Special Report on DSM-5-TR—What Social Workers Need To Know

by Jonathan B. Singer, PhD, LCSW

(Corrected on 3/24/22 to clarify criteria for Prolonged Grief Disorder)

   On Friday, March 18, 2022, almost nine years after the publication of the DSM-5 (APA, 2013), the American Psychiatric Association (APA) published the text revision of DSM-5, known as DSM-5-TR. That day, I tweeted out some of the key changes. The purpose of this article is to highlight some of the changes in DSM-5-TR that social workers need to know.

     The text revisions include:

• updated descriptions of the prevalence, risk, and prognostic factors for each disorder based on new findings from research.
• one new disorder in the chapter Trauma and Related Stressors called prolonged grief disorder (F43.8). This is the only disorder that should be referred to as a DSM-5-TR disorder, because it is new to the text revision. All other disorders should be referred to as DSM-5 disorders.
• a change in terminology from intellectual disability (previously mental retardation) to intellectual developmental disorder [(F70) mild; (F71) moderate; (F72) severe; (F73) profound].
• a new category for Other Conditions That May Be a Focus of Clinical Attention - Suicidal behavior and nonsuicidal self-injury (NSSI).
• codes for the initial encounter of someone with suicidal ideation or attempt (T14.91A), subsequent encounters (T14.91D), and a history (but not current) suicidal behavior (Z91.51).
• codes for current NSSI (R45.88) and a history (not current) of NSSI (Z91.52).

     Interestingly, even though the DSM-5-TR includes codes for suicidal behavior and NSSI, they kept Suicidal Behavior Disorder and NSSI Disorder in the section Conditions for Further Study.

     As one would expect in a book called “text revision,” there are several notable updates to the language that is used in the DSM-5-TR.

• The Gender Dysphoria chapter updates problematic terminology to preferred terminology, e.g. “natal sex” to “birth-assigned gender,” “natal male/natal female” to “individual assigned male/female at birth,” “gender reassignment treatments” to “gender affirming treatments,” and “desired gender” to “experienced gender.” The term cisgender wasn’t in DSM-5. In contrast, DSM-5-TR not only includes a definition of cisgender, but also suggests the word “nontransgender” as a way of centering transgender people. DSM-5-TR added a post-transition specifier for Gender Dysphoria.  
• DSM-5-TR continues to acknowledge that race is a social construct. While this might seem obvious to social workers, the DSM-5 was written by medical doctors who are taught to consider people as biological beings first and foremost. “Also, for the first time ever, the entire DSM text has been reviewed and revised by a Work Group on Ethnoracial Equity and Inclusion to ensure appropriate attention to risk factors such as the experience of racism and discrimination, as well as to the use of non-stigmatizing language.” Examples of the influence of the committee include the use of the term Latinx, and the term racialized instead of racial to highlight the socially constructed nature of race. The DSM-5-TR decenters whiteness by avoiding the use of “minority” and “non-White.”

Prolonged Grief Disorder

     The historical context of prolonged grief disorder (F43.8) is relevant. The DSM has been moving toward pathologizing grief reactions since the publication of DSM-5, when they removed the bereavement exclusion from the chapter on depressive disorders. Prior to 2013, if someone had depressive symptoms that met criteria for major depressive disorder but was grieving the death of a loved one, they would not meet criteria for the disorder. That exclusion was removed in DSM-5. Fast forward nine years to a global pandemic in which a million Americans have died (and 5 million outside of the U.S.), and the DSM Task Force approves the first disorder that centers on the death of a loved one.

      To meet criteria for prolonged grief disorder in adults, the death must have been at least 12 months ago, or for children and adolescents at least 6 months ago. There has to be clinically significant yearning/longing for and preoccupation with thoughts or memories of the deceased person. The bereaved person has to have experienced three of eight symptoms daily in the past 30 days related to the death, including feeling as if part of you has died, disbelief, avoidance of reminders, intense emotional pain, interpersonal difficulties, emotional numbness, feelings of life being meaningless, and/or intense loneliness.

     Proponents of the inclusion of the disorder include Columbia University School of Social Work professor Kathy Shear (developer of complicated grief treatment), who told The New York Times (March 18, 2022) that she is in favor of anything that helps people. The diagnosis will make it possible for therapists to bill for grief-related treatments without diagnosing their clients with a depressive disorder or posttraumatic stress disorder.

     Critics of the disorder’s inclusion point to the pathologizing of grief responses and establishing a length of time for “normal” bereavement. Joanne Cacciatore, an associate professor of social work at Arizona State University, was quoted in the same March 18, 2022 article in The New York Times as saying, “I completely, utterly disagree that grief is a mental illness.... When someone who is a quote-unquote expert tells us we are disordered and we are feeling very vulnerable and feeling overwhelmed, we no longer trust ourselves and our emotions.... To me, that is an incredibly dangerous move, and short sighted.” 

Other Key Changes

• Attenuated psychosis syndrome: In DSM-5, this diagnosis included the phrase “with relatively intact reality testing.” Not surprisingly, this was the source of much confusion for a diagnosis that has, at its core, psychotic processes.
• Autism spectrum disorder: In DSM-5, Criterion A included the phrase “as manifested by the following” and then included three deficits in social communication and social interaction. Apparently, some people thought that meant you could pick one of the three. DSM-5-TR clarifies that all three deficits need to be present to meet Criterion A.
• Bipolar I and Bipolar II: Language was changed to make it easier to distinguish the presence of psychotic features and mood changes in bipolar disorder compared to the psychotic disorders, e.g. schizoaffective disorder.
• Persistent depressive disorder: They removed “dysthymia” as a parenthetical comment associated with any DSM-5 diagnosis. This term was a hold-over from DSM-IV’s dysthymic disorder. They eliminated all but two specifiers: “anxious distress” and “atypical.”
• Social anxiety disorder: They removed “social phobia” as a parenthetical comment, because the term no longer has clinical utility as the field has completely adopted the term social anxiety disorder.

     There are a dozen more changes similar to those above. To read more about them, please consult the fact sheets on the APA website. 

Should You Buy the DSM-5-TR?

     Should social workers run out and purchase the DSM-5-TR? Not if you have the DSM-5. The APA provided DSM-5-TR Fact Sheets that summarize key changes but not the diagnostic codes.

     Allen Frances, MD, chair of the DSM-IV task force and critic of DSM-5, tweeted out his opinion about reasons that social workers do not need to buy the DSM-5-TR.

Conclusion

     All social workers should understand how the DSM came to be, how it is used, and how they can best serve as advocates for their clients in systems that use the DSM. Some people find great comfort and community in getting a diagnosis. Some people experience symptom relief from medication and experience a significant improvement in their quality of life. Many folks, however, are seen by providers as their diagnosis, and get shuffled along in a system that's more focused on paperwork and reimbursement than diving into the real issues that brought them to services in the first place. As social workers, we must be critical of the structures that are in place, including diagnostic systems, so that we serve as agents of social change.

Jonathan B. Singer, PhD, LCSW, is associate professor at Loyola University Chicago School of Social Work, and founder and host of the award-winning Social Work Podcast. His scholarship focuses on the intersection of suicide, schools, education and technology.