What is the DSM-V-TR and Why is it Important?

Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision
The DSM–5 is the standard classification of mental disorders used by mental health professionals in the United States. It is being updated in March of 2022 to include many changes to diagnostic criteria.



History

The ​American Psychiatric Association (APA} published the Diagnostic and Statistical Manual of Mental Disorders in 1952; it was based on the ICD-6 and the military system. It has morphed and been updated many times over the last 30 years based on focus, acceptance, peer studies, environmental factors, mental health stigmas, research, international involvement, socioeconomic, racial and cultural differences and focus. The years include: 1952, 1974, 1980, 1987, 1994, 2000, 2013 and 2022.


The update in March of 2022 will be the eighth time.


"Cultural Concepts" were added to the DSM-5 in 2013 to help clinicians to assess cultural factors influencing patients’ perspectives of their symptoms and treatment options. It includes questions about patients’ background in terms of their culture, race, ethnicity, religion or geographical origin. The interview provides an opportunity for individuals to define their distress in their own words and then relate this to how others, who may not share their culture, see their problems. This gives the clinician a more comprehensive foundation on which to base both diagnosis and care. (2013 American Psychiatric Association).


Michael B. First, M.D., co-chair of the Revision Subcommittee and DSM-5-TR editor, said the revised manual includes updates that are vital to clinicians and researchers. These include clarifying modifications to the criteria sets for more than 70 disorders, updates to descriptive text for the majority of disorders based on literature reviews, and a comprehensive review of the impact of racism and discrimination on the diagnosis and manifestations of mental disorders.


The link below from the American Psychiatric Association describing the update is below.

https://psychnews.psychiatryonline.org/doi/10.1176/appi.pn.2022.1.20



Nine years have elapsed since publication of DSM-5 in 2013, longer than historical revisions to DSM after five to seven years.


While many Americans are mourning, some may experience prolonged grief disorder, which is characterized by incapacitating feelings of grief. A new diagnosis of prolonged grief disorder has been added. "First said the addition is the result of years of research and clinical experience indicating that some people experience a pervasive inability to move past grief over the loss of a loved one and that these symptoms are severe enough to affect day-to-day functioning. It is estimated that following the nonviolent loss of a loved one, 1 in 10 bereaved adults is at risk for developing prolonged grief disorder."


It can happen when someone close to the bereaved person has died within at least 6 months for children and adolescents, or within at least 12 months for adults. In prolonged grief disorder, the bereaved individual may experience intense longings for the deceased or preoccupation with thoughts of the deceased, or in children and adolescents, with the circumstances around the death. These grief reactions occur most of the day, nearly every day for at least a month, the individual experiences clinically significant distress or impairment in social, occupational, or other important areas of functioning.


Some of the symptoms of prolonged grief disorder are:

  • Identity disruption (e.g., feeling as though part of oneself has died).

  • Marked sense of disbelief about the death.

  • Avoidance of reminders that the person is dead.

  • Intense emotional pain (e.g., anger, bitterness, sorrow) related to the death.

  • Difficulty with reintegration (e.g., problems engaging with friends, pursuing interests, planning for the future).

  • Emotional numbness.

  • Feeling that life is meaningless.

  • Intense loneliness (i.e., feeling alone or detached from others).


If this diagnosis was in the DSM-IV when my Mom passed I would have definitely have fit the diagnosis criteria, and that is ok.

If I'm honest with myself I had years of some of these symptoms (avoidance, anger, bitterness, difficulty with reintegration, detachment, disbelief and identity disruption). I also had PTSD symptoms for years. I saw images of my mom passing on the couch in my parents living room over and over at all hours of the day and anytime I was not otherwise distracted. It didn't matter if I was at work, driving or home with my family the images and memories were intrusive and stole a lot of my time, sleep and everyday functioning.


The five stages of grief according to Elisabeth Kübler-Ross are, denial, anger, bargaining, depression and acceptance. They are a part of the framework that makes up our learning to live with the one we lost. They are tools to help us frame and identify what we may be feeling. But they are not stops on some linear timeline in grief.


Not everyone goes through all of them or in a prescribed order. Our hope is that with these stages comes the knowledge of grief ‘s terrain, making us better equipped to cope with life and loss. At times, people in grief will often report more stages. Just remember your grief is an unique as you are. As with everything mental health we are always learning and trying to sharpen our tools to help others navigate through it. In 2020, David Kessler—an expert on grief and the coauthor with Elisabeth Kübler-Ross a sixth stage: meaning.



"In this book, Kessler gives readers a roadmap to remembering those who have died with more love than pain; he shows us how to move forward in a way that honors our loved ones. Kessler’s insight is both professional and intensely personal. His journey with grief began when, as a child, he witnessed a mass shooting at the same time his mother was dying. For most of his life, Kessler taught physicians, nurses, counselors, police, and first responders about end of life, trauma, and grief, as well as leading talks and retreats for those experiencing grief. Despite his knowledge, his life was upended by the sudden death of his twenty-one-year-old son."


I think that this is an important step and could be great guide for people to find the ability to move on. Below is the link to "Finding Meaning."


Book link: https://grief.com/sixth-stage-of-grief/


 

Americans are currently facing several ongoing disasters that have caused death and suffering, such as COVID-19, the withdrawal in Afghanistan, floods, fires, hurricanes, gun violence and the negative effects of Covid-19 lockdowns, reduced social interaction and the uptick in mental health issues and suicide.


In addition to the updates above and in the link; additionally, DSM-5-TR update includes new symptom codes that allow clinicians to indicate the presence or history of suicidal behavior and nonsuicidal self-injury.


Although the suicide rate dropped overall in 2020, there were increases among young adults, as well as American Indians, Alaska Natives, Black Americans, and Hispanic Americans, the National Center for Health Statistics reported. “I think it’s pretty much general knowledge now that COVID affected different demographic groups differently, and some were hit harder than others,” Sally Curtin, lead author of the report and a member of the center’s Division of Vital Statistics, told CNN. See link for data updated November, 2021 https://www.webmd.com/mental-health/news/20211103/suicide-rates-2020-cdc


In addition, the suicide rate for active-duty troops rose to 28.7 per 100,000 in 2020, up from 26.3 the previous year, according to the latest edition of an annual Defense Department report. This is the highest rate since the Pentagon began keeping detailed records in 2008.


https://www.defenseone.com/threats/2021/10/active-duty-suicide-rate-hits-record-high/185882/


This is a very disturbing and scary trend that needs immediate attention and an all hands on deck approach. The new codes are:


  • The suicidal behavior symptom code can be used for individuals who have engaged in potentially self-injurious behavior with at least some intent to die as a result of the act.


Evidence of intent to end their life can be explicit or inferred from the behavior or circumstances. A suicide attempt may or may not result in actual self-injury.


  • The nonsuicidal self-injury symptom code can be used for individuals who have engaged in intentional self-inflicted damage to their body that is likely to induce bleeding, bruising, or pain (for instance, by cutting, burning, stabbing, hitting, or excessive rubbing) in the absence of suicidal intent.

Keep in mind the DSM-5 - TR updates are only additional tools that clinicians have help diagnose patients. It is not a treatment guide. Through clinician experience, education, research and tools like the DSM-5 providers can try and diagnose mental illness by using the same resources. This is important because it is common especially today for providers to change, be unavailable, or no longer be covered by your insurance so the patient has to move on and the need for providers using the same guidance to reach a diagnosis is critical.


In a Covid-19 world, many patients are not getting mental health services in person. Many have changed to "e" visits or some have gotten lost in the fog of Covid-19 healthcare availability and priorities. It is critical that we treat mental illness just as we do any physical disease and acute illness. If you or your loved one needs help please get it.
National Suicide Hotline 800-273-8255

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