As the stigma around mental health continues to fade, the field itself is changing — some might say for the better.
In March 2022, American Psychiatric Association (APA) Publishing released a Text Revision (TR) to the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5) to add clarity around certain mental health conditions and diagnostic criteria and codes.
Highlights in the newly updated DSM-5-TR include the addition of prolonged grief disorder as a condition, as well as symptom codes for suicidal behavior and nonsuicidal self-injury.
The APA also consulted culture and equity professionals to acknowledge the historical role of racial discrimination in clinical diagnoses. Language throughout the DSM-5-TR was updated to promote inclusivity for People of Color and marginalized groups.
The DSM-5-TR has refined some of its diagnostic criteria and codes, which may better inform how mental health professionals work with their clients and how they file claims with insurance companies.
Although the DSM-5-TR cannot fully address the unique experiences and situations of every individual, improved diagnostic criteria may help clinicians identify their clients’ disorders or conditions with more accuracy.
“For the [clients] whose symptoms are not fully represented in the present DSM-5, this is a start to treatment planning and more thoughtfully diagnosing,” said Kendra Kubala, PsyD, a trauma psychologist in Pennsylvania and New York and Psych Central Advisory Board member, in an email.
The DSM-5-TR added symptoms associated with prolonged grief disorder to its list of diagnostic criteria. Now, clinicians can make a formal diagnosis for those who have faced difficulty coping with loss for an extended period of time.
Still, everyone’s grieving process is different, and there’s some controversy among clinicians when it comes to linking a person’s experiences of loss to a mental health disorder.
“I think these [clients] would generally get lumped into adjustment disorders or depression diagnoses,” said Karin Gepp, PsyD, a clinical psychologist in New York and Psych Central Advisory Board member, said in an email.
“But studies have shown that 1 in 10 adults may experience prolonged grief — especially now, with this pandemic having killed so many people suddenly, this is a really important addition,” she said.
According to the DSM-5-TR, the diagnostic criteria for prolonged grief includes:
The DSM-5 removed “unspecified mood disorder” as a diagnosis in its 2013 update, which meant that clinicians had to diagnose their clients with a specific mood disorder instead.
The DSM-5-TR has reverted to the “unspecified” diagnosis to include a range of possible mood disorders, which may help clinicians avoid potential misdiagnoses.
“Unspecified mood disorder has been reinstated to provide diagnosis to someone whose presenting symptoms do not fit neatly under bipolar or depressive disorders,” Kubala said.
According to Gepp, distinguishing between bipolar disorder and depressive disorders takes time. Often, symptoms concurrent with bipolar disorder are not always noticeable at the onset.
“When a patient is misdiagnosed with depression and prescribed an SSRI, this could push that person into a manic episode,” Gepp explained.
According to Gepp, the DSM-5-TR reinstating unspecified mood disorder allows practitioners more time to observe a client’s symptoms to provide a more accurate diagnosis and subsequent prescription.
The DSM-5-TR has added self-harm without the presence of suicidality to its list of diagnoses.
Because not everyone who has engaged in self-harm may do so with the intent of ending their life, lumping it into suicidality could blur assessments made by clinicians.
“It’s good to differentiate those, as there [are] many people who self-harm without an intention of suicide,” Gepp said. “The intent of the injury is the focus, which makes it easier to track the behaviors for us and assess risk.”
In addition, diagnostic codes for suicidal behavior without the presence of other mental health disorders have been included in the new updates.
The DSM-5-TR includes changes to its language around gender and gender identity to help reduce stigma by clarifying that these aspects of a person are not selected by choice.
This includes the more accurate and inclusive changes of:
Roberto Lewis-Fernandez, MD, a professor of clinical psychiatry at Columbia University and chair of the DSM-5-TR Cross-Cutting Culture Review Group, told Psych Central that reviewing the DSM through a lens of equity and inclusion and making appropriate changes were high on the committees’ priority list.
Debra Rose Wilson, PhD, MSN, RN, a professor, holistic healthcare practitioner, and Psych Central Advisory Board member, said the addition of racial and cultural perspectives in the DSM-5-TR is beneficial.
“If we’re going to be talking about this, then we should talk about social norms and cultural norms and how they’re going to be different depending on race and where you live, and I think that’s worth identifying,” Wilson said by phone.
According to Lewis-Fernandez, future iterations of the DSM-5 will likely incorporate further changes, specifically around how social, sociocultural, and genetic disorder causations intersect, all with the goal of enabling clients to be seen within a more holistic framing.
“The role of social determinants of mental health has been increasingly recognized in recent years,” he said. “DSM-5-TR started to incorporate this information but there is still more that needs to be done in this area.”
The DSM-5-TR’s acknowledgment of how race and discrimination have historically impacted mental health care is a step forward in creating more safe and inclusive environments for People of Color and marginalized groups.
But barriers to quality mental health care still exist, such as cost factors, health insurance, and enough access to culturally competent counselors and therapists.
According to Kubala, the varied opinions and shifting cultural dynamics within the mental health field speak to the necessity of ongoing updates to the DSM. As research in the field continues to evolve, so will the manual.
“It’s always beneficial to have an open dialogue between [clients], providers, and the public regarding mental illness, and ways in which the field is continually evolving in an effort to provide the most comprehensive, sensitive, research-based, compassionate, appropriate treatment,” Kubala said.
Fact checked on March 17, 2022
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