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.
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?