Hello and welcome to the course! I assume you have completed my first course, Using the DSM-5: Try It, You’ll Like It, and now you want more. If you have not read or completed my first course, I strongly recommend doing so before reading this second course on the DSM-5-TR (APA, 2022).

Why?

The first course on the DSM-5 (APA, 2013) is foundational. It outlines the conceptual and practical changes between the DSM-IV-TR (published in 2000) and the DSM-5 (published in 2013), emphasizing how to apply the DSM-5 in clinical practice to strengthen assessment, diagnosis, and treatment planning skills. The revisions from the DSM-IV-TR to the DSM-5 primarily addressed diagnostic criteria, specifiers (course, severity, and descriptive), classification titles and categories, and the sequencing of chapters. These updates included additions, removals, and clarifications. While much of the textual content in the DSM-5 – such as sections on diagnostic features, course and development, prevalence, differential diagnosis, and comorbidity – was revised, more than half of the material from the DSM-IV-TR remained unchanged. This content largely reflected research published in the 1980s and 1990s, with some studies dating back to the 1970s.

This second course on the DSM-5-TR (published in 2022) builds upon this foundational knowledge and expands it further. The DSM-5-TR serves as the authoritative source for the diagnostic language and framework used throughout this course.

This course summarizes the outdated research from the DSM-5 that has been removed and replaced with published studies primarily spanning the years 2000 to 2020. It also highlights new content that informs and enhances clinical practice – such as updated suicide risk factors for nearly every diagnosis, guidance on incorporating sex- and gender-related considerations, and discussions on how prejudicial attitudes and beliefs can contribute to diagnostic errors. Please refer to the Quick Reference Guide: Risk Factors for Suicide Ideation, Attempt, or Completion, below in this course. Importantly, the DSM-5-TR also eliminated all ICD-9-CM diagnostic and procedural codes that were previously included in the DSM-5.

Revisions to the DSM-5 Text

So, what is a text revision? It is a review of the text to identify and remove or replace out-of-date material and add content based on current research and cultural needs. As described by the APA (2022),

The DSM-5-TR development effort involved more than 200 experts (the majority of whom were involved in the development of DSM-5), who were given the task of conducting literature reviews covering the past 10 years and reviewing the text to identify out-of-date material.

Mirroring the structure of the DSM-5 process, experts were divided into 20 disorder review groups, each headed by a section editor. Four cross-cutting review groups (Culture, Sex and Gender, Suicide, and Forensic) reviewed all the chapters, focusing on material involving their specific expertise. The text was also reviewed by a work group on Ethnoracial Equity and Inclusion to ensure appropriate attention to risk factors such as racism and discrimination, and the use of nonstigmatizing language. (pp. 10-11)

In 2022, the American Psychiatric Association (APA) published the Text Revision (TR) to its DSM-5, which was published in 2013. The table below summarizes the topical areas in each chapter that were revised:

Key Features	Associated Features	Culture-Related Diagnostic Issues
Recording Procedures	Prevalence	Diagnostic Markers
Specifiers	Development and Course	Suicide Risk
Diagnostic Features	Risk and Prognostic Factors	Functional Consequences
Differential Diagnosis	Comorbidity

The DSM-5-TR contains one new diagnosis: Prolonged Grief Disorder (located in Trauma- and Stressor-Related Disorders). This was added in recognition of the fact that, although grief, despair, and general dysphoria are normal components of the bereavement process following the death of a loved one, these emotions can, in some cases, become abnormally prolonged or intense.

The DSM-5-TR’s text provides contextual information to aid in your diagnostic decision-making. The revised text is more TRAUMA-INFORMED. It addresses the risk of suicide, being bullied, domestic violence, sexual abuse, and neglect. For example,

Individuals with anxiety may be more likely to have suicidal thoughts, attempt suicide, and die by suicide than those without anxiety. Panic disorder, generalized anxiety disorder, and specific phobia have been identified as the anxiety disorders most strongly associated with a transition from suicidal thoughts to suicide attempt. (p. 216)

This new content that distinguishes between suicidal thoughts and suicidal behavior, and the associated transition from one to the other, is very clinically helpful. This information guides intake assessment procedures, case management services, treatment plan development, and termination and referral practices.

Now, let us dial down within the anxiety disorders and consider the following DSM-5-TR description for panic disorders:

Approximately 25% of primary care patients with panic disorder report suicidal thoughts. Panic disorder may increase the risk for future suicidal behaviors, but not deaths.

Epidemiological survey data of panic attack symptoms show that the cognitive symptoms of panic (e.g., derealization) may be associated with suicidal thoughts, whereas physical symptoms (e.g., dizziness, nausea) may be associated with suicidal behaviors. (p. 240)

This new content that distinguishes between suicidal behaviors and deaths is clinically instructive. The new information that associates cognitive symptoms with suicidal thoughts and physical symptoms with suicidal behaviors is further useful. Knowing this information refines your delivery of clinical services to diverse individuals, groups, and families.

These are just two examples. Depending on your professional practice setting, you may be interested in the following specific examples of disorders containing new DSM-5-TR content related to trauma, such as bullying, abuse, neglect, and adverse childhood experiences:

• ADHD, p. 73

• Specific Learning Disorder, p. 84

• Delusions, p. 102

• Schizophrenia, p. 118

• Bipolar I Disorder, p. 147

• Disruptive Mood Dysregulation Disorder, p. 180

• Major Depressive Disorder, p. 190

• Specific Phobia, p. 226

• Posttraumatic Stress Disorder, p. 305

• Obsessive-Compulsive Disorder, p. 328

• Body Dysmorphic Disorder, p. 274

• Hoarding Disorder, p. 279

• Dissociative Identity Disorder, pp. 332-333

• Somatic Symptom and Related Disorders, p. 350, p. 354

• Functional Neurological Symptom Disorder, p. 362

• Paranoid Personality Disorder, p. 740

The DSM-5-TR is more CULTURALLY SENSITIVE. It addresses awareness of disability, social isolation/deprivation/adversity, clinical bias, poverty, racism, marginalization, microaggressions, and discrimination. Misdiagnosis of schizophrenia among individuals with mood disorders with psychotic features or other psychiatric conditions occurs more frequently in members of underserved and racialized ethnic groups – particularly African Americans in the United States. Such diagnostic errors may stem from clinical bias, systemic racism, or discrimination, which can contribute to limited access to high-quality information and the misinterpretation of symptoms.

Other adverse consequences of discrimination include unequal access to care and clinician bias in both diagnosis and treatment. For example, African Americans presenting with mood disorders or other psychiatric conditions are more likely to be misdiagnosed with schizophrenia, experience more coercive pathways to care, receive less time in outpatient treatment, and face more frequent use of physical restraints and suboptimal interventions.

These are just two examples of this topic. Depending on your professional practice setting, you may be interested in the following specific examples of disorders containing new DSM-5-TR content related to discrimination, racism, stereotyping, or clinical bias:

• Specific Learning Disorder, p. 84

• Delusions, p. 101

• Schizophrenia, pp. 118-119

• Bipolar I Disorder, p. 147

• Major Depressive Disorder, p. 189

• Posttraumatic Stress Disorder, p. 310

• Gender Dysphoria, p. 519

• Conduct Disorder, p. 534

• Alcohol Use Disorder, pp. 556-558

• Tobacco Use Disorder, p. 648

• General Personality Disorder, p. 796

• Paranoid Personality Disorder, pp. 739-740

• Antisocial Personality Disorder, p. 751

The DSM-5-TR uses language that challenges the view that races are discrete and natural entities, such as racialized instead of racial (to highlight the socially constructed nature of race). And more specifically,

• The emerging term Latinx (used as both singular and plural) replaces Latino/a to promote gender-inclusive terminology.

• The term Caucasian is avoided because it is based on outdated and inaccurate assumptions about the geographic origins of a so-called “pan-European” ethnicity.

• The terms minority and non-White are not used, as they define social groups in relation to a racialized majority, thereby reinforcing social hierarchies.

• The term culture is not used to describe a single, discrete social group (e.g., “prevalence differs across cultures”). Instead, it reflects the diversity of cultural views and practices within societies. The preferred alternatives are cultural contexts or cultural backgrounds. (p. 18)

Clinicians are encouraged to actively recognize and address all forms of racism, bias, and stereotyping throughout the processes of clinical assessment, diagnosis, and treatment. The DSM-5-TR supports this effort by guiding clinicians to consider how a client’s clinical presentation may be influenced by their position within social structures and hierarchies that shape exposure to adversity and access to resources. The revised text also emphasizes the importance of routinely evaluating how cultural meanings, identities, and practices affect the development and course of mental disorders. This awareness enables clinicians to assess potential signs and symptoms of psychopathology more accurately. Consider the following examples:

1. The role of bilingualism as an environmental factor in delays or differences in language development (see childhood-onset fluency disorder, p. 53).
   
   
2. Differential diagnosis of a silent period in immigrant children learning a second language (selective mutism, p. 223).
   
   
3. Culture and trauma language added to premenstrual dysphoric disorder:

Culture-Related Diagnostic Issues
DSM-5	DSM-5-TR
Premenstrual dysphoric disorder has been observed in individuals in the United States, Europe, India, and Asia, with a broad prevalence range. Nevertheless, frequency, intensity, and expressivity of symptoms; and help-seeking patterns may be significantly influenced by social and cultural factors. (p.173)	Premenstrual dysphoric disorder has been observed in individuals in the United States, Europe, India, Nigeria, Brazil, and Asia, with a broad prevalence range. Nevertheless, as with most mental disorders frequency, intensity, and expressivity of symptoms; perceived consequences; help-seeking patterns; and management may be significantly influenced by social and cultural factors, such as a history of sexual abuse or domestic violence, limited social support, and cultural variations in attitudes toward menstruation. (p. 199)

“Regarding sex and gender, much of the information on the expression of psychiatric illness in women and men is based on self-identified gender” (DSM-5-TR, p. 19). Accordingly, the DSM-5-TR uses the terms gender differences or men and women when discussing variations related to gender. The terms male and female are used specifically when referring to biological differences between the sexes.

Each section of the DSM-5-TR addressing disorder prevalence was reviewed to ensure that findings accurately reflect the geographic areas or social groups included in the data collection. For example, prevalence rates reported for the U.S. general population are based on studies conducted within that context. This approach helps prevent overgeneralization of findings to communities that have not yet been studied. Additionally, prevalence data for specific ethnoracial groups were incorporated into the text revision when existing research provided reliable estimates derived from representative samples.

If you are interested in learning more about identifying clinical bias, consider the following examples of disorders that include new content related to misdiagnosis, overdiagnosis, or underdiagnosis:

• Autism Spectrum Disorder, p. 63

• ADHD, p. 74

• Delusions, p. 101

• Schizophrenia, p. 119

• Bipolar I Disorder, pp. 147-148, p. 150

• Major Depressive Disorder, p. 190

• Panic Attacks, p. 245

• Dissociative Identity Disorder, p. 335

• Oppositional Defiant Disorder, p. 525

• Intermittent Explosive Disorder, p. 528

• Antisocial Personality Disorder, p. 751

This course provides an overview of the textual revisions in the DSM-5-TR, equipping you to use the manual effectively for accurate client diagnosis. I strongly recommend purchasing the DSM-5-TR and reviewing the full list of updates yourself. The remainder of this course follows the chapter organization of the DSM-5-TR and highlights the subheadings that have been modified between the DSM-5 (2013) and the DSM-5-TR (2022).

Enjoy the course!

Neurodevelopmental Disorders

Overview

The DSM-5-TR introduces several nuanced updates across the neurodevelopmental disorders, aimed at improving diagnostic clarity and enhancing cultural, developmental, and contextual sensitivity. Notable changes include refined guidance in differential diagnosis, particularly in distinguishing autism spectrum disorder (ASD), language disorders, and ADHD from other overlapping conditions, as well as expanded commentary on how symptoms may present differently based on age, gender, and cultural background. Additionally, the revised text includes more robust discussions of comorbidity, functional impact, and the association of certain disorders with suicidal ideation or behavior.

Language Disorder

Differential Diagnosis

The DSM-5-TR expands guidance on distinguishing Language Disorder from Autism Spectrum Disorder by emphasizing behavioral and interactional differences. While both may involve delayed language development, autism spectrum disorder typically includes behaviors not seen in language disorder – such as reduced social interest, atypical social interactions, and rigid adherence to routines.

Speech Sound Disorder

Comorbidity

An update notes that speech impairments may be differentially expressed in certain genetic conditions, suggesting a need for careful assessment of genetic and developmental contexts when evaluating speech sound disorder.

Childhood-Onset Fluency Disorder

Differential Diagnosis

New text clarifies that oral reading dysfluencies – often observed in specific learning disorder with impairment in reading can be misinterpreted as stuttering. Timed reading assessments may misrepresent the true abilities of children who stutter.

It is now explicitly recommended that clinicians differentiate dysfluencies related to second-language acquisition from those consistent with a fluency disorder. True fluency disorders typically appear in both languages.

Social (Pragmatic) Communication Disorder

Differential Diagnosis

Revisions further delineate this diagnosis from autism spectrum disorder, clarifying that it should only be used when there is no evidence of restricted or repetitive behaviors (i.e., Criterion B of autism spectrum disorder). Social pragmatic difficulties may be qualitatively similar but are generally less severe in this condition.

Autism Spectrum Disorder

Diagnostic Features

Expanded descriptions emphasize how autism may present subtly in individuals with strong language or cognitive abilities, who may mask their symptoms. Examples include relatively intact eye contact but poor integration with gestures or prosody. New language highlights that repetitive behaviors (e.g., rocking, finger flicking) may be self-soothing and that diagnosis remains clinical, not determined by any single tool.

Associated Features

While not unique to autism, theory-of-mind deficits, executive dysfunction, and weak central coherence are commonly observed. These features may shape symptom presentation and should inform the clinical formulation.

Prevalence

New notes caution that reported prevalence may be influenced by underdiagnosis or misdiagnosis, particularly among ethnoracial minorities.

Culture-Related Diagnostic Issues

The DSM-5-TR identifies disparities in age of diagnosis and diagnostic accuracy in racialized and socially oppressed children, particularly African American youth, who are often misdiagnosed with conduct or adjustment disorders.

Sex- and Gender-Related Diagnostic Issues

Females with autism may demonstrate better social reciprocity and more context-sensitive behavior, potentially leading to underrecognition. Special interests in females may appear more socially normative. The DSM-5-TR also reports elevated rates of gender variance, particularly among females with autism.

Association With Suicidal Thoughts or Behavior

Individuals with autism are at increased risk for suicide, including suicidal ideation, plans, and attempts. Risk is especially elevated among those with impaired social communication, even after controlling for other psychiatric conditions.

Differential Diagnosis

• Anxiety Disorders: Overlapping symptoms like social withdrawal can complicate diagnosis.
• Obsessive-Compulsive Disorder: Repetitive behaviors in OCD tend to be anxiety-driven and ego-dystonic, whereas in autism, they may be pleasurable and ego-syntonic.
• Personality Disorders: In adults without intellectual or language impairments, autism may resemble schizotypal or schizoid personality disorders; developmental history is key to differential diagnosis.

Clinical Example

To help you understand and appreciate the refinements to the DSM-5-TR, below is an excerpt from an actual neurodevelopmental evaluation that I conducted on a client. This client is a 15-year-old female who received prior neuropsychological testing for suspected autism, but the results were not conclusive. This is why I reference the content and results from this initial testing. As you read this clinical example, please note how I used the DSM-5-TR in the following ways:

• Use of severity specifiers (per instructions on page 58),
• Anchored other clinical conditions deserving attention in addition to the autism (per instructions on page 59),
• Used the differential diagnosis section of the DSM-5-TR to conceptualize the autism profile as encompassing the prior ADHD diagnosis and clinical rationale for excluding it in my report (per new text revisions on pages 60-62), and
• Provided treatment recommendations (per new text revision content about association with suicidal thoughts or behavior on page 65).

My clinical preference is to consolidate diagnostic formulations whenever possible and to avoid assigning clients multiple diagnoses. Over-diagnosing can lead to fragmented treatment planning, create confusion for clients and their families, and increase the risk of further stigmatization or marginalization. This approach is particularly relevant when considering the inclusion of oppositional defiant disorder in a diagnostic formulation.

Before reviewing my clinical example, I want to provide a brief digital update to the DSM-5-TR. Since its publication in March 2022, the American Psychiatric Association (APA) has continued to make periodic text revisions. These updates are available exclusively through the online or digital version of the DSM-5-TR, which can be accessed via the APA’s website at https://psychiatryonline.org. The following Other Condition That May Be of Clinical Attention was added to page 836 of the DSM-5-TR after its publication:

R45.89 Impairing Emotional Outbursts

This category may be used when the focus of clinical attention is displays of anger or distress manifested verbally (e.g., verbal rages, uncontrolled crying) and/or behaviorally (e.g., physical aggression toward people, property, or self) that lead to significant functional impairment. In addition to occurring in the context of a number of different mental disorders (e.g., attention-deficit/hyperactivity disorder, autism spectrum disorder, oppositional defiant disorder, generalized anxiety disorder, posttraumatic stress disorder, mood and psychotic disorders), they can also occur independently of other conditions, as is often the case in young children. (p.836)

You will better understand my use of this “R-code” in my clinical example. Please note that client identifying information has been masked or altered to protect privacy.

Below is content from my report section titled REASON FOR EVALUATION

According to Micah’s earlier 2021 Neuropsychological Evaluation,

Micah displays a lack of empathy toward others, she struggles in understanding social cues, she also struggles in making and maintaining friends. Micah has also been struggling with appropriate behaviors outside and inside the home.

Her scores on the GARS indicated that it was "very likely" that Micah is on the autism spectrum.

Additionally, her score on a task assessing mental flexibility was in the mildly impaired range. This was probably the most significant deficit revealed through the neuropsychological testing. This component of "executive functions" is among the most important for meaningful, rational, and appropriate behavior, and is related to basic problem-solving skills and appropriate responding in social situations. Individuals with poor mental flexibility tend to get stuck in cognitive ruts--can't shift thinking when necessary, resulting in inappropriate responses to situations. It appears that Micah can become easily confused and somewhat bewildered in coping with the complex circumstances that constitute everyday living.

Nonetheless, ASD was listed as a diagnostic “rule out” (R/O) – not as the primary diagnosis, and ADHD superseded ASD in the diagnostic sequencing.

Below is content from my report section titled DSM-5-TR DIAGNOSTIC FORMULATION

Based on the developmental history, standardized behavioral diagnostic instruments, caregiver interviews, questionnaires, and clinician observation measures, Micah qualifies for the following DSM-5-TR diagnoses:

F84.0 Autism Spectrum Disorder (ASD) [PRINCIPAL DIAGNOSISs]

• Requiring substantial support for deficits in social communication (Level 2-Moderate)
• Requiring substantial support for restricted, repetitive behaviors (Level 2-Moderate)
• Without accompanying intellectual impairment
• Without accompanying language impairment

Micah’s ASD is associated with the following neurodevelopmental, mental, or behavioral conditions:

• Z55.9 Other Problems Related to Education and Literacy (has 504 plan and needs an IEP)
• R45.89 Impairing Emotional Outbursts (high levels of emotional reactivity, temper outbursts or distress manifested verbally, angry or irritable mood, argumentative, oppositional defiant behavior)
• Z91.49 Personal History of Psychological Trauma (discussed in earlier Neuropsychological Evaluation)
• Z91.51 History of Suicidal Behavior (started ~age 11; hospitalized twice; nothing past ~6 months since attending high school]
• Z91.52 History of Nonsuicidal Self-Injury (started ~age 11 and continues up to past ~6 months since attending high school]

This evaluator excludes the following previously diagnosed disorder listed in Micah’s earlier Neuropsychological Evaluation:

Attention-Deficit/Hyperactivity Disorder (ADHD). According to Dr. Neuropsychologist:

Within the neurocognitive screening battery, Micah performed poorly on tasks assessing mathematical abilities. Also, her scores on measures of verbal and visual memory were in the impaired range. Additionally, her score on a task assessing mental flexibility was in the mildly impaired range. This was probably the most significant deficit revealed through the neuropsychological testing. This component of "executive functions" is among the most important for meaningful rational, and appropriate behavior, and is related to basic problem-solving skills and appropriate responding in social situations. Individuals with poor mental flexibility tend to get stuck in cognitive ruts--can't shift thinking when necessary, resulting in inappropriate responses to situations. It appears that Micah can become easily confused and somewhat bewildered in coping with the complex circumstances that constitute everyday living.

…

She was earlier diagnosed with ADHD by Dr. Attention. [per a current report from mother, Micah started caffeine pills ~ at age 4 and started stimulants ~ at age 6; discontinued ~ at age 8; started Vyvanse July 2024]

Micah’s deficits with the executive function skill of flexibility, identified by results from the CEFI, ABAS-3, and SPM, 2 are more aligned with ASD than ADHD. Moreover, the DSM-5-TR indicates the following as definitive to ASD (p. 58):

Inflexibility of behavior causes significant interference with functioning in one or more contexts. Difficulty switching between activities. Problems of organization and planning hamper independence.

Abnormalities of attention are common in individuals with ASD, as is hyperactivity. Individuals with ADHD and those with ASD exhibit inattention, social dysfunction, and difficult-to-manage behavior. The social dysfunction and peer rejection seen in individuals with ADHD must be distinguished from the social disengagement, isolation, and indifference to facial and tonal communication cues seen in individuals with ASD. Children with ASD may display tantrums because of an inability to tolerate a change from their expected course of events. In contrast, children with ADHD may misbehave or have a tantrum during a significant transition because of impulsivity or poor self-control, and symptoms cannot be solely due to oppositional behavior, defiance, hostility, or failure to understand tasks or instructions (APA, 2022).

Many children with autism have been diagnosed with ADHD, oppositional-defiant disorder (ODD), language disorder, mood disorder, or sensory integration disorder before receiving an autism diagnosis. These problems are all part of autism itself and are subsumed under the diagnosis of ASD. Even though children with autism and children with ODD have similar mood and behavior problems, in comparison to the norm, children with autism have significantly more opposition, aggression, irritability, explosiveness, and moodiness. In a study of 435 children with autism, 42% met criteria for ODD. However, because mood and behavior problems are common in autism, an additional diagnosis of ODD may not be necessary (Mayes, 2012).

Below is content from my report section titled RECOMMENDED TREATMENT SERVICES & SUPPORTS

ASD is a neurodevelopmental condition that impacts an individual in three core skill areas:

• Language and Communication
• Social Relationships and Emotional Responses
• Sensory Use and Interests

In children with ASD, deficits in social and communication skills can impede learning, particularly learning that occurs through social interaction or in peer-based settings. At home, insistence on routines, resistance to change, and sensory sensitivities may disrupt eating and sleeping and make routine caregiving challenging. Significant difficulties with planning, organization, and adapting to change can adversely affect academic achievement, even among students with above-average intelligence. ASD is not a degenerative disorder, and it is typical for learning and adaptive compensation to continue throughout the lifespan. (APA, 2022).

To promote Micah’s growth and development, the following recommendations are provided:

Critical Items. Currently, Micah does not manifest psychotic symptoms, catatonic behavior, non-suicidal self-injurious behavior, suicidal ideation or behaviors, or severe conduct issues. Nonetheless, future professional monitoring of Micah’s neurobehavioral functioning and mental status is recommended because children with impairments in social communication and social-emotional reciprocity combined with interpersonal rejection sensitivity have a higher risk of self-harm with suicidal intent, suicidal thoughts, suicide plans, and suicide death by age 16 (APA, 2022).

Reflection questions about this clinical example:

1. How did my separating of the severity specifiers into two designations instead of combining them into one, such as “Level 2 Moderate ASD,” align with the DSM-5-TR?
   
   
2. Why did I use specifiers about intellectual impairment and language impairment?
   
   
3. Where does the DSM-5-TR instruct me to use the phrase “associated with the following neurodevelopmental, mental, or behavioral conditions?”
   
   
4. How did I infuse Educational Problems from the DSM-5-TR’s Other Conditions That May Be a Focus of Clinical Attention?
   
   
5. How did I use the DSM-5-TR content to support my diagnostic formulation?
   
   
6. What content from the section Association With Suicidal Thoughts or Behavior did I use in the treatment recommendations, and why?

Attention-Deficit/Hyperactivity Disorder (ADHD)

Comorbidity

Sleep disturbances are frequently reported, including insomnia, restless legs syndrome, and circadian rhythm disruptions. These can exacerbate cognitive and behavioral symptoms.

Association With Suicidal Thoughts or Behavior

ADHD is associated with suicidal ideation in children and suicide attempts in adults, particularly when comorbid with mood, conduct, or substance use disorders.

Functional Consequences

Functional impairments differ by symptom type. Inattention is more associated with academic and peer neglect, while hyperactivity and impulsivity increase risk for peer rejection and accidents. Individuals with ADHD face elevated risks of PTSD, traffic violations, obesity, hypertension, and early mortality due to accidents.

Differential Diagnosis

Clinicians are advised to rule out PTSD, especially in young children who may manifest restlessness, irritability, and inattention after trauma. A thorough trauma history is essential.

Comorbidity

ADHD often co-occurs with sleep disorders, hypersomnolence, and several medical conditions (e.g., allergies, autoimmune disorders, epilepsy). Sleep-related cognitive impairments may further complicate diagnostic clarity.

Specific Learning Disorder

Culture-Related Diagnostic Issues

The DSM-5-TR emphasizes considering the individual’s cultural and educational background during assessment. Risk factors for refugee and migrant youth include teacher bias, bullying, racism, parent-school misunderstandings, and trauma.

Association With Suicidal Thoughts or Behavior

Individuals with learning disorders, particularly those exposed to domestic violence or with a history of major depression, are at increased risk for suicidal behavior.

Stereotypic Movement Disorder

Differential Diagnosis

The revision helps distinguish stereotypic movement disorder from:

• Substance-induced repetitive behaviors, especially due to stimulant use
• Functional (conversion) movements, which may have abrupt onset, high distractibility, and comorbid functional neurological symptoms

Tic Disorders

Diagnostic Features

A new clinical insight warns that discussing or observing tics may provoke symptoms in others with tic disorders, sometimes leading to misinterpretation of intent, especially in structured environments like schools or legal settings.

Risk and Prognostic Factors

Genetic overlap exists with ADHD, OCD, and autism spectrum disorder. Tics are typically exacerbated by stress or fatigue and improve during focused activity.

Association With Suicidal Thoughts or Behavior

Approximately 10% of youth with chronic tic disorders experience suicidal ideation or behaviors, particularly when co-occurring with anxiety, depression, or social withdrawal.

Differential Diagnosis

Functional Tic Disorder should be considered in individuals reporting prolonged “tic attacks” (15 minutes to several hours). Features such as abrupt onset, variability, and inconsistency may help differentiate functional symptoms from primary tic disorders.

Schizophrenia Spectrum and Other Psychotic Disorders

Overview

The DSM-5-TR introduces substantive updates to enhance diagnostic precision and cultural responsiveness across the schizophrenia spectrum and related psychotic disorders. Major revisions clarify how to distinguish delusions from culturally normative beliefs, highlight the relevance of social and structural determinants (such as trauma and marginalization), and update risk and prognostic factors. There is also a broader emphasis on sex and gender influences, suicide risk, and the importance of accurate differential diagnosis. These changes aim to reduce diagnostic bias and provide clinicians with clearer frameworks for interpreting complex symptom presentations.

Changes Made to the Introduction

Delusions

The DSM-5-TR provides new clarification on differentiating delusions from strongly held beliefs. The degree of conviction and resistance to contradictory evidence remains central, but cultural context is now emphasized. Beliefs such as supernatural causation or spiritual influence may appear delusional in one culture but be normative in another. Elevated religiosity is also noted as a common feature in many psychotic presentations. Importantly, fears expressed by individuals who have experienced trauma (e.g., torture, discrimination) should be evaluated carefully to avoid mislabeling trauma-related fears as persecutory delusions.

Cultural Considerations in the Assessment of Psychotic Symptoms

Cultural competence is reinforced in the DSM-5-TR, which advises the use of culturally adapted tools and interviews, such as the Cultural Formulation Interview, to enhance diagnostic accuracy. The revision also warns against misinterpreting unfamiliar metaphors or idioms, especially when assessing individuals in a non-native language or through an interpreter.

Delusional Disorder

Risk and Prognostic Factors

The DSM-5-TR now highlights a familial association between delusional disorder, schizophrenia, and schizotypal personality disorder, strengthening the genetic and physiological understanding of these conditions.

Schizophrenia

Development and Course

The course of schizophrenia is reframed to highlight cognitive impairment and negative symptoms as core, relatively stable features distinct from positive symptoms. Cognitive deficits often emerge before psychosis and remain stable, while negative symptoms can either be stable traits or emerge post-onset with more variability. The text reinforces that schizophrenia is not typically a progressive neurodegenerative disorder, but functional decline can occur in more severe chronic cases.

Risk and Prognostic Factors

The DSM-5-TR connects increased schizophrenia risk to social deprivation, trauma, and marginalization, especially among refugees, migrants, and socially oppressed groups. Symptom severity is also linked to adverse childhood experiences. Notably, ethnic and racialized individuals face higher rates of schizophrenia diagnosis in areas where they are underrepresented – a phenomenon possibly influenced by discrimination, reduced social support, stigma, and limited access to culturally grounded interpretations of psychotic experiences.

Culture-Related Diagnostic Issues

The expression of psychotic symptoms varies across cultures in terms of hallucination type, delusional content, and emotional impact. For example, visual hallucinations are more prominent in some cultures. The revision also acknowledges the overdiagnosis of schizophrenia in marginalized racial and ethnic groups, particularly African Americans, due to clinical bias and misinterpretation of symptoms.

Sex- and Gender-Related Diagnostic Issues

Hormonal fluctuations are linked to changes in psychotic symptom expression. The DSM-5-TR notes worsening of symptoms during menstruation, symptom improvement during pregnancy, and relapse postpartum, correlated with changes in estrogen levels. Additionally, a midlife onset peak in women is associated with menopausal hormonal shifts.

Association With Suicidal Thoughts or Behavior

The updated text expands suicide risk factors to include depressive symptoms, hopelessness, recent discharge, and higher IQ. Suicide risk is elevated during early illness, after hospitalization, and in individuals with poor treatment adherence or repeated admissions.

Differential Diagnosis

Updated criteria continue to emphasize the importance of distinguishing schizophrenia from:

• Substance/medication-induced psychotic disorders, particularly when symptoms are transient or closely tied to substance use.
• Schizoaffective disorder, which now requires mood symptoms for the majority of the illness duration (as opposed to a “substantial portion” in DSM-IV).

Schizoaffective Disorder

Development and Course

The DSM-5-TR provides additional guidance on diagnostic shifts. Individuals may initially be diagnosed with mood disorders before independent psychotic symptoms emerge, or conversely, a diagnosis may evolve from schizoaffective disorder to schizophrenia, especially under DSM-5’s more stringent Criterion C, which now demands that mood symptoms persist for the majority of the illness.

Differential Diagnosis

Distinguishing schizoaffective disorder from psychotic disorder due to another medical condition, schizophrenia, or mood disorders requires detailed longitudinal observation and collateral information about the temporal pattern of psychotic versus mood symptoms.

Substance/Medication-Induced Psychotic Disorder

Differential Diagnosis

Updates stress the importance of separating substance-induced symptoms from those of:

• Schizophrenia and related disorders, particularly when evaluating persistent symptoms post-substance use
• Other specified or unspecified psychotic disorders, when presentation is atypical or incomplete

Psychotic Disorder Due to Another Medical Condition

Diagnostic Features

The DSM-5-TR introduces a three-pronged framework for assessing whether psychosis stems from a medical condition:

• Biological plausibility: Whether the identified condition is physiologically capable of causing psychosis.
• Temporality: Whether psychotic symptoms coincide with the onset, exacerbation, or remission of the medical issue.
• Typicality: Whether symptoms are atypical for primary psychotic disorders (e.g., presence of visual or olfactory hallucinations, unusual age of onset, or dreamlike delusions).

Clinicians are reminded to rule out other causes, such as substance-induced psychosis or psychiatric side effects of medical treatments.

Differential Diagnosis

The DSM-5-TR emphasizes that no single symptom (e.g., visual hallucinations) is pathognomonic for a medical versus psychiatric cause. Clinicians should consider the total clinical picture and avoid over-reliance on individual symptom features when differentiating etiologies.

Bipolar and Related Disorders

Overview

The DSM-5-TR introduces several refinements to the diagnostic understanding and clinical characterization of bipolar and related disorders. Across bipolar I and II, the text now includes updated epidemiological data, expanded discussion of risk factors (including trauma and genetic influences), and deeper exploration of course patterns, comorbidities, and cultural and gender considerations. New specifiers clarify episode features (e.g., catatonia, peripartum onset), and greater attention is given to misdiagnosis risks and functional impacts. The revisions emphasize nuanced clinical decision-making and cultural humility to improve diagnostic accuracy and treatment outcomes.

Bipolar I Disorder

Diagnostic Features

Bipolar I disorder remains defined by the presence of at least one manic episode, with or without depressive or hypomanic episodes. The DSM-5-TR reiterates this requirement while emphasizing the recurring nature of mood episodes across the lifespan.

Associated Features

New content highlights trait-like features associated with bipolar I disorder, including hyperthymic, cyclothymic, and anxious temperaments, as well as sleep disturbances, circadian rhythm instability, heightened reward sensitivity, and links to creativity.

Prevalence

Updated prevalence data show a 12-month prevalence of 1.5% among U.S. adults, with similar rates between men and women. Prevalence varies by ethnicity, being higher among Native Americans and lower among African Americans, Hispanics, and Asian/Pacific Islanders.

Development and Course

Onset most often occurs in the early 20s, with a slightly younger mean age for women. The course is highly heterogeneous, with first-episode polarity often predicting subsequent episode types. Notably, mixed features in mania are linked to poorer outcomes, including higher suicide risk and reduced response to lithium.

Risk and Prognostic Factors

Environmental: Childhood adversity (e.g., trauma, parental psychopathology) predicts earlier onset and more severe progression. Manic episodes are often triggered by goal-attainment events, while depressive relapses are more linked to negative life events. Substance use, particularly cannabis, exacerbates manic symptoms.

Genetic and Physiological: Bipolar I disorder has a high heritability (up to 90% in twin studies). However, risk is influenced by complex genetic-environment interactions. The disorder shares genetic markers with schizophrenia, and emerging findings suggest that susceptibility to mania and depression may be inherited separately.

Culture-Related Diagnostic Issues

While symptoms are consistent across cultures, expression and interpretation vary. For instance, delusional themes (e.g., religious or grandiose) differ culturally. Misdiagnosis is a concern, particularly among African Americans, who may be misclassified with schizophrenia due to linguistic, cultural, or systemic biases. Delayed treatment access may also contribute to more florid psychotic presentations in marginalized populations.

Sex- and Gender-Related Diagnostic Issues

Women may experience exacerbated mood symptoms during the premenstrual and perimenopausal periods. The postpartum period presents a high risk for manic and mixed episodes, and postpartum psychosis is closely linked to bipolar I disorder. The peripartum onset specifier should be used for mood episodes beginning during pregnancy or within 4 weeks of delivery.

Association With Suicidal Thoughts or Behavior

Bipolar disorders carry a high suicide risk, with 5%–6% dying by suicide. Risk is increased in individuals with alcohol use disorder, which is common in this population.

Functional Consequences

Self-perceived stigma is associated with reduced functioning. Occupational, social, and interpersonal impairments are common during active episodes.

Differential Diagnosis

• Major depressive disorder: Often misdiagnosed due to depressive predominance in bipolar I. Clues to bipolar I include early onset, psychotic symptoms, family history, and poor antidepressant response.
• Other differentials include:
• Bipolar disorder due to a medical condition
• Schizoaffective disorder
• Disruptive mood dysregulation disorder

Comorbidity

Most individuals with bipolar I have three or more psychiatric comorbidities. These include:

• Personality disorders, especially borderline, schizotypal, and antisocial
• Medical comorbidities, such as cardiovascular disease, autoimmune conditions, metabolic syndrome, and obesity
• Sociocultural factors influence comorbidity patterns, including the prevalence of substance use disorders in cultures with fewer prohibitions on alcohol.

Bipolar II Disorder

Diagnostic Features

While major depressive episodes in bipolar II mirror those in unipolar depression, coexisting insomnia and hypersomnia, and atypical symptoms (e.g., hypersomnia, hyperphagia) are especially common. These are overrepresented among women with bipolar II.

Development and Course

Bipolar II disorder is highly recurrent, with over 50% of individuals experiencing a new episode within one year. It is also associated with greater seasonal variation in mood. The presence of hypomanic symptoms during depression can help differentiate bipolar II from major depressive disorder, especially in older adults.

Risk and Prognostic Factors

Genetic architecture appears partially distinct from both bipolar I and schizophrenia, suggesting nuanced hereditary mechanisms.

Association With Suicidal Thoughts or Behavior

Suicide risk is elevated in bipolar II, especially due to the long duration spent in depressive states. Rates of both attempts and deaths are significantly higher than in the general population.

Differential Diagnosis

• Major depressive disorder: Misdiagnosis is common due to the dominance of depressive episodes and difficulty detecting past hypomania.
• Other differentials include:
  • Schizophrenia
  • Schizoaffective disorder
  • Bipolar due to medical condition
  • Substance/medication-induced bipolar disorder

Comorbidity

• Anxiety disorders are common and linked to worse outcomes.
• Substance use disorders, particularly alcohol (42%) and cannabis (20%), are frequently comorbid.
• PTSD is less common than in bipolar I, but eating disorders (especially binge-eating) are more prevalent.
• Premenstrual syndromes are more common and may exacerbate mood lability.
• Medical comorbidities include cardiovascular disease, migraine, and autoimmune disorders.

Substance/Medication-Induced Bipolar and Related Disorder

Diagnostic Features

The key feature of substance- or medication-induced bipolar and related disorders is a noticeable and ongoing mood disturbance that dominates the clinical picture. This disturbance is marked by unusually elevated, expansive, or irritable mood, along with significantly increased activity or energy (Criterion A). These symptoms are believed to result directly from the effects of a substance, such as a drug of abuse, medication, or toxin exposure (Criterion B). This diagnosis requires the presence of elevated or irritable mood and increased energy, directly attributable to a substance. Symptoms must emerge during or soon after substance use and not be better explained by an independent mood disorder. The diagnosis should only be made when the mood disturbance is the predominant clinical concern and severe enough to warrant clinical attention.

Differential Diagnosis

• Substance intoxication/withdrawal: Distinguished by whether mood symptoms are prominent and impairing.

Bipolar and Related Disorder Due to Another Medical Condition

Differential Diagnosis

• Delirium and major or mild neurocognitive disorder: This diagnosis requires that mood symptoms be directly attributable to a physiological consequence of a medical condition and not limited to delirium. It may be made alongside neurocognitive disorders if symptoms of mania or irritability are prominent.

Other Specified Bipolar and Related Disorder

Diagnostic Clarification

Category 5: Manic episode superimposed: Includes presentations such as a manic episode superimposed on schizophrenia spectrum disorders, provided the episode does not meet criteria for schizoaffective disorder.

Specifiers for Bipolar and Related Disorder

With Catatonia

This specifier applies to current manic or depressive episodes in bipolar I or II if catatonic features are present for most of the episode.

With Peripartum Onset

This specifier applies to hypomanic or depressive episodes in bipolar II (or manic or depressive episodes in bipolar I) that begin during pregnancy or within 4 weeks postpartum. Differentiation from maternity blues is emphasized, maternity blues are transient, non-impairing, and not a mental disorder.

Severity Specifiers

Severity of mood episodes is based on symptom count, symptom intensity, and functional impairment:

• Mild: Minimum criteria met
• Moderate: Significant impairment
• Severe: Requires near-constant supervision for safety

Depressive Disorders

Overview

The DSM-5-TR offers expanded clinical guidance and updated epidemiological, cultural, and risk-related content across the depressive disorders category. Key updates include greater attention to sociocultural adversity (e.g., racism, poverty), gender-specific risk factors (e.g., hormonal transitions, coping behaviors), and improved diagnostic clarity for differentiating mood symptoms from those related to trauma, medical conditions, or cultural norms. Several disorders include new data on suicide risk and comorbidity patterns, especially in historically marginalized populations. Overall, the revisions enhance diagnostic precision, promote cultural sensitivity, and improve the recognition of depressive disorders across diverse presentations.

Disruptive Mood Dysregulation Disorder

Prevalence

While population samples show no consistent gender difference, clinical samples often show a male predominance in disruptive mood dysregulation disorder (DMDD).

Risk and Prognostic Factors

• Environmental: Adverse conditions such as neglect, parental mental illness, trauma, grief, divorce, and malnutrition are associated with the core features of DMDD.
• Genetic and Physiological: A family history of depression and findings from twin studies suggest a genetic link between early irritability and future risk of unipolar depression and anxiety.

Culture-Related Diagnostic Issues

Sociocultural factors, especially those linked to racism, conflict, or chronic adversity, may shape how DMDD presents. Clinicians are cautioned to distinguish between context-appropriate emotional responses and symptoms consistent with DMDD.

Sex- and Gender-Related Diagnostic Issues

Twin studies reveal developmental differences in irritability between sexes: boys show increasing genetic influence with age, while for girls, environmental factors become more influential in adolescence and young adulthood.

Major Depressive Disorder

Diagnostic Features

Clarified criteria now emphasize that symptoms must be new or significantly worsened relative to the person’s baseline. Difficulty in self-reporting due to cognitive symptoms or denial is acknowledged, and collateral information is recommended to aid diagnostic accuracy.

Risk and Prognostic Factors

• Environmental: Social determinants such as low income, limited education, racism, and gender-based violence are linked to elevated depression risk, particularly in women.
• Genetic and Physiological: Female reproductive stages (e.g., premenstrual, postpartum, perimenopausal) are identified as vulnerable periods for depression onset.

Culture-Related Diagnostic Issues

Depressive symptoms (e.g., anger, crying, somatic complaints) often differ culturally, requiring clinicians to contextualize symptoms based on local meaning systems. Misdiagnosis, particularly as schizophrenia in marginalized racial groups, may occur due to discrimination and misinterpretation. Chronicity is higher among African American and Caribbean Black populations in the U.S., possibly due to systemic inequities.

Sex- and Gender-Related Diagnostic Issues

Women often exhibit atypical depressive symptoms (e.g., hypersomnia, interpersonal sensitivity), whereas men may engage in maladaptive coping (e.g., substance use, risk-taking).

Association With Suicidal Thoughts or Behavior

Individuals with major depressive disorder face a 17-fold increased risk of suicide compared to the general population. While women attempt suicide more, men are more likely to die by suicide. Anhedonia is strongly associated with suicidal ideation. Risk increases with comorbidities such as borderline personality disorder, substance use, and anxiety disorders.

Functional Consequences

Women report greater interpersonal impairment, highlighting the social toll of depression.

Differential Diagnosis

Must be distinguished from:

• Bipolar I disorder, bipolar II disorder, or other specified bipolar and related disorder
• Depressive disorder due to another medical condition
• Persistent depressive disorder
• Premenstrual dysphoric disorder
• Disruptive mood dysregulation disorder
• Major depressive episodes superimposed on schizophrenia, delusional disorder, schizophreniform
• disorder, or other specified or unspecified schizophrenia spectrum and other psychotic disorder
• Schizoaffective disorder
• Bereavement
• Sadness

Comorbidity

• Women: Higher rates of anxiety, bulimia, and somatic symptom disorders
• Men: More likely to report alcohol and substance use disorders

Persistent Depressive Disorder

Prevalence

Rates appear higher in high-income countries, but the disorder has comparable disability and suicide risk across all income levels.

Culture-Related Diagnostic Issues

Chronic depressive symptoms may be normalized in certain groups, reducing help-seeking or detection.

Association With Suicidal Thoughts or Behavior

Persistent depressive disorder carries an elevated suicide risk, regardless of socioeconomic setting.

Differential Diagnosis

Includes:

• Other depressive disorders
• Bipolar I and II disorders
• Cyclothymic disorder

Premenstrual Dysphoric Disorder

Diagnostic Features

Diagnosis requires clinically significant distress or impairment during the week prior to menstruation.

Prevalence

Symptoms may be more common in adolescent girls compared to adults.

Culture-Related Diagnostic Issues

Cultural views on menstruation and factors such as abuse history and limited social support influence symptom presentation and severity.

Association With Suicidal Thoughts or Behavior

The premenstrual phase is considered a heightened risk period for suicide in some individuals.

Differential Diagnosis

• Other medical conditions: Includes medical conditions (e.g., thyroid deficiency, anemia) that may mimic depressive symptoms and must be ruled out.

Substance/Medication-Induced Depressive Disorder

Prevalence

High rates (≥40%) of alcohol- or stimulant-induced depressive episodes are reported among individuals with substance use disorders.

Development and Course

Substance-induced depression often resolves with abstinence, though residual symptoms may predict relapse into substance use.

Risk and Prognostic Factors

Depression may reflect systemic adversity, including poverty, racism, and marginalization.

Diagnostic Markers

Toxicology screening is of limited diagnostic value due to symptom persistence beyond substance detection. A detailed clinical history and mental status exam remain the cornerstone of diagnosis.

Depressive Disorder Due to Another Medical Condition

Sex- and Gender-Related Diagnostic Issues

Poststroke and cardiovascular disease may place women at higher risk for developing depression.

Differential Diagnosis

Delirium and major or mild neurocognitive disorder: Must be distinguished from delirium and neurocognitive disorders when mood symptoms are secondary.

Other Specified Depressive Disorder

Diagnostic Clarification

Includes major depressive episodes superimposed on schizophrenia spectrum disorders (excluding schizoaffective disorder).

Unspecified Depressive Disorder

Diagnostic Clarification

Used when full criteria are not met and when depressive symptoms cause significant distress or impairment, but do not fit another defined disorder.

Anxiety Disorders

Overview

The DSM-5-TR enhances clinical understanding of anxiety disorders by incorporating new research on suicide risk, cultural influences, biological mechanisms, and differential diagnosis. Across the category, anxiety disorders are now recognized as significant risk factors for suicidal ideation, attempts, and death. The revision also strengthens guidance on culturally informed assessment, especially for youth and marginalized populations, while clarifying diagnostic boundaries between anxiety and related disorders.

Changes Made to the Introduction

The DSM-5-TR introduces new research confirming that individuals with anxiety disorders are at increased risk for suicidal ideation, attempts, and death by suicide. Among anxiety disorders, panic disorder, generalized anxiety disorder, and specific phobia show the strongest associations with transitioning from suicidal thoughts to attempts.

Separation Anxiety Disorder

Culture-Related Diagnostic Issues

Cultural variability is acknowledged in self-report patterns; for instance, Taiwanese youth report more separation anxiety symptoms than U.S. youth, emphasizing the need for culturally informed assessment.

Association With Suicidal Thoughts or Behavior

A large twin study links childhood bullying with later suicidal thoughts, suggesting environmental adversity is a significant risk factor in those with separation anxiety.

Differential Diagnosis

Prolonged grief disorder: Separation anxiety must be distinguished from prolonged grief disorder. While both involve distress related to attachment figures, yearning for the deceased characterizes grief, whereas fear of separation from living attachment figures is central in separation anxiety.

Selective Mutism

Risk and Prognostic Factors

Emerging evidence suggests that abnormal auditory efferent activity during speech may cause atypical self-perception of vocalizations, potentially explaining reluctance to speak in individuals with selective mutism.

Differential Diagnosis

New clarifications help distinguish selective mutism from:

• Silent periods in second-language learners
• Communication disorders with speech or language impairments

Specific Phobia

Sex- and Gender-Related Diagnostic Issues

Animal, natural environment, and situational specific phobias are predominantly experienced by women, whereas blood-injection-injury phobia is experienced nearly equally among women and men. The average age at onset of specific phobia during childhood does not differ between girls/women and boys/men.

Association With Suicidal Thoughts or Behavior

Specific phobia is now recognized as a significant risk factor for both suicidal ideation and attempts. A 10-year longitudinal study in Germany found that 30% of first suicide attempts in youth could be linked to specific phobia.

Social Anxiety Disorder

Risk and Prognostic Factors

Genetic contributions are stronger in children than in adults, and stronger for anxiety symptoms than for full clinical diagnoses.

Sex- and Gender-Related Diagnostic Issues

No differences in age at onset are observed between males and females.

Association With Suicidal Thoughts or Behavior

Among U.S. adolescents, social anxiety disorder increased suicide risk for Latinx youth, even when controlling for major depression and income. This pattern was not found in non-Latinx White youth, pointing to cultural variation in suicide vulnerability.

Panic Disorder

Sex- and Gender-Related Diagnostic Issues

Panic disorder is twice as common in women as in men. Women more often report shortness of breath and nausea, while men more frequently report sweating.

Association With Suicidal Thoughts or Behavior

About 25% of primary care patients with panic disorder report suicidal thoughts. The disorder increases the risk of suicidal behavior, though not necessarily completed suicide.

Differential Diagnosis

• Only limited-symptom panic attacks: Updates distinguish limited-symptom panic attacks from full-syndrome panic disorder.

Panic Attack Specifier

Risk and Prognostic Factors

New findings link panic attacks to chronic illness experiences. For instance, individuals with COPD who have negative beliefs about breathlessness and poor perceived control show higher panic symptoms.

Sex- and Gender-Related Diagnostic Issues

Women report more panic attacks and endorse different physical symptoms than men, reflecting gender-based variations in symptom expression.

Agoraphobia

Association With Suicidal Thoughts or Behavior

Roughly 15% of individuals with agoraphobia report suicidal thoughts or behaviors, underlining the clinical importance of suicide risk screening.

Differential Diagnosis

Avoidance related to other medical conditions: Agoraphobic avoidance should be differentiated from avoidance due to medical conditions, such as mobility limitations or chronic illness.

Generalized Anxiety Disorder

Association With Suicidal Thoughts or Behavior

Psychological autopsy studies identify generalized anxiety disorder as the most common anxiety diagnosis in individuals who have died by suicide.

Differential Diagnosis

Clarified distinctions are provided from:

• Panic disorder
• Illness anxiety disorder and Somatic symptom disorder

Other Specified and Unspecified Anxiety Disorders

Diagnostic Clarification

These categories continue to cover clinically significant anxiety symptoms that do not meet full criteria for another disorder and are not better classified as adjustment disorders with anxiety or mixed anxiety and depressed mood.

Obsessive-Compulsive and Related Disorders

Overview

The DSM-5-TR introduces refined clinical guidance across obsessive-compulsive and related disorders, particularly regarding insight levels, cultural expression, diagnostic clarity, and suicide risk. Greater specificity is provided in distinguishing comorbid psychotic features, recognizing culture-bound syndromes, and outlining the impact of comorbid conditions on prognosis. The updates also expand on sensory phenomena, family accommodation, and culturally specific beliefs associated with body and olfactory concerns.

Changes Made to the Introduction

In the DSM-5-TR, clearer guidance is provided for individuals with absent insight or delusional beliefs. Clinicians should not assign an additional psychotic disorder unless delusions extend beyond the content of the obsessive-compulsive or related disorder (e.g., food poisoning beliefs in body dysmorphic disorder that reflect general paranoia rather than preoccupation with appearance).

Obsessive-Compulsive Disorder

Associated Features

The DSM-5-TR highlights the presence of sensory phenomena in up to 60% of individuals with OCD, such as physical sensations or feelings of incompleteness that precede compulsions. Dysfunctional beliefs, like an inflated sense of responsibility, intolerance of uncertainty, and over-importance of thoughts, are common but not unique to OCD. The involvement of family or friends in rituals (accommodation) is noted to be a key factor in symptom maintenance, especially in children, and a treatment target.

Culture-Related Diagnostic Issues

Cultural influences shape both the expression and interpretation of OCD symptoms. For example, some religious or cultural groups may underreport sexual obsessions, and violent or aggressive obsessions may be more common in environments marked by urban violence. Cultural attributions for OCD range from physical and social to spiritual and supernatural explanations.

Association With Suicidal Thoughts or Behavior

Severity of OCD, the presence of unacceptable thought symptoms, and comorbid depression and anxiety are linked to increased suicide risk. A history of suicidality is also a predictor.

Body Dysmorphic Disorder

Culture-Related Diagnostic Issues

Cultural norms influence specific body concerns, such as eyelids in Japan or muscle size in Western contexts. The traditional Japanese diagnosis of shubo-kyofu (a subtype of taijin kyofusho) resembles body dysmorphic disorder.

Sex- and Gender-Related Diagnostic Issues

Muscle dysmorphia primarily affects men, who are also more likely to have substance use disorders, while women are more likely to have eating disorders. Men often fixate on genitals, muscle build, and hair thinning, whereas women more frequently worry about weight and various body parts.

Association With Suicidal Thoughts or Behavior

High risk for suicide is linked to comorbid conditions (depression, eating and substance use disorders), unemployment, low self-esteem, and perceived abuse.

Trichotillomania (Hair-Pulling Disorder)

Differential Diagnosis

Stereotypic movement disorder: There is many overlapping symptoms. The distinction from stereotypic movement disorder has been identified as a diagnostic consideration.

Excoriation (Skin-Picking) Disorder

Culture-Related Diagnostic Issues

Although prevalence data across cultures is limited, clinical presentations are reported to be consistent across different countries.

Differential Diagnosis

• Dermatitis Artefacta: Important distinctions are made between excoriation disorder and dermatitis artefacta. Diagnosis hinges on the absence of deception; if deception is present, malingering or factitious disorder may be more appropriate diagnoses.

Other Specified Obsessive-Compulsive and Related Disorder

Olfactory Reference Disorder

The DSM-5-TR formally recognizes olfactory reference disorder as a presentation under "other specified" conditions. It is marked by a persistent belief of emitting a foul odor, resulting in excessive behaviors like showering or reassurance-seeking. Known in Japan as jikoshu-kyofu, this condition causes significant distress and impairment, and is culturally categorized under taijin kyofusho.

Trauma- and Stressor-Related Disorders

Overview

The DSM-5-TR introduces prolonged grief disorder (PGD) as a new diagnostic category and expands or clarifies existing content across the spectrum of trauma- and stressor-related disorders. Key revisions focus on developmental, cultural, and contextual considerations; increased emphasis on suicide risk; refined differential diagnoses; and a more nuanced understanding of trauma exposures, including medical and occupational settings.

Changes Made to the Introduction

The DSM-5-TR introduces prolonged grief disorder (PGD) as a new diagnosis in this chapter, addressing longstanding clinical concern over grief responses that are abnormally intense or prolonged following the death of a close relationship.

Reactive Attachment Disorder (RAD)

Diagnostic Features

The DSM-5-TR emphasizes that accurate diagnosis is improved through multi-informant assessment across multiple contexts.

Culture-Related Diagnostic Issues

Cultural caregiving practices and norms around attachment may affect symptom expression and the interpretation of behavior. Caution is advised when diagnosing RAD in cultural contexts where attachment constructs have not been extensively studied. Higher prevalence may occur in settings involving caregiver trauma, migration, or displacement.

Comorbidity

RAD may overlap with symptoms of externalizing disorders and ADHD, although this association is not definitively established.

Disinhibited Social Engagement Disorder (DSED)

Risk and Prognostic Factors

Blunted reward sensitivity and poor inhibitory control may be linked to indiscriminate social behavior. Preliminary findings suggest neurobiological associations, though further research is needed.

Culture-Related Diagnostic Issues

Diagnosis should consider cultural expectations of children’s social behavior. Social disinhibition must be outside culturally normative boundaries.

Functional Consequences of Disinhibited Social Engagement Disorder

Social functioning, peer, and adult relationships may be impaired, with increased vulnerability to victimization.

Comorbidity

Frequently co-occurs with ADHD, externalizing disorders, and conditions associated with neglect, such as language and cognitive delays.

Posttraumatic Stress Disorder (PTSD)

Diagnostic Features

There has been a significant amount of content added to the diagnostic features section. Here is a summary of the new text. When reviewing PTSD criteria, keep in mind that the specific criteria outlined in the DSM-5-TR refer primarily to adults. For children aged 6 and under, the criteria are modified and numbered differently to reflect developmental appropriateness.

PTSD symptoms tend to be more severe and longer-lasting when the trauma is intentional and interpersonal, such as torture or sexual violence. Sexual trauma encompasses a wide range of experiences, including forced penetration, substance-facilitated assault, unwanted touching, and non-contact events like forced exposure to pornography or being photographed sexually without consent.

Bullying may also qualify as a traumatic event if it includes credible threats of serious harm or sexual violence. In children, developmentally inappropriate sexual experiences, even without physical injury, can meet Criterion A for trauma exposure.

Medical emergencies may qualify as traumatic events if the individual experienced intense fear, helplessness, or terror. Examples include waking during surgery or undergoing extremely painful treatments like burn wound care.

Indirect trauma exposure can also lead to PTSD. Mental health professionals, first responders, and others who are repeatedly exposed to the aftermath of trauma (e.g., war, abuse, or genocide) as part of their work may meet the criteria under indirect exposure (Criterion A4).

It’s common for individuals to have experienced multiple traumatic events. When assessing for PTSD, ask clients to identify the event they view as the most distressing, as their intrusive symptoms (Criterion B) and avoidance behaviors (Criterion C) typically relate to that specific experience.

Behaviors such as reckless driving, substance misuse, and risky sexual behavior can be trauma-related, especially when they emerge after the event. However, these only count toward Criterion E2 if they directly increase the risk of serious harm or death and are not part of someone’s job duties (e.g., military combat). Poor decisions that are harmful but not life-threatening – like overspending or binge eating – don’t qualify under this criterion.

Lastly, it’s important to distinguish between trauma-related startle responses and physiological reactions triggered by reminders of the trauma. The former can happen without conscious awareness of the trigger, while the latter generally involves some recognition that the response is related to the traumatic experience.

Prevalence

Research based on earlier DSM-IV data indicates that PTSD rates are higher among U.S. Latinx, African American, and American Indian populations compared to White populations. These differences may be influenced by a range of contributing factors, including greater exposure to trauma, historical and ongoing experiences of racism and discrimination, and disparities in access to high-quality mental health care. Additional influences may include differences in socioeconomic status, social support networks, and other community resources that affect both risk and recovery. Clinicians need to consider how these intersecting factors may shape both the presentation and persistence of PTSD symptoms across diverse populations.

Developmental Course

In older adults, PTSD symptoms may worsen due to declining physical health, cognitive decline, and increased social isolation. These factors can complicate recovery and should be considered in assessment and treatment planning.

Risk and Prognostic Factors

PTSD risk can be influenced by factors that increase vulnerability to trauma or amplify emotional responses during and after traumatic events.

Pretraumatic Factors: These include early emotional or behavioral problems (by age 6) and a history of mental health conditions such as panic disorder, depression, PTSD, or OCD.

Posttraumatic Factors: Environmental stressors after trauma – such as forced migration, chronic daily stress, or systemic racism – can worsen PTSD symptoms. For example, exposure to racial or ethnic discrimination may lead to a more persistent course of PTSD, especially among African American and Latinx individuals.

Culture-Related Diagnostic Issues

Exposure to trauma and the risk of developing PTSD can vary across demographic, cultural, and occupational groups, even when individuals experience similar types of traumatic events. Cultural background significantly shapes how PTSD symptoms are expressed in both adults and children. In some cultures, trauma may be interpreted through spiritual beliefs or result in strong negative self-perceptions, which can appear exaggerated or atypical to outside observers. Additionally, cultural concepts of distress that resemble PTSD are found globally and may include diverse expressions of psychological suffering attributed to frightening or traumatic experiences. These cultural frameworks influence not only the presentation of PTSD symptoms but also the range of associated comorbid disorders.

Sex- and Gender-Related Issues

PTSD is more prevalent and chronic in women, although symptom profiles are comparable between genders.

Association With Suicidal Thoughts or Behavior

PTSD is linked to higher suicide risk, especially in transitioning from ideation to planning or attempt.

Acute Stress Disorder (ASD)

Diagnostic Features

Symptoms must last at least 3 days and no longer than 1 month post-trauma. Shorter durations are not classified as ASD.

Sex- and Gender-Related Issues

Higher prevalence in women may reflect sex-based differences in trauma processing, neurobiology, and cultural expectations.

Adjustment Disorders

Specifiers

The DSM-5-TR provides clarification on the duration and specifiers for adjustment disorders. While the diagnosis requires that symptoms resolve within 6 months of the stressor or its consequences ending, the updated text acknowledges that symptoms may persist longer if the stressor is ongoing (e.g., chronic illness) or has long-term impacts (e.g., financial hardship following divorce). The “acute” specifier indicates symptom duration of less than 6 months, while the “persistent (chronic)”specifier is now defined as symptom duration of 6 months or longer in the presence of a persistent or long-lasting stressor. This clarification helps clinicians better classify prolonged reactions to chronic or residual stress.

Culture-Related Diagnostic Issues

Cultural context plays a critical role in determining whether a response to stress is maladaptive. The DSM-5-TR emphasizes that stressors and responses to them may be interpreted differently across cultures. For instance, distress from significant life events may not be seen as pathological in cultures where suffering is considered part of the human experience. Additionally, migrants and refugees face unique challenges due to contextual and cultural changes, complicating diagnosis. Importantly, the DSM-5-TR also notes that in some cultures, self-immolation is recognized as a suicide risk associated with adjustment disorders.

Association With Suicidal Thoughts or Behavior

Adjustment disorders continue to be associated with an elevated risk of suicide and suicide attempts. This highlights the importance of ongoing risk assessment in individuals presenting with significant distress following a major life stressor.

Differential Diagnosis

Bereavement: The DSM-5-TR distinguishes adjustment disorder from bereavement, reinforcing the need for careful assessment to determine whether symptoms represent a normal grief response or a clinically significant maladaptive reaction to stress.

New Diagnosis - Prolonged Grief Disorder (PGD)

Diagnostic Features

Prolonged Grief Disorder (PGD) is a newly recognized diagnosis in the DSM-5-TR. It refers to an intense, disabling grief reaction that persists for at least 12 months in adults (or 6 months in children and adolescents) following the death of a close relationship. Core symptoms include overwhelming yearning or longing for the deceased, persistent preoccupation with the loss, disruptions in identity, and profound disbelief about the death. Individuals may also experience emotional numbness, a sense that life is meaningless or empty, and significant difficulty re-engaging in life. These symptoms must go beyond the cultural norms of mourning and cause substantial functional impairment.

Associated Features

Prolonged grief disorder is often accompanied by guilt, negative self-perceptions, and a reduced sense of future purpose or life expectancy. Somatic complaints, such as appetite changes, are common and may mirror symptoms experienced by the deceased. Individuals frequently show increased health care use, poor self-care, and harmful health behaviors. Hallucinations involving the deceased, such as hearing their voice, are more common in prolonged grief and often reflect disrupted identity or meaning. Additional features include anger, blame, restlessness, and sleep disturbances.

Prevalence

Current prevalence rates for adults are unclear. While some studies have reported rates as high as 9.8%, these findings are considered questionable. In contrast, research indicates that the prevalence among adolescents may be approximately 18%.

Development and Course

Prolonged grief disorder typically begins within months after a loss but may be delayed or prolonged, particularly in cases of traumatic loss (e.g., child death, violent death). Comorbid PTSD and older age can complicate the course, with older adults at greater risk for cognitive decline. In children, grief may appear as behavioral regressions, somatic symptoms, or separation anxiety, especially after the loss of a caregiver. Adolescents may struggle with disrupted identity, emotional numbness, or risk-taking behaviors. Across development, difficulty reintegrating into life roles and prolonged preoccupation with the loss can lead to stalled milestones, hopelessness, or intense loneliness.

Risk and Prognostic Factors

Risk factors for PGD include pre-existing mental health conditions, the nature of the death (sudden, violent, or unexpected), inadequate social support, or dependency on the deceased (child, spouse, parent). Prognostic factors, such as the presence of other mental health disorders or the severity of grief symptoms, can influence the course and outcome of PGD.

Culture-Related Diagnostic Issues

Prolonged grief disorder is observed across cultures, but its symptoms, duration, and expression may vary based on cultural beliefs and practices. For example, nightmares or hallucinations of the deceased may hold special significance in some traditions, while indirect signs like poor self-care or substance use may be more common expressions of grief. The inability to perform culturally important mourning rituals can intensify grief. Higher rates of symptoms have been noted among African Americans, potentially linked to more frequent exposure to sudden or violent death. Cultural norms also shape the social roles of the bereaved and expectations around mourning. Diagnosis requires that symptoms exceed culturally accepted grief practices and are not explained by traditional mourning customs.

Sex- and Gender-Related Diagnostic Issues

Some studies have found higher rates of the disorder or greater symptom severity among bereaved women; however, other research suggests that gender differences are minimal or not statistically significant.

Association With Suicidal Thoughts or Behavior

Individuals with prolonged grief disorder are at increased risk for suicidal ideation, even when accounting for co-occurring depression and PTSD. This elevated risk appears consistent across age groups and countries. Factors such as stigma, social isolation, disrupted connections, and emotional distress contribute to suicidal thoughts. Risk is particularly high following violent deaths (e.g., homicide, suicide, or accidents) and the loss of a child under age 25. While suicidal ideation is well-documented, more research is needed to determine whether it translates into a higher rate of suicidal behavior.

Functional Consequences of Prolonged Grief Disorder

Prolonged grief disorder is linked to significant disruptions in work and social life, increased use of tobacco and alcohol, and elevated risks for serious health conditions such as heart disease, cancer, and weakened immune function. In children and adolescents, it can negatively impact educational goals, lead to early school withdrawal, and lower academic achievement – particularly affecting young women’s views on future relationships. Among middle-aged and older adults, prolonged grief symptoms may also contribute to impaired cognitive functioning.

Differential Diagnosis

Prolonged grief disorder is diagnosed when intense grief symptoms persist beyond 12 months (6 months for children) and impair functioning, exceeding cultural or social norms. It is distinct from normal grief, major depressive disorder, PTSD, separation anxiety, and psychotic disorders, based on the focus of distress (loss vs. mood or trauma), symptom patterns, and absence of broader psychotic features. Temporary grief exacerbations around anniversaries are common and not sufficient for diagnosis.

Comorbidity

Prolonged grief disorder commonly co-occurs with major depressive disorder, PTSD, and substance use disorders. PTSD is especially likely when the loss was sudden or violent. Separation anxiety disorder may also co-occur, particularly when a strong attachment to living individuals exists alongside grief.

Assessment Tool

You may find yourself asking, “How do I assess for Prolonged Grief Disorder (PGD)? How do I distinguish normal grief from PGD or other conditions such as Major Depressive Episode (MDE)?” A practical way to begin is with two quick steps.

First, review footnote “1” on the bottom left of page 184 in the DSM-5-TR. This footnote provides a concise comparison of how affect, mood, thought content, and self-ideation typically present in MDE versus in normal grief. This distinction can be extremely helpful during intake, when clinicians are often tasked with determining whether the client is experiencing an expected grief reaction or symptoms that warrant further diagnostic consideration.

Second, use the PG-13-R. Prigerson, Shear, and Reynolds (2022) have extensively evaluated the Prolonged Grief Disorder (PGD) diagnostic criteria and the Prolonged Grief Disorder-Revised (PG-13-R) scale. For mental health intake settings, the PG-13-R offers a brief, straightforward self-report measure that helps identify clients who may be experiencing clinically significant grief-related distress. The scale includes 13 items, with 10 rated on a 5-point scale from “not at all” to “overwhelmingly.” Scores range from 10 to 50, with higher scores indicating greater symptom burden. Because the PG-13-R aligns closely with DSM-5-TR criteria, a total score of 30 or higher is generally considered suggestive of probable PGD. Clients who score in this range typically warrant a more comprehensive diagnostic assessment and consideration for grief-focused treatment as part of the intake evaluation.

Click Here to Access an Online Version of the PG-13-R.

Clinical Example

Amina is a 13-year-old African American girl residing with her white adoptive parents and two siblings. Three of the children in the home, including Amina and her twin sister, were adopted together from Cape Verde as part of the same sibling group. Amina’s early history is significant for medical instability, prolonged institutional care, failure-to-thrive, and early childhood trauma.

Amina’s teachers and adoptive parents report increasing concerns regarding her emotional functioning, academic engagement, and psychological well-being. Over the past year, Amina has shown:

• Persistent preoccupation with her biological mother
• Episodes of tearfulness, rumination, and withdrawal during class
• Suicidal ideation and statements of hopelessness
• Intermittent hallucinations described as “voices” or “shadows” during high distress
• Difficulty focusing, impulsive behavior, and academic decline
• Heightened emotional responses around Mother’s Day, birthdays, and adoption anniversaries

Amina often becomes distressed when watching peers interact with their mothers, reporting afterward: “It reminds me that I never got to know my mom.”

Her grief reactions are described as persistent, intense, developmentally incongruent, and significantly impairing.

Amina was born prematurely in Cape Verde following a traumatic delivery that resulted in her biological mother’s death. She spent approximately two months in a malnutrition unit due to failure-to-thrive, jaundice, and medical instability. Her early health concerns included:

• Failure-to-thrive
• Malaria and tuberculosis
• Chronic ear infections
• Possible mild developmental delays
• Institutional care with limited individualized caregiving

Amina was first placed in an orphanage and later adopted at age five. She experienced:

• Separation from siblings prior to adoption reunification
• Lack of stable early attachment figures
• Limited access to nurturing environments
• Possible traumatic memories related to medical interventions or institutional care

Her adoptive parents describe her as highly sensitive to themes of abandonment, loss, and belonging.

Cultural, Racial, and Transracial Adoption Considerations

Amina’s experience as a Black child in a white adoptive family adds significant layers to her grief, identity development, and overall mental health. These considerations are central – not peripheral – to her case.

Layered Grief and Cultural Loss

Amina’s grief extends beyond the death of her mother and includes:

• Loss of cultural identity
• Loss of connection to her birth community
• Loss of shared racial experiences within her family
• Loss of access to language, traditions, and cultural narratives

These cultural losses intensify her longing for her mother.

Visible Difference and Social Mirroring

Amina does not see her racial identity reflected within her immediate family, which can heighten:

• Feelings of being “different” or less connected
• Sensitivity to belonging and attachment
• Symbolic significance of her biological mother as the one person who “looked like her”
• Developmentally normal – but emotionally amplified – identity distress

Racialized Experiences

As a Black child navigating predominantly white environments, Amina may face:

Microaggressions or bias

Confusion about how to interpret racialized encounters

Limited caregiver capacity to fully model racial coping skills

Increased longing for a biological parent who could share her lived racial experience

Clinical Relevance

These factors interact with trauma and grief. Amina’s racial identity development intensifies her grief and shapes how she interprets early loss and adoption. Culturally responsive care and family-supported racial socialization are essential components of treatment.

Functional Impairment

Amina’s grief significantly disrupts:

• Academic performance
• Peer relationships
• Emotion regulation
• Family interactions
• Identity development
• Self-worth and safety

Her symptoms impair daily functioning across home, school, and social contexts.

DSM-5-TR Diagnostic Formulation

Amina is a 13-year-old African American girl adopted into a white family who presents with persistent sadness, longing for her deceased biological mother, identity-related distress, and functional impairment in academic, emotional, and relational domains. Her grief response appears to be significantly shaped by early traumatic loss, including the death of her mother during childbirth, prolonged hospitalization, institutional care, and disruptions in early attachment. These experiences, compounded by delayed developmental milestones, significant medical complications, and limited access to stable caregiving early in life, contribute to heightened vulnerability for trauma- and grief-related disorders. As Amina enters adolescence, her emerging racial identity as a Black child in a white adoptive family intensifies questions about belonging, origin, and connection, deepening her preoccupation with her mother and amplifying the symbolic meaning of this loss. Her presentation includes chronic yearning, difficulty accepting the death, identity disturbance, emotional dysregulation, and suicidal ideation, all persisting far beyond the expected cultural and developmental timeframe. While differential diagnoses such as depressive disorders, trauma-related disorders, and early-onset psychosis are considered, her symptoms most centrally reflect Prolonged Grief Disorder, with additional risk factors including family psychiatric history and cumulative early adversity. An integrated treatment approach addressing grief, trauma, identity development, and family cultural socialization is indicated.

Dissociative Disorders

Overview

The DSM-5-TR deepens its discussion of dissociative identity disorder (DID), dissociative amnesia, and depersonalization/derealization disorder by refining the presentation of clinical features, enhancing cultural guidance, and identifying comorbidities and functional consequences. While no new disorders are introduced in this chapter, key updates provide clinicians with expanded clarity regarding symptom expression, diagnostic thresholds, and related behaviors such as suicidality.

Dissociative Identity Disorder

Diagnostic Features

In DSM-5-TR, it is clarified that in some cases of dissociative identity disorder (DID), especially the possession-form, alternate identities are externally observable. However, elaborate identity presentations with distinct names or physical traits (e.g., accents, handwriting, clothing) occur in only a minority of non-possession cases and are not required for diagnosis. Individuals may report hallucinations across all sensory modalities and can experience subtle or overt switching between identity states. Amnesia is often broad, affecting daily and non-traumatic memories. These gaps may be noted by others, and individuals commonly rationalize or minimize them.

Associated Features

Functional neurological symptoms, such as non-epileptic seizures and persistent headaches, are noted, particularly in non-Western contexts. Avoidant personality features are common, and some individuals may show borderline traits under stress.

Development and Course

Dissociative Identity Disorder can begin at any age. In children, the condition may manifest through imaginary companions or mood-related states rather than overt identity shifts. Identity confusion may later be triggered by trauma or stressors, even minor ones.

Risk and Prognostic Factors

Early, chronic childhood trauma – especially before age 6 – is a significant risk factor for dissociative identity disorder. About 90% of individuals with DID report histories of abuse, neglect, or trauma. Risk is heightened in those exposed to family dysfunction, bullying, medical trauma, or war. Genetic studies suggest moderate heritability, while neurobiological findings point to changes in brain areas related to memory and emotion. Poor outcomes are associated with ongoing trauma, revictimization, substance use, and involvement in abusive relationships.

Culture-Related Diagnostic Issues

Cultural background shapes how DID presents. In some societies, alternate identities may appear as spirit possessions or religious figures. Unlike culturally sanctioned possession states, dissociative possession is involuntary, distressing, and disruptive. Cross-cultural and intergenerational trauma may also influence symptom expression, particularly in communities affected by violence and oppression.

Association With Suicidal Thoughts or Behavior

Individuals with DID are at significantly increased risk for suicide and self-harm. Over 70% of outpatients with DID report suicide attempts, often with multiple incidents. Risk factors include a history of severe, cumulative trauma; high rates of comorbid PTSD, depression, and substance use; and dissociation itself, which independently contributes to suicidal behavior. The severity of dissociative symptoms is directly linked to higher rates of suicide attempts and nonsuicidal self-injury.

Functional Consequences

Functioning among individuals with DID varies greatly. Some children and adolescents struggle with school and relationships, while others may find school to be a stabilizing environment. Among adults, impairment ranges from minimal – especially in high-functioning professionals – to severe, impacting most areas of daily life. Even in higher-functioning individuals, symptoms often disrupt personal relationships and parenting more than work performance. Over time, some individuals show improvement, but others may continue to experience significant impairment consistent with chronic mental illness.

Differential Diagnosis

Depersonalization/derealization disorder: Depersonalization/derealization disorder is characterized by ongoing or recurring episodes of feeling detached from one’s self (depersonalization), surroundings (derealization), or both. Unlike dissociative identity disorder, individuals with this condition do not experience distinct personality or identity states, nor do they typically report dissociative amnesia.

Schizophrenia and other psychotic disorders: some symptoms may resemble those seen in psychotic disorders, but they are distinct in that individuals with depersonalization/derealization disorder maintain intact

Dissociative Amnesia

Diagnostic Features

Dissociative amnesia typically involves retrograde memory loss, often for everyday events in addition to trauma. Individuals may recall parts of traumatic experiences while remaining amnestic to others.

Development and Course

Acute dissociative amnesia (e.g., related to combat) may resolve quickly after the removal of the triggering environment. In contrast, dissociative fugue may be more persistent. Later-life stress or trauma may trigger a breakdown in previously stable autobiographical memory, often co-occurring with symptoms of PTSD, mood disorders, or substance misuse.

Risk and Prognostic Factors

Dissociative amnesia is primarily associated with exposure to severe, chronic, or acute trauma. Early life adversities, especially repeated physical and sexual abuse, abuse by close attachment figures, and cumulative trauma. significantly increase the risk of memory disturbances. Some individuals may recall similar traumatic events but remain unable to remember specific episodes, even when documented. Generalized dissociative amnesia is more often linked to extreme acute trauma (e.g., combat, torture) or profound psychological conflict from which escape seems impossible. Additionally, genetic studies suggest that approximately half the variability in dissociative symptoms is heritable, while the rest is largely attributed to unique traumatic environmental experiences, particularly those involving early or chronic exposure.

Culture-Related Diagnostic Issues

In cultural contexts where possession is a normative spiritual belief, symptoms of dissociative amnesia or fugue may be interpreted as signs of pathological possession. In such settings, amnesia may not always stem from trauma but instead may follow intense psychological stressors – such as marital conflict, family issues, or experiences of cultural restriction or oppression – that challenge the individual's sense of identity or autonomy.

Association With Suicidal Thoughts or Behavior

Individuals with dissociative amnesia often experience suicidal or self-destructive behaviors. The psychological distress driving generalized amnesia can be severe, and the risk of suicide may increase if the amnesia suddenly lifts and the person is confronted with overwhelming, previously inaccessible memories.

Functional Consequences

Functional impairment in dissociative amnesia varies widely. Individuals with trauma-related amnesia from childhood or adolescence may struggle with forming and maintaining relationships, while some compensate through compulsive overachievement in work. Those with acute generalized amnesia typically experience severe impairment across all areas of functioning. A significant subset develops chronic autobiographical memory loss that persists despite attempts to relearn personal history, resulting in long-term, debilitating effects on daily life.

Differential Diagnosis

Memory deficits associated with electroconvulsive therapy (ECT); acute dissociative reactions to stressful events: Memory loss following ECT typically affects the day of treatment and may occasionally extend to broader retrograde or anterograde amnesia. Unlike dissociative amnesia, ECT-related memory issues are not linked to trauma and usually resolve after treatment ends. In individuals with dissociative disorders and severe depression, ECT does not worsen dissociation and may even improve memory as depressive symptoms subside.

Memory changes with aging or mild neurocognitive disorder: Memory difficulties in mild neurocognitive disorder typically involve problems learning and retaining new information, assessed through tasks like verbal recall. In contrast, dissociative amnesia often involves retrograde memory loss tied to personal life events. Similar recall issues may also appear in normal cognitive aging, but without the trauma-related context or severity seen in dissociative amnesia.

Depersonalization/Derealization Disorder

Culture-Related Diagnostic Issues

Cultural interpretations (e.g., supernatural explanations) may buffer or exacerbate individual distress. In some settings, depersonalization/derealization may not be pathologized if culturally normalized.

Differential Diagnosis

Traumatic brain injury: Depersonalization and derealization symptoms may occur after a traumatic brain injury (TBI), but they are typically distinguished from depersonalization/derealization disorder by their onset following the injury and the absence of the full symptom profile required for a clinical diagnosis.

Dissociation due to another medical condition: Dissociative symptoms with late onset or atypical presentation may indicate an underlying medical condition. A thorough medical and neurological evaluation is essential, especially to rule out seizure disorders such as epilepsy.

Somatic Symptom and Related Disorders

Overview

The DSM-5-TR refines the understanding of somatic symptom disorder (SSD) and related conditions by expanding clinical guidance on severity specifiers, course characteristics, and cultural and gender influences. Although no new disorders are added, this revision highlights the functional impact and suicidal risk across these diagnoses, underscoring the importance of differential diagnosis and comorbidity assessment.

Changes Made to the Introduction

In functional neurological symptom disorder and pseudocyesis (categorized under other specified somatic symptom and related disorder), diagnosis centers on clinical evidence of symptom incongruity with known physiological or medical conditions.

Somatic Symptom Disorder (SSD)

Diagnostic Features

The DSM-5-TR clarifies the severity specifiers for somatic symptom disorder based on the number of psychological symptoms outlined in Criterion B. Mild cases involve one Criterion B symptom and are more common, whereas moderate and severe forms involve two or more Criterion B symptoms, often alongside multiple somatic complaints or one particularly severe symptom, and are associated with greater functional impairment. While the diagnostic criteria are considered appropriate for children and adolescents, research in youth populations remains limited compared to adults.

Prevalence

Somatic symptom disorder is estimated to affect approximately 4%–6% of the general adult population, with higher rates observed in primary care (10%–20%) and psychosomatic settings (up to 60%). Women report more somatic symptoms than men, suggesting a higher prevalence among women.

Development and Course

Somatic symptom disorder typically follows a chronic and fluctuating course. Its progression is influenced by the number of symptoms, age, comorbid conditions, and level of impairment. Personality traits such as low harm avoidance and high cooperativeness are associated with a quicker remission.

Culture-Related Diagnostic Issues

Cultural differences in somatic symptom reporting may be shaped by sociocultural factors, particularly the stigma associated with mental illness, which can influence how distress is expressed and understood across cultural contexts.

Sex- and Gender-Related Diagnostic Issues

Women tend to report more, and more severe, somatic symptoms than men, particularly in clinical settings involving chronic pain. While trauma exposure, including sexual abuse and intimate partner violence, contributes to somatic symptom expression in both sexes, a history of multiple adverse childhood experiences is especially linked to increased symptom expression among women.

Association With Suicidal Thoughts or Behavior

Somatic symptom disorder is linked to increased risk of suicidal thoughts and behaviors. This association is likely influenced by the frequent comorbidity with depressive disorders, which share overlapping symptoms and contribute to overall psychological distress.

Differential Diagnosis

• Psychological factors affecting other medical conditions: Somatic symptom disorder is diagnosed when individuals experience distressing or impairing somatic symptoms, regardless of the presence of a medical condition, paired with excessive or disproportionate thoughts, feelings, or behaviors related to those symptoms

• Factitious disorder and malingering: Unlike factitious disorder and malingering, where individuals intentionally falsify symptoms to deceive, those with somatic symptom disorder experience genuine and distressing symptoms that are not fabricated or self-induced. Their suffering is authentic, even when no clear medical explanation is found.

Comorbidity

Somatic symptom disorder frequently co-occurs with anxiety and depressive disorders, which are present in up to half of cases and contribute significantly to impaired functioning and reduced quality of life. Other common comorbidities include posttraumatic stress disorder, obsessive-compulsive disorder, and, in men, sexual dysfunction. Additionally, elevated psychological features associated with somatic symptom disorder (Criterion B) are also observed in various general medical conditions.

Illness Anxiety Disorder

Development and Course

Age does not significantly differentiate those with illness anxiety from others in medical settings, indicating consistent presentation across the adult lifespan.

Functional Neurological Symptom Disorder (FNSD)

Diagnostic Features

Diagnosis of functional neurological symptom disorder requires clear clinical evidence that symptoms are incompatible with known neurological conditions. This determination should be made within the broader clinical context by a clinician with neurological expertise. Importantly, this is not a diagnosis of exclusion and may be made even when an individual has a co-occurring neurological condition such as epilepsy or multiple sclerosis.

Prevalence

While transient functional neurological symptoms are common, the exact prevalence of the disorder remains unknown. Incidence rates for persistent symptoms are estimated at 4–12 per 100,000 annually in the U.S. and northern Europe. In specialty settings, prevalence appears higher, with about 5%–15% of neurology clinic patients and similar rates reported in psychiatric settings in Japan and Oman.

Sex- and Gender-Related Diagnostic Issues

Functional neurological symptom disorder is two to three times more common in women across most symptom types. Clinical data suggest men more often present with cognitive impairment and weakness, while women report higher rates of past sexual and physical trauma.

Association With Suicidal Thoughts or Behavior

Individuals with functional neurological symptom disorder are at increased risk for suicidal thoughts and attempts. Studies show higher rates of suicidal ideation compared to those with recognized neurological diseases. Risk factors for suicide attempts include childhood maltreatment, risky alcohol use, and more severe dissociative symptoms.

Factitious Disorder

Diagnostic Features

New clarification: Individuals may fabricate symptoms outside of medical settings, such as misleading others in person or online, even when not seeking medical attention.

Differential Diagnosis

• Deception to avoid legal liability: Must distinguish from deception aimed at avoiding legal consequences or external incentives, which would suggest malingering.

Feeding and Eating Disorders

Overview

The DSM-5-TR maintains the diagnostic structure of the DSM-5 for feeding and eating disorders but includes enhanced detail in prevalence estimates, suicidality, and cultural and developmental nuances to support greater diagnostic precision and clinical awareness.

Pica

Prevalence

Limited data indicate that pica affects approximately 5% of school-age children. It is also observed in about one-third of pregnant women, particularly among those experiencing food insecurity. Pica is commonly associated with nutritional deficiencies and limited access to adequate food.

Sex- and Gender-Related Diagnostic Issues

Pica occurs across both genders. A notable gender-related manifestation: pregnancy-related pica, where specific nonfood cravings such as chalk or ice may emerge.

Avoidant/Restrictive Food Intake Disorder (ARFID)

Prevalence

Limited data exist on the prevalence of avoidant/restrictive food intake disorder (ARFID). One Australian study reported a frequency of 0.3% among individuals aged 15 years and older.

Differential Diagnosis

Obsessive-compulsive and related disorders due to pediatric acute-onset neuropsychiatric syndrome: Avoidant/restrictive food intake disorder (ARFID) can overlap with obsessive-compulsive disorder (OCD) when food avoidance stems from preoccupations or ritualized eating behaviors. However, a concurrent diagnosis should only be made if all ARFID criteria are met and the eating disturbance is a primary clinical concern requiring targeted treatment.

Developmentally normal behavior: Food selectivity or “picky eating” is a common and typically transient phase in toddler and early childhood development. Avoidant/restrictive food intake disorder should not be diagnosed in these cases unless the eating behavior leads to significant nutritional deficiency, weight loss, or marked functional impairment as outlined in Criterion A.

Anorexia Nervosa

Culture-Related Diagnostic Issues

Recent updates highlight that anorexia nervosa is present across diverse cultural and social groups, though its expression may vary. In some populations, particularly in parts of Asia, individuals may restrict food for reasons other than fear of weight gain – such as gastrointestinal discomfort – reflecting culturally sanctioned explanations. Additionally, in the U.S., mental health service use among individuals with eating disorders is significantly lower in underserved racial and ethnic groups, pointing to disparities in access and engagement with care.

Association With Suicidal Thoughts or Behavior

Suicide risk is significantly elevated: Individuals with anorexia nervosa have suicide rates 18 times higher than matched peers. This underscores the need for suicide risk screening even in the absence of depressive symptoms.

Differential Diagnosis

Extra caution is advised when presenting features are atypical—for example, onset after age 40 or in individuals without clear body image disturbances. Differential diagnoses should include medical or psychiatric causes of significant weight loss or low body weight.

Bulimia Nervosa

Prevalence

Recent data indicate that bulimia nervosa remains more common in women than men, with 12-month prevalence rates ranging from 0.14% to 0.3% in U.S. adults. Lifetime prevalence ranges from 0.28% to 1.0%. Rates are similar across U.S. ethnoracial groups and are highest in high-income countries. Emerging data also suggest rising prevalence in some low- and middle-income countries.

Culture-Related Diagnostic Issues

While prevalence rates of bulimia nervosa appear similar across U.S. ethnoracial groups, treatment utilization is significantly lower among underserved ethnic and racialized populations compared to non-Latinx White individuals. This highlights a disparity in access to or engagement with care for eating disorders.

Binge-Eating Disorder

Prevalence

Binge-eating disorder affects approximately 0.44% to 1.2% of adults annually in the U.S., with lifetime rates between 0.85% and 2.8%. It is two to three times more common in women than in men. Prevalence is similar across U.S. ethnoracial groups and comparable to rates in other high-income countries. Emerging data suggest similar or higher rates in parts of Latin America, with U.S.-based Mexican Americans showing higher prevalence than individuals in Mexico.

Association With Suicidal Thoughts or Behavior

Approximately 25% of individuals with binge-eating disorder report suicidal ideation. Elevated suicide risk appears independent of weight status and may be influenced by comorbid depression, low self-esteem, or emotional dysregulation.

Elimination Disorders

Overview

The DSM-5-TR retains the core diagnostic criteria from the DSM-5 for enuresis and encopresis but includes expanded clinical observations related to prevalence, sex differences, cultural issues, and comorbidity, enhancing diagnostic clarity and awareness of differential patterns.

Enuresis

Prevalence

Recent updates to the DSM-5-TR provide more specific prevalence estimates for both daytime and nocturnal enuresis. Boys and children from socially marginalized groups may experience higher rates, as may youth with learning disabilities or ADHD.

Culture-Related Diagnostic Issues

The DSM-5-TR emphasizes the cross-cultural consistency of enuresis prevalence and developmental trajectory across countries such as the U.S., various European nations, Africa, and Asia.

Sex- and Gender-Related Diagnostic Issues

Nocturnal enuresis remains significantly more common in males, especially in younger children and milder cases limited to nighttime episodes, with an approximate male-to-female ratio of 2:1. Daytime wetting, however, is more frequently associated with urinary tract infections in females.

Comorbidity

Children with enuresis often show elevated rates of developmental and behavioral concerns compared to their continent peers. Common comorbidities include delays in speech, language, learning, and motor development. Encopresis and constipation frequently co-occur with both daytime and nighttime incontinence. Sleep-related disorders, such as parasomnias and restless legs syndrome, are associated with nocturnal enuresis. Notably, children with sleep-disordered breathing, such as heavy snoring or sleep apnea, may benefit from adenotonsillectomy, which results in dryness in about half of these cases. Urinary tract infections are particularly common in children with daytime incontinence and nonmonosymptomatic nocturnal enuresis.

Encopresis

Prevalence

The DSM-5-TR clarifies that the majority of children older than age 4 who are diagnosed with encopresis present with the subtype “with constipation and overflow incontinence.” This emphasis reflects clinical observation that most cases are not due to intentional soiling but are instead associated with chronic constipation leading to involuntary leakage. This clarification supports more accurate diagnosis and treatment planning by distinguishing between functional and behavioral causes of fecal incontinence.

Sleep-Wake Disorders

Overview

The DSM-5-TR retains the structure and diagnostic criteria of sleep-wake disorders introduced in DSM-5 but adds clarifying updates across multiple areas, including comorbidity, suicide risk, cultural considerations, and clinical recording procedures. These updates reflect a more integrative view of sleep disorders as both independent conditions and potential early indicators or complications of other psychiatric and medical disorders.

Changes Made to the Introduction

Co-Occurring Disorders and Differential Diagnosis

The DSM-5-TR reinforces the high comorbidity between sleep disorders and other mental and medical conditions. Depression, anxiety, neurocognitive changes, and physical disorders such as cardiac and pulmonary disease frequently co-occur with sleep disturbances. Sleep disorders may act as prodromal symptoms, risk factors, or exacerbating features of other conditions. Accurate differential diagnosis now demands a multidimensional approach, considering coexisting conditions as the norm rather than the exception. REM sleep behavior disorder is highlighted as a possible early sign of neurodegenerative diseases such as Parkinson’s, increasing its clinical importance in early identification and intervention.

Key Concepts and Terms

The DSM-5-TR retains the classification of sleep into REM and three NREM stages (N1, N2, N3), as measured by polysomnography. It emphasizes changes in sleep architecture across the lifespan and clarifies diagnostic tools, including the multiple sleep latency test (MSLT), used to assess physiological sleepiness during daytime. New terminology and a stronger integration of polysomnographic parameters are standard across the chapter to promote diagnostic consistency.

Association With Suicidal Thoughts or Behavior

Insomnia and nightmares are both reaffirmed as significant risk factors for suicidal ideation and behaviors, independent of depression. Particularly in adolescents, insufficient sleep duration (<8 hours) is associated with increased risk of self-harm and suicidality. These findings reinforce the importance of assessing sleep symptoms as part of suicide risk evaluations.

Insomnia Disorder

Recording Procedures

DSM-5-TR allows for greater clinical nuance with specifiers that denote comorbid conditions, such as co-occurring mental disorders, medical conditions, or other sleep disorders, aiding in treatment planning and documentation.

Culture-Related Diagnostic Issues

Insomnia is considered a universal human experience, yet cultural frameworks significantly shape its perception and response. Some cultures interpret insomnia as a natural part of aging or stress and rely on non-medical coping strategies such as prayer or herbal treatments. Explanatory models vary and often attribute insomnia to environmental or bodily imbalances, potentially delaying biomedical treatment-seeking.

Sex- and Gender-Related Diagnostic Issues

Insomnia’s onset in women is frequently linked to childbirth and menopause. Despite higher reported rates in perimenopausal and postmenopausal women, objective sleep studies suggest better preservation of sleep quality in older women than men, indicating a disparity between subjective reports and physiological data.

Association With Suicidal Thoughts or Behavior

The updated text confirms that insomnia symptoms serve as an independent predictor of suicidal thoughts and behaviors, underlining the need for routine screening in individuals presenting with sleep disturbances.

Hypersomnolence Disorder

Recording Procedures

The DSM-5-TR includes specifiers for hypersomnolence disorder to document clinically relevant comorbidities. Clinicians can specify whether the condition co-occurs with a mental disorder (including substance use), a medical condition, or another sleep disorder. When using these specifiers, the diagnosis should list hypersomnolence disorder (F51.11) followed by the name and diagnostic code of each comorbid condition (e.g., F51.11 hypersomnolence disorder, with major depressive disorder; F33.1 major depressive disorder, recurrent, moderate).

Differential Diagnosis

DSM-5-TR reiterates the importance of distinguishing hypersomnolence from narcolepsy, fatigue associated with mental or medical conditions, and other sources of excessive sleepiness.

Narcolepsy

Subtypes and Diagnostic Features

The diagnostic framework remains consistent, but associated features now include impairments in working memory and executive function despite average intelligence, expanding the understanding of cognitive consequences in narcolepsy.

Culture-Related Diagnostic Issues and Diagnostic Markers

Cultural differences in narcolepsy presentation and interpretation may affect diagnosis and help-seeking. Among African Americans, narcolepsy may present earlier and without classic cataplexy, often complicated by comorbidities linked to social determinants of health. In some cultures, symptoms like sleep paralysis are interpreted as supernatural, influencing how individuals respond to the condition.

Obstructive Sleep Apnea Hypopnea

Diagnostic Features

DSM-5-TR emphasizes that most cases remain undiagnosed and clarifies that diagnostic criteria differ for children and adults, highlighting the need for age-appropriate assessment.

Associated Features

Obstructive sleep apnea hypopnea may present with insomnia and various nonspecific symptoms, including morning headaches and sexual dysfunction. It is often associated with hypertension and, in severe cases, abnormal cardiac, respiratory, or hematologic findings that may indicate coexisting conditions.

Prevalence

Obstructive sleep apnea hypopnea is common, especially among men, older adults, and certain racial and ethnic groups, with higher rates linked to obesity. Prevalence increases with age and is often undiagnosed, particularly in older adults and underserved populations. Social determinants of health may contribute to disparities across groups.

Differential Diagnosis

Key differentials include central sleep apnea and nocturnal asthma, both of which may present similarly but require distinct management approaches.

Central Sleep Apnea

Subtypes

Clarified subtypes include central apnea due to medical conditions without Cheyne-Stokes breathing, typically resulting from dysfunction in brainstem respiratory control.

Relationship to ICSD

The ICSD-3 identifies eight subtypes of central sleep apnea, each with specific diagnostic criteria. Most require at least five central events per hour and related symptoms, with central events making up at least 50% of total apneas and hypopneas. Infant and premature infant subtypes have distinct criteria from adult forms.

Sleep-Related Hypoventilation

Subtypes

Clarified subtypes now include idiopathic, congenital, and comorbid presentations. Each reflects differing underlying mechanisms, from genetic origins to overlap with other sleep disorders.

Sex- and Gender-Related Diagnostic Issues

Contrary to previous assumptions, new evidence indicates that obesity hypoventilation affects men and women equally, with some data suggesting a slightly higher prevalence in women.

Non-Rapid Eye Movement Sleep Arousal Disorders

Development and Course

DSM-5-TR now emphasizes that violent or sexual behaviors during sleepwalking are more likely in adults, refining understanding of the course and clinical risk associated with NREM sleep arousal disorders.

Nightmare Disorder

Risk and Prognostic Factors

Middle-aged adults experiencing frequent nightmares may also present with mood disturbance, insomnia, substance use, and other stressors. These associations are supported by data from diverse populations, including studies in Hong Kong and Finland.

Culture-Related Diagnostic Issues

Nightmares may hold spiritual significance in some cultures, serving as indicators of moral, emotional, or ancestral disturbances. This underscores the need for cultural sensitivity in assessment.

Association With Suicidal Thoughts or Behavior

Nightmares are independently associated with elevated risk for suicidal thoughts and behaviors.

Differential Diagnosis

Nightmares must be differentiated from PTSD, acute stress disorder, and sleep-related seizures.

Rapid Eye Movement Sleep Behavior Disorder

Prevalence

REM sleep behavior disorder affects about 1%–2% of middle-aged to older adults, with similar rates between men and women in some studies. Prevalence may be higher in individuals with psychiatric disorders, potentially due to medication effects.

Culture-Related Diagnostic Issues

Chinese individuals with REM sleep behavior disorder showed similar clinical features to non-Latinx Whites but were more likely to wander at night and less likely to experience sleep-related injuries, possibly due to earlier family detection.

Sex- and Gender-Related Diagnostic Issues

REM sleep behavior disorder is most commonly observed in men over the age of 50; however, it is increasingly being recognized in women and younger individuals.

Differential Diagnosis

It is important to distinguish this disorder from medication-induced parasomnia and asymptomatic REM sleep without atonia.

Substance/Medication-Induced Sleep Disorder

Specifiers

DSM-5-TR now categorizes four types of substance-induced sleep disturbances: insomnia, daytime sleepiness, parasomnia, and mixed type. This enables a more precise diagnosis based on the nature and effects of the substance.

Relationship to ICSD

Unlike DSM-5-TR, ICSD-3 classifies these conditions under their respective symptom phenotypes without a distinct category for substance-induced insomnia. This reflects differing diagnostic frameworks across nosologies.

Sexual Dysfunctions

Overview

The DSM-5-TR retains the diagnostic framework from DSM-5 for sexual dysfunctions but incorporates important clarifications, population considerations, and culturally responsive language. It highlights the importance of acknowledging gender-diverse individuals, expands discussion on suicidality, and underscores contextual influences on sexual health and distress.

Introduction

Population Considerations

The DSM-5-TR acknowledges that gender-diverse individuals, including transgender, nonbinary, and agender persons, may not align with the traditionally binary, sex-based diagnostic categories used in this section. Clinicians are encouraged to consider individualized clinical presentations and to use diagnostic criteria flexibly and sensitively. It is also emphasized that sexual dysfunctions can occur alongside medical or mental health conditions, and that multiple sexual dysfunction diagnoses may coexist in a single individual.

Delayed Ejaculation

Diagnostic Features

Delayed ejaculation is diagnosed when a man consistently experiences a significant delay, infrequency, or inability to ejaculate during partnered sexual activity, despite adequate stimulation and desire, for at least six months, and when it causes distress. Diagnosis relies on self-report and clinical judgment, considering sexual history, age, and relational context. There is no set standard for what constitutes an abnormal delay, and definitions often focus on intravaginal latency. The condition should not be diagnosed if symptoms stem solely from unrealistic sexual expectations or are consistent with normal aging.

Associated Features

Delayed ejaculation is linked to relationship distress, sexual dissatisfaction, and factors such as frequent masturbation, unrealistic sexual expectations, and partner or relationship issues. It may lead to sexual avoidance or physical discomfort during sex.

Development and Course

Delayed ejaculation may be lifelong or acquired, with causes ranging from biomedical to psychosocial. Its prevalence increases with age due to changes in ejaculatory function and medical or medication-related factors.

Risk and Prognostic Factors

Delayed ejaculation is influenced by psychosocial factors like depression and relationship issues, as well as medical conditions, neurological disorders, certain medications, substance use, and age-related hormonal and nerve changes.

Sex- and Gender-Related Diagnostic Issues

By definition, delayed ejaculation is a diagnosis specific to males. Similar distress related to difficulties achieving orgasm in females is classified as female orgasmic disorder.

Functional Consequences

Delayed ejaculation is often linked to significant psychological distress in one or both partners, reinforcing the importance of addressing the relational and emotional impact during assessment and treatment.

Erectile Disorder

Diagnostic Features

Erectile disorder involves persistent difficulty obtaining or maintaining an erection or reduced rigidity during most sexual activity for at least 6 months, causing significant distress. It differs from the broader term "erectile dysfunction" by requiring duration and clinical impact for diagnosis.

Prevalence

Erectile disorder becomes increasingly common with age, affecting up to 75% of men over 70. It is rare in men under 40 and shows no significant differences across ethnoracial groups or sexual orientation in older adults.

Culture-Related Diagnostic Issues

Erectile disorder prevalence varies by country, influenced by cultural norms around masculinity, aging, and sexual performance. Cultural anxieties, such as concerns about genital size or fertility, may affect symptom reporting and experience.

Sex- and Gender-Related Diagnostic Issues

Erectile disorder is a diagnosis specific to males. In females, similar distress related to sexual arousal difficulties is classified as female sexual interest/arousal disorder.

Diagnostic Markers

Diagnostic tests for erectile disorder help distinguish psychological from physical causes and may include sleep-based assessments, vascular and nerve studies, and hormone, glucose, and lipid evaluations, especially in older men or those with medical comorbidities.

Association With Suicidal Thoughts or Behavior

Erectile disorder, especially with comorbid depression or prostate cancer treatment, is linked to increased risk of suicidal thoughts and behaviors.

Female Orgasmic Disorder

Association With Suicidal Thoughts or Behavior

Sexual dissatisfaction and arousal dysfunction have been linked to increased risk of suicidal thoughts in female veterans and service members, even after adjusting for PTSD and depression.

Female Sexual Interest/Arousal Disorder

Sex- and Gender-Related Diagnostic Issues

There is no evidence that the prevalence or expression of this disorder differs between heterosexual and lesbian women.

Association With Suicidal Thoughts or Behavior

As with other female sexual dysfunctions, this condition is associated with increased risk for suicidal ideation, highlighting the need for thorough psychosocial assessment.

Genito-Pelvic Pain/Penetration Disorder

Culture-Related Diagnostic Issues

Cultural narratives that prioritize male pleasure and stigmatize female sexual agency can hinder help-seeking and shape how symptoms are communicated. In some cultures, women may frame their symptoms indirectly, such as expressing dissatisfaction with marriage rather than explicitly reporting pain.

Male Hypoactive Sexual Desire Disorder

Comorbidity

It is rarely diagnosed in isolation and frequently co-occurs with erectile disorder, delayed ejaculation, or premature ejaculation.

Premature (Early) Ejaculation

Functional Consequences

Single men may experience greater distress due to interference with dating and establishing new relationships.

Substance/Medication-Induced Sexual Dysfunction

Associated Features

Cannabis and alcohol are both central nervous system depressants and are noted as potential contributors to sexual dysfunction. However, some research suggests cannabis may also enhance orgasm satisfaction in certain individuals, reflecting the complexity of substance-related effects.

Sex- and Gender-Related Diagnostic Issues

Gender differences in sexual side effects from medications are noted, with men more likely to report issues with desire and orgasm, while women more often report arousal difficulties, particularly with antidepressant use.

Gender Dysphoria

Overview

The DSM-5-TR enhances the conceptualization of gender dysphoria by addressing language inclusivity, expanding on developmental and clinical trajectories, and incorporating suicide risk factors and comorbid conditions specific to transgender and gender-diverse individuals.

Changes Made to the Introduction

The DSM-5-TR introduces expanded terminology and updated concepts to better reflect diverse gender identities and experiences. New and revised terms include disorders of sex development, birth-assigned sex, gender-affirming treatments, experienced gender, gender fluid, gender neutral, cisgender, and non-transgender. These updates reflect evolving language and clinical understanding of gender diversity.

Gender Dysphoria

Specifiers

The DSM-5-TR introduces two specifiers for gender dysphoria: “with a disorder/difference of sex development” for individuals with a documented medical diagnosis, and “posttransition” for those undergoing treatments to support their affirmed gender.

Diagnostic Features

The DSM-5-TR notes an increase in early social transition among children. Many parents now seek support from gender clinics after their child has already socially transitioned, indicating a shift toward earlier recognition and affirmation of gender identity in childhood.

Associated Features

There is an observed overrepresentation of autism spectrum traits in individuals with gender dysphoria across all age groups. Conversely, those with autism spectrum disorder are more likely to express gender diversity, suggesting an intersection that may warrant further clinical attention.

Prevalence

DSM-5-TR notes that while clinical prevalence of gender dysphoria is estimated at less than 0.1%, self-reported data from population surveys suggest higher rates of transgender identity and gender incongruence. Variability in assessment methods limits comparability across studies, and many individuals do not seek specialty care, likely resulting in underestimates.

Development and Course

Gender dysphoria may present in early childhood (prepubertal onset) or emerge later during or after puberty (late/postpubertal onset). These differing trajectories influence identity development, support needs, and clinical presentation.

Risk and Prognostic Factors

The DSM-5-TR outlines multiple factors influencing the development and persistence of gender dysphoria. Early, intense gender nonconformity and older age at presentation are linked to greater likelihood of persistence. Potential contributors include environmental influences, a history of transvestism in postpubertal-onset cases, and genetic factors, with evidence of higher concordance in monozygotic twins. Some endocrine differences have been noted, though systemic hormone abnormalities are not typical in individuals without a disorder of sex development (DSD). For those with a DSD, significant variations in prenatal androgen exposure or sensitivity increase the likelihood of later gender dysphoria.

Culture-Related Diagnostic Issues

Gender dysphoria is observed across diverse global cultures, including societies with recognized nonbinary gender categories. However, it is unclear if individuals in these contexts meet DSM-5-TR diagnostic criteria. Cultural attitudes toward gender nonconformity influence mental health outcomes, though anxiety remains common even in more accepting societies.

Sex- and Gender-Related Diagnostic Issues

Referral patterns for gender dysphoria vary by age and sex assigned at birth. In children, more individuals assigned male at birth are referred, while in adolescents and young adults, referrals are increasingly higher for those assigned female at birth. Among adults, individuals assigned male at birth more commonly seek gender-affirming treatment.

Association With Suicidal Thoughts or Behavior

Transgender individuals experience disproportionately high rates of suicidal ideation and attempts, with reported rates ranging from 30% to 80%. Risk factors include gender-based victimization, maltreatment, depression, substance use, and young age. These data highlight the urgent need for affirming and protective interventions.

Differential Diagnosis

Clinicians must differentiate gender dysphoria from other conditions, such as autism spectrum disorder, where gender-related behaviors may stem from different developmental pathways but still warrant affirming care.

Comorbidity

Gender dysphoria frequently co-occurs with anxiety, depression, and trauma-related disorders. PTSD may develop in response to gender-based harassment and violence, underscoring the psychological impact of social stigma and discrimination.

Disruptive, Impulse-Control, and Conduct Disorders

Overview

The DSM-5-TR introduces nuanced insights into risk factors, cultural and sex/gender considerations, and associations with suicidal behavior across several disorders in this category. There is also greater attention to comorbidity and developmental context, supporting improved diagnostic clarity and intervention planning.

Oppositional Defiant Disorder

Risk and Prognostic Factors

The DSM-5-TR highlights the bidirectional influence between children with oppositional defiant disorder (ODD) and their environments. The disorder is more common in children who experience disrupted caregiving, such as frequent changes in primary caregivers. These children are also at increased risk for both engaging in bullying behavior and being targets of peer bullying.

Culture-Related Diagnostic Issues

Cultural norms and diagnostic bias may influence the reported prevalence of oppositional defiant disorder (ODD). While ODD is more common in boys in Western cultures, prevalence is similar across genders in non-Western cultures. Interestingly, first-generation migrants and refugees may show lower risk for ODD despite experiencing adversity.

Sex- and Gender-Related Diagnostic Issues

Sex and gender differences in oppositional defiant disorder are minimal, though harsh parenting may be a stronger risk factor for girls than for boys.

Differential Diagnosis

ODD must be differentiated from adjustment disorder and posttraumatic stress disorder (PTSD). Adjustment disorder may present with similar behavioral symptoms following a stressor, and PTSD may involve oppositional behavior tied to trauma-related responses.

Comorbidity

ODD commonly co-occurs with ADHD and conduct disorder. Importantly, it is mutually exclusive with disruptive mood dysregulation disorder (DMDD), which shares overlapping symptoms but requires careful diagnostic distinction.

Clinical Example

To help you understand and appreciate the refinements in the DSM-5-TR, the following is an excerpt from a neurodevelopmental evaluation I conducted. The client is a 10-year-old male who had previously undergone neuropsychological testing for suspected autism; however, the results were inconclusive. I reference the findings from this initial evaluation to provide context.

As you review this clinical example, note how I used the differential diagnosis section of the DSM-5-TR to integrate features of oppositional defiant disorder into the autism profile, rather than assigning it as a separate diagnosis. My clinical approach emphasizes consolidating diagnostic formulations whenever possible and avoiding the assignment of multiple diagnoses. Overdiagnosis can fragment treatment planning, create confusion for clients and their families, and increase the risk of stigmatization or marginalization. This approach is particularly relevant when considering the inclusion of oppositional defiant disorder within an autism diagnostic profile.

Based on the published literature and research, I developed the model titled “The Connection Between ASD Noncompliant Behavior and Irritable Mood” and included this in my written report.

Please note that client identifying information has been masked or altered to protect privacy.

Below is content from my report section titled “DSM-5-TR Clinical Case Formulation”.

Other Conditions That May Be a Focus of Clinical Attention

• Z62.820 Parent-Biological Child Relational Problem

  Encompasses reported disruptive, oppositional, and defiant-related behaviors (angry/irritable mood, argumentative/defiant behavior).

Colman’s predominant affective expressions are anger and irritation. While these symptoms are core to ODD (and DMDD), despite receiving this diagnosis nearly three years ago (per Dr. Neuropsychologist), numerous pharmacological trials (i.e., clonidine, lamotrigine, escitalopram, aripiprazole, sertraline), and other interventions (therapy/counseling and Brain Balance), all treatments have failed to remediate Colman’s chronic irritable/angry mood and argumentative/defiant behavior. This is evidence that ODD is an incorrect diagnosis.

The additional problem with a diagnosis of ODD is that it inherently complicates the ability to identify and modify maladaptive interpersonal interactions – specifically antecedents, behavior, and consequences. Even the DSM-5-TR acknowledges this fact (pp. 523-524):

The symptoms of the disorder often are part of a pattern of problematic interactions with others. Furthermore, individuals with this disorder typically do not regard themselves as angry, oppositional, or defiant. Instead, they often justify their behavior as a response to unreasonable demands or circumstances. Thus, it can be difficult to disentangle the relative contribution of the individual with the disorder to the problematic interactions he or she experiences. For example, children with oppositional defiant disorder may have experienced a history of hostile parenting, and it is often impossible to determine if the child’s behavior caused the parents to act in a more hostile manner toward the child, if the parents’ hostility led to the child’s problematic behavior, or if there was some combination of both. Whether or not the clinician can separate the relative contributions of potential causal factors should not influence whether the diagnosis is made.

Because a diagnosis of ODD interferes with conducting a functional analysis of Colman’s problematic behavior, it must be excluded as a clinical diagnostic option. Yet, it is helpful to understand that only 17% of parents of children with autism describe their children as predominantly happy, pleasant, and cooperative (Mayes & Calhoun, 1999). In the Journal of Autism and Developmental Disorders, Kalvin and colleagues (2021) elaborated on why:

Recent studies indicate that high levels of affective irritability are common in children with ASD … In this study, 93% of children with ASD and clinically significant noncompliant behavior, measured using the oppositional behavior scale of the Pediatric Behavior Scale, were reported as having irritable mood often or very often, and 82.4% were reported as having temper outbursts often or very often.

In addition to the risk factors for irritability that can be common across childhood disorders, irritability in children with ASD may also arise due to challenges conferred by the core symptoms of the disorder. For example, difficulty communicating one’s thoughts, feelings or needs to others, having one’s repetitive behaviors prevented or interrupted, and exposure to aversive sensory experiences may result in frustration and heightened irritability. In addition, interpersonal and social communication difficulties that place children with ASD at risk for negative social experiences, such as peer rejection, may engender feelings of hostility and anger.

In children with ASD, irritability and disruptive behaviors are likely to persist over time and contribute to functional impairment over and above the unique effects of ASD. Irritability and disruptive behavior also pose significant disruption to family life, resulting in heightened parental stress and interference in daily functioning for families of children with ASD.

Noncompliant behavior, another problem common among children with ASD, is also likely to be associated with symptoms of irritability. In children, noncompliance occurs in response to limits or demands imposed by parents or other authority figures and when such limits are perceived as interfering with a child’s desires or goals. Such real or perceived blocked goals, in turn, can lead to frustration and thereby elevate the risk for irritability … Further, since restrictive behavior and rigidity, including insistence on sameness and difficulty with transitions, may predispose children with ASD to experience daily parental limits as challenging, noncompliance in children with ASD may be especially associated with frustration and increased susceptibility to irritability.

Further, our findings regarding the relative strength of the associations of anxiety versus noncompliance with irritability, coupled with the unique effect of noncompliance on irritability, suggest that processes related to noncompliance play a larger role in the manifestation of irritability for children with ASD. It may be that anxiety experienced by children with ASD often leads to experiences other than irritability, such as withdrawal and sadness, whereas the experience of blocked goals associated with noncompliance more directly heightens frustration and manifests in irritability.

Reflection questions about this clinical example:

1. What are your thoughts about how I conceptualized Colman’s ODD within Z62.820 parent-biological child relational problem?
   
   
2. How does my conceptualizing of Colman’s ODD as a manifestation of ASD (diagnostic criteria B. Restricted, repetitive patterns of behavior, interests, or activities; 2. Insistence on sameness, inflexible adherence to routines, or ritualized patterns of verbal or nonverbal behavior) influence your diagnostic practice?
   
   
3. How does thinking about diagnostic symptoms as interactional phenomena between family members instead of one-way events influence your treatment planning of clients?

Intermittent Explosive Disorder

Associated Features

Neurobiological findings support a role for serotonergic dysregulation in intermittent explosive disorder (IED), particularly in the limbic system and orbitofrontal cortex – areas associated with impulse control and emotional regulation.

Prevalence

Intermittent explosive disorder (IED) has a 1-year U.S. prevalence of 2.6% and is more common among younger individuals, those with lower education, and some racial/ethnic groups, particularly African American and Caribbean Black adolescents. Cultural and diagnostic biases may affect reported rates. Some studies show higher prevalence in males, though findings on sex differences are mixed.

Association With Suicidal Thoughts or Behavior

Intermittent explosive disorder (IED) comorbid with PTSD is linked to a significantly increased risk of lifetime suicide attempts. Among soldiers with suicidal ideation, IED and PTSD were the only disorders strongly associated with suicide attempts, though IED’s independent role was less clear.

Conduct Disorder

Prevalence

Adolescent-onset conduct disorder is more commonly linked to environmental and psychosocial stressors, including experiences of systemic oppression or discrimination among ethnically marginalized groups.

Association With Suicidal Thoughts or Behavior

There is a significantly higher rate of suicidal thoughts, attempts, and completed suicide among individuals with conduct disorder. A large longitudinal study from Taiwan confirmed that even after adjusting for comorbid mood, anxiety, and substance use disorders, conduct disorder remained a strong predictor of suicide attempts.

Pyromania

Prevalence and Development

Pyromania remains rare and is often underrecognized. The disorder typically begins in adolescence or early adulthood and follows a chronic or episodic course.

Association With Suicidal Thoughts or Behavior

Research on male fire setters indicates elevated rates of suicide and suicide attempts during follow-up. However, it is unclear whether these findings apply specifically to individuals with a diagnosis of pyromania, as distinct from other fire-setting behaviors.

Kleptomania

Association With Suicidal Thoughts or Behavior

Kleptomania is linked to an elevated risk of suicide attempts.

Substance-Related and Addictive Disorders

Overview

The DSM-5-TR refines terminology and provides enhanced guidance on diagnostic specifiers, comorbidities, prevalence trends, and demographic considerations. It avoids using the term "drug addiction" due to its stigma and imprecise meaning, opting instead for the broader, clinically neutral term substance use disorder. Additional clarity is offered around substance-induced versus substance/medication-induced mental disorders. Across substance categories, the DSM-5-TR integrates expanded information on cultural, sex/gender, and environmental influences, as well as associations with suicidality.

Changes Made to the Introduction

"Substance use disorder" is the preferred diagnostic term, encompassing a range of severity. The term “drug addiction” is excluded due to its variable definitions and negative connotations. Additionally, “substance/medication-induced mental disorders” is now used to clearly differentiate these diagnoses from intoxication or withdrawal alone.

Alcohol-Related Disorders

Specifiers

Severity and remission specifiers are now outlined with ICD codes (e.g., mild, moderate, severe; early vs. sustained remission).

Prevalence

Alcohol use disorder prevalence varies by community and is influenced by historical trauma and discrimination. Caution is advised when generalizing estimates across Native American populations due to cultural diversity.

Risk and Prognostic Factors

Poverty, discrimination, limited access to treatment, and environmental availability of alcohol are highlighted as significant risk factors.

Culture-Related Diagnostic Issues

Ethnic density may provide protective social support, while neighborhood segregation can increase exposure to alcohol-related risks.

Sex- and Gender-Related Diagnostic Issues

Though biological risk mechanisms are similar, environmental contributors (e.g., peer influence) differ by sex, especially during adolescence. Alcohol use during pregnancy, though declining, may indicate a severe disorder.

Association With Suicidal Thoughts or Behavior

Alcohol consumption is broadly linked to suicidality, though fewer studies focus specifically on alcohol use disorder.

Alcohol Intoxication

Associated Features

Alcohol intoxication contributes to interpersonal violence, accidental injury, and increased suicide risk. Withdrawal is more severe in individuals with a history of alcohol dependence, comorbid disorders, or concurrent depressant use.

Prevalence

The DSM-5-TR update highlights the high prevalence of alcohol intoxication across the lifespan, particularly among adolescents and adults. It cites data from 2018 showing that nearly half of U.S. 12th graders reported having been drunk at least once. Among adults, the 12-month prevalence of high-risk drinking – defined as four or more drinks per day for women and five or more for men – varies by ethnoracial group, with the highest rates among Native Americans and the lowest among Asians and Pacific Islanders.

Sex- and Gender-Related Diagnostic Issues

On average, women are less tolerant of equivalent amounts of alcohol when compared to men.

Association With Suicidal Thoughts or Behaviors

An international study across emergency departments in 17 countries found that acute alcohol use significantly increases the risk of suicide attempts, independent of chronic alcohol use. Each additional drink was associated with a 30% increase in suicide attempt risk.

Alcohol Withdrawal

Risk and Prognostic Factors

The DSM-5-TR clarifies that alcohol withdrawal is most likely to occur in individuals with heavier and chronic alcohol use. Those with co-occurring conduct disorder or antisocial personality disorder, dependence on other depressant substances (e.g., sedative-hypnotics), or a history of multiple withdrawal episodes are at increased risk for withdrawal. The text also identifies clinical markers that predict severe withdrawal, such as the presence of alcohol withdrawal delirium, prior episodes of severe withdrawal, hypokalemia, thrombocytopenia, and systolic hypertension.

Differential Diagnosis

Alcohol withdrawal must be differentiated from alcohol-induced mental disorders. This distinction hinges on the temporal relationship between alcohol use and symptom onset, as well as the presence or absence of independent mental health conditions.

Alcohol-Induced Mental Disorders

Diagnostic and Associated Features

The DSM-5-TR emphasizes the importance of distinguishing alcohol-induced mental disorders from independent psychiatric conditions. Although these presentations often mimic primary mental health disorders, the key to accurate diagnosis is establishing a temporal connection to alcohol use. Individuals with alcohol-induced mental disorders typically exhibit many of the same features seen in alcohol use disorder, reinforcing the need for a comprehensive clinical assessment.

Caffeine-Related Disorders

Prevalence

The revised text notes a rising prevalence of caffeine intoxication due to the increased consumption of caffeinated energy drinks – particularly among adolescents and young adults in high-income countries. Between 2007 and 2011, emergency department visits in the United States related to energy drink consumption more than doubled, reflecting a growing public health concern.

Caffeine Withdrawal

Sex- and Gender-Related Diagnostic Issues

Caffeine metabolism varies by sex and hormonal status. In females, caffeine is metabolized more slowly when using oral contraceptives or during the luteal phase of the menstrual cycle. Additionally, caffeine clearance is significantly reduced in the second and third trimesters of pregnancy. These physiological changes may prolong adverse effects and modify withdrawal symptom presentation, although they may also reduce the severity of withdrawal in some cases.

Differential Diagnosis

Caffeine withdrawal symptoms should be distinguished from those associated with caffeine-induced sleep disorder. Accurate diagnosis depends on identifying whether the presenting symptoms are a result of reduced caffeine intake or an ongoing disruptive effect of caffeine on sleep patterns.

Cannabis-Related Disorders

Diagnostic Features

The DSM-5-TR expands on the various forms of cannabis use, highlighting the increasing popularity of vaping and dabbing, particularly among youth. These methods involve inhaling psychoactive components without combustion or using concentrated cannabis products. Oral ingestion through edibles or beverages is also noted. Regular cannabis use leads to tolerance, and cessation can result in a distressing withdrawal syndrome that may prompt continued use or relapse.

Sex- and Gender-Related Diagnostic Issues

Women tend to report more severe cannabis withdrawal symptoms than men, particularly mood-related (e.g., irritability, restlessness) and gastrointestinal symptoms (e.g., nausea, stomachaches). These differences may contribute to a telescoping effect, where women progress more quickly from first use to cannabis use disorder.

Comorbidity

Cannabis use disorder is frequently comorbid with other substance use disorders, such as those involving alcohol, cocaine, and opioids – raising the risk of additional substance-related complications by a factor of approximately nine. Additionally, cannabis use disorder often co-occurs with major depressive disorder, bipolar I and II, PTSD, anxiety disorders, and personality disorders. The DSM-5-TR underscores growing concern about cannabis as a risk factor for psychotic disorders. Use during vulnerable developmental periods is associated with a threefold increase in risk for psychosis, with potential to trigger or worsen symptoms and negatively impact treatment outcomes.

Cannabis Intoxication

Diagnostic Features

The revised text includes synthetic cannabinoids (e.g., Spice), which produce effects similar to cannabis at low doses – such as euphoria, talkativeness, and relaxation. At higher doses, however, users are more likely to experience hallucinations or delusions. These products are gaining traction and may present with distinct clinical profiles.

Comorbidity

Cannabis intoxication commonly overlaps with cannabis use disorder. Clinicians are advised to refer to the broader comorbidity section under cannabis use disorder for context on frequently co-occurring conditions.

Cannabis Withdrawal

Diagnostic Features

Cannabis withdrawal is marked by behavioral and emotional symptoms such as irritability, anxiety, depressed mood, sleep difficulty, and decreased appetite. These symptoms can lead to distress, continued use, and relapse. Unlike withdrawal from substances like opioids or alcohol, emotional and behavioral disturbances are more prominent than physical signs.

Associated Features

Withdrawal may be accompanied by fatigue, difficulty concentrating, yawning, and rebound symptoms such as hypersomnia and increased appetite following initial loss of appetite or insomnia.

Developmental and Course

Withdrawal symptoms are seen in both adolescents and adults. As with cannabis use disorder, females may experience more intense withdrawal symptoms than males.

Differential Diagnosis

Clinicians must distinguish cannabis withdrawal from other psychiatric or substance-related conditions, especially when the individual continues to use cannabis to alleviate emerging symptoms.

Comorbidity

Cannabis withdrawal is frequently associated with comorbid mental health concerns, particularly depression, anxiety, and antisocial personality disorder. Given its strong overlap with cannabis use disorder, treatment planning should account for these co-occurring conditions.

Phencyclidine Use Disorder

Diagnostic Features

The DSM-5-TR retains the diagnostic framework for phencyclidine use disorder (PCP), including classification of severity and remission status using ICD-10-CM specifiers. Clinicians should document both severity (mild, moderate, severe) and current remission status (early or sustained) to improve clarity in treatment planning and clinical communication.

Prevalence

Although specific prevalence data for phencyclidine use disorder are lacking, overall rates appear to be low. In the U.S., the broader category of hallucinogen use disorder (which includes phencyclidine) affects approximately 0.1% of individuals aged 12 and older. Additionally, only 0.3% of admissions to U.S. substance use treatment facilities identify phencyclidine as the primary drug of use.

Risk and Prognostic Factors

A general population study in Australia found that ketamine use was more common among men and was associated with high levels of alcohol consumption, specifically more than 11 standard drinks per day.

Sex- and Gender-Related Diagnostic Issues

While the exact gender ratio for phencyclidine use disorder is unknown, data from U.S. substance use treatment admissions indicate that men make up the majority of cases, with 62% identifying phencyclidine as their primary substance.

Differential Diagnosis

Phencyclidine use disorder must be distinguished from phencyclidine intoxication and phencyclidine-induced mental disorders, both of which may present with similar features such as hallucinations, paranoia, agitation, or dissociation. Temporal factors, symptom duration, and functional impairment should guide differential diagnosis.

Other Hallucinogen Use Disorder

Diagnostic Criteria

The DSM-5-TR continues to use ICD-10-CM specifiers to identify the severity (mild, moderate, severe) and remission status (early or sustained) for other hallucinogen use disorder. These specifiers provide greater diagnostic clarity and support clinical tracking over time.

Differential Diagnosis

Distinguishing other hallucinogen use disorder from hallucinogen intoxication and hallucinogen-induced mental disorders is critical. Timing of symptom onset, persistence beyond acute intoxication, and pattern of use should inform diagnostic clarity.

Comorbidity

This disorder frequently co-occurs with other substance use disorders (particularly cocaine, stimulants, and tobacco), personality disorders, PTSD, and panic attacks. The presence of comorbid conditions may compound functional impairments and complicate treatment.

Other Hallucinogen Intoxication

Association With Suicidal Thoughts or Behavior

Though completed suicides are rare, intoxication with hallucinogens has been associated with increased suicidal ideation and erratic behavior, particularly when accompanied by preexisting psychiatric conditions.

Functional Consequences of Other Hallucinogen Intoxication

Acute intoxication may cause a range of physiological and psychological symptoms, including hyperthermia, cardiac complications, hallucinations, and seizures. Severe reactions – such as hepatic failure, cerebral infarction, or rhabdomyolysis – can be life-threatening, especially with synthetic hallucinogens.

Comorbidity

As with hallucinogen use disorder, intoxication often occurs in individuals with concurrent substance use disorders and mental health conditions. Evaluation should consider both acute and underlying psychopathology.

Inhalant Use Disorder

Culture-Related Diagnostic Issues

The DSM-5-TR highlights specific sociocultural contexts that may increase the prevalence of inhalant use. Isolated Indigenous communities and street-involved youth in low- and middle-income countries are noted to have elevated rates of inhalant misuse. These patterns are often linked to systemic poverty, easy access to inhalants, and inhalant use as a means of coping with social marginalization and homelessness.

Association With Suicidal Thoughts or Behavior

Inhalant use disorder is associated with increased suicidal thoughts and behaviors, particularly among individuals who have a history of trauma or comorbid anxiety and depression. This risk is notably present among both adolescents and adults in the United States.

Inhalant Intoxication

Functional Consequences of Inhalant Intoxication

The DSM-5-TR notes that inhalant intoxication can lead to a range of high-risk and antisocial behaviors. These include impulsive or reckless acts (e.g., unprotected sex, physical fights), property destruction, and criminal behavior, as well as a higher incidence of serious accidents.

Opioid Use Disorder

Diagnostic Features

The DSM-5-TR provides an expanded description of opioids to include natural (e.g., morphine, codeine), semi-synthetic (e.g., heroin, oxycodone), and synthetic opioids (e.g., fentanyl, tramadol). It also includes medications with mixed agonist-antagonist properties (e.g., buprenorphine). The criteria clarify that opioid use disorder can develop from prescribed medications when used beyond prescribed amounts and not solely for pain relief, reinforcing the importance of identifying nonmedical use patterns.

Associated Features

Opioid use disorder is associated with a high risk of overdose, whether intentional or unintentional. Overdose typically presents with unconsciousness, respiratory depression, and pinpoint pupils. Importantly, the DSM-5-TR notes that overdoses can occur even in the absence of intoxication-seeking behaviors, underscoring the need for comprehensive risk assessment.

Risk and Prognostic Factors

New information emphasizes personality and behavioral traits such as novelty-seeking and impulsivity as risk factors. Environmental and familial influences also significantly increase vulnerability. This expansion supports a biopsychosocial understanding of the disorder.

Sex- and Gender-Related Diagnostic Issues

The DSM-5-TR identifies gendered patterns in the development and progression of opioid use disorder. Women are more likely than men to begin opioid use in response to trauma, especially sexual violence, and often progress to opioid use disorder more quickly – a phenomenon referred to as telescoping. Women also tend to present with more severe symptoms at treatment entry.

Association With Suicidal Thoughts or Behavior

Opioid use disorder is strongly linked to increased suicide risk. While overlapping risk factors complicate differentiation between accidental overdose and suicide attempts, the DSM-5-TR highlights the importance of assessing for underlying depressive states and recognizing suicide attempts as distinct from nonfatal overdose events when possible.

Comorbidity

Opioid use disorder frequently co-occurs with other substance use disorders and serious mental illnesses, including mood, anxiety, and personality disorders. These comorbidities contribute to greater functional impairment and complicate treatment planning.

Opioid Intoxication

Associated Features

Intoxication is characterized by reduced respiratory rate and blood pressure, pinpoint pupils, and mild hypothermia. The severity and duration of intoxication depend on the pharmacokinetics of the opioid used. Overdose may be fatal and is a common clinical concern.

Differential Diagnosis

Clinicians should distinguish between opioid intoxication and opioid-induced mental disorders, considering overlapping symptoms and timing of onset relative to substance use.

Opioid Withdrawal

Associated Features

Withdrawal can occur across multiple contexts: medical tapering, substance misuse, or self-treatment of psychiatric symptoms. Symptoms vary depending on the duration and intensity of use and the half-life of the substance.

Prevalence

The DSM-5-TR reinforces that physical dependence and withdrawal symptoms are common among regular users of either prescription or illicit opioids.

Development and Course

Withdrawal severity is influenced by the specific opioid used and the duration of use. Gradual tapering during medical management can reduce symptom severity. In opioid use disorder, withdrawal and relapse often form a cyclical pattern that perpetuates substance use.

Sedative-, Hypnotic-, or Anxiolytic-Related Disorders

Diagnostic Criteria

The DSM-5-TR now includes updated specifiers for remission status across severity levels. Clinicians should now indicate both the severity (mild, moderate, severe) and the remission status (early or sustained) using the appropriate ICD-10 codes (e.g., F13.11 for mild in early or sustained remission; F13.21 for moderate/severe).

Culture-Related Diagnostic Issues

Cultural context and national prescribing practices significantly influence the prevalence of use and misuse of these substances. The DSM-5-TR highlights that variations in the availability and prescribing of sedatives, hypnotics, or anxiolytics across countries and populations may contribute to differing rates of use disorders internationally.

Differential Diagnosis

Clinicians are reminded to differentiate between sedative, hypnotic, or anxiolytic use disorder and other related conditions, including intoxication, withdrawal, and substance-induced mental disorders. Accurate diagnosis requires careful evaluation of timing, symptom presentation, and substance use patterns.

Comorbidity

There is a noted increase in risk for developing a use disorder when sedative, hypnotic, or anxiolytic use co-occurs with other psychiatric or substance use disorders. Comorbidity is also associated with a decreased likelihood of remission, emphasizing the need for integrated and sustained treatment strategies.

Sedative, Hypnotic, or Anxiolytic Intoxication

Prevalence

The DSM-5-TR includes updated epidemiological data showing that, as of 2018, approximately 2.4% of individuals age 12 or older in the United States reported nonmedical use of tranquilizers or sedatives, with the prevalence rising to 4.9% among those ages 18–25. This highlights ongoing public health concerns, particularly among young adults.

Stimulant Use Disorder

Diagnostic Criteria

The DSM-5-TR includes detailed ICD-10-CM specifiers for stimulant use disorder, categorized by the type of stimulant (amphetamine-type substances, cocaine, or other/unspecified stimulants), level of severity (mild, moderate, severe), and remission status (early or sustained). Each category now has specific diagnostic codes that clinicians should document accurately to reflect both clinical severity and substance type.

Diagnostic Features

This section clarifies that stimulant use disorder encompasses the misuse of amphetamines (including prescription stimulants such as methylphenidate) and cocaine. While other substances like caffeine, nicotine, and MDMA also have stimulant properties, they are classified under different categories. Cocaine- and amphetamine-related disorders are grouped under one rubric due to their similar neurobehavioral effects. The presentation includes distinctions in routes of administration (e.g., crack cocaine via inhalation) and rapid onset of effects.

Risk and Prognostic Factors

Increased risk is associated with male gender, prior substance use, Cluster B personality disorders, and specific social factors such as being separated or widowed. In the U.S., men who have sex with men are at higher risk for methamphetamine use. These temperamental and environmental factors are important considerations for prevention and early intervention strategies.

Association With Suicidal Thoughts or Behavior

There is limited data directly linking stimulant use disorder to suicide. Most studies focus on stimulant use broadly, rather than diagnosed disorders, highlighting a need for more targeted research.

Functional Consequences of Stimulant Use Disorder

Chronic use of methamphetamine and cocaine is associated with neurocognitive impairments such as deficits in attention, memory, and executive functioning. Repeated use can lead to transient psychosis, seizures, and possibly long-term neurotoxicity. Hospitalized patients with stimulant use disorders experience a significantly higher risk of 30-day readmission, underscoring the clinical impact of the disorder.

Stimulant Intoxication

Prevalence

While the exact prevalence of stimulant intoxication is unknown, stimulant use data serve as an upper-bound estimate. In the U.S., 12-month prevalence rates for cocaine use are highest among individuals aged 18–25 (6.2%) and among men (3%). Methamphetamine use is less common overall, with a 0.6% 12-month prevalence across all age groups. Use varies by race/ethnicity, with Whites having slightly higher reported rates than other groups, though small sample sizes limit reliable estimates for American Indians/Alaska Natives. Notably, many users do not meet the full criteria for intoxication, which requires significant behavioral or psychological symptoms.

Stimulant Withdrawal

Diagnostic Criteria

DSM-5-TR provides updated coding guidance based on the type of stimulant used and whether a comorbid use disorder is present. Withdrawal codes differ for amphetamine-type substances and cocaine, and whether the disorder is mild, moderate/severe, or absent. This emphasizes the need for precise diagnostic coding based on clinical presentation and use history.

Tobacco Use Disorder

Diagnostic Criteria

Tobacco use disorder diagnostic criteria remain consistent but are now paired with specific ICD-10-CM codes that reflect moderate and severe severity levels in early or sustained remission. There is no mild severity specifier coded in this edition.

Prevalence

While cigarettes remain the most commonly used form of tobacco, the DSM-5-TR highlights the growing prevalence of e-cigarette use, particularly among younger populations. Globally, daily tobacco smoking remains more common in men, although the gender disparity varies widely by region, from very high in East Asia to nearly equal in Australasia.

Development and Course

Tobacco addiction can begin soon after initial use, with some criteria such as craving emerging early. However, meeting the full criteria for a use disorder typically unfolds over several years of continued use.

Culture-Related Diagnostic Issues

Tobacco use disorder is more prevalent in populations exposed to racial and ethnic discrimination. Additionally, higher rates have been observed among lesbian, gay, and bisexual individuals, with sexual orientation-related discrimination identified as a potential contributing factor.

Association With Suicidal Thoughts or Behavior

National data show a 2- to 3-fold increased risk for suicidal thoughts and behaviors among individuals with past-year cigarette use, especially with early initiation of tobacco use.

Comorbidity

Tobacco use disorder frequently co-occurs with mood and anxiety disorders. In particular, individuals with major depressive disorder are nearly twice as likely to smoke. Even after controlling for socioeconomic status, depression remains independently associated with smoking. Comorbidity is also high with bipolar I disorder, PTSD, panic disorder, and several personality disorders.

Tobacco Withdrawal

Functional Consequences of Tobacco Withdrawal

Withdrawal can cause clinically significant distress and functional impairment in a minority of smokers, though for many, symptoms are transient and manageable with intervention.

Other (or Unknown) Substance Use Disorders

Diagnostic Criteria

This diagnosis serves as a residual category for substances not included elsewhere in the DSM-5-TR. Severity and remission specifiers follow the standard three-level format (mild, moderate, severe) with remission statuses clearly indicated. The appropriate ICD-10-CM codes correspond to these specifiers.

Diagnostic Features

The DSM-5-TR reinforces the importance of avoiding misclassification. Substances that already have a designated category (e.g., synthetic cannabinoids, cathinones, propofol) should be diagnosed under their respective substance class, not under “other” or “unknown” substances. This section emphasizes accurate diagnostic placement to guide treatment and reporting.

Differential Diagnosis

Clinicians should distinguish other (or unknown) substance use disorder from other substance intoxication, withdrawal, and substance-induced mental disorders. Accurate history and toxicology can assist in classification when the specific substance is not initially known.

Other (or Unknown) Substance Intoxication

Specifier

A specifier for perceptual disturbances is included when hallucinations (with intact reality testing) or sensory illusions occur in the absence of delirium. These disturbances may involve visual, auditory, or tactile modalities.

Coding Notes

The DSM-5-TR provides updated ICD-10-CM coding guidance that differentiates by:

• The presence or absence of perceptual disturbances, and
• The severity of any comorbid substance use disorder (mild vs. moderate/severe), or its absence.

For example:

• Without perceptual disturbances:
  • Mild use disorder: F19.120
  • Moderate/severe use disorder: F19.220
  • No comorbid use disorder: F19.920
• With perceptual disturbances:
  • Mild use disorder: F19.122
  • Moderate/severe use disorder: F19.222
  • No comorbid use disorder: F19.922

This detailed coding distinction supports more accurate clinical documentation and billing when the specific substance is unknown or does not fit into other established substance categories.

Other (or Unknown) Substance Withdrawal

Specifier: With Perceptual Disturbances

As with intoxication, the withdrawal diagnosis may also include a specifier for perceptual disturbances (hallucinations or illusions) when they occur without delirium and with preserved reality testing.

Coding Updates

The ICD-10-CM codes differ based on the presence of perceptual disturbances and the status of comorbid substance use disorder:

Without perceptual disturbances:

Mild use disorder: F19.130

Moderate/severe use disorder: F19.230

No comorbid use disorder: F19.930

With perceptual disturbances:

Mild use disorder: F19.132

Moderate/severe use disorder: F19.232

No comorbid use disorder: F19.932

These distinctions help ensure clinical precision when assigning withdrawal diagnoses in situations where the substance is unknown or doesn't fit traditional classification.

Gambling Disorder

Diagnostic Features

The DSM-5-TR clarifies that gambling disorder may be diagnosed even when symptoms are medication-induced, particularly in cases where dopaminergic medications (e.g., for Parkinson’s disease) result in compulsive gambling behavior. This change emphasizes the need to assess the presence of a gambling disorder regardless of etiology, provided diagnostic criteria are met.

Culture-Related Diagnostic Issues

The DSM-5-TR elaborates on how cultural and ethnoracial context influences gambling behaviors and symptom expression. Specific gambling activities (e.g., pai gow, cockfights, horse racing) may be more or less prevalent across different populations, and endorsement of diagnostic criteria may also vary accordingly.

Sex- and Gender-Related Diagnostic Issues

Sex- and gender-related patterns in gambling behavior are further detailed. Men continue to have higher rates of gambling disorder, though the gender gap may be narrowing. Differences are noted in motivation, behavior, and comorbidity: women are more likely to gamble in response to negative affect and may feel more shame, while men may gamble for excitement. Gambling preferences also diverge, men often favor strategic or competitive games (e.g., cards, sports betting), while women more commonly engage in non-strategic games (e.g., slot machines, bingo). Comorbidities differ as well; women with gambling disorder are more likely than men to have co-occurring depressive, bipolar, or anxiety disorders.

Comorbidity

The DSM-5-TR notes that in most cases where gambling disorder co-occurs with another mental disorder, the other disorder precedes the onset of gambling disorder. This suggests that gambling may serve as a maladaptive coping strategy or secondary issue following the emergence of another psychiatric condition.

Neurocognitive Disorders

Overview

The DSM-5-TR refines specifiers and diagnostic guidance across neurocognitive disorders, incorporating more detailed risk and cultural considerations. It emphasizes gender differences in symptom presentation, highlights suicide risk across several conditions (particularly Alzheimer’s and TBI-related disorders), and stresses the importance of cultural competence in assessment and caregiving. Updates also include clearer distinctions between overlapping syndromes and better guidance on differential diagnosis in complex presentations.

Delirium

Diagnostic Criteria

The DSM-5-TR includes specifiers for both duration: acute (lasting hours to days) and persistent (lasting weeks to months), and for psychomotor activity level: hyperactive, hypoactive, or mixed. These specifiers aim to capture the heterogeneity of delirium presentations and support more accurate characterization and clinical management.

Risk and Prognostic Factors

Risk factors for delirium include older age, cognitive or sensory impairments, comorbid illness, and infections. Functional impairment and prior stroke are also notable contributors. Importantly, the DSM-5-TR highlights that falls are not a risk factor for delirium. In children, delirium may signal significant medical morbidity. Anticholinergic medications were not validated as predictors of delirium in recent meta-analyses.

Sex- and Gender-Related Diagnostic Issues

The DSM-5-TR notes that men are more likely to exhibit hyperactive symptoms such as agitation and mood lability, while women are more likely to present with hypoactive features. Male sex is considered a risk factor for delirium, with gender-related factors potentially interacting with other risks.

Other Specified Delirium

Subsyndromal delirium is now recognized, characterized by disturbances in attention and cognition that do not meet full diagnostic criteria but may still warrant clinical attention.

Major and Mild Neurocognitive Disorders

Prevalence

While overall prevalence of dementia is higher in women, this is largely attributed to their longer life expectancy. Ethnic and racial disparities in prevalence and incidence exist, though comparisons are complicated by methodological differences.

Risk and Prognostic Factors

Risk varies by race and ethnicity, influenced by comorbid conditions, environmental factors, education level, and other social determinants of health. Lower education and literacy, in particular, increase NCD risk and are unevenly distributed across groups.

Culture-Related Diagnostic Issues

The DSM-5-TR emphasizes cultural considerations, such as stereotype threat, clinician bias, and linguistic diversity, that can affect diagnostic accuracy. Additionally, caregiving roles and expectations differ cross-culturally and may shape how neurocognitive impairments are interpreted and addressed.

Association With Suicidal Thoughts or Behavior

Large-scale studies suggest elevated suicide risk among individuals with neurocognitive disorders compared to the general population.

Major or Mild Neurocognitive Disorder Due to Alzheimer’s Disease

Associated Features

Neuropsychiatric symptoms – such as depression, agitation, and psychosis – are common, often more distressing than cognitive symptoms, and may be the impetus for clinical intervention.

Prevalence

Prevalence varies by race/ethnicity, age, and method of assessment. U.S. data show rates between 3.5% and 14.4% among individuals aged 65 and older.

Risk and Prognostic Factors

Risk factors include low education, midlife hypertension, diabetes, hearing loss, and late-life depression, among others. Ethnoracial variations in genetic vulnerability are also noted.

Culture-Related Diagnostic Issues

In some cultures, memory loss in old age is seen as normative, potentially delaying diagnosis. Very low education levels can also interfere with cognitive assessments.

Sex- and Gender-Related Diagnostic Issues

Some data suggest faster cognitive decline in women. Because women perform better on verbal memory tasks, standardized cut-offs may result in underdiagnosis or delayed recognition in men.

Association With Suicidal Thoughts or Behavior

Alzheimer’s disease carries a moderate suicide risk, sometimes years after diagnosis. Risk may relate to impaired decision-making and cognitive inhibition.

Functional Consequences

Alzheimer’s-related NCD significantly impairs independence, safety, and occupational functioning. Caregivers frequently experience health and psychological burdens, with social networks often deteriorating alongside the patient’s decline.

Differential Diagnosis

Differentiation from other neurocognitive disorders is essential, particularly in early stages.

Major or Mild Neurocognitive Disorder Due to Traumatic Brain Injury

Diagnostic Features

The DSM-5-TR maintains a detailed clinical definition of traumatic brain injury (TBI) as a disruption to brain structure or function caused by biomechanical forces, such as acceleration/deceleration or blast injuries. The diagnosis requires observable signs such as posttraumatic amnesia, altered mental state, or sensory-motor deficits not better explained by other medical or psychological causes. Importantly, the diagnosis excludes impairments resulting from intoxication, medical treatment, or psychological trauma alone. TBI severity is categorized as mild, complicated mild, moderate, or severe, based on specified clinical thresholds.

Development and Course

Persistent symptoms following mild TBI or later cognitive decline should prompt differential diagnostic consideration of co-occurring mental health disorders such as major depressive disorder, PTSD, anxiety, or substance use disorders. Negative cognitive expectations or sleep problems may also worsen perceived impairment. However, DSM-5-TR highlights that improvement is possible even years after moderate or severe TBI, with more patients showing recovery than deterioration within the first five years.

Risk and Prognostic Factors

There is an emphasis on post-injury psychological and medical comorbidities as modifiers of long-term outcomes. The course and severity of cognitive decline are influenced by multiple interacting factors, including the severity of the original injury and the individual's biopsychosocial context.

Diagnostic Markers

While neuroimaging and clinical signs may offer supportive evidence, they are not diagnostic in isolation. No specific biomarkers have been validated to independently diagnose NCD due to TBI, underscoring the need for clinical judgment.

Association With Suicidal Thoughts or Behavior

The DSM-5-TR adds detail on suicide risk following TBI, particularly in moderate to severe cases. Depression increases this risk but does not fully explain it. Suicidal ideation may emerge a year or more after injury and persist for years. Youth with a history of concussion and both civilian and military/veteran populations with TBI are at heightened suicide risk, especially those seeking rehabilitative or mental health services. This underscores the importance of routine suicide risk screening in individuals with a history of TBI.

Functional Consequences

TBI-related cognitive impairments impact 3.17 million people in the U.S., affecting work, daily functioning, and quality of life. These individuals often require long-term support. Functional impairment varies based on the severity of cognitive deficits and the presence of psychiatric, neurological, or social comorbidities. Rehabilitation outcomes are influenced by family and community support as well as individual psychological resilience.

Differential Diagnosis

Clinicians should distinguish TBI-related NCD from other mental and medical conditions, as well as from factitious disorder or malingering when indicated.

Comorbidity

PTSD is a frequent comorbidity in individuals with TBI, especially among civilian, military, and veteran populations. This co-occurrence may complicate diagnosis and treatment planning, necessitating a comprehensive approach.

Substance/Medication-Induced Major or Mild Neurocognitive Disorder

Diagnostic Features

Diagnosis requires establishing a temporal relationship between substance use and cognitive deficits. Deficits must not have been present before substance use.

Major or Mild Neurocognitive Disorder Due to HIV Infection

Associated Features

According to the DSM-5-TR, major or mild neurocognitive disorder (NCD) due to HIV infection is more commonly observed in individuals who are older, have lower levels of education, or are female. The condition is also more prevalent among individuals with comorbid mental health diagnoses such as major depressive disorder, as well as those with substance use disorders and medical conditions – especially diabetes and hypertension. These factors may contribute to increased vulnerability to HIV-related neurocognitive impairment.

Development and Course

The DSM-5-TR emphasizes that while neurocognitive disorders (NCDs) can be a consequence of HIV infection, a sudden or abrupt change in mental status in individuals living with HIV should prompt clinicians to consider other medical causes. These may include secondary infections or complications not directly related to HIV itself. This clarification underscores the importance of differential diagnosis in assessing new or worsening cognitive symptoms in individuals with HIV.

Comorbidity

The DSM-5-TR highlights that rates of comorbid conditions associated with neurocognitive disorder (NCD) due to HIV infection may vary based on sex and ethnoracial background. Women and individuals from underserved ethnic and racialized groups may experience differing patterns or higher prevalence of comorbidities, underscoring the importance of culturally informed assessment and care when addressing HIV-associated NCD.

Major or Mild NCD Due to Parkinson’s Disease

Diagnostic Features

Cognitive decline in Parkinson’s disease varies significantly across individuals. Neurocognitive progression may be slow or minimal in some.

Differential Diagnosis

The primary differential diagnosis is NCD with Lewy bodies; antipsychotic-induced parkinsonism should also be considered.

Major or Mild NCD Due to Huntington’s Disease

Association With Suicidal Thoughts

Suicide risk is elevated, with common comorbid symptoms including depression and psychosis. Clinicians should routinely monitor mood and suicidal ideation.

Paraphilic Disorders

Overview

The DSM-5-TR introduces clarifications and expansions to the descriptive text of several paraphilic disorders. Updates include revised prevalence information, refined diagnostic differentials, the inclusion of cultural and legal considerations in sexual masochism and sexual sadism disorders, and a broader acknowledgment of risk factors such as suicidality. These updates aim to better contextualize paraphilic behaviors within developmental, sociocultural, and forensic frameworks.

Voyeuristic Disorder

Prevalence

The DSM-5-TR provides updated context regarding the prevalence of voyeuristic behaviors versus voyeuristic disorder. While voyeuristic acts are relatively common – reported in up to 34.5% of individuals in a Quebec sample, fewer report experiencing intense desire (9.6%) or persistent behavior (2.1%), which are necessary for a clinical diagnosis. The true prevalence of voyeuristic disorder remains unknown, but is likely much lower than that of the behavior itself. Gender ratios consistently show higher rates in men than women, ranging from 2:1 to 3:1. Among incarcerated sex offenders in Austria, 3.7% were found to meet criteria for voyeuristic disorder.

Development and Course

A new note highlights that, similar to other sexual preferences, voyeuristic interests and behaviors may decrease with age, reflecting a developmental trajectory influenced by biological and psychosocial changes.

Differential Diagnosis

Voyeuristic behavior must be distinguished from symptoms arising in other conditions, such as manic episodes, major neurocognitive disorder, intellectual developmental disorder, personality changes due to another medical condition, substance intoxication, and schizophrenia.

Frotteuristic Disorder

Prevalence

While frotteuristic acts may occur in up to 30% of adult men, the prevalence of frotteuristic disorder is much lower, with intense desire and persistent behavior reported by only a small fraction. In clinical settings, 10%–14% of men with paraphilic disorders may meet diagnostic criteria. Rates among women are likely lower.

Differential Diagnosis

Clarifications reaffirm that frotteuristic acts must be distinguished from disinhibited behavior occurring in the context of manic episodes, major neurocognitive disorder, intellectual disability, personality changes due to medical conditions, substance intoxication, and psychotic disorders such as schizophrenia.

Sexual Masochism Disorder

Diagnostic Features

Sexual masochism disorder is diagnosed only when individuals experience distress or impairment from their masochistic interests. Those who engage in consensual BDSM practices without distress are not diagnosed with the disorder.

Associated Features

Sexual masochism disorder may be associated with extensive use of sadomasochistic pornography and possible hyposensitivity to pain, but there is no clear evidence linking it to childhood sexual abuse.

Culture-Related Diagnostic Issues

Cultural updates now clarify the importance of distinguishing sexually motivated masochistic behavior from non-sexual self-harm or self-mortification performed in religious or cultural contexts (e.g., hook suspensions or self-flagellation during ritual observances).

Association With Suicidal Thoughts or Behavior

While direct associations between sexual masochism disorder and suicidal behavior are unknown, stigma-related shame and guilt among BDSM-involved individuals may be linked to suicidal ideation.

Functional Consequences

The functional consequences of sexual masochism disorder are unclear, but individuals with asphyxiophilic interests face higher risks of sexual distress, psychological issues, and accidental death, though it remains uncertain how often these cases meet full diagnostic criteria.

Differential Diagnosis

The manual continues to differentiate sexual masochism from other self-injurious behaviors, sexual role-play, or normative consensual practices not associated with distress or impairment.

Sexual Sadism Disorder

Diagnostic Features

The DSM-5-TR clarifies that sexual sadism disorder may be diagnosed in both individuals who openly admit to sadistic sexual interests and those who deny such interests despite strong evidence. Diagnosis depends on the presence of distress, impairment, or behavior involving nonconsenting individuals, even if self-reported distress is absent.

Prevalence

The DSM-5-TR notes that while the exact prevalence of sexual sadism disorder is unknown, it is rare and primarily studied in forensic populations. In community samples, a small percentage of both men and women report engaging in BDSM-related behaviors, though these do not necessarily meet diagnostic criteria for the disorder.

Development and Course

The DSM-5-TR highlights that sexual sadistic preferences typically emerge in adolescence and may persist lifelong, though sexually sadistic behaviors may decline with age. The course of sexual sadism disorder can vary based on the individual’s level of distress or risk of harming others. Empirical data on its development remain limited.

Culture-Related Diagnostic Issues

An important new consideration is the legal and cultural variability in the acceptance of sadistic sexual practices. The degree of distress or functional impairment may depend on societal norms or legal ramifications in a given cultural context.

Association With Suicidal Thoughts or Behavior

While no direct link between sexual sadism disorder and suicidality has been established, research suggests that individuals involved in BDSM may experience stigma-related shame and guilt, which can be associated with suicidal ideation.

Differential Diagnosis

Differentiation must be made between consensual BDSM practices and sexually sadistic behavior that involves nonconsensual harm. It must also be distinguished from conduct disorder, antisocial personality disorder, and sexual offenses committed without an underlying sadistic preference.

Pedophilic Disorder

Diagnostic Features

The revised text provides additional guidance for distinguishing individuals with pedophilic disorder from those who have committed sexual offenses against children without meeting full diagnostic criteria. Risk factors for a diagnosis include use of child pornography, interest in boys, multiple or unrelated victims, and explicit self-reports of sexual attraction to children.

Associated Features

Emotional congruence with children – such as preferring interactions with children or identifying more with them than adults – is associated with pedophilic sexual interest and may increase the risk of sexual reoffending.

Sex- and Gender-Related Diagnostic Issues

Laboratory assessments of sexual interest, such as physiological responses to child stimuli, may aid in diagnosing pedophilic disorder in men but are less reliable for women due to limited research.

Differential Diagnosis

The manual distinguishes pedophilic disorder from other paraphilic disorders and from individuals who commit child sexual abuse in the absence of sustained sexual interest in children.

Transvestic Disorder

Differential Diagnosis

Updates in the DSM-5-TR emphasize that not all cross-dressing behavior is indicative of a disorder. Clinicians are encouraged to assess for distress, impairment, and the presence of sexual arousal patterns when determining whether the behavior qualifies as transvestic disorder.

Other Mental Disorders and Additional Codes

This chapter introduces updated diagnostic codes for psychiatric presentations that qualify as mental disorders – defined by symptoms causing clinically significant distress or impairment in social, occupational, or other important areas of functioning – but do not meet the specific diagnostic criteria in the previous Section II chapters. These new codes facilitate the documentation and classification of previously unclassified mental disorders. Additionally, a new code for “No diagnosis or condition” has been added for cases where an evaluation determines that no mental disorder or condition is present.

The updates introduce two categories for cases where psychiatric symptoms (e.g., dissociative symptoms) are directly caused by another medical condition but do not meet the criteria for any mental disorder in Section II due to that condition:

1. Other specified mental disorder due to another medical condition
2. Unspecified mental disorder due to another medical condition

For these updated diagnoses, the medical condition must now be listed first, followed by the appropriate code for either other specified or unspecified mental disorder due to another medical condition.

The categories other specified mental disorder and unspecified mental disorder are now residual categories, applied when all the following criteria are met:

• Psychiatric symptoms cause clinically significant distress or impairment in functioning.
• The presentation does not meet the criteria for any specific mental disorder in Section II.
• The presentation does not align with any of the other specified or unspecified mental disorder categories in Section II.
• No other mental disorder diagnosis applies.

As part of the updates in the DSM-5-TR, the other specified category is now used when the clinician specifies the reason why the presentation does not meet the criteria for existing diagnostic categories (e.g., other specified mental disorder due to complex partial seizures, with dissociative symptoms). The unspecified category is used when the clinician chooses not to provide a specific reason.

Additional Codes

Z03.89 No Diagnosis or Condition

This code applies to situations in which the person has been evaluated, and it is determined that no mental disorder or condition is present.

Other Conditions That May Be a Focus of Clinical Attention

For quick reference to all codes in this section, see the DSM-5-TR Classification. Conditions and problems that may be a focus of clinical attention are listed in the subsequent text as follows:

1. Suicidal behavior

2. Abuse and neglect

3. Relational problems

4. Educational problems

5. Occupational problems

6. Housing problems

7. Economic problems

8. Problems related to the social environment

9. Problems related to interaction with the legal system

10. Problems related to other psychosocial, personal, and environmental circumstances

11. Problems related to access to medical and other health care

12. Circumstances of personal history

13. Other health service encounters for counseling and medical advice

14. Additional conditions or problems that may be a focus of clinical attention

Suicidal Behavior and Nonsuicidal Self-Injury

Coding Note for ICD-10-CM Suicidal Behavior

The updates to the coding guidelines clarify the use of 7th characters for T codes as follows:

• A (Initial Encounter): This should be used when the individual is receiving active treatment for the condition (e.g., emergency department visit or when a new clinician is evaluating and treating the individual).
• D (Subsequent Encounter): This is used for encounters after the individual has received active treatment and is now in the healing or recovery phase (e.g., routine care, such as medication adjustments, aftercare, or follow-up visits).

Suicidal Behavior

The DSM-5-TR introduces updated codes to document suicidal behavior more accurately and consistently across clinical settings. These revisions clarify how to distinguish between current and past suicidal behavior based on the clinical context and encounter type.

Current Suicidal Behavior

T14.91XA – Initial Encounter: Use this code when suicidal behavior is part of the individual’s initial clinical presentation or when active treatment is being provided (e.g., emergency evaluation or crisis intervention).

T14.91XD – Subsequent Encounter: Use this code for follow-up or ongoing care after the individual has already received active treatment related to suicidal behavior (e.g., medication adjustment, aftercare, or recovery-phase visits).

Z91.51 – History of Suicidal Behavior: Use this code when there is a documented lifetime history of suicidal behavior, but no current suicidal intent or behavior is present at the time of evaluation.

Nonsuicidal Self-Injury

The DSM-5-TR includes updated guidance and new codes to better capture nonsuicidal self-injurious behaviors as distinct from suicidal behavior. This clarification supports more accurate documentation and differentiation of intent during assessment and treatment planning. This category applies to individuals who have intentionally inflicted harm upon their own body – resulting in bleeding, bruising, or pain (e.g., cutting, burning, stabbing, hitting, or excessive rubbing) – without suicidal intent.

R45.88 – Current Nonsuicidal Self-Injury: Use when nonsuicidal self-injurious behavior is part of the current clinical presentation.

Z91.52 – History of Nonsuicidal Self-Injury: Use when there is a documented lifetime history of nonsuicidal self-injurious behavior, but no such behavior is currently present.

Relational Problems

Parent-Child Relational Problems

Z62.820 Parent-Biological Child

Z62.821 Parent-Adopted Child

Z62.822 Parent-Foster Child

Z62.898 Other Caregiver-Child

This category is used when the main clinical concern involves problems in the relationship between a parent (or parental figure) and a child. The term includes biological, adoptive, or foster parents, as well as other relatives or caregivers (like grandparents) who act as the child’s primary caregiver. This applies when the focus of treatment is the quality of the parent-child relationship, or the relationship issues are significantly affecting a mental disorder or medical condition in either the parent or the child.

Types of problems

• Behavioral: Issues with control, supervision, involvement, overprotection, excessive pressure, escalating arguments, or avoidance.
• Cognitive: Negative assumptions, hostility, scapegoating, or feelings of estrangement.
• Affective: Sadness, apathy, or anger directed toward the other person.

Clinicians should always consider the child’s developmental stage and cultural background when evaluating and diagnosing this type of relational problem.

Educational Problems

Z55.0 Illiteracy and Low-Level Literacy

Z55.1 Schooling Unavailable and Unattainable

Z55.2 Failed School Examinations

Z55.3 Underachievement in School

Z55.4 Educational Maladjustment and Discord With Teachers and Classmates

Z55.8 Problems Related to Inadequate Teaching

Z55.9 Other Problems Related to Education and Literacy

Occupational Problems

This category is used when difficulties related to a person’s job, employment situation, or work environment are the main focus of clinical attention – or when such problems significantly affect a mental disorder’s course, treatment, or prognosis.

Z56. 0 Unemployment

Z56.1 Change of Job

Z56.2 Threat of Job Loss

Z56.3 Stressful Work Schedule

Z56.4 Discord With Boss and Workmates

Z56.5 Uncongenial Work Environment

Z56.6 Other Physical and Mental Strain Related to Work

Z56.81 Sexual Harassment on the Job

Z56.9 Other Problem Related to Employment

Housing Problems

Z59.01 Sheltered Homelessness

This category is used when living in a shelter or temporary housing situation (e.g., homeless or warming shelter, domestic violence shelter, motel, temporary or transitional housing program) affects an individual’s mental health treatment, course, or prognosis. Clinicians should use this code when housing instability is relevant to the person’s care or contributes to mental or physical health difficulties.

Z59.02 Unsheltered Homelessness

This category applies when living without shelter affects an individual’s treatment or prognosis. It includes people residing in places not meant for habitation, such as streets, parks, cars, abandoned buildings, or other makeshift settings.

Z59.9 Other Housing Problem

This category may be used when there is a problem related to housing circumstances other than as specified above.

Economic Problems

This category is used when financial hardship affects an individual’s treatment or prognosis. It includes issues such as food or water insecurity, poverty, low income, or inadequate social, health, or welfare support.

Z59.1 Food Insecurity

Z58.6 Lack of Safe Drinking Water

Z 59.9 Other Economic Problem

This category may be used when there is a problem related to economic circumstances other than as specified above.

Problems Related to Interaction With the Legal System

This category applies when involvement with the legal system affects an individual’s treatment or prognosis. It includes issues such as criminal convictions, incarceration, release from prison, or other legal matters like civil disputes or child custody cases.

Other Health Service Encounters for Counseling and Medical Advice

Z31.5 Genetic Counseling

This category applies when an individual seeks genetic counseling to understand the risk of developing or passing on a mental disorder with a genetic component (e.g., bipolar disorder) for themselves, family members, or future children.

Z71.3 Dietary Counseling

This category may be used when the individual seeks counseling related to dietary issues like weight management.

Additional Conditions or Problems That May Be a Focus of Clinical Attention

R41.81 Age-Related Cognitive Decline

This category applies when normal, age-related decline in cognitive functioning affects clinical attention. Individuals may notice mild memory lapses or difficulty with complex problem-solving, but symptoms are within normal limits and not due to a mental or neurological disorder.

Quick Reference Guide

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Risk Factors for Suicide Ideation, Attempt, or Completion

Psychiatric Disorders & Symptom-Based Risk Factors
Neurodevelopmental & Neurobehavioral Disorders	Screening for suicidal thoughts in individuals with intellectual and developmental disabilities (IDD) is essential, especially with changes in behavior.
	ADHD is a risk factor for suicidal ideation and behavior in children.
	Poor reading ability is associated with suicidal thoughts and behavior.
	Individuals with motor disorders have substantially increased risk of suicide attempts and deaths.
	Suicide is a high-risk outcome in late adolescence and early adulthood for those with prenatal alcohol exposure.
	Children with ASD and impaired social communication have higher rates of self-harm with suicidal intent, suicidal thoughts, and suicide plans by age 16.
Psychotic Disorders
	Suicidal behavior may occur in response to command hallucinations to harm oneself or others.
	Risk of suicidal behavior appears elevated, particularly during acute episodes.
Mood Disorders
	Symptom-Based Risk Factors
	Prominent hopelessness.
	Cognitive decision-making deficits.
	Short-duration hypomania or mixed features.
	Increased percentage of days spent depressed in the past year.
	Interpersonal rejection sensitivity.
	Social disconnectedness.
	Anhedonia shows a particularly strong association with suicidal ideation.
	Additional Findings
	Lifetime suicide risk in bipolar disorder is 20–30 times higher than the general population.
	Across diagnostic categories, suicide attempters carry more risk alleles for depression than non-attempters.
Panic & Anxiety Disorders
	Panic attacks and recent panic disorder diagnoses are linked to higher rates of suicidal thoughts and behaviors.
	Derealization (cognitive symptom) is associated with suicidal thoughts.
	Dizziness and nausea (physical symptoms) are associated with suicidal behaviors.
	Individuals with anxiety disorders are more likely to have suicidal thoughts, attempts, and suicide deaths.
	Panic disorder, GAD, and specific phobia are most strongly associated with transitions from suicidal thoughts to attempts.
	Psychological autopsy studies identify GAD as the most common anxiety diagnosis in suicide deaths.
Obsessive-Compulsive & Related Disorders
	Greater suicide risk is linked to OCD symptom severity and the presence of unacceptable thought content.
	Individuals with body dysmorphic disorder (BDD) possess several demographic and clinical risk factors for suicide, including perceived abuse, poor self-esteem, appearance concerns, and high rates of suicidal thoughts and attempts.
Trauma, Grief, & Dissociative Disorders
	Traumatic events (e.g., childhood abuse, sexual trauma) significantly increase suicide risk.
	PTSD is associated with higher likelihood of transitioning from suicidal ideation to plans or attempts.
	Stigma, isolation, thwarted belongingness, avoidance, and distress in bereavement contribute to suicidal ideation.
	Dissociation is an independent risk factor for repeated suicide attempts.
	Suicidal behavior may occur when dissociative amnesia suddenly resolves, exposing intolerable memories.
	Numerous interacting risk factors for self-destructive or suicidal behavior.
	Over 70% of outpatients with DID have attempted suicide; multiple attempts and other high-risk behaviors are common.
Somatic Symptom-Related Disorders
	Somatic symptom disorder is associated with suicidal thoughts and attempts.
Disturbed Eating
	Suicide risk is markedly elevated in bulimia nervosa and anorexia nervosa (approximately 18-fold).
Sleep Disruption
	Insomnia is an independent risk factor for suicidal thoughts and behaviors.
Gender Dysphoria
	Transgender individuals show 30%–80% rates of suicidality or suicide attempts.
	Risk factors include past maltreatment, gender-based victimization, and younger age.
Disruptive Behavior Disorders
	ODD is associated with increased suicide attempt risk.
	Individuals with conduct disorder exhibit higher-than-expected rates of suicidal thoughts, attempts, and suicide deaths.
	Fire-setting behaviors correlate with increased suicide and suicide attempt rates.
	Kleptomania is associated with increased suicide attempt risk.
Substance-Related Disorders
	Substance use disorders broadly increase suicide risk.
	No unique suicide‑specific risk factors identified in other/unknown substance use disorders.
Neurocognitive Disorders
	Alzheimer’s disease carries moderate long‑term suicide risk; ongoing assessment of mood and suicidality is recommended.
	Individuals with moderate or severe TBI have increased long‑term suicide risk.
Personality Disorders
	Impulsive and antisocial traits elevate suicide risk.
	Suicidal thoughts/behaviors often triggered by perceived rejection, separation threats, or increased responsibility.
	Exposure to overwhelming emotions, imperfection, or failure can provoke suicidal ideation.
Influencing Risk Factors
	Desire to give up in the face of perceived insurmountable obstacles.
	Intense wish to end an excruciating emotional state.
	Inability to envision future enjoyment.
	Desire not to be a burden to others.
	Resolution of these cognitions may be a more reliable marker of reduced suicide risk than mere denial of suicidal intent.
Escalating Risk Factors
	Influencing Markers
	Most consistent predictor: history of suicide attempts or threats.
	Access to lethal means (e.g., firearm).
	Level of planning, including choosing time/place to minimize rescue.
	Acute mental state concerns, especially agitation.
	Recent inpatient discharge.
	Recent discontinuation of lithium or clozapine.
	Environmental Triggers
	Recent diagnosis of a potentially fatal medical condition.
	Sudden loss of a close relative or partner.
	Job loss or housing displacement.
Anxious Distress Specifier – Associated Suicide Risk
	General Risk Observations
	High anxiety levels correlate with increased suicide risk, longer illness duration, and poorer treatment response.
	Presence of this specifier indicates more severe symptoms, worse prognosis, and higher risk of suicidal ideation and functional impairment.
	Cognitive Symptoms
	Difficulty concentrating due to persistent worry or rumination.
	Affective Symptoms
	Fear that something terrible may happen.
	Fear of losing control or “going crazy.”
	Physical Symptoms
	Restlessness, pacing, jitteriness.
	Feeling keyed up or tense; muscle tension, trembling, aches, soreness.
	Motor agitation is linked to more severe presentation, mixed features, and higher suicide‑attempt risk.
Nonsuicidal Self-Injury (NSSI) Risk Factors
	Multiple NSSI methods, high frequency of self‑injury, early age at onset, and using NSSI for relief or self‑punishment predict both suicidal ideation and attempts.
	Suicide attempts frequently follow NSSI by 1–2 years.
	Individuals engaging in NSSI require suicide risk assessment and collateral information regarding recent stressors or mood changes.
	Influencing Events
	Interpersonal conflicts or negative emotions (e.g., depression, anxiety, anger).
	Persistent preoccupation with self‑injury.
	Frequent thoughts about self‑injury.
	Environmental stress and social isolation.
	Activating Feelings
	Anxiety
	Boredom
	Rising tension
	Embarrassment or shame
	Feelings of deserved punishment
	Desired Relief or Response
	Relief from negative emotional or cognitive states (e.g., tension, sadness, loss of control).
	Resolution of interpersonal difficulties (e.g., perceived rejection).
	Induction of positive feeling states (e.g., gratification, pleasure).

 

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Important Notes

According to research conducted by Zimmerman et al. (2019), anxious distress is common among depressed patients and provides empirical support for the validity of the DSM-5 anxious distress specifier. Approximately three-quarters of patients with depression met criteria for the anxious distress specifier. Those with anxious distress were more likely to have comorbid anxiety disorders, particularly panic disorder and generalized anxiety disorder, and scored higher on measures of anxiety, depression, and anger. Patients meeting criteria for anxious distress also reported higher rates of substance use disorders, poorer functioning in the week prior to evaluation, and reduced coping ability compared to patients without the specifier. Importantly, anxious distress was associated with poorer functioning and coping even after controlling for the presence of an anxiety disorder.

Much of the content used in this quick reference guide is described in the DSM-5-TR’s chapter Conditions for Further Study, specifically, Suicide Behavior Disorder (pp. 990-923) and Nonsuicidal Self-Injury Disorder (pp. 923-926). Understanding of Suicidal Behavior Disorder (SBD) has progressed slowly since its introduction a decade ago. To date, the diagnosis has been used primarily in research settings to define cohorts exhibiting suicidal behavior. Its clinical utility for predicting future suicide risk remains limited, and further research is needed to clarify how best to measure SBD and to delineate its boundaries from related conditions and other forms of self-harm (Oliogu & Ruocco, 2024).

Conclusion

The DSM-5-TR introduces meaningful updates that reflect a deeper understanding of the nuanced interplay between diagnostic criteria, cultural and demographic factors, and evolving clinical practice. These revisions emphasize the importance of recognizing the lived experiences of diverse populations, refining diagnostic language, and improving clarity regarding symptom presentation and prevalence.

For mental health professionals, staying current with these changes supports more accurate assessment, informed treatment planning, and culturally responsive care. Whether addressing neurocognitive decline, substance use, or complex paraphilic disorders, the DSM-5-TR encourages clinicians to consider diagnostic categories through both clinical and socio-contextual lenses. As the field of mental health continues to advance, the DSM-5-TR remains an essential resource for providing ethical, evidence-based, and compassionate care to diverse client populations.

I wish you the best!

References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). https://doi.org/10.1176/appi.books.9780890425596

American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders (5th ed., text rev.). https://doi.org/10.1176/appi.books.9780890425787

Oliogu, E. & Ruocco, A. C. (2024). DSM-5 Suicidal behavior disorder: A systematic review of research on clinical utility, diagnostic boundaries, measures, pathophysiology and interventions. Frontiers in Psychiatry, 15:1278230. doi: 10.3389/fpsyt.2024.1278230

Prigerson, H. G., Shear, M. K., & Reynolds, C. F. (2022). Prolonged grief disorder diagnostic criteria-helping those with maladaptive grief responses. JAMA Psychiatry, 79, 277-278. doi: 10.1001/jamapsychiatry.2021.4201.

Zimmerman, M., Martin, J., McGonigal, P., Harris L., Kerr, S, Balling, C., Kiefer, R., Stanton, K. & Dalrymple, K. (2019). Validity of the DSM-5 anxious distress specifier for major depressive disorder. Depression Anxiety. 36, 31-38. https://doi.org/10.1002/da.22837