Part I

Welcome to Part I of our two-part blog series regarding DSM-5-TR updates. Earlier this year, the American Psychiatric Association (APA) released the DSM-5-TR, which includes updates to the DSM 5. Before you panic, let me reassure you that most of the changes are minor. The primary purpose of the updates is to clarify the descriptive text of certain DSM disorders. Most of the changes include minor phrasing updates and grammatical changes. The criteria sets remain essentially unchanged.

The significant change in the DSM-5-TR is the addition of some new diagnoses, which we review here. Let’s dive in.

Prolonged Grief Disorder.

Unfortunately, this newly added diagnosis is rather relevant at this moment in history as we are coming out of the global pandemic. This disorder describes a maladaptive grief reaction that causes clinically significant distress or impairment in social, occupational, or other areas of functioning. For adults, it can only be diagnosed 12 months after someone close to the client has passed; for children and adolescents it is 6 months after death.

Here are excerpts from the DSM-5-TR:

1. Since death, one or both of the following most days to a clinically significant degree AND symptom occurred nearly every day for at least the last month.
2. Intense yearning/longing for the deceased person
3. Preoccupation with thoughts or memories of deceased (for youth, focus may be circumstances of death)
4. Since death, at least 3 of the following:
5. Identity disruption (e.g., feeling as though part of oneself has died) since the death.
6. Marked sense of disbelief about the death.
7. Avoidance of reminders that the person is dead (in children and adolescents, may be characterized by efforts to avoid reminders).
8. Intense emotional pain (e.g., anger, bitterness, sorrow) related to the death.
9. Difficulty reintegrating into one’s relationships and activities after the death (e.g., problems engaging with friends, pursuing interests, or planning for the future).
10. Emotional numbness (absence or marked reduction of emotional experience) as a result of the death.
11. Feeling that life is meaningless as a result of the death.
12. Intense loneliness as a result of the death.

The APA added this diagnosis so people experiencing prolonged grief are not wrongly diagnosed with major depressive disorder and consequently receive appropriate help and support. This diagnosis is also different from normal grief. To receive this diagnosis, the duration and severity of grief really needs to exceed social, cultural and religious norms for the individual. That being said, the Z Code for uncomplicated bereavement is still in the DSM-5-TR  and most appropriate when a normal grief reaction is the focus of clinical treatment.

Suicidal behavior and non-suicidal injury.

Also new to the DSM-5-TR are T and Z codes for suicidal behavior, and a Z code for non-suicidal self-injury. These are not diagnoses; instead they have been added to the section that describes other conditions that may be a focus of clinical attention. 

You will not be tested on the different numbers of the T and Z codes. All you will need to know is that if you learn that the client has suicidal behavior during your first encounter with them, they should be assigned a T code. If you have been working with the client and subsequently learn about their suicidal behavior, they get a different T code. If your client has any history of suicidal behavior, a specific Z code is necessary. There are also two Z codes for non-suicidal self-injury--one is for the current presentation and the other is for a history of it in the client’s lifetime. Since, tragically, suicide is on the rise, all these codes were added to help keep people safe, communicate amongst professionals, and properly classify clients’ behaviors related to suicide and non-suicidal self-injuries.

Stimulant-Induced Mild Neurocognitive Disorder

Neurocognitive symptoms, such as difficulties with learning, memory and executive function, can be associated with prolonged cocaine or methamphetamine use. Therefore the DSM-5-TR added this disorder to capture this phenomenon and included it in the existing list of substance-induced mild neurocognitive disorders.

Unspecified mood disorder

The final major change I want to discuss here is the return of Unspecified Mood disorder. It was featured in the DSM-IV-TR but fell by the wayside when the DSM 5 reclassified various mood disorders. According to the DSM-5-TR, 

“This category applies to presentations in which symptoms are characteristic of a mood disorder that causes clinically significant distress or impairment in social, occupational, or other important areas of functioning predominate but do not at the time of the evaluation meet the full criteria for any of the disorders in either the bipolar or the depressive disorders diagnostic classes in which it is difficult to choose between unspecified bipolar and related disorder and unspecified depressive disorder (e.g., acute agitation).” (DSM-5-TR, p. 169, 210)

Practical implications

Described above are the most important changes made to the DSM. Out of all the new diagnoses, learning the ins and outs of prolonged grief disorder is going to be the most impactful update. As you can see, there isn’t reason to worry. The DSM section in your current test prep will certainly prepare you for the exam, whether you are taking the Ca Clinical, National MFT or the ASWB Clinical or Master level exams.