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Recent advancements and emerging clinical data on practical psychopharmacology have transformed guidelines for care, specifically for the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). Originally published in 2013, the American Psychiatric Association recently published the DSM-5 Text Revision, and in a 2022 Psych Congress session titled, "DSM-5 Text Revision (DSM-5-TR): What’s New and What’s Different," Dr. Michael B. First, a Professor of Clinical Psychiatry at the Columbia University New York State Psychiatric Institute, will explore some of these updates.

Before the start of this year’s Psych Congress, let’s take a closer look at what mental health clinicians might learn in this session.

Diagnostic Entities Incorporated

Three disorders were included in the DSM-5-TR: prolonged grief disorder, unspecified mood disorder, and stimulant-induced mild neurocognitive disorder. Dr. First defines each disorder according to the updated guideline:

• Prolonged grief disorder: This disorder is characterized by an intense yearning for a deceased loved one for at least 12 months after their death that can lead to impaired functioning. This yearning could present as grief-related symptoms, such as emotional numbness, intense emotional pain, and avoidance of reminders associated with their deceased loved one.
• Unspecified mood disorder: This disorder serves as a broader category for mood symptoms that don’t meet the full criteria of any other disorder in either the bipolar or the depressive disorder diagnostic classes.
• Stimulant-induced neurocognitive disorder: The disorder was developed in recognition of the fact that neurocognitive symptoms can be correlated with stimulant use, such as alcohol, inhalants, sedatives, hypnotics, and anxiolytics. It’s been included in the existing types of substance-induced mild neurocognitive disorders.

Changes in Diagnostic Criteria & Specifier Definitions

These changes have been made for over 70 disorders, but only a few of these changes are significant. According to Dr. First, these changes could address diagnostic challenges and prevent misdiagnosis.

The major changes include new criteria sets and specifier definitions for a few disorders: criterion A for autism spectrum disorder, severity specifiers for manic episodes, course specifiers for adjustment disorder, and criterion A for delirium. These changes include:

• Autism spectrum disorder: Criterion A was originally defined as “any of the following” or “all of the following” types of social communication. But that phrasing has changed to “as manifested by all of the following.”
• Manic episodes: The “mild” severity specifier had previously been inconsistent with Criterion C, which required a patient’s mood disturbance to be severe enough to impair social or occupation functioning, require hospitalization, or include psychotic features. The DSM-5-TR now includes three specifiers: mild if minimum symptom criteria is met, moderate if there’s an increase in activity or impairment of judgement, and severe if patient supervision is needed.
• Adjustment disorder: Originally, the DSM-5 left out parameters indicating the duration of adjustment disorder symptoms. In the DSM-5-TR, “acute” symptoms are defined as persisting for less than six months, and “persistent” symptoms are defined as persisting for more than six months.
• Delirium: While attentional disturbance, which is one of the symptoms of delirium, is defined clearly as the reduced ability to direct, focus, sustain, and shift attention, a component of this disorder’s definition focused on “reduced orientation to the environment,” which researchers have found to be unclear. The new guidelines have been adjusted to avoid using the term “orientation,” so it’s now defined as a “disturbance in attention accompanied by reduced awareness of the environment.”

As data continues to emerge, the American Psychiatric Association along with clinicians such as Dr. First will continue to adapt the guidelines and develop new ones to provide the highest level of care for patients.

References:

First, M.B., Yousif, L.H., Clarke, D.E., Wang, P.S., Gogtay, N. and Appelbaum, P.S. (2022), DSM-5-TR: overview of what’s new and what’s changed. World Psychiatry, 21: 218-219. https://doi.org/10.1002/wps.20989