Chapter 1. Use of the Manual

Subtypes and specifiers are provided for increased diagnostic specificity. Subtypes define mutually exclusive and jointly exhaustive phenomenological subgroupings within a diagnosis and are indicated by the instruction “Specify whether” in the criteria set (e.g., in anorexia nervosa, Specify whether restricting type or binge-eating/purging type). In contrast, specifiers are not intended to be mutually exclusive or jointly exhaustive, and as a consequence, more than one specifier may be applied to a given diagnosis. Specifiers (as opposed to subtypes) are indicated by the instruction “Specify” or “Specify if” in the criteria set (e.g., in social anxiety disorder, “Specify if: performance only”). Specifiers may define homogeneous subgroupings of individuals along relevant dimensions (e.g., etiology, treatment response); they may also convey information that is relevant to the management of the individual’s disorder, such as the “with other medical comorbidity” specifier in sleep-wake disorders. Although the fifth character within an ICD-10-CM code is sometimes designated to indicate a particular subtype or specifier (e.g., “0” in the fifth character in the F06.70 diagnostic code for mild neurocognitive disorder due to traumatic brain injury to indicate the absence of a behavioral disturbance vs. a “1” in the fifth character of the F06.71 diagnostic code for mild neurocognitive disorder due to traumatic brain injury to indicate the presence of a behavioral disturbance), the majority of subtypes and specifiers included in DSM-5-TR are not reflected in the ICD-10-CM code and are indicated instead by recording the subtype or specifier after the name of the disorder (e.g., social anxiety disorder, performance type).

Although decades of scientific effort have gone into developing the diagnostic criteria sets for the disorders included in Section II, it is well recognized that this set of categorical diagnoses does not fully describe the full range of mental disorders that individuals experience and present to clinicians on a daily basis throughout the world. Hence, it is also necessary to include “other specified” or “unspecified” disorder options for presentations that do not fit exactly into the diagnostic boundaries of disorders in each chapter. Moreover, there are settings (e.g., emergency department) where it may only be possible to identify the most prominent symptom expressions associated with a particular chapter (e.g., delusions, hallucinations, mania, depression, anxiety, substance intoxication, neurocognitive symptoms). In such cases, it may be most appropriate to assign the corresponding “unspecified” disorder as a placeholder until a more complete differential diagnosis is possible.

DSM-5 provides two diagnostic options for presentations that do not meet the diagnostic criteria for any of the specific DSM-5 disorders: other specified disorder and unspecified disorder. The other specified category is provided to allow the clinician to communicate the specific reason that the presentation does not meet the criteria for any specific category within a diagnostic class. This is done by recording the name of the category, followed by the specific reason. For example, with an individual with persistent hallucinations occurring in the absence of any other psychotic symptoms (a presentation that does not meet criteria for any of the specific disorders in the chapter “Schizophrenia Spectrum and Other Psychotic Disorders”), the clinician would record “other specified schizophrenia spectrum and other psychotic disorder, with persistent auditory hallucinations.” If the clinician chooses not to specify the reason that the criteria are not met for a specific disorder, then “unspecified schizophrenia spectrum and other psychotic disorder” would be diagnosed. Note that the differentiation between other specified and unspecified disorders is based on the clinician’s choice to indicate or not the reasons why the presentation does not meet full criteria, providing maximum flexibility for diagnosis. When the clinician determines that there is enough available clinical information to specify the nature of the presentation, the “other specified” diagnosis can be given. In those cases where the clinician is not able to further specify the clinical presentation (e.g., in emergency room settings), the “unspecified” diagnosis can be given. This is entirely a matter of clinical judgment.

It is a long-standing DSM convention for conditions included in the “Conditions for Further Study” chapter in Section III to be listed as examples of presentations that can be specified using the “other specified” designation. The inclusion of these conditions for further study as examples does not represent endorsement by the American Psychiatric Association that these are valid diagnostic categories.

In the absence of clear biological markers or clinically useful measurements of severity for many mental disorders, it has not been possible to completely separate normal from pathological symptom expressions contained in diagnostic criteria. This gap in information is particularly problematic in clinical situations in which the individual’s symptom presentation by itself (particularly in mild forms) is not inherently pathological and may be encountered in those for whom a diagnosis of “mental disorder” would be inappropriate. Therefore, a generic diagnostic criterion requiring distress or disability has been used to establish disorder thresholds, usually worded “the disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.” Assessing whether this criterion is met, especially in terms of role function, is an inherently difficult clinical judgment. The text following the definition of a mental disorder acknowledges that this criterion may be especially helpful in determining an individual’s need for treatment. Use of information from the individual as well as from family members and other third parties via interview or self- or informant-reported assessments regarding the individual’s performance is often necessary.

The general convention in DSM-5 is to allow multiple diagnoses to be assigned for those presentations that meet criteria for more than one DSM-5 disorder. When more than one diagnosis is given in an inpatient setting, the principal diagnosis is the condition established after study to be chiefly responsible for occasioning the admission of the individual. When more than one diagnosis is given for an individual in an outpatient setting, the reason for visit is the condition that is chiefly responsible for the ambulatory medical services received during the visit. In most cases, the principal diagnosis or the reason for visit is also the main focus of attention or treatment. It is often difficult (and somewhat arbitrary) to determine which diagnosis is the principal diagnosis or the reason for visit. For example, it may be unclear which diagnosis should be considered “principal” for an individual hospitalized with both schizophrenia and alcohol use disorder, because each condition may have contributed equally to the need for admission and treatment. The principal diagnosis is indicated by listing it first, and the remaining disorders are listed in order of focus of attention and treatment. When the principal diagnosis or reason for visit is a mental disorder due to another medical condition (e.g., major neurocognitive disorder due to Alzheimer’s disease, psychotic disorder due to malignant lung neoplasm), ICD coding rules require that the etiological medical condition be listed first. In that case, the principal diagnosis or reason for visit would be the mental disorder due to the medical condition, the second listed diagnosis. For maximum clarity, the disorder listed as the principal diagnosis or the reason for visit can be followed by the qualifying phrase “(principal diagnosis)” or “(reason for visit).”

The modifier “provisional” can be used when there is currently insufficient information to indicate that the diagnostic criteria are met, but there is a strong presumption that the information will become available to allow that determination. The clinician can indicate the diagnostic uncertainty by recording “(provisional)” following the diagnosis. For example, this modifier might be used when an individual who appears to have a presentation consistent with a diagnosis of current major depressive disorder is unable to give an adequate history, but it is expected that such information will become available after interviewing an informant or reviewing medical records. Once that information becomes available and confirms that the diagnostic criteria were met, the modifier “(provisional)” would be removed. Another use of “provisional” is for those situations in which differential diagnosis depends exclusively on whether the duration of illness does not exceed an upper limit as required by the diagnostic criteria. For example, a diagnosis of schizophreniform disorder requires a duration of at least 1 month but less than 6 months. If an individual currently has symptoms consistent with a diagnosis of schizophreniform disorder except that the ultimate duration is unknown because the symptoms are still ongoing, the modifier “(provisional)” would be applied and then removed if the symptoms remit within a period of 6 months. If they do not remit, the diagnosis would be changed to schizophrenia.

The term “substance/medication-induced mental disorder” refers to symptomatic presentations that are due to the physiological effects of an exogenous substance on the central nervous system, including symptoms that develop during withdrawal from an exogenous substance that is capable of causing physiological dependence. Such exogenous substances include typical intoxicants (e.g., alcohol, inhalants, hallucinogens, cocaine), psychotropic medications (e.g., stimulants; sedatives, hypnotics, anxiolytics), other medications (e.g., steroids), and environmental toxins (e.g., organophosphate insecticides). Editions of DSM from DSM-III to DSM-IV referred to these as “substance-induced mental disorders.” To emphasize that medications and not just substances of abuse can cause psychiatric symptoms, the term was changed to “substance/medication-induced” in DSM-5.

Historically, mental disorders were divided into those that were termed “organic” (caused by physical factors) versus those that were “nonorganic” (purely of the mind; also referred to as “functional” or “psychogenic”), terms that were included in DSM up through DSM-III-R. Because these dichotomies misleadingly implied that the nonorganic disorders have no biological basis and that mental disorders have no physical basis, DSM-IV updated this terminology as follows: 1) the terms “organic” and “nonorganic” were eliminated from DSM-IV; 2) the disorders formerly called “organic” were divided into those due to the direct physiological effects of a substance (substance-induced) and those due to the direct physiological effects of a medical condition on the central nervous system; and 3) the term “nonorganic mental disorders” (i.e., those disorders not due to either substances or medical conditions) was replaced by “primary mental disorder.” In DSM-5, this terminology was further refined, replacing “primary” with “independent” (e.g., Criterion C in substance/medication-induced anxiety disorder starts with “the disturbance is not better accounted for by an anxiety disorder that is not substance-induced. Evidence of an independent anxiety disorder could include . . .” [italics added for reference]). This was done to reduce the potential for confusion given that the term “primary” has historically had other meanings (e.g., it is sometimes used to indicate which disorder among several comorbid disorders was the first to occur). The use of “independent mental disorder” should not be construed to mean that the disorder is independent of other potential causal factors such as psychosocial or other environmental stressors.

Another dichotomy adopted by prior editions of DSM that reflected mind-body dualism was the division of disorders into “mental disorders” and “physical disorders.” In conjunction with the elimination of organic/nonorganic terminology, DSM-IV replaced the “mental disorder” versus “physical disorder” dichotomy with a “mental disorder” vs. “general medical condition” dichotomy, based on chapter location within the International Classification of Diseases (ICD). Medical conditions in ICD have been divided into 17 chapters based on a variety of factors, which include etiology (e.g., Neoplasms [Chapter 2]), anatomical location (e.g., Diseases of the ear and mastoid process [Chapter 8]), body system (e.g., Diseases of the circulatory system [Chapter 9]), and context (e.g., Pregnancy, childbirth and the puerperium [Chapter 15]). In the ICD framework, mental disorders are those located in Chapter 5, and general medical conditions are those located within the other 16 chapters. Because of concerns that the term “general medical condition” could be conflated with general practice, DSM-5 uses the term “another medical condition” to emphasize the fact that mental disorders are medical conditions and that mental disorders can be precipitated by other medical conditions. It is important to recognize that “mental disorder” and “another medical condition” are merely terms of convenience and should not be taken to imply that there is any fundamental distinction between mental disorders and other medical conditions, that mental disorders are unrelated to physical or biological factors or processes, or that other medical conditions are unrelated to behavioral or psychosocial factors or processes.