Release of Updated & Revised DSM-5-Text Revision (DSM-5-TR)

DSM-5-TR Additions and Revisions

Text Revisions

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:

1. report the scientific knowledge accumulated over the 10 years since the development of the DSM-5.
2. add information and make intentional language changes to recognize the roles of racism, cultural considerations, and social determinants of mental health in the diagnosis of mental disorders and change the language used around gender and gender identity, and marginalized groups to be more inclusive and help reduce stigma.

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.

Corrected Mental Disorder Codes

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.

New Mental Disorder

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.

New Other Conditions of Clinical Attention

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:

• 91A Suicidal Behavior, Initial encounter (At intake session the client has suicidal behavior.)
• 91D Suicidal Behavior, Subsequent encounter (The client has previously received treatment while having suicidal behavior and now is presenting for treatment again while having suicidal behavior.)
• 51 History of Suicidal Behavior (Suicidal behavior has occurred during the client's lifetime.) Note that this is a "life-time" diagnosis that remains permanently listed as part of the client's diagnosis list.

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:

• 88 Current Nonsuicidal Self-Injury (Client is actively engaged in self-injury without being suicidal.)
• 52 History of Nonsuicidal Self-Injury (Intentional self-injury has occurred during the client's lifetime.) This is a life-time diagnosis.

Same Disorder With a New Name

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.

Revised Criteria Sets That May Alter Prior DSM-5 Diagnosis

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.

Added or Removed Diagnosis Specifiers

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.

New Specifiers

• Bipolar I: severity specifiers and ICD-10 codes for a current manic episode.
• Bipolar II: severity specifiers and ICD-10 codes for a current hypomanic episode
• Other Specified Obsessive-Compulsive Related Disorder: added specifier, "Olfactory Reference Disorder"

Revised Specifiers

• Bipolar I:
• the specifiers Mood-Congruent Psychotic Features and Mood-Incongruent Psychotic Features are now further defined as current manic or current depressive episode
• definitions for the levels of severity, mild, moderate, and severe, are changed
• Persistent Depressive Disorder: the available specifiers are "with anxious distress" and "atypical features"; the other five provided in the DSM-5 were eliminated
• Gender Dysphoria: terminology in the specifiers updated to use culturally sensitive and less stigmatizing language

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.

• The DSM-5 resulted in the biggest change in diagnosis since the DSM-III, published in 198o. As often happens when structural changes are made in a diagnostic system, it was noted after using the DSM-5 for a few years that many diagnostic criteria sets lacked clarity and/or were misleading.
• Research in the past 10 years has been robust, particularly in the areas of biological, developmental, socio-economic, and cultural aspects of mental disorders.
• Changes in assigned ICD-10-CM codes for specific disorders occur regularly. The National Center for Health Statistics (NCHS) oversees the ICD-10-CM codes in the United States and approves and publishes changes to ICD-10-CM codes on a yearly basis. The DSM-5-TR contains the ICD-10-CM codes approved through 2021.

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.