the death of someone with whom the bereaved had a close relationship (Criterion A). Key symptoms, experienced daily to a disabling degree, are an intense yearning or longing for the deceased and/or preoccupation with thoughts or memories of the deceased. For children and adolescents, this preoccupation may focus on the circumstances of the death (Criterion B).
The symptoms associated with Prolonged Grief Disorder have some overlap with those of Major Depressive Disorder and Posttraumatic Stress Disorder, so a careful differential diagnosis is essential (see the "Differential Diagnosis" section for PGD, DSM-5-TR, p. 326). Both of these have symptoms that overlap with Prolonged Grief Disorder but differ by lacking the intense yearning and preoccupation with the deceased. Several other DSM mental disorders develop after a stressor such as the death of a close other. Z63.4 Uncomplicated Bereavement, another focus of clinical attention (DSM-5-TR, p. 834), is a normal reaction to loss of a loved one with symptoms similar to depression. An Adjustment Disorder, a time-limited maladaptive response occurring within 3 months of a stressor, could develop following the death of a close other.
Learn more about Prolonged Grief Disorder (PGD) by studying the criteria set and reading all of the text sections, pp. 323-327. Be alert for journal articles discussing the new diagnosis PGD versus other grief reactions and behaviors.
Suicidal Behavior and Nonsuicidal Self-Injury are additions in the DSM-5-TR as conditions of clinical attention (DSM-5-TR, p. 822) with several ICD-10 codes each to indicate if the client is currently engaged in suicidal behavior or nonsuicidal self-injury or has a history of such behavior. These additions, part of the symptoms in many diagnostic categories, will help the counselor document suicidal and nonsuicidal self-injury behaviors as part of the client's DSM diagnosis list and treatment plan. A mental disorder is not also required to list either condition.
Suicidal Behavior is defined as "potentially self-injurious behavior with at least some intent to die as a result of the action" (DSM-5-TR, p. 822). Codes for Suicidal Behavior:
Nonsuicidal Self-Injury is the behavior of intentionally inflicting damage to one's body that will "likely induce bleeding, bruising or pain" (DSM-5-TR, p. 822). Codes for Nonsuicidal Self-Injury:
All diagnosable conditions in the DSM-5-TR chapter "Conditions That May Be the Focus of Clinical Attention" are listed with minimal definition and description. Both Suicidal Behavior and Nonsuicidal Self-Injury were included in the DSM-5 as proposed disorders needing further study. The same criteria sets and text sections for each remain in the DSM-5-TR in the chapter "Conditions for Further Study." To better understand when these conditions should be diagnosed, read the more detailed set of diagnostic criteria and text sections for each of these behaviors in the DSM-5-TR, pp. 920-926.
As the International Classification of Diseases is the global system for coding and reporting all diseases, violent acts, and accidents that cause morbidity and mortality, the APA intends for the DSM-identified mental disorders to harmonize more closely with those of the ICD. APA approved name changes for two DSM-5 mental disorders to make the names identical to the disorders in the ICD-11.
Functional Neurological Symptom Disorder (DSM-5-TR, pp. 360-364), a Somatic Symptom and Related Disorder, replaces the prior name, Conversion Disorder. Functional Neurological Symptom Disorder requires one or more symptoms of altered voluntary motor or sensory functioning incompatible with known neurological or medical conditions, e.g., loss of hearing with no damage to nerves, blood circulation, and ear structures. The counselor selects among the eight ICD-10 codes provided in the "Coding Note" to indicate the motor or sensory function symptom type.
Intellectual Developmental Disorder (DSM-5-TR, pp. 37-46), a disorder in the Neurodevelopmental Disorders category, replaces the DSM-5 name, Intellectual Disability. Intellectual Developmental Disorder is a disorder of both "intellectual and adaptive functioning deficits with a failure to meet developmental and socio-cultural standards for personal independence and social responsibility" (DSM-5-TR, p. 37). The counselor selects among four ICD-10 codes based on the level of severity, mild to profound, of the disorder.
Familiarize yourself with these new names. Try to always use these terms when speaking in professional settings and case conferences.
The preface to the DSM-5-TR Manual states that "this revised manual integrates the original DSM-5 diagnostic criteria for over 70 disorders, with modifications mostly for clarity" (DSM-5-TR, pp. xxi-xxii). Among these, only a few are criteria set changes for a commonly encountered mental disorder that might change or modify a prior DSM-5 diagnosis. These are the criteria sets for Autism Spectrum Disorder, Substance/Medication-Induced Bipolar and Related Disorders, Major Depressive Disorder, and Avoidant/Restrictive Food Intake Disorder.
Autism Spectrum Disorder. Criterion A is revised to clearly require that all of the three types of deficits be present, stating "as manifested by all of the following." These deficits are A.1 deficits in social-emotional reciprocity, A.2 deficits in nonverbal communicative behaviors used for social interaction, and A.3 deficits in developing, maintaining, and understanding relationships (DSM-5-TR, p. 56).
Substance/Medication-Induced Bipolar and Related Disorders. Criterion B.1 addresses when the Criterion A symptoms must develop. It now includes "after exposure to or withdrawal from a medication" (DSM-5-TR, p. 162).
Major Depressive Disorder. In the DSM-5, Criterion D read, "the occurrence of the major depressive episode (the current, presenting episode) is not better explained by a mental disorder . . . on the schizophrenia spectrum or other psychotic disorders." Criterion D is revised in the DSM-5-TR to read, "at least one major depressive episode is not better explained by a mental disorder . . . on the schizophrenia spectrum or other psychotic disorders" (DSM-5-TR, p. 183). Client's may now be diagnosed with Major Depressive Disorder whether or not the current episode of depression includes symptoms of psychosis as long as over their lifetime they had at least one major depressive episode without concurrent symptoms of another mental disorder.
Avoidant/Restrictive Food Intake Disorder. Criterion A in the DSM-5-TR is revised to no longer require that the eating or feeding disturbance be "manifested by persistent failure to meet appropriate nutritional and/0r energy needs." The DSM-5-TR Criteria A (p. 376) states the eating or feeding disturbance must be associated with one or more of the four listed symptoms: significant weight loss, dependence on enteral feeding or oral supplements, significant nutritional deficiency, or marked interference with psycho-social functioning. Any one of these symptoms is sufficient for meeting Criteria A.
For each of these mental disorders, counselors, particularly those working with children and adolescents, need to review the criteria changes and the text section "Diagnostic Features." This section more fully describes and gives examples of the symptoms the client may present and the rationale for the diagnostic criteria.
Many of the DSM-5-TR mental disorders manifest in a variety of symptoms and symptom patterns (e.g., Major Depressive Disorder). Specifiers are extensions to a diagnosis that further clarify the course, severity, or special features of the client's disorder or illness. Specifiers allow for a more specific diagnosis that will help the counselor select more effective treatment for each client. In both the DSM-5-TR Manual and Desk Reference, the available specifiers and associated ICD-10 codes follow the diagnostic criteria of each mental disorder with the exception of the specifiers for the mental disorders in the Bipolar and Related Disorders and Depressive Disorders categories. Their specifiers are listed and defined at the end of each category in a separate section titled "Specifiers for Bipolar and Related Disorders" (DSM-5-TR, pp. 169-175) and "Specifiers for Depressive Disorders" (DSM-5-TR, pp. 210-214).
Many of the DSM-5-TR revised specifiers are for diagnoses that counselors rarely encounter unless in a medical primary care setting. Below are new or revised specifiers for mental disorders frequently identified by counselors.
For adults, immediately applying new knowledge leads to learning and mastery. The most valuable way to become aware of a mental disorder's specifiers is to always use specifiers to further define the diagnosis. A severity specifier has been required for every diagnosis since the adoption of the DSM-5. Once you identify that a client's symptoms meet the diagnostic criteria, read the list of other possible specifiers. Over time you will be able to recall specifiers for the most frequently encountered disorders. Note that sometimes the specifiers are indicated in the ICD-10 code. If no code is available, the specifier is added to the name of the mental disorder.
What is the rationale for publishing a revised version of the DSM-5 Manual?
It is the practice of the American Psychiatric Association to issue a text revision for a current edition of the Diagnostic and Statistical Manual when new scientific evidence or the need to clarify or change diagnostic criteria for a significant number of mental disorders requires revision to the diagnostic criteria and/or the accompanying text in order to be accurate. The focus of this revision of the DSM-5 has not been on new mental disorders but rather on improving the criteria sets and scientific resource text sections.
Revision of the DSM-5 was needed.
When will the changes in the DSM-5-TR be incorporated into the NBCC examinations?
Candidates can expect to see narratives and items written to the DSM-5-TR on the new format of the National Clinical Mental Health Counseling Examination (NCMHCE) when it is available for certification candidates in the fall of 2022 and beginning in November 2022 for state licensure candidates.
For the National Counselor Examination (NCE), subject matter experts are reviewing all items and making necessary changes during 2022 form review meetings. New forms of the NCE published in 2023 will incorporate the DSM changes where necessary.
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