Special Report on DSM-5-TR—What Social Workers Need to Know

BY JONATHAN SINGER

DSM-5-TR

On Friday, March 18, 2022, almost nine years after the publication of the DSM-5 (APA, 2013), the
American Psychiatric Association (APA) published the text revision of DSM-5, known as DSM-5-TR.
The purpose of this article is to highlight some of the changes in DSM-5-TR that social workers need
to know.

The text revisions include:

 Updated descriptions of the prevalence, risk, and prognostic factors for each disorder based
on new findings from research.
 One new disorder in the chapter Trauma and Related Stressors called prolonged grief
disorder (F43.8). This is the only disorder that should be referred to as a DSM-5-TR disorder,
because it is new to the text revision. All other disorders should be referred to as DSM-
5 disorders.
 A change in terminology from intellectual disability (previously mental retardation)
to intellectual developmental disorder [(F70) mild; (F71) moderate; (F72) severe; (F73)
profound].
 a new category for Other Conditions That May Be a Focus of Clinical Attention - Suicidal
behavior and nonsuicidal self-injury (NSSI).
 Codes for the initial encounter of someone with suicidal ideation or attempt (T14.91A),
subsequent encounters (T14.91D), and a history (but not current) suicidal behavior (Z91.51).
 Codes for current NSSI (R45.88) and a history (not current) of NSSI (Z91.52).

Interestingly, even though the DSM-5-TR includes codes for suicidal behavior and NSSI, they kept
Suicidal Behavior Disorder and NSSI Disorder in the section Conditions for Further Study.

As one would expect in a book called “text revision,” there are several notable updates to the
language that is used in the DSM-5-TR.

 The Gender Dysphoria chapter updates problematic terminology to preferred terminology,

e.g. “natal sex” to “birth-assigned gender,” “natal male/natal female” to “individual assigned
male/female at birth,” “gender reassignment treatments” to “gender affirming treatments,”
and “desired gender” to “experienced gender.” The term cisgender wasn’t in DSM-5. In
contrast, DSM-5-TR not only includes a definition of cisgender, but also suggests the word
“nontransgender” as a way of centering transgender people. DSM-5-TR added a post-
transition specifier for Gender Dysphoria.
 DSM-5-TR continues to acknowledge that race is a social construct. While this might seem
obvious to social workers, the DSM-5 was written by medical doctors who are taught to
consider people as biological beings first and foremost. “Also, for the first time ever, the
 entire DSM text has been reviewed and revised by a Work Group on Ethnoracial Equity and
Inclusion to ensure appropriate attention to risk factors such as the experience of
racism and discrimination, as well as to the use of non-stigmatizing language.”
Examples of the influence of the committee include the use of the term Latinx, and the
term racialized instead of racial to highlight the socially constructed nature of race. The DSM-
5-TR decenters whiteness by avoiding the use of “minority” and “non-White.”

Prolonged Grief Disorder

The historical context of prolonged grief disorder (F43.8) is relevant. The DSM has been moving
toward pathologizing grief reactions since the publication of DSM-5, when they removed the
bereavement exclusion from the chapter on depressive disorders. Prior to 2013, if someone had
depressive symptoms that met criteria for major depressive disorder but was grieving the death of
a loved one, they would not meet criteria for the disorder. That exclusion was removed in DSM-5.
Fast forward nine years to a global pandemic in which a million Americans have died (and 5 million
outside of the U.S.), and the DSM Task Force approves the first disorder that centers on the death
of a loved one.

To meet criteria for prolonged grief disorder in adults, the death must have been at least 12
months ago, or for children and adolescents at least 6 months ago. There has to be clinically
significant yearning/longing for and preoccupation with thoughts or memories of the deceased
person. The bereaved person has to have experienced three of eight symptoms daily in the past 30
days related to the death, including feeling as if part of you has died, disbelief, avoidance of
reminders, intense emotional pain, interpersonal difficulties, emotional numbness, feelings of life
being meaningless, and/or intense loneliness.

Prolonged Grief Disorder

 It occurs in individuals, who have experienced a death of a person close to them over a 12-month period
for adults and 6 months for children and adolescents.
 The grief response persists following the death and is characterized by intense yearning/longing for the
deceased or preoccupation with thoughts of the deceased.
 Children and adolescents, however, may be preoccupied by the circumstances surrounding death.
 Severity and duration of the grief response exceeds cultural, social, and religious norms.
 Presentation of symptoms are not attributed to another mental disorder and result in significant distress
or impairment in daily functioning.
 It must also exhibit three or more of the following symptoms that are clinically significant most days.
Symptoms must be present almost every day for at least 30 days:
 Intense emotional pain related to the death.
 Avoidance of reminders that the person is dead (in children and adolescents, may be characterized
by efforts to avoid reminders).
  Marked sense of disbelief about the death.
 Difficulty reintegrating into one’s relationships and activities after the death.
 Identity disruption since the death.
 Intense loneliness as a result of the death.
 Emotional numbness (absence or marked reduction of emotional experience) as a result of the death.
 Feeling that life is meaningless as a result of the death.

Symptomatic Codes for Suicidal and Non-Suicidal Self-Injurious

Behavior
New symptomatic codes identify the presence or history of suicidal and non-suicidal self-injurious behaviors.
Researchers will now have a systematic way to track prevalence of these behaviors and other correlating factors
that need ongoing attention.

Diagnostic Criteria
The new manual provides updates and modifications to the set of criteria for over 70 disorders with revised
descriptive text for a number of disorders. It also contains an analysis of the effects racism and discrimination on
the manifestation and diagnosis of mental disorders.

Diagnostic criteria for several disorders were clarified, to include the following diagnoses:
 Major depressive disorder
 Cyclothymic disorder
 Autism spectrum disorder
 Avoidant-restrictive food intake disorder
 Bipolar I and bipolar II disorder
 Manic episode
 Persistent depressive disorder
 Post-Traumatic Stress Disorder in children
 Attenuated psychosis syndrome (in the chapter “Conditions for Further Study”)
 Substance/medication-induced mental disorders
 Delirium
 Attenuated psychosis syndrome: In DSM-5, this diagnosis included the phrase “with
relatively intact reality testing.” Not surprisingly, this was the source of much
confusion for a diagnosis that has at its core, psychotic processes.
 Autism spectrum disorder: In DSM-5, Criterion A included the phrase “as manifested by
the following” and then included three deficits in social communication and social
interaction. Apparently, some people thought that meant you could pick one of the
three. DSM-5-TR clarifies that all three deficits need to be present to meet Criterion A.
 Bipolar I and Bipolar II: Language was changed to make it easier to distinguish the
presence of psychotic features and mood changes in bipolar disorder compared to
the psychotic disorders, e.g. schizoaffective disorder.
 Persistent depressive disorder: They removed “dysthymia” as a parenthetical
comment associated with any DSM-5 diagnosis. This term was a hold-over from DSM-
 IV’s dysthymic disorder. They eliminated all but two specifiers: “anxious distress” and
“atypical.”
 Social anxiety disorder: They removed “social phobia” as a parenthetical comment
because the term no longer has clinical utility as the field has completely adopted the
term social anxiety disorder.

Additionally, changes to criteria were amended to include:

 The return of “Unspecified Mood Disorder” for mixed-mood presentations that do not fit the criteria for
bipolar or depressive disorders.
 Coding updates for substance use and neurocognitive disorders.
 The inclusion of symptom codes that specify the presence or history of non-suicidal self-injury and
suicidal behavior.

Specifier Definitions
Changes to specifier definitions were also identified and are as follows:
 The post-transition specifier for Gender Dysphoria
 The acute/persistent specifier for Adjustment Disorder
 Narcolepsy specifiers
 The mood congruent/mood incongruent specifier for Bipolar Disorder
 The mixed features specifier for Major Depressive Disorder and Manic Episode

Other Changes
 The term “neuroleptic,” which refers to a class of medication, will only be used when referring to
“neuroleptic malignant syndrome” and will now be replaced with “antipsychotic medication” or other
terms depending on the context.
 “Desired gender” will be referred to as “experienced gender.”
 “Cross-sex medical procedure” will now be regarded as “gender-affirming medical procedure,”
 “Natal male”/ “natal female” will be called “individual assigned male/female at birth.”
 Conversion disorder is now functional neurological symptom disorder.
 Intellectual disability is now intellectual developmental disorder.