#66760: A Clinician's Guide to the DSM-5-TR

The comprehensive text revision in the DSM-5-TR represents a significant update to the descriptive content for most mental disorders compared to the DSM-5. This revision focused on several key areas [1]:

The extensive text revisions in the DSM-5-TR serve several vital purposes. They incorporate the latest research findings and clinical knowledge accumulated since the DSM-5 was published in 2013, providing clinicians with more up-to-date and nuanced information to aid in accurate diagnosis and treatment planning. These revisions reflect evolving understandings of how factors like culture, gender, and comorbidity impact mental health, aligning the manual more closely with current best practices in mental health care [24,25]. This emphasis on cultural competence, gender-affirming care, and comprehensive assessment of suicide risk represents a significant advancement in the field. Additionally, the updated text helps researchers by providing revised frameworks for studying mental disorders and their various dimensions. By addressing these critical areas, the DSM-5-TR aims to enhance the clinical utility of the manual and ensure it reflects the most current knowledge in the field of mental health by focusing on these areas; the DSM-5-TR aims to enhance the clinical utility of the manual and ensure it reflects current knowledge in the field of mental health. This comprehensive revision underscores the dynamic nature of psychiatric diagnosis and the ongoing efforts to refine our understanding of mental disorders.

The DSM-5-TR also added several new diagnostic entities and symptom codes (Table 1) [1].

The DSM-5-TR included clarifying modifications to the diagnostic criteria for more than 70 disorders [1]. These modifications were primarily aimed at improving clarity and reducing ambiguity in the criteria sets rather than fundamentally changing the conceptual definitions of the disorders. Here is a description of these changes:

It is important to note that while these modifications are significant for ensuring diagnostic accuracy, they are not as substantial as adding new disorders or significant revisions to existing ones. Clinicians are encouraged to review the specific changes relevant to their practice areas.

The DSM-5-TR incorporated updated terminology throughout the manual in its comprehensive revision process. This update in terminology serves several important purposes:

The DSM-5-TR incorporates several important terminology updates to reflect current scientific understanding and promote more sensitive, accurate language. Throughout the text, "neuroleptic medications" have been replaced with "antipsychotic medications or other dopamine receptor blocking agents," providing a more precise description of these drugs' mechanisms. In sections on gender dysphoria, "desired gender" has been updated to "experienced gender," acknowledging individuals' lived experiences better. The language surrounding substance use disorders has been revised to reduce stigma and align with the understanding of addiction as a medical condition. Terminology related to neurodevelopmental disorders has been updated to reflect current research and clinical practice. Additionally, the manual refines language used to describe cultural factors in mental health, emphasizing the importance of cultural competence in diagnosis and treatment. These changes demonstrate the ongoing effort to keep the DSM-5-TR relevant, accurate, and sensitive. The manual aims to improve communication among professionals, enhance diagnostic accuracy, and foster a more nuanced understanding of mental health conditions by adopting more precise, less stigmatizing, and culturally appropriate language.

The DSM-5-TR incorporated several updates to ICD-10-CM codes to align with the latest changes in diagnostic classifications (Table 2) [1]. Critical updates to the ICD-10-CM codes in the DSM-5-TR include the following.

The DSM-5-TR addressed culture, racism, and discrimination, representing a notable shift from the DSM-5 [1,2].

The DSM-5-TR incorporates an iterative revision process that allows for ongoing updates and improvements to the diagnostic manual [1]. This approach represents a significant shift from previous editions of the DSM, enabling more responsive and timely updates based on emerging research and clinical evidence.

The DSM-5-TR included clarifying modifications to the diagnostic criteria for more than 70 disorders. These modifications improved clarity and reduced ambiguity in the criteria sets without fundamentally changing the conceptual definitions of the disorders. The main goal was to enhance the reliability and validity of diagnoses by making the criteria more precise and more accessible to interpret consistently across clinicians.

The modifications affected a wide range of disorders across multiple categories in the DSM, indicating a comprehensive review of the manual. Most modifications were minor clarifications to wording designed to resolve ambiguities or inconsistencies in the original DSM-5 criteria. These changes underwent a formal review process, including approval by the DSM Steering Committee, the APA Board of Trustees, and the APA Assembly. Examples of clarifications include:

While these modifications do not fundamentally alter the disorders, they may lead to more accurate and consistent diagnoses in clinical practice. Clear criteria can produce more consistent research results across different studies and settings.

These clarifications underscore the ongoing effort to improve the precision and utility of the DSM for both clinical and research purposes. They reflect the dynamic nature of psychiatric diagnosis and the importance of continually refining diagnostic criteria based on clinical experience and emerging research.

The development and inclusion of prolonged grief disorder (PGD) in the DSM-5-TR represents a significant milestone in the field of mental health and bereavement research. Historically, research on pathological grief reactions dates to the 1990s, with various terms and criteria sets proposed over the years, including "complicated grief" and "persistent complex bereavement disorder" [26]. The concept of prolonged grief as a distinct disorder has been debated for decades among researchers and clinicians. Numerous studies have demonstrated that a small but significant portion of bereaved individuals experience persistent, intense grief that impairs their functioning, showing that prolonged grief is distinct from other mental health conditions like depression and post-traumatic stress disorder.

The proposal to include PGD was submitted to the APA nearly two decades ago and underwent extensive review and debate within the psychiatric community. Officially included in the DSM-5-TR published in March 2022, PGD replaced the previous persistent complex bereavement disorder, which had appeared in the DSM-5's Section III (Conditions for Further Study). The DSM-5-TR defines PGD as persistent yearning or longing for the deceased or preoccupation with thoughts of the deceased, along with several other symptoms lasting at least 12 months for adults and six months for children [1]. The symptoms must cause clinically significant distress or impairment and exceed cultural, religious, or age-appropriate norms.

However, the inclusion of PGD has sparked debate within the psychiatric community. Some critics argue that it pathologizes normal grief, while others contend that it is necessary to identify and treat those experiencing severe, persistent grief reactions [26]. The inclusion of PGD in the DSM-5-TR also aligns with its recognition in the ICD-11, although there are some differences in specific criteria. Overall, the incorporation of PGD reflects a growing acknowledgment of prolonged, impairing grief as a distinct clinical entity, aiming to improve diagnosis and treatment for individuals suffering from severe grief reactions while recognizing the need for careful differentiation from normal grieving processes.

Prolonged grief disorder was newly added to the DSM-5-TR as a formal diagnosis in the category of Trauma- and Stressor-Related Disorders. Here are the critical points about PGD and its diagnostic requirements in the DSM-5-TR [1]:

The inclusion of PGD in the DSM-5-TR aims to improve the recognition and treatment of maladaptive grief responses, particularly in the context of increased deaths due to the COVID-19 pandemic. However, its inclusion has also sparked some controversy in the psychiatric community, with debates about the potential medicalization of normal grief processes.

The development and inclusion of unspecified mood disorder in the DSM-5-TR represents a vital update aimed at addressing a gap in diagnostic options [1]. This category was added to provide clinicians with a diagnostic option when it is challenging to distinguish between unipolar and bipolar presentations, particularly in cases where irritable mood or agitation predominates. Historically, this category was unintentionally removed from the DSM-5 when the mood disorders diagnostic class was eliminated in favor of separate bipolar and depressive disorder classifications. The inclusion of unspecified mood disorder allows clinicians to avoid prematurely choosing between bipolar disorder and depressive disorder, which can have significant implications for treatment and long-term patient outcomes.

The unspecified mood disorder category also enhances compatibility with other diagnostic systems, such as ICD-10-CM and ICD-11, which include similar classifications. Due to the absence of a mood disorders grouping in the DSM-5-TR, unspecified mood disorder is located within both the depressive disorders and the bipolar disorders chapters. It applies to presentations with symptoms characteristic of a mood disorder that cause clinically significant distress or impairment but do not meet the full criteria for any specific mood disorder. This category serves as a diagnostic placeholder when there is insufficient information to make a more specific diagnosis, with the expectation that a more precise diagnosis may be made later as more information becomes available. Overall, including unspecified mood disorder reflects an effort to provide clinicians with greater flexibility in diagnosis, particularly in complex or unclear cases, while aligning the manual more closely with other diagnostic systems.

The development and inclusion of stimulant-induced mild neurocognitive disorder in the DSM-5-TR represents an essential update to the classification of substance-induced cognitive impairments [1]. Historically, the DSM-IV included a category for persisting dementia resulting from four substance classes: alcohol, sedatives/hypnotics/anxiolytics, inhalants, and other/unknown substances [18]. The DSM-5 replaced this single dementia category with major and mild neurocognitive disorders for these same substance classes [2]. A growing literature on stimulant-induced neurocognitive impairments supported the existence of persistent cognitive deficits resulting from stimulant use, with studies demonstrating that these deficits, while not severe enough to interfere with independence in daily activities, were significant enough to require more tremendous mental effort, compensatory strategies, or accommodation.

In the DSM-5-TR, cocaine-induced mild neurocognitive disorder and amphetamine-type substance–induced mild neurocognitive disorder were added to acknowledge the increasing evidence that chronic stimulant use can lead to lasting cognitive impairments, even after cessation of use [1]. This inclusion provides a diagnostic category for clinicians to capture the cognitive effects of stimulant use accurately. While specific diagnostic criteria are not detailed in the search results, it likely follows the general structure for substance-induced disorders, requiring evidence of cognitive decline that is etiologically related to stimulant use. The inclusion of this disorder allows for better recognition and potential treatment of cognitive impairments associated with stimulant use. It may facilitate research into the long-term effects of such substances on cognitive functioning. Overall, this addition aligns stimulant-induced cognitive impairments with other recognized substance-induced neurocognitive disorders in the DSM, reflecting an ongoing effort to refine and update the manual based on emerging research and clinical observations in substance-related disorders.

The diagnostic criteria for stimulant-induced mild neurocognitive disorder are as follows [1]:

Additionally, the clinician should specify the etiological subtype if possible (e.g., due to Alzheimer disease, vascular disease, traumatic brain injury, etc.). The presence or absence of behavioral disturbances should be noted. For some etiological subtypes, the level of certainty of the diagnosis (possible or probable) can be specified.

It is important to note that while these criteria help identify mild neurocognitive disorder, clinical judgment and comprehensive assessment are crucial for accurate diagnosis.

Including a code for "no diagnosis or condition" in the DSM-5-TR represents an essential addition to the manual, addressing a longstanding need in clinical practice and documentation [1]. This new code allows clinicians to indicate that a comprehensive diagnostic evaluation was conducted explicitly, but no mental disorder or condition warranting clinical attention was found. The development of this code stemmed from the recognition that there are situations where individuals undergo mental health assessments but do not meet the criteria for any mental disorder. Nevertheless, there was previously no standardized way to document this outcome.

The addition of this code serves several vital purposes in clinical practice. It clearly communicates that a thorough evaluation was performed, even when no diagnosis was made. This is particularly useful in contexts where the absence of a diagnosis needs to be formally recorded, such as in administrative or billing processes. The code also helps differentiate between cases where no disorder is present versus cases with insufficient information to diagnose. Furthermore, it can be valuable in research settings, allowing for more accurate categorization of study participants. Including this code in the DSM-5-TR reflects the manual's ongoing efforts to improve the accuracy and utility of clinical documentation in mental health care, providing clinicians with a more comprehensive set of tools for describing the outcomes of their diagnostic assessments.

The DSM-5-TR introduced significant changes regarding the documentation of suicidal behavior by adding new symptom codes to indicate both the presence and history of suicidal behavior [1]. This addition was part of a broader effort to improve the assessment and documentation of suicide risk in clinical practice. The DSM-5 had already included a Suicide Risk section in the text for most disorders to emphasize the importance of suicide risk assessment during clinical evaluations [2]. In the DSM-5-TR, these sections were expanded and renamed "Association with Suicidal Thoughts or Behavior."

The new symptom codes for suicidal behavior were added to the chapter "Other Conditions That May Be a Focus of Clinical Attention" in the DSM-5-TR. These codes allow clinicians to document current suicidal behavior (for both initial and subsequent encounters) as well as a history of suicidal behavior. Including these codes serves several important purposes: it helps improve the accuracy of clinical documentation, facilitates better tracking and research on suicidal behavior, and encourages clinicians to assess for these behaviors as part of routine clinical practice. Importantly, these codes can be used without requiring any other mental health diagnosis, recognizing that suicidal behavior can occur in various contexts. This change reflects a growing recognition of the need to address suicidal behavior as a distinct clinical concern, separate from, but often related to, other mental health conditions.

The DSM-5-TR introduced new symptom codes for nonsuicidal self-injury (NSSI), representing a significant update in the documentation and recognition of this clinically meaningful behavior [1]. This addition was part of a broader effort to improve the assessment and documentation of self-harming behaviors in clinical practice. The inclusion of these codes allows clinicians to document both current nonsuicidal self-injury and a history of nonsuicidal self-injury.

The new symptom codes for NSSI were added to the "Other Conditions That May Be a Focus of Clinical Attention" chapter in the DSM-5-TR. These codes serve several important purposes: they help improve the accuracy of clinical documentation, facilitate better tracking and research on self-injurious behaviors, and encourage clinicians to assess for these behaviors as part of routine clinical practice. Importantly, these codes can be used without requiring any other mental health diagnosis, recognizing that NSSI can occur in various contexts and may not always be associated with a specific mental disorder. This change reflects a growing recognition of the need to address self-injurious behaviors as distinct clinical concerns, separate from, but often related to, other mental health conditions. Including these codes in the DSM-5-TR aims to draw attention to the importance of assessing and documenting NSSI, potentially leading to improved identification and treatment of individuals engaging in these behaviors.

Attenuated psychosis syndrome (APS) is characterized by the presence of attenuated (less severe) psychotic symptoms that do not meet the full criteria for a psychotic disorder. These symptoms typically include delusions, hallucinations, or disorganized speech in a milder form, with relatively intact reality testing.

The inclusion of APS in the DSM aims to identify individuals who may be at high risk for developing a full psychotic disorder, particularly schizophrenia. To meet the criteria for APS, symptoms must have begun or worsened in the past year, be present at least once per week in the last month, and cause distress or disability to the individual [1]. Notably, the symptoms should not be better explained by another mental disorder or substance use. The concept of APS has sparked debate in the psychiatric community, with some arguing for its potential in early intervention and prevention of psychosis. In contrast, others express concerns about potential overdiagnosis and stigmatization. As research continues, the status of APS may evolve in future editions of the DSM.

Depressive episodes with short-duration hypomania is a condition included in the Conditions for Further Study section of the DSM-5-TR, indicating that more research is needed before it can be considered an official diagnosis. This proposed disorder is characterized by individuals who experience major depressive episodes along with brief periods of hypomania that last less than four days. These short hypomanic episodes do not meet the current DSM criteria for bipolar II disorder, which requires hypomanic episodes to last at least four consecutive days.

The inclusion of this condition in the DSM-5-TR reflects growing recognition that shorter periods of hypomania may be clinically significant and more common than previously thought. Research suggests that individuals with depressive episodes and short-duration hypomania may represent a distinct clinical group that falls on a spectrum between unipolar depression and bipolar II disorder. These patients often experience mood instability, increased energy levels, and changes in behavior during their brief hypomanic periods, which can impact their overall functioning and treatment needs. The study of this condition aims to improve diagnostic accuracy and potentially lead to more appropriate treatment strategies for individuals who may be currently misdiagnosed with unipolar depression. However, there is ongoing debate in the psychiatric community about the optimal duration criterion for hypomania and the potential implications of broadening the bipolar spectrum.

Caffeine use disorder (CUD) is a condition included in the DSM-5-TR under the Conditions for Further Study section, indicating that more research is needed before it can be considered an official diagnosis. The proposed criteria for CUD are like other substance use disorders but with a more conservative threshold to prevent overdiagnosis, given the prevalence of nonproblematic caffeine use in the general population. For a potential CUD diagnosis, an individual must endorse at least three criteria [1]:

Research suggests that CUD may affect a significant portion of caffeine consumers, with one study finding that 8% of a sample of U.S. adults met the proposed DSM-5 criteria [2]. Individuals meeting these criteria tend to consume more caffeine, are often younger, and are more likely to be cigarette smokers. They may experience caffeine-related functional impairment, poorer sleep, and greater levels of depression, anxiety, and stress. Symptoms of CUD can include anxiety, insomnia, and other issues that interfere with daily life. While caffeine is widely consumed and generally considered safe, CUD highlights that, for some individuals, caffeine use can become problematic and may require clinical attention. However, more research is needed to fully understand this condition's prevalence, severity, and clinical significance before it can be officially recognized as a disorder in future editions of the DSM.

Internet gaming disorder (IGD) is a condition included in the Conditions for Further Study section of the DSM-5-TR, indicating that more research is needed before it can be considered an official diagnosis [1]. The DSM-5 defines IGD as "a pattern of excessive and prolonged Internet gaming that results in a cluster of cognitive and behavioral symptoms, including progressive loss of control over gaming, tolerance, and withdrawal symptoms, analogous to the symptoms of substance use disorders" [1]. To meet the criteria for IGD, an individual must experience five or more of nine specified symptoms within a year, such as preoccupation with gaming, withdrawal symptoms when gaming is taken away, and loss of interest in other activities.

The inclusion of IGD in the DSM-5 reflects growing concern about the potential negative impacts of excessive online gaming, particularly among young people. Research suggests that individuals with IGD may experience significant impairment in various areas of life, including academic performance, social relationships, and mental health. However, the prevalence of IGD appears to be relatively low, with studies estimating that between 0.3% and 1.0% of the general population might qualify for a potential diagnosis. The condition criteria focus on Internet games and do not include general Internet use, online gambling, or social media use. While IGD's inclusion in the DSM-5 has stimulated further research and clinical attention, debate continues in the scientific community about whether gaming addiction should be classified as a distinct mental disorder. As research in this area progresses, our understanding of IGD and its potential impacts on mental health may evolve.

Neurobehavioral disorder associated with prenatal alcohol exposure (ND-PAE) is a condition included in the DSM-5-TR under the Conditions for Further Study section [1]. It is characterized by a pattern of impairments in neurocognition, self-regulation, and adaptive functioning resulting from prenatal alcohol exposure. To meet the diagnostic criteria for ND-PAE, there must be confirmed prenatal alcohol exposure, along with evidence of impaired neurocognitive functioning, self-regulation, and adaptive functioning. Symptoms typically manifest in childhood and lead to significant distress or impairment in social, academic, or other important areas of functioning [1].

Individuals with ND-PAE may experience cognitive deficits, such as planning, attention, learning, and memory difficulties. Behavioral regulation issues, including mood or behavioral regulation problems, attention deficits, and impulse control challenges, can also arise. Additionally, these individuals may face difficulties in adaptive functioning, including social communication and interaction problems and impaired daily living skills. Estimates suggest that 2-5% of children in the United States may have a fetal alcohol spectrum disorder (FASD), with ND-PAE being a subset of this group [22]. Diagnosis requires confirmation of prenatal alcohol exposure and a comprehensive assessment of neurocognitive, behavioral, and adaptive functioning. Treatment typically involves a multidisciplinary approach that includes educational interventions, behavioral therapies, and sometimes medication for specific symptoms. While ND-PAE is a lifelong condition, early intervention and appropriate support can improve outcomes significantly. Notably, the only way to prevent ND-PAE is to avoid alcohol consumption during pregnancy. This condition represents an effort to capture better the range of effects that prenatal alcohol exposure can have on a child's development and functioning, extending beyond the physical features associated with fetal alcohol syndrome [1].

Suicidal behavior disorder (SBD) was introduced in the DSM-5 as a condition for further study, indicating that more research was needed before it could be considered for inclusion as an official diagnosis [2]. SBD is characterized by a self-initiated sequence of behaviors believed at the time of initiation to cause one's death, occurring within the last 24 months. The proposal aimed to improve the recognition, documentation, and treatment of suicidal behavior as a distinct clinical concern, separate from, but often related to, other mental health conditions.

The inclusion of SBD in the DSM-5 sparked debate in the psychiatric community [2]. Proponents argued that it could enhance research, improve communication during clinical hand-offs, and maintain focus on suicidal behavior as a significant clinical concern. Critics, however, raised concerns about the potential over-medicalization of behavior and increased liability for mental health professionals. Research on SBD over the past decade has primarily focused on its clinical utility in predicting future suicide risk, its association with related disorders, the development of psychometric measures, its pathophysiology, and potential interventions. However, studies have shown that the clinical utility of SBD for predicting future suicide risk is limited. In the DSM-5-TR, published in 2022, SBD was not included as a formal diagnosis. Instead, new symptom codes were added to indicate current suicidal behavior and history of suicidal behavior, allowing clinicians to document these behaviors without requiring any other mental health diagnosis. This change reflects ongoing efforts to improve the assessment and documentation of suicide risk in clinical practice while acknowledging the complexities involved in classifying suicidal behavior as a distinct disorder.

Nonsuicidal self-injury disorder (NSSID) is a condition included in the Conditions for Further Study section of the DSM-5-TR, indicating that more research is needed before it can be considered an official diagnosis [1]. NSSID is characterized by deliberate self-inflicted damage to the surface of one's body without suicidal intent. To meet the diagnostic criteria, an individual must have engaged in self-injury for at least five days within the past year, with the expectation that the injury will lead to minor or moderate physical harm. The behavior is typically associated with interpersonal difficulties or negative feelings and thoughts, such as depression, anxiety, or self-criticism. Individuals with NSSID often report engaging in self-injury to obtain relief from negative emotions, to resolve interpersonal difficulties, or to induce positive feelings.

Studies have shown that individuals meeting NSSID criteria often experience more severe psychopathology and impairment compared to those who self-injure but do not meet full criteria. NSSID can occur both independently and comorbidly with other mental health conditions, such as depression, anxiety disorders, and borderline personality disorder. Including NSSID in the DSM-5-TR aims to improve the recognition and treatment of clinically significant self-injurious behaviors while stimulating further research to understand this condition better. However, there is ongoing debate regarding the optimal diagnostic criteria, particularly concerning the frequency threshold and the potential risk of pathologizing behaviors that may be transient or part of normal development, especially in adolescents [1].

The inclusion of prolonged grief disorder has been one of the most controversial changes. Critics argue that it may pathologize normal grief reactions, potentially leading to overdiagnosis and unnecessary treatment. Some concerns defining grief as a disorder after just one year (or six months in children) may not account for cultural variations in grieving processes.

Some mental health professionals worry that the DSM-5-TR continues the trend of medicalizing typical human experiences. This concern extends beyond just grief to other areas of human distress that may be inappropriately labeled as disorders.

With the addition of new disorders and modifications to existing criteria, there are concerns about potential overdiagnosis and subsequent overtreatment, particularly with psychiatric medications.

Despite efforts to improve cultural sensitivity, some critics argue that the DSM-5-TR still does not adequately account for cultural variations in the expression of mental distress.

There are ongoing debates about the validity and reliability of specific diagnoses, with some arguing that the categorical approach to mental disorders does not accurately reflect the complexity and dimensionality of mental health.

Some critics raise concerns about the potential influence of the pharmaceutical industry on diagnostic criteria, suggesting that new or broadened diagnoses might benefit drug companies.

Like its predecessors, the DSM-5-TR relies primarily on observable symptoms rather than biological markers. Given advancements in neuroscience and genetics, some argue that this approach is outdated.

There is ongoing debate about whether a dimensional approach to mental health (as proposed by alternative systems like the RDoC) might be more appropriate than the DSM's categorical approach.

Some critics argue that the APA, which publishes the DSM, has a financial conflict of interest that may influence decisions about what to include in the manual.

These controversies highlight the ongoing challenges in developing a comprehensive and universally accepted system for diagnosing mental disorders. They also underscore the importance of continued research and debate in mental health.

The Hierarchical Taxonomy of Psychopathology (HiTOP) represents a significant departure from the traditional categorical approach of the DSM-5-TR. While the DSM-5-TR relies on discrete diagnostic categories mainly determined by expert consensus, HiTOP adopts a dimensional, data-driven approach to classifying mental health problems [27]. HiTOP organizes psychopathology into a hierarchical structure, ranging from broad, general dimensions to more specific symptoms, based on empirical evidence from large-scale studies. This dimensional approach addresses several DSM limitations, including arbitrary boundaries between normality and pathology, high comorbidity rates, within-disorder heterogeneity, and diagnostic instability.

One of the critical differences between HiTOP and the DSM-5-TR is how they conceptualize mental health problems. The DSM-5-TR views disorders as distinct categories with clear boundaries, while HiTOP sees them as existing on continua of severity. For example, where the DSM-5-TR might diagnose social anxiety disorder as a discrete condition, HiTOP would place an individual on a spectrum of social anxiety, ranging from mild discomfort to severe impairment. This dimensional approach allows for more nuanced assessment and potentially more tailored treatment planning. Additionally, HiTOP's hierarchical structure explicitly accounts for comorbidity by grouping related syndromes, whereas the DSM-5-TR's categorical approach often results in multiple, seemingly separate diagnoses for a single individual. While HiTOP shows promise in addressing some of the DSM-5-TR's limitations, it is still a work in progress and faces widespread clinical implementation and acceptance challenges.

The Research Domain Criteria (RDoC) framework and the DSM-5-TR represent two distinct approaches to understanding and classifying mental health disorders. While the DSM-5-TR is a categorical system primarily designed for clinical diagnosis, RDoC is a dimensional, research-oriented framework that aims to integrate multiple levels of information to understand the fundamental mechanisms underlying mental health and illness [28]. The DSM-5-TR provides specific diagnostic criteria for mental disorders, organized into distinct categories, and is widely used by clinicians for diagnosis and treatment planning. In contrast, RDoC does not provide diagnostic categories but focuses on examining functional dimensions of behavior across a spectrum from normal to abnormal.

One of the critical differences between RDoC and DSM-5-TR lies in their underlying philosophies and goals. The DSM-5-TR aims to provide a common language for clinicians and researchers, facilitating communication and standardizing diagnoses. It is based on observable symptoms and clinical presentation. RDoC, on the other hand, was developed to address limitations in the current diagnostic systems by focusing on neurobiology and behavioral dimensions that cut across traditional diagnostic boundaries. RDoC organizes research into five main domains (negative valence systems, positive valence systems, cognitive systems, social processes, and arousal/regulatory systems), each of which can be studied at various levels of analysis, from genes to self-report. While the DSM-5-TR is immediately applicable in clinical settings, RDoC is primarily a research framework aimed at advancing our understanding of the biological and psychological mechanisms underlying mental health disorders, with the long-term goal of informing future diagnostic systems and treatment approaches.

The Network Analysis Approach represents a significant shift in how mental disorders are conceptualized and studied, with implications for the DSM-5-TR and future iterations of diagnostic manuals [29]. Unlike the traditional DSM approach, which views mental disorders as discrete categories caused by underlying latent variables, the Network Analysis Approach posits that mental disorders are complex systems of interacting symptoms. This approach focuses on how symptoms directly influence each other rather than being caused by an underlying disorder. For example, insomnia might lead to fatigue, which could then cause concentration problems.

Network analysis offers a new perspective on comorbidity, suggesting that disorders co-occur because of shared symptoms that bridge different symptom networks. While the DSM-5-TR still essentially uses a categorical approach to diagnosis, network analysis aligns more closely with dimensional models of psychopathology, which are gaining traction in psychiatric research. This approach allows for a more personalized understanding of an individual's symptom patterns, potentially leading to more tailored treatment approaches than those based on broad DSM categories.

Studies using network analysis have provided insights into the structure of various DSM disorders, including depression, anxiety, and PTSD, potentially informing future revisions of the manual. The network approach suggests that targeting central symptoms in a network might be more effective than treating all symptoms equally, which could influence how DSM disorders are conceptualized and treated. While not directly incorporated into the DSM-5-TR, network analysis can be seen as complementary to current diagnostic practices, offering additional insights into the structure and dynamics of mental disorders. As network analysis gains more empirical support, it may influence future revisions of the DSM, potentially leading to more dynamic and interconnected models of mental disorders.

Transdiagnostic approaches represent a shift from the traditional categorical diagnostic system used in the DSM-5-TR, instead focusing on standard processes and factors that cut across multiple disorders [30]. While the DSM-5-TR maintains a categorical approach to diagnosis, it has incorporated some transdiagnostic elements, reflecting the growing recognition of shared features across disorders. For example, the DSM-5-TR includes dimensional assessments and cross-cutting symptom measures that can be applied across diagnostic categories. Additionally, the manual's text revisions have emphasized common risk factors, comorbidities, and overlapping symptoms between disorders.

The transdiagnostic perspective aligns with emerging research, suggesting that many mental health conditions share underlying psychological and biological mechanisms. This approach aims to identify core processes that contribute to developing and maintaining various disorders, potentially leading to more efficient and effective treatments. While the DSM-5-TR does not fully embrace a transdiagnostic framework, its updates reflect a growing awareness of the limitations of strict categorical diagnoses. The inclusion of dimensional assessments and the emphasis on comorbidity in the DSM-5-TR can be seen as steps toward a more nuanced understanding of mental health that aligns with transdiagnostic principles. However, the fundamental structure of the DSM-5-TR remains rooted in discrete diagnostic categories, highlighting the ongoing tension between categorical and dimensional approaches to understanding and treating mental health disorders.

Clinical staging models represent an alternative approach to psychiatric diagnosis and treatment that has gained attention in recent years [31]. However, they are not formally incorporated into the DSM-5-TR. These models aim to identify where individuals lie along a continuum of illness, from at-risk to chronic and severe conditions. Unlike the categorical approach of the DSM-5-TR, clinical staging models emphasize the progression and extension of mental disorders over time. They propose that mental health problems develop through a series of stages, each with distinct clinical and neurobiological features.

While the DSM-5-TR maintains a primarily categorical approach to diagnosis, it does acknowledge the potential utility of dimensional assessments and cross-cutting symptom measures, which align somewhat with the principles of clinical staging. The DSM-5-TR's emphasis on early identification and intervention for mental health problems also resonates with the goals of clinical staging models. However, the DSM-5-TR does not formally adopt a staging framework for any disorders. Some researchers argue that integrating clinical staging models into future revisions of the DSM could enhance its clinical utility, particularly for youth mental health and early intervention services. These models could potentially bridge the gap between categorical diagnoses and the complex, often overlapping presentations seen in clinical practice. As research in this area progresses, future editions of the DSM may incorporate more elements of clinical staging, particularly if evidence continues to support its utility in improving treatment selection and understanding patterns of illness progression.

Personalized diagnosis represents a shift away from the categorical approach used in the DSM-5-TR towards a more individualized understanding of mental health conditions [31]. While the DSM-5-TR provides standardized diagnostic criteria for mental disorders, personalized diagnosis aims to tailor the diagnostic process to everyone's unique biological, psychological, and social characteristics.

The DSM-5-TR relies on symptom-based criteria to categorize mental disorders, which allows for consistency in diagnosis across clinicians and settings. However, this approach has been criticized for not fully capturing the complexity and heterogeneity of mental health presentations. In contrast, personalized diagnosis incorporates a broader range of data, including genetic information, biomarkers, environmental factors, and individual life experiences. This approach often utilizes advanced technologies like machine learning to predict individual outcomes and treatment responses. While the DSM-5-TR has made some moves towards dimensionality, such as including severity specifiers and cross-cutting symptom measures, personalized diagnosis goes further by considering the unique combination of factors that contribute to an individual's mental health status. This approach aligns with the growing understanding that mental disorders are complex and multifaceted, influenced by a variety of interacting factors. However, while personalized diagnosis holds promise for improving treatment outcomes and understanding individual variations in mental health, it is still an evolving field. The DSM-5-TR remains the standard for clinical diagnosis in many settings due to its established reliability and utility in professional communication. As research in personalized diagnosis advances, it may increasingly complement and potentially reshape traditional diagnostic approaches in future iterations of diagnostic manuals.

The DSM-5-TR continues and expands upon the emphasis on cultural considerations in psychiatric diagnosis introduced in previous editions. The manual includes a dedicated chapter titled "Culture and Psychiatric Diagnosis" in Section III, which provides comprehensive guidance on integrating cultural concepts into clinical practice. This chapter introduces the Cultural Formulation Interview (CFI), a semi-structured interview guide designed to help clinicians systematically assess cultural factors that may impact a patient's mental health presentation, diagnosis, and treatment.

The CFI consists of 16 questions that explore the patient's cultural identity, explanatory models of illness, psychosocial stressors, cultural features of the patient-clinician relationship, and overall cultural assessment. Additionally, the DSM-5-TR includes 12 supplementary modules to the CFI that allow for more in-depth exploration of specific cultural domains such as explanatory models, level of functioning, social network, and cultural identity. These tools aim to enhance cultural competence in clinical practice and improve the accuracy and relevance of psychiatric diagnoses across diverse populations.

Throughout the manual, each disorder includes sections on "Culture-Related Diagnostic Issues" and "Sex- and Gender-Related Diagnostic Issues," which have been updated to reflect current research and understanding of how cultural and gender factors may influence the presentation, prevalence, and course of mental disorders. The DSM-5-TR also emphasizes the importance of considering the impact of racism, discrimination, and other social determinants of mental health in assessment and diagnosis. This comprehensive approach to cultural formulation in the DSM-5-TR represents a significant step towards more culturally sensitive and accurate psychiatric diagnosis and treatment planning.