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DSM-5-TR Notes: Elements of a Diagnosis

Elements of a Diagnosis

  • Diagnostic criteria are guidelines for making diagnoses and should be informed by clinical judgment.
  • Text descriptions (e.g., diagnostic features, differential diagnoses) can help support diagnosis.
  • After assessing diagnostic criteria, clinicians should consider applying disorder subtypes and/or specifiers as appropriate.
  • Specifiers and subtypes may change over the course of the disorder and can be relevant to current presentation (e.g., good to fair insight; predominantly inattentive presentation; in a controlled environment) or lifetime course (e.g., with seasonal pattern, bipolar type in schizoaffective disorder).
  • Full criteria must be currently met to apply most specifiers; some specifiers indicate lifetime course and can be assigned regardless of current status.
  • If symptom presentation does not meet full criteria for any disorder but causes clinically significant distress or impairment, consider the "other specified" or "unspecified" category corresponding to the predominant symptoms.

Subtypes and Specifiers

  • Subtypes provide mutually exclusive and jointly exhaustive phenomenological subgroupings within a diagnosis.
    • Indicated by the instruction “Specify whether” (e.g., anorexia nervosa: specify whether restricting type or binge-eating/purging type).
  • Specifiers are not meant to be mutually exclusive or jointly exhaustive; more than one specifier may be applied to a given diagnosis.
    • Indicated by the instruction “Specify” or “Specify if” (e.g., social anxiety disorder, performance only).
  • Subtypes and/or specifiers help define a more homogeneous subgrouping of individuals who share certain features and convey information relevant to management (e.g.,
    • major depressive disorder, with mixed features;
    • with other medical comorbidity in sleep-wake disorders).
  • ICD-10-CM vs DSM-5-TR coding:
    • The fifth character within an ICD-10-CM code may indicate a subtype/specifier for some codes (e.g., F02.80 vs F02.81 for major neurocognitive disorder due to Alzheimer's disease with/without behavioral disturbance).
    • The majority of DSM-5-TR subtypes/specifiers are not reflected in the ICD-10-CM code and are indicated by recording the subtype or specifier after the disorder name (e.g., social anxiety disorder, performance type).

Use of Other Specified and Unspecified Mental Disorders

  • DSM-5 recognises that diagnostic criteria sets do not fully describe the full range of mental disorders encountered.
  • There are settings (e.g., emergency departments) where only the most prominent symptom expressions may be identifiable; in such cases, a placeholder diagnosis may be most appropriate until a more complete differential diagnosis is possible.
  • DSM-5 provides two options for presentations that do not meet criteria for any specific DSM-5 disorder:
    • Other specified disorder: to communicate the specific reason the presentation does not meet criteria for any specific category within a diagnostic class.
    • Unspecified disorder: used when the clinician chooses not to specify the reason.
  • Example of "other specified":
    • "other specified schizophrenia spectrum and other psychotic disorder, with persistent auditory hallucinations" (persistent hallucinations without other psychotic symptoms).
  • If the clinician does not specify the reason, the diagnosis would be "unspecified schizophrenia spectrum and other psychotic disorder".
  • Differentiation between "other specified" and "unspecified" depends on whether the clinician indicates the reasons for not meeting full criteria.
  • When enough information is available to specify the nature of the presentation, an "other specified" diagnosis can be given; if not enough information is available (e.g., in the emergency room), an "unspecified" diagnosis can be given.
  • Conditions listed in the DSM-5-TR text under the chapter "Conditions for Further Study" may be cited as examples for the "other specified" designation; inclusion as examples does not constitute endorsement of them as valid diagnostic categories.

Use of Clinical Judgment

  • DSM-5 is a classification tool for clinical, educational, and research settings.
  • Diagnostic categories, criteria, and text are intended for use by clinically trained professionals.
  • DSM-5 should not be applied mechanically; criteria are guidelines informed by clinical judgment, not a rigid cookbook.
  • Clinical judgment can justify a diagnosis even if presentation falls slightly short of full criteria, provided the present symptoms are persistent and severe.
  • Conversely, lack of familiarity with DSM-5 or overly flexible application reduces its utility as a common language for communication.

Clinical Significance Criterion

  • There is no complete biological marker or clinically useful severity measure for many mental disorders; hence, a generic criterion requiring distress or impairment is used to establish disorder thresholds.
  • The criterion is worded as: the disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
  • Assessing whether this criterion is met, especially regarding role function, requires clinical judgment.
  • Information from the individual, family members, and other third parties (via interview or self-/informant-reported assessments) is often necessary to assess functional impact.

Coding and Recording Procedures

  • The official coding system in use in the United States since October 1, 2015 is ICD-10-CM.
  • ICD-10-CM provides the diagnostic codes for mental disorders used in clinical practice in the U.S. and is required for reimbursement in many settings.
  • Most DSM-5 disorders have an alphanumeric ICD-10-CM code preceding the disorder name (or coded subtype/specifier) in DSM-5-TR and its criteria.
  • For some diagnoses (e.g., neurocognitive disorders, substance/medication-induced disorders), the appropriate code depends on further specification and is listed within the criteria set with coding notes; sometimes clarified in the text’s “Recording Procedures.”
  • Some disorder names are followed by alternative terms in parentheses.
  • Diagnostic codes facilitate medical record keeping, data collection, and statistical reporting; in the U.S., ICD-10-CM codes for DSM-5-TR disorders are required for Medicare reimbursement.

Principal Diagnosis/Reason for Visit

  • DSM-5 generally allows multiple diagnoses when criteria are met for more than one disorder.
  • In inpatient settings, the principal diagnosis is the condition chiefly responsible for admission after study.
  • In outpatient settings, the reason for visit is the condition chiefly responsible for the ambulatory services.
  • The principal diagnosis is typically the main focus of attention and treatment.
  • If a mental disorder is due to another medical condition (e.g., major neurocognitive disorder due to Alzheimer's disease), the etiologic medical condition is listed first; the mental disorder would be the secondary diagnosis.
  • For maximum clarity, the principal diagnosis or reason for visit can be followed by the qualifier "(principal diagnosis)" or "(reason for visit)".
  • Example of prioritization: determining the principal diagnosis when schizophrenia and alcohol use disorder are both present may be unclear, as both contribute to admission and treatment.

Provisional Diagnosis

  • The modifier "provisional" is used when there is currently insufficient information to determine that criteria are met but there is strong presumption that information will become available.
  • The clinician can record the diagnostic uncertainty by appending "(provisional)" after the diagnosis.
  • Example: a presentation consistent with current major depressive disorder but incomplete history; information may become available after interviewing an informant or reviewing medical records.
  • The provisional modifier may also be used when duration is critical for diagnosis and the duration is yet unknown (e.g., schizophreniform disorder requires duration between 1 month and less than 6 months).
  • If the duration is confirmed or criteria are met, the provisional modifier is removed and the diagnosis may be updated (e.g., to schizophrenia).

Notes About Terminology

  • Substance/Medication-Induced Mental Disorder refers to symptomatic presentations due to physiological effects of an exogenous substance on the CNS, including withdrawal symptoms.
  • Substances include typical intoxicants (e.g., alcohol, inhalants, hallucinogens, cocaine), psychotropic medications (e.g., stimulants; sedatives, hypnotics, anxiolytics), other medications (e.g., steroids), and environmental toxins (e.g., organophosphate insecticides).
  • The term was changed from "substance-induced mental disorders" to "substance/medication-induced" in DSM-5 to emphasize medications can cause psychiatric symptoms.
  • Independent Mental Disorders: historical terms like "organic" vs "nonorganic" mental disorders were simplified in DSM-5. The terminology evolved from DSM-III-R through DSM-5:
    • Eliminated "organic" and "nonorganic" distinctions.
    • Substances- or medical condition-related disorders are categorized as such (substance-induced, mental disorders due to a medical condition).
    • Replaced the term "nonorganic mental disorders" with "independent mental disorder" to indicate not simply secondary to substances or medical conditions, while recognizing psychosocial factors remain relevant.
  • The term "independent mental disorder" does not imply absence of psychosocial or environmental factors.
  • Other Medical Conditions: DSM-5 replaces mind–body dualism with a mental disorder vs. general medical condition dichotomy based on ICD chapter placement.
    • Mental disorders are located in ICD Chapter 5; general medical conditions are in other chapters.
    • DSM-5 uses the term "another medical condition" to emphasize that mental disorders can be precipitated by other medical conditions.
    • These terms do not imply a fundamental distinction in biology or causation beyond terminology convenience.

Types of Information in the DSM-5-TR Text

  • The DSM-5-TR text provides contextual information to aid diagnostic decision-making and appears after diagnostic criteria for each disorder.
  • It includes the following sections (when applicable):
    • Recording Procedures
    • Subtypes
    • Specifiers
    • Diagnostic Features
    • Associated Features
    • Prevalence
    • Development and Course
    • Risk and Prognostic Factors
    • Culture-Related Diagnostic Issues
    • Sex- and Gender-Related Diagnostic Issues
    • Diagnostic Markers
    • Association With Suicidal Thoughts or Behavior
    • Functional Consequences
    • Differential Diagnosis
    • Comorbidity
  • If information is limited, certain sections may not be included.
  • Recording Procedures: guidelines for reporting the disorder name and selecting/recording the appropriate ICD-10-CM code; instructions for applying subtypes and/or specifiers.
  • Subtypes and/or Specifiers: brief descriptions of applicable subtypes/specifiers.
  • Diagnostic Features: descriptive text illustrating criteria use and interpretation; e.g., some negative symptoms may be due to medication side effects.
  • Associated Features: clinical features not in the criteria but occurring more frequently in people with the disorder (e.g., generalized anxiety disorder with somatic symptoms not contained in criteria).