In March of this year, the American Psychiatric Association came out with the DSM-5-TR, the text revision of the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders. Text revisions have changes that are less significant than the changes between editions, and the DSM-IV was also followed by the DSM-IV-TR. So, what do the latest changes mean for those of us who are dealing with mental illnesses? I wasn’t sufficiently motivated to go to the library and look at the actual book, but the APA has quite a bit of info on its website Psychiatry.org and its Psychiatric News site, so I stuck with that.
New diagnosis: Prolonged grief disorder
Prolonged grief disorder has been added as a new diagnosis. It had been included in the DSM-5 as a “condition for further study.” The APA explicitly says that the intention is not to pathologize grief. The Psychiatric News says: “Individuals who meet the criteria for prolonged grief disorder experience something dramatically different from the grief normally experienced by anyone who loses a loved one. The grief is intractable and disabling in a way that typical grieving is not.” They say that the aim is to help get appropriate care for people who need it.
The “prolonged” time frame is greater than a year in adults and greater than 6 months in children. Like any mental illness diagnosis, symptoms must be present to the extent that they cause clinically significant distress or impairment in functioning. Symptoms include:
- intense yearning or longing for the deceased
- preoccupation with thoughts or memories of the deceased
- identity disruption
- avoidance of reminders that the person is dead
- feelings/thoughts about the death including a marked sense of disbelief, intense emotional pain related to the death, feeling that life is meaningless, intense loneliness
- difficulty reintegrating into one’s relationships and activities after the death
- emotional numbness
Reactions to this new diagnosis
On March 18, the New York Times ran an article titled How Long Should It Take to Grieve? Psychiatry Has Come Up With an Answer. The article itself is more balanced than the title implies, and includes voices both for and against the new diagnosis.
I feel much the same way about this as I did about the removal of the bereavement exclusion criterion for major depressive disorder in the DSM-5. The majority of grief is “normal,” but it seems reasonable that in some people, it can go beyond that and lead to illness that causes clinically significant distress and impairment in social/occupational functioning. Given that health care systems are often set up such that you need to have a diagnosis to get access to or coverage for services, having a diagnosis might make it possible for some people to access help that would be more difficult to access if they didn’t have a diagnosis.
Neither prolonged grief disorder nor the axing of the bereavement exclusion mean that anyone and their pet cat who’s grieving should be slapped with a diagnosis. Is there the possibility of overdiagnosis? Sure. But should a diagnosis simply not exist because some clinicians suck? I don’t think so. I think the NYT headline is irresponsible, because it suggests anyone who’s been grieving longer than a year will automatically be diagnosed, which is absurd and not at all what the DSM-5-TR suggests. The committee that came up with the diagnostic criteria had been considering using a 6-month timeframe, but they stretched it to a year to reduce the risk of overdiagnosis. Misdiagnosis and overdiagnosis are serious issues that definitely require some sort of mechanism to address, but I think that needs to be dealt with at the level of the professionals making the diagnoses rather than at the level of the DSM.
Resurrected diagnosis: Unspecified mood disorder
The DSM-IV-TR had a diagnosis of mood disorder NOS. The DSM-5 did away with this, and then it was brought back in the DSM-5-TR but renamed unspecified mood disorder. It’s basically a placeholder diagnosis for when it’s not initially clear what the true diagnosis is. So if someone shows up in ER and it’s unclear whether they’ve got unipolar or bipolar depression, they might be admitted with a diagnosis of unspecified mood disorder, and then the diagnosis would be clarified once there’d been the opportunity for further assessment. To me, this makes more sense than having to pick unipolar or bipolar based on a single assessment in ER without much collateral or background information.
Autism Spectrum Disorder criteria clarification
The DSM-5 criteria for autism spectrum disorder included “persistent deficits in social communication and social interaction across multiple contexts, as manifested by the following:” and then listed deficits in social-emotional reciprocity, nonverbal communicative behaviours, and developing/understanding relationships.
The DSM-5-TR adds “all of,” so it’s now “as manifested by all of the following.” That was the intended meaning in the DSM-5 (after all, the word and means and, not or), so this addition clarifies rather than changes the criteria.
Reactions to this change
A post in the aspergirls subreddit expresses hope that some additional changes in the DSM-5-TR chapter on autism will actually make it easier to get diagnosed. I’m not going to include what she quoted because I can’t verify that it’s accurate (you can click on the link if you want to read it), but the poster did say that she actually viewed the DSM-5-TR itself. The quoted material notes that clinicians should recognize that some people on the spectrum develop compensatory strategies that make their autism less noticeable, but the effort this requires takes a toll on them and they struggle in novel situations.
There’s a petition on Change.org organized by the Center for Neurodivergence (a self-advocacy group) challenging what it sees as more restrictive diagnostic criteria in the DSM-5-TR that will make it more difficult for people to get diagnosed. The petition mentions a podcast with Michael B. First, the editor and co-chair of the DSM-5-TR, in which he was talking about autism getting overdiagnosed.
The podcast was The Modern Therapist’s Survival Guide, and a transcript is published on their website. I can see how the Center for Neurodivergence got that impression, but I don’t think that’s what Dr. First was actually trying to say. My impression is that he was trying to say that some clinicians had been interpreting [a, b, and c] as [a, b, or c], and this was leading to overdiagnosis. To address the issue, the APA was just making it clear that and did, in fact, mean and. I have no idea if diagnosis-happy pediatric psychiatrists have been blissfully overdiagnosing for the last few years, but given that adult diagnosis seems to be off of almost everyone’s radar, I doubt that population crossed Dr. First’s mind at all.
Diagnostic name-tweaking
The DSM-IV diagnosis of dysthymic disorder was changed to persistent depressive disorder (dysthymia) in the DSM-5. The DSM-5-TR got rid of the dysthymia bit altogether. There were a number of diagnostic specifiers for PDD in the DSM-5, but the DSM-5-TR got rid of most of them except with anxious distress and with atypical features. I don’t think that’s going to change anything in anyone’s life.
Similarly, the DSM-5 diagnosis of social anxiety disorder (social phobia) was updated to simply social anxiety disorder.
Codes for suicidal behaviour and nonsuicidal self-injury
The DSM-5-TR has adopted codes that are already in use in the World Health Organization’s International Classification of Diseases (ICD-10-CM) to indicate suicidal behaviour or self-harm without suicidal intent (nonsuicidal self-injury). These aren’t stand-alone disorder diagnoses, but rather a way of making note of behaviours.
Language around gender
In the chapter on gender dysphoria, there have been some updates in the terminology used to better reflect modern language:
- “desired gender” has been changed to “experienced gender”
- “cross-sex medical procedure” has been changed to “gender-affirming medical procedure,”
- “natal male”/”natal female” has been changed to “individual assigned male/female at birth”
“Post-transition” has also been added as a diagnostic specifier.
Other changes and thoughts on the DSM-5-TR
There have been some changes related to race. The term Caucasian has been axed, Latino/Latina has been changed to Latinx, and “race/racial” has been changed to “racialized.”
There have been a variety of other tweaks, including some wording changes in the criteria for bipolar I and II, but these are more about clarity than actually changing anything. In a number of cases, it looks like the APA decided that language changes they made with the DSM-5 actually made things murkier rather than clearer, so some of the DSM-5-TR language moves closer to what was in the DSM-IV-TR.
Aside from the new prolonged grief disorder, I don’t think the DSM-5-TR is likely to change much of anything for anyone. They’ve tidied a few things up, and now they’ll make some money off of it.
Now it’s over to you. Any thoughts on these changes?
Making Sense of Psychiatric Diagnosis aims to cut through the misunderstanding and stigma, drawing on the DSM-5 diagnostic criteria and guest narratives to present mental illness as it really is.
It’s available on Amazon and Google Play.
Thank you for this, I’m really glad to stay in the know!
The gender terminolgy updates seem good. I’m still not sold on NSSI. And you proved, once again, that clickbait headlines are a scourge of our time. Thanks for the update – I definitely wouldn’t have pursued this on my own.
Damn clickbait.
Yeah, the NSSI thing is a bit weird.
It makes people very uncomfortable. Sometimes, I enjoy that.
Gotta take little bits of enjoyment where you can. Lol
I was most interested in the language around gender dysphoria. I like the changes and hope the professionals who make up the DSM, stay progressive for the duration.
Also, my hope is that they remain respectful in the gender dysphoria area.
Me too.
Yes, that was definitely a positive change to see.
I think most of these are very appropriate changes, particularly the gender-related language and the autism clarification.
I agree.
Despite being a former nurse, you continue to share your knowledge and expertise with us on nursing subjects. Thank you! Your information is best practice and up to date. I’m not a psych nurse so I’m not the most knowledgeable about mental health, but I’m always learning.
P.S. I’m a geriatric nurse who deals with acute patients and lots of patients over the age of 90! There’s a lot of behaviors and dementia patients too, which can be challenging at times… esp. the dementia.
I bet.
Good information to have! Thanks for sharing it, because the average person never sees the DSM-5-TR or if they do, they can’t easily understand the terminology. For myself alone, my opinion about the politically correct changes? Aw. I don’t mind what someone is called, what racial ‘name’ they think is respectful and so forth. It’s none of my business. I’m not going to fall in line though, disrespectful or not. I have a good acquaintance who has recently begun a transformation from male to female, and that person has the best grasp of what they want to be called going. “GENDER NON-SPECIFIC”, but they don’t insist on those (IMO remember) idiotic gender pandering labels such as they, them, or it or whatever. The whole terminology around that gender issue kinda gets on my nerves. If you don’t know what a person IS as to male or female, isn’t it more polite and less confusing to say nothing about gender until they offer an option to you? I have no side in the transgender issue at all. If someone doesn’t want a gender label at all (GENDER NON-SPECIFIC) again, that’s fine too. So is (for me) Mrs. Miss, M’am, Madam, She, and Her. I have been called Mr., Sir, and dude in my time, and I didn’t punch the mistaken fool in their pie hole. I just think it’s gone too far now. My opinion only.
I think in this case since it is psychiatrists making gender dysphoria diagnoses, it makes sense that they would change their wording for the diagnostic criteria for that to better fit with the language the language that’s most commonly accepted among the people they’re treating.
I don’t think the terminology is difficult. I mean my teenage daughter loves reading my DSM. She almost seems to know more then I do. haha!
Good for her!
You do have a good point. I understand though, that it’s a minefield relatively. Because the subjects don’t all agree with what the nomenclature should be in the first place. My friend says “No pronouns necessary”. And since he’s in the early stages, you can plainly see he’s a man. I wonder if it’s coming down to a point where gender will be discarded as an archaic way of identifying people. Maybe we’ll just be ‘people” with no labels necessary. That’d be nice.
It would.
Does prolonged grief disorder can apply in cases where a person is separated from someone but not because of death? Eg divorce and so on.
I like the gender terminology changes; clarity is everyone’s friend.
*ignore “can”, was editing and left it in!
Prolonged grief disorder is death-specific, but a diagnosis of adjustment disorder could be made if someone wasn’t coping with a transition like divorce.
You are a gift, Ashley and we don’t deserve your excellence. Well done with this post! I’m a whole therapist and didn’t even know there was a new edition lol. I’m gonna order a copy and share this post with my therapist friends.
Thanks!
I think the grief addiction is spot on after working in the field I have several clients who have lost a love one and are just stuck in fear of moving on so wanting what they had but not seeing the potential of what a love one would want them to have. It’s a hard one to help and I hope this opens up avenues where they can get the additional help they need
I hope so too.
I don’t understand the race terminology changes because I’m an Asian in Aaia and we use the DSM too…so my people have always called white people Caucasian. Do we know say “white”…?
And we’re a multi-ethnic society where everyone’s racialised to different degrees but so are white people (tho for them it’s in positive ways) because they’re numerically a minority.
From what I read, the point that they were trying to make is that the notion of race is socially constructed.
Wow, I’ll have to read more about race being a social construct then! 😊😊😊😊😊
I’ve been puzzled by it despite learning about the history of race categories recently, because I thought it does apply to physical healthcare.
I think it’s probably that certain gene pools are more likely to contain certain genetic variants that affect risk for certain health conditions, but the idea of races being fundamentally distinct based on appearance characteristics like skin colour and hair colour is what’s socially constucted.
I like the gender changes. Ideally people would just let folks like me be people, but alas, far too many people in my life and my society just really get all kinds of angry and seek to ensure I don’t get human rights. So the some of the different words – in particular “desired gender” being changed – are some consolation lol. Wonder when doctors would update “SH identifies as X…” (because it’s subtle but matters a lot to many trans folks i know) to “SH is X”.
I hope that change will happen soon.
💞
Has everyone lost their mind? Do you really think a severely autistic person who is still in diapers, has epilepsy, engages in severe face and head punching is the same as aspergers? No. They are totally different and the only reason someone would want to lump all of this together is because dealing with severe autism is much more time and money consuming than having to do assessments or billing codes for someone who is biting pieces of skin off their body, punching themselves or requires 2:1 or 3:1 assist. GTfoutta here already with this scam. We see what you are doing. This is a slap in the face to people with actual autism before it was hijacked by researchers and others who want to downplay and minimize people on the spectrum who require real supports and services. It’s taking away from the most vulnerable people those who require intensive services, but yeah let’s pretend we can lump everyone in a one size fits all so you can keep billing for services and ignore those with autism who actually need real services. Disgraceful. Ignorant. A systemic failure on all levels. Evil.