DSM-5-TR Notes: Elements of a Diagnosis

Diagnostic Criteria

Guidelines for making diagnoses, informed by clinical judgment, and supported by text descriptions.

Specifiers

Non-mutually exclusive descriptors (e.g., 'performance only' for social anxiety disorder) that provide additional information about a diagnosis, indicated by 'Specify' or 'Specify if'.

Subtypes

Mutually exclusive and jointly exhaustive phenomenological subgroupings within a diagnosis (e.g., restricting type for anorexia nervosa), indicated by 'Specify whether'.

Other Specified Disorder

A diagnostic category used when a presentation does not meet criteria for a specific DSM-5 disorder, but the clinician chooses to specify the reason why.

Unspecified Disorder

A diagnostic category used when a presentation does not meet criteria for a specific DSM-5 disorder, and the clinician chooses not to specify the reason, often due to insufficient information in settings like emergency rooms.

Clinical Judgment

The professional expertise used to interpret diagnostic criteria, justify a diagnosis even if symptoms are slightly short of full criteria (if persistent and severe), and ensure appropriate application of DSM-5.

Clinical Significance Criterion

A generic criterion requiring that symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning for a disorder to be diagnosed.

ICD-10-CM

The official coding system used in the United States since October 1, 2015, which provides diagnostic codes for mental disorders for clinical practice and reimbursement.

Principal Diagnosis

In inpatient settings, the condition chiefly responsible for admission after study; in outpatient settings, the reason for the visit and the main focus of attention and treatment.

Provisional Diagnosis

A modifier used when there is insufficient information to confirm a diagnosis, but there is a strong presumption that the criteria will eventually be met, or when duration is critical but not yet known.

Substance/Medication-Induced Mental Disorder

Symptomatic presentations due to the physiological effects of an exogenous substance on the CNS, including withdrawal symptoms; encompasses psychotropic medications and environmental toxins.

Independent Mental Disorder

A term replacing 'nonorganic mental disorders' in DSM-5 to indicate that a mental