DSM-5-TR: Rationale, Process, and Overview of Changes
Abstract
The DSM-5 text revision (DSM-5-TR) is the first published revision of the DSM-5 since its publication in 2013. Like the previous text revision (DSM-IV-TR), the main goal of the DSM-5-TR is to comprehensively update the descriptive text accompanying each DSM disorder on the basis of reviews of the literature over the past 10 years. In contrast to the DSM-IV-TR, in which updates were confined almost exclusively to the text, the DSM-5-TR includes many other changes and enhancements of interest to practicing clinicians, such as the addition of diagnostic categories (prolonged grief disorder, stimulant-induced mild neurocognitive disorder, unspecified mood disorder, and a category to indicate the absence of a diagnosis); the provision of ICD-10-CM symptom codes for reporting suicidal and nonsuicidal self-injurious behavior; modifications, mostly for clarity, of the diagnostic criteria for more than 70 disorders; and updates in terminology (e.g., replacing “neuroleptic medications” with “antipsychotic medications or other dopamine receptor blocking agents” throughout the text and replacing “desired gender” with “experienced gender” in the text for gender dysphoria). Finally, the entire text was reviewed by an Ethnoracial Equity and Inclusion Work Group to ensure appropriate attention to risk factors such as the experience of racism and discrimination, as well as the use of nonstigmatizing language.
HIGHLIGHTS
•
The goal of DSM-5-TR is to comprehensively update the descriptive text accompanying each DSM disorder to reflect the literature published over the 10 years since publication of the DSM-5.
•
The DSM-5-TR also includes the changes and enhancements made to the DSM-5 since its original publication in 2013 that occurred during the ongoing DSM-5 iterative revision process.
•
The revision involved a long-overdue review of the text by an Ethnoracial Equity and Inclusion Work Group that provided context and guidance when the text included references to ethnoracial differences.
The newly released Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR) is the first revised edition since the publication of the DSM-5 in 2013. Although occasional corrections, updates, and clarifications to the DSM-5 have been posted on the DSM website and added to the manual on Psychiatry Online (www.psychiatryonline.org) since 2013, the DSM-5-TR results from a comprehensive review and update to the text that accompanies the diagnostic criteria sets, hence the “text revision” designation. Although the centerpiece of every edition of the DSM since DSM-III is the diagnostic criteria, more than 95% of the DSM by word count consists of the text, which aims to provide clinically useful information to aid in the diagnosis of each disorder. According to an online survey of behavioral health care practitioners that assessed reported use of the DSM in everyday practice, most practitioners acknowledged reviewing relevant sections of the text either sometimes or often, both when making an initial diagnosis and during ongoing treatment (1). It is therefore important for clinical practice that this resource be kept up to date. Some sections of the text, such as Diagnostic Features and Differential Diagnosis, do not require updating unless the diagnostic criteria change or clarification of clinically descriptive information is needed. In contrast, most of the other sections of the text—including Prevalence, Development and Course, Risk and Prognostic Factors, Culture-Related Diagnostic Issues, Sex- and Gender-Related Diagnostic Issues, and Diagnostic Markers—are based on continually evolving scientific literature, which results in these sections’ becoming increasingly outdated and in need of revision over time. This article provides an overview of the changes, their rationales, and the process by which they were made.
DSM-III, which was published in 1980, was the first edition of the DSM to include diagnostic criteria for every disorder, as well as the first to include expansive text that described the essential and associated features, age at onset, course, impairment, complications, predisposing factors, prevalence, sex ratio, familial pattern, and differential diagnosis. The development of subsequent DSM editions, up to and including DSM-5, entailed revising all these elements in tandem and, except for DSM-III-R, was coordinated with the release of new editions of the World Health Organization’s International Classification of Diseases (Table 1).
| DSM edition, year published | NCHS ICD-CM (WHO ICD) version in effectb | Disorders added or removed | Changes to disorder definitions | Changes to subtypes and specifiers | Changes to text |
|---|---|---|---|---|---|
| DSM-II, 1968 | ICD-8 | + | + | + | + |
| DSM-III, 1980 | ICD-9-CM (ICD-9) | + | + | + | + |
| DSM-III-R, 1987 | ICD-9-CM (ICD-9) | + | + | + | + |
| DSM-IV, 1994 | ICD-9-CM (ICD-10) | + | + | + | + |
| DSM-IV-TR, 2000 | ICD-9-CM (ICD-10) | − | + (limited to 5 corrections) | − | + |
| DSM-5, 2013 | ICD-9-CM and ICD-10-CMc (ICD-10) | + | + | + | + |
| DSM-5 online, 2014–2019 | ICD-9-CM and ICD-10-CMc (ICD-10) | − | + | + | + |
| DSM-5-TR, 2022 | ICD-10-CM (ICD-11)d | + | + | + | + |
a
+, yes; −, no.
b
ICD-CM codes are the only codes permissible for clinical use in the United States since 1977 and are the only codes provided in DSM. They are modified versions of the WHO ICD codes, which are used internationally. CM, Clinical Modification; NCHS, National Center for Health Statistics; WHO, World Health Organization.
c
ICD-9-CM codes were used for coding purposes in the United States through September 30, 2015. ICD-10-CM codes have been used in the United States since October 1, 2015.
d
ICD-11 was approved by the World Health Assembly in May 2019. It has not yet been determined when ICD-11 codes will be required in the United States.
DSM-IV-TR was the first revision in which the text was almost entirely updated without significant changes to the diagnostic criteria. To avoid the disruptive effects of frequent DSM revisions (2), a long pause between publication of the DSM-IV and the next full revision of the manual was anticipated. The likelihood that this lengthy interval would render the DSM text increasingly out of date led the American Psychiatric Association (APA) to undertake a revision confined to the DSM-IV’s text (3).
After publication of the DSM-5 in 2013, APA adopted an iterative revision process that allows the DSM to be updated on an ongoing basis (4). Changes made to the criteria and text from 2014 to 2019 were posted on the DSM-5 website (www.dsm5.org) and implemented in the online version of the manual (at www.psychiatryonline.org) on a rolling basis. As was the case with DSM-IV-TR, the indeterminate date for undertaking the next major revision of the manual meant that an empirically based process needed to be put in place to update the entire text. Consequently, a DSM-5 text revision began in 2019, culminating in the publication of the DSM-5-TR in 2022. It should be noted that unlike the DSM-IV-TR, the changes in DSM-5-TR include additional updates beyond the text, including clarifications to criteria sets, updated diagnostic coding, newly coded behaviors, and a new disorder approved as part of the iterative revision process described in greater detail below. DSM-5-TR also incorporated all iterative updates made in the DSM-5 online version, as well as additional changes that arose in the context of developing the DSM-5-TR.
DSM-5-TR Revision Process
DSM-5-TR is the product of two separate but complementary revision processes: the DSM iterative revision, overseen by the DSM Steering Committee, and the DSM-5 text revision development, conducted by the DSM Text Revision Subcommittee, which reported to the DSM Steering Committee. All DSM revision activities and maintenance are overseen by the APA’s Division of Research in collaboration with other divisions, such as American Psychiatric Association Publishing. The process of making changes to the DSM-5 in the context of the DSM iterative revision (5, 6) starts with the receipt of proposals submitted to the APA DSM Web portal. Submissions, along with their supporting evidence, are rigorously evaluated by the Steering Committee, working in conjunction with one of the five standing Review Committees, each covering a broad domain of psychiatric diagnoses (e.g., internalizing disorders). After preliminary approval by the Steering Committee, proposals are posted on the DSM-5 website for public comment. The comments are then reviewed to inform a final decision by the DSM Steering Committee whether to approve the proposed changes, followed by review by the APA Assembly and Board of Trustees. According to a report describing the first 3 years of the submission process (7), 29 proposals were received, which ultimately resulted in the addition of prolonged grief disorder, the provision of ICD-10-CM symptom codes for suicidal behavior and nonsuicidal self-injury, and revisions of the diagnostic criteria for avoidant/restrictive food intake disorder and the narcolepsy subtypes. Two proposals to add disorders were rejected without further review because of fundamental conceptual problems. Three proposals requested changes to the text for intellectual developmental disorder, schizophrenia, and pedophilic disorder, and one involved recommending the use of consistent language when referring to self-harm; except for a proposed change to the text for pedophilic disorder, all changes were implemented. Seventeen were returned to the submitter with requests for additional data. Finally, one proposal was still being reviewed at the time the report (7) was written.
Minor changes made to the diagnostic criteria in the years before work started on DSM-5-TR were the product of the DSM Minor Changes Subcommittee, which was tasked with identifying instances of unclear or ambiguous wording in the diagnostic criteria as well as inconsistencies among diagnostic criteria sets or between diagnostic criteria and associated text.
The DSM-5-TR text updates involved the contribution of more than 200 content experts, most of whom participated in the DSM-5 development process as either members of or consultants to one of the original 13 workgroups. The content experts were distributed among 21 review groups that corresponded to the 21 disorder chapters included in the DSM-5, each with its own section editor. Each expert was assigned primary responsibility for reviewing and revising the text for one or more of the disorders in the chapter that was the purview of the review group. Experts were tasked with reviewing text sections to identify inaccurate or out-of-date material on the basis of their extensive knowledge of the literature, complemented by literature reviews covering the period from January 2010 to December 2019. Proposed updates or corrections were accompanied by an explanation of the justification for the changes, such as noting findings from more recent large-scale epidemiological studies or results from newer, more methodologically sound studies. Three cross-cutting review groups, each with expertise in cross-diagnostic topics (culture-related diagnostic issues, sex- and gender-related issues, and the association of the disorder with suicidal thoughts and behavior), also simultaneously reviewed and updated the text sections relevant to their areas of special expertise.
The next level of review, conducted by the section editors, vice-chairs, and cochairs, involved verifying that the proposed changes were adequately justified. The near-finished manuscript drafts then underwent additional reviews by the Forensic Review Group, which considered the forensic implications of proposed changes, and a review by the cochairs that identified and flagged proposed updates that had any potential to benefit a commercial interest. These flagged proposals were referred to the conflict-of-interest review editor, who reviewed the financial disclosure statements of the expert who had proposed the change to determine whether the proposed update appeared to pose a possible financial conflict, in which case the proposed change was modified or rejected. Finally, an Ethnoracial Equity and Inclusion Work Group, consisting of 10 mental health practitioners from diverse ethnic and racialized backgrounds with expertise in disparity reduction practices, reviewed the entire text, examining references to race, ethnicity, and related concepts and making changes that served to avoid including discriminatory clinical information and perpetuating stereotypes. For example, throughout the text the term racial has been replaced by racialized to highlight the socially constructed nature of race as opposed to its being a natural discrete entity. Finally, a version of the manuscript with the proposed changes highlighted was reviewed by the members of the DSM Steering Committee, who, once their concerns were adequately addressed, gave their final approval.
During review of the DSM-5 text, additional inconsistencies in the diagnostic criteria sets and specifiers were identified, similar in degree and kind to those identified by the Minor Changes Subcommittee. Most of the criteria set changes noted in Box 1 were made after the comprehensive text review. Proposals to correct identified problems in the criteria sets were presented to the DSM Steering Committee for approval, and those deemed clinically significant were also referred to the APA Assembly and Board of Trustees for final approval.
Overview of Significant Changes in DSM-5-TR
Addition of Diagnostic Entities
Diagnostic entities that are new to DSM-5-TR include prolonged grief disorder, unspecified mood disorder, and stimulant-induced mild neurocognitive disorder, as well as a code for “no diagnosis or condition” and symptom codes to indicate suicidal behavior and nonsuicidal self-injury.
Prolonged grief disorder.
Prolonged grief disorder is characterized by the continued presence of intense yearning for the deceased, persistent preoccupation with thoughts of the deceased at least 12 months after the death of a loved one, or both, along with other grief-related symptoms such as emotional numbness, intense emotional pain, and avoidance of reminders that the person is deceased, which are sufficiently severe to cause clinically significant distress or impairment in functioning (8). The notion that pathological grief could constitute a diagnostic entity separate from depression dates to the early 1990s (9, 10). Over the past three decades, increasing recognition and conclusive research has demonstrated that prolonged grief disorder constitutes a distinct mental disorder. Estimates of its prevalence among bereaved individuals 1 year after the death of an important person in the individual’s life range from 4% to 10% (11–13). Numerous studies have shown that prolonged grief disorder is distinct from other mental disorders, including major depressive disorder, generalized anxiety disorder (9, 14, 15), and posttraumatic stress disorder (16, 17), and is associated with significant suffering and enduring functional impairments (18). Prolonged grief disorder has idiosyncratic neurobiological (19) and clinical (20–22) correlates. It can persist unabated for months or even years (23). In addition, it can be associated with marked increases in risks for serious medical conditions, including cardiac disease, hypertension, cancer, and immunological deficiency (24), as well as reduced quality of life (25). Prolonged grief disorder may respond only to targeted interventions (26, 27). This abundance of evidence supported the inclusion of prolonged grief disorder in DSM-5-TR.
Unspecified mood disorder.
DSM-5 provides residual “other specified” and “unspecified” categories corresponding to each of the diagnostic classes included in section II of the manual. These residual categories are intended to provide a diagnostic code for presentations that do not fit exactly into the diagnostic boundaries of any of the disorders in a diagnostic class (e.g., subthreshold major depression) as well as for clinical situations (e.g., evaluation in an emergency department setting) in which it may be possible to determine only the relevant general diagnostic class (e.g., schizophrenia spectrum and other psychotic disorder) because of insufficient diagnostic information (e.g., duration of symptoms and possible overlap between mood and psychotic symptoms). In such situations, the unspecified category serves as a diagnostic placeholder with the expectation (or hope) that the specific diagnosis will eventually become known as additional information becomes available. In the case of presentations in which irritable mood or agitation predominates, it can be quite challenging to decide whether the appropriate diagnostic class is bipolar or depressive, given that irritability and agitation may be characteristic of either a manic episode or a major depressive episode. In such cases, the clinician was essentially forced to choose arbitrarily between unspecified bipolar disorder and unspecified depressive disorder, despite their significantly different treatment implications. Moreover, even if it later becomes clear that a presentation initially diagnosed as unspecified bipolar disorder reflects a depressive disorder, the potential negative impact of having received an incorrect diagnosis of bipolar disorder in terms of future insurability and risk assessment could be lifelong. To address this dilemma, an unspecified mood disorder category that allows the clinician to avoid prematurely choosing between bipolar disorder and depressive disorder has been added to DSM-5-TR.
Stimulant-induced mild neurocognitive disorder.
DSM-IV included a category for persisting dementia resulting from the following four substance classes: alcohol; sedatives, hypnotics, or anxiolytics; inhalants; and other or unknown substances. Reflecting the dimensional nature of neurocognitive impairment, DSM-5 replaced the single dementia category with two categories, major neurocognitive disorder and mild neurocognitive disorder, either of which can be induced by substances from the same four substance classes as in DSM-IV. The literature on stimulant-induced neurocognitive disorder (28–34), however, supports the existence of an array of persisting cognitive deficits resulting from stimulant use that, although not severe enough to interfere with the capacity for independence in everyday activities, are serious enough to require greater mental effort, use of compensatory strategies, or accommodation. Thus, cocaine-induced mild neurocognitive disorder and amphetamine-type substance–induced mild neurocognitive disorder have been added to the DSM-5-TR.
No diagnosis or condition.
DSM-5-TR now includes a recommended ICD-10-CM diagnostic code for “no diagnosis or condition” in the chapter “Other Mental Disorders and Additional Codes.” The lack of a recommended ICD-10-CM diagnostic code in DSM-5 to indicate the absence of a mental disorder or condition created problems in some clinical settings, given that an ICD-10-CM code is generally required for all clinical encounters. Providers can use this code to indicate that they have conducted an evaluation and have concluded that the individual’s clinical presentation does not meet the criteria for any psychiatric diagnosis. For example, such a code might be used to indicate the absence of a diagnosis of a mental disorder on discharge from a facility or to indicate the lack of a mental disorder in the context of a workplace evaluation for fitness for duty.
Suicidal behavior and nonsuicidal self-injury symptom codes.
Suicidal behavior is explicitly mentioned in the diagnostic criteria for only two conditions: major depressive episode (in bipolar I disorder, bipolar II disorder, and major depressive disorder) and borderline personality disorder, potentially giving the misimpression that suicidal behavior is not a central concern in other conditions, such as schizophrenia, alcohol use disorder, bipolar disorder, and posttraumatic stress disorder, each of which is associated with elevated rates of suicidal behavior. DSM-5 added a Suicide Risk section to the text for most disorders to help ensure that clinicians would make suicide risk assessment an important consideration during their evaluations. These cross-cutting text sections were expanded in DSM-5-TR and renamed “Association With Suicidal Thoughts or Behavior.” Moreover, taking advantage of the fact that the ICD-10-CM classification includes codes for recording the presence of certain psychiatric symptoms, symptom codes indicating current suicidal behavior as well as a history of suicidal behavior have been added to the DSM-5-TR chapter “Other Conditions That May Be a Focus of Clinical Attention.” Following a similar rationale, codes for current nonsuicidal self-injury and history of nonsuicidal self-injury have also been added.
Changes to Criteria Sets
Modifications and clarifications were made to the criteria sets for more than 70 disorders, primarily for clarification of ambiguous wordings and inconsistencies (DSM-5-TR, page xxi), and are summarized in Box 1.
Box 1. Clinically important changes to DSM-5 diagnostic criteria
•
For intellectual developmental disorder, deficits in adaptive functioning are not required to be directly related to intellectual impairments; this clarification was communicated in a revision of the Diagnostic Features section of the text.
•
For autism spectrum disorder, the intended meaning of criterion A (deficits in social communication and social interaction) is that deficits in all three of the relevant domains (i.e., social-emotional reciprocity; nonverbal communication used for social interaction; and developing, maintaining, and understanding relationships) are required, rather than in any one of the three domains.
•
Clinically significant mood episodes superimposed on schizophrenia or primary psychotic disorder (except for schizoaffective disorder) warrant an additional diagnosis of other specified bipolar disorder or other specified depressive disorder rather than an additional diagnosis of bipolar disorder or major depressive disorder.
•
Major depressive disorder should be diagnosed in addition to persistent depressive disorder if criteria are met for a major depressive episode at any time during the ≥2 years of symptoms required for a diagnosis of persistent depressive disorder.
•
Depressive and anxiety symptoms that develop in response to a psychosocial stressor but that do not meet the criteria for a specific depressive or anxiety disorder should be diagnosed as adjustment disorder rather than as other or unspecified depressive or anxiety disorder.
•
Avoidant/restrictive food intake disorder can be diagnosed in the absence of a persistent failure to meet appropriate nutritional or energy needs if the eating or feeding disturbance interferes with psychosocial functioning.
•
Delirium is defined by a disturbance in attention accompanied by reduced awareness of the environment, as opposed to reduced orientation to the environment.
•
Severity specifiers (mild, moderate, and severe) for manic episodes and major depressive episodes are defined differently.
•
Narcolepsy subtypes have been revised to align with the International Classification of Sleep Disorders: type 1 (cataplexy or hypocretin deficiency) and type 2 (absence of cataplexy and either no hypocretin deficiency or hypocretin not measured).
A comprehensive list of significant changes to the criteria sets and the reasons for the changes are included in the online supplement to this article.
Updated Terminology
The names of several disorders have been updated. A convention for indicating alternative names for disorders that goes back to DSM-III involves the inclusion of alternative terms in parentheses (e.g., “dysthymic disorder [or depressive neurosis]”). Provision of these alternatives facilitates the transition from outdated terminology (e.g., neurosis), and in some cases indicates equivalent ICD terminology (“intellectual disability [intellectual developmental disorder]”) or equivalent terminology used by other medical specialties (“conversion disorder [functional neurological symptom disorder]”). Other updated terminology and parenthesized alternative terms in DSM-5-TR and the reasons for the updates are listed in Table 2.
| DSM-5-TR | DSM-5 | Background |
|---|---|---|
| Intellectual developmental disorder (intellectual disability) | Intellectual disability (intellectual developmental disorder) | Change to intellectual developmental disorder allowed for harmonization with ICD-11. |
| Persistent depressive disorder | Persistent depressive disorder (dysthymia) | Inclusion of dysthymia is confusing because the terms are not synonymous. |
| Social anxiety disorder | Social anxiety disorder (social phobia) | Social anxiety disorder has been in use since 1994; the parenthetical social phobia is no longer needed. |
| Functional neurological symptom disorder (conversion disorder) | Conversion disorder (functional neurological symptom disorder) | Functional neurological symptom disorder is the preferred name in the medical literature. |
Although medication names are rarely included in the DSM given its emphasis on diagnosis rather than treatment, in some instances medications appear in the names of disorders (e.g., neuroleptic-induced parkinsonism) and the text (e.g., “developing within a few weeks of starting or raising the dosage of a medication [such as a neuroleptic]” in the text for medication-induced acute akathisia). Different terms were used in the DSM-5 text to refer to dopamine receptor–blocking agents. Specifically, the term antipsychotics was generally used when referring to medications used to manage symptoms of psychosis, whereas terms such as neuroleptics, dopamine antagonists, and dopamine blocking drugs were used when referring to the pharmacological class, most often in the context of adverse effects that can occur with any of the drugs in this class (e.g., drug-induced parkinsonism). The term neuroleptic was coined by Jean Delay and Pierre Deniker in 1955 and refers to the effects on cognition and behavior of the original antipsychotic agents, such as apathy and constricted range of emotions. It is now considered outdated because, among other things, newer agents do not necessarily have such effects. With the goal of achieving consistency in terminology, DSM-5-TR has adopted the following conventions: antipsychotics is used when referring to medications used to manage psychotic symptoms; antipsychotic medications or other dopamine receptor blocking agents is used when referring to the broader pharmacological class; and the anachronistic term neuroleptic is retained in only two instances: as a component of the terms neuroleptic malignant syndrome and neuroleptic sensitivity, because both of these terms are widely recognized and accepted among psychiatrists and neurologists.
Finally, reflecting the rapid evolution in the terminology used in the DSM-5 gender dysphoria text, several terms that are no longer favored by the transgender patient and clinician communities have been updated in DSM-5-TR. Specifically, the terms natal male, natal female, and natal gender have been replaced by, respectively, assigned male at birth, assigned female at birth, and assigned gender at birth; desired gender has been replaced by experienced gender; and the terms cross-sex medical procedure and cross-sex hormone treatment have been replaced by, respectively, gender-affirming medical procedure and gender-affirming hormone treatment.
The Future
With continued advances in the field, the DSM will continue to be updated to provide clinicians and researchers with the most accurate information for diagnosing patients’ conditions and conducting research. The ongoing nature of the updates can be illustrated by the implementation of several changes even since the publication of DSM-5-TR. Examples include the addition of a symptom code for impairing emotional outbursts (35), the provision of a unique code for prolonged grief disorder (no longer shared with other diagnoses), and the adaptation of the newly released ICD-10-CM codes from the National Center for Health Statistics to provide codable symptom specifiers for major neurocognitive disorder with behavioral or psychological disturbances (e.g., major neurocognitive disorder with psychotic disturbance) (36). Maintaining the utility of the DSM as the prime diagnostic reference for psychiatry remains the overriding goal.
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Received: 25 June 2022
Revision received: 3 September 2022
Accepted: 20 October 2022
Published online: 13 December 2022
Published in print: August 01, 2023
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The authors report no financial relationships with commercial interests.
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