|
| A) | 1840s | ||
| B) | 1910s | ||
| C) | 1940s | ||
| D) | 1970s |
Before the development of a comprehensive diagnostic system, there was little agreement on categories of psychological disorders or what disorders were psychological versus medical. The first large-scale attempt at generating mental health diagnoses was published in the 1840s, and it was primarily an attempt to obtain statistical data through the census and consisted of a single diagnosis of idiocy/insanity. Following this, in 1917, to better standardize the classification of mental disorders across mental hospitals, the American Psychiatric Association (APA) developed a standard nomenclature for some psychological disorders that would be included in the American Medical Association's Standard Classified Nomenclature of Disease. Although this was an essential step in the direction of identifying standardized psychological diagnoses, it was limited in that it did little to distinguish between psychological and medical disorders, and it was primarily focused on the most severe disorders that were seen in inpatient units.
| A) | 25 disorders | ||
| B) | 182 disorders | ||
| C) | 265 disorders | ||
| D) | 300 disorders |
Although DSM-I was a significant advancement, it was still limited in many ways, particularly by the lack of a consistent and agreed-upon definition for mental illness. As an example, homosexuality was listed in DSM-I as a sociopathic personality diagnosis, which reflected more on the social traditions at the time of DSM-I than on the actual psychological aspects of homosexuality. By the 1960s, many viewed the concept of mental illness as a myth or as a way for society to exert control over those who might deviate from societal norms [8,9]. In 1968, in conjunction with the development of the ICD-7, the APA published a revision of the manual DSM-II [10]. This revision was like DSM-I in many ways, and it increased the number of psychological diagnoses to 182 disorders. DSM-II also no longer made use of the term reaction, which was used throughout much of DSM-I to indicate that all mental disorders were reactions to environmental factors [11]. For example, there was a section on schizophrenic reaction, which implied that psychotic symptoms arose from environmental stressors such as insufficient mothering. DSM-II was still heavily influenced by psychodynamic theory, and disorders such as neurosis and homosexuality continued to appear in the manual. In 1974, during the seventh printing of DSM-II, homosexuality was removed from the DSM, following controversy over the diagnosis and over data indicating that there were few differences in the psychological adjustment between heterosexual and homosexual men [12].
| A) | 1968 | ||
| B) | 1974 | ||
| C) | 1980 | ||
| D) | 1987 |
In the mid-1970s, the DSM came under scrutiny by clinicians who questioned the DSM's utility from both a clinical and a research perspective. Spitzer and Fleiss published a highly influential paper indicating that DSM-II diagnoses were unreliable, meaning that they did not yield consistent results across diagnosticians and settings [13]. A vital aspect of a diagnosis involves consistent communication between clinicians about the diagnosis, and a diagnostic system that yields unreliable results across most diagnostic categories is a significant problem. Thus, in 1974, only a few years after the publication of DSM-II, the decision was made to revise the DSM again, with Robert Spitzer as the chairman of the DSM-III task force. The primary goals for DSM-III were to make the DSM more consistent with the ICD, standardize diagnostic practices between the United States and other countries, and improve the standardization and validity of diagnoses. To make these improvements, the methods for establishing the diagnostic criteria for a disorder were changed. In previous versions of the DSM, diagnoses consisted of brief and sometimes vague descriptions of the disorder, with many descriptions being heavily influenced by theory rather than observable factors. In DSM-III, diagnoses were structured using the research diagnostic criteria and the Feighner criteria, which were published scientific reports for how a psychiatric diagnostic system should be structured [14,15]. It was here that many DSM diagnoses, like their current descriptions, began to fully appear, with the inclusion of diagnostic categories such as anxiety and affective disorders, schizophrenia, and antisocial personality disorder. When published in 1980, DSM-III contained 265 mental health diagnoses, which was a significant increase from DSM-II [16]. In addition to including more explicit diagnostic criteria, DSM-III introduced a multiaxial system that allowed for multiple facets of diagnosis and the notation of medical diagnoses, acknowledging that mental and physical health problems often co-occur. The multiaxial system also allowed attention to be given to more chronic disorders, with Axis II diagnoses including mental retardation and personality disorders. Finally, DSM-III also included more textual descriptions of theoretically neutral disorders dispensed with previous theoretically driven diagnoses. Many of these changes resulted in DSM-III being a far more reliable tool than DSM-II and facilitated better communication among professionals about the disorders they were treating.
| A) | Removal of all diagnostic criteria | ||
| B) | Introduction of the multiaxial system | ||
| C) | Elimination of all personality disorders | ||
| D) | Focus on theoretical approaches only |
In the mid-1970s, the DSM came under scrutiny by clinicians who questioned the DSM's utility from both a clinical and a research perspective. Spitzer and Fleiss published a highly influential paper indicating that DSM-II diagnoses were unreliable, meaning that they did not yield consistent results across diagnosticians and settings [13]. A vital aspect of a diagnosis involves consistent communication between clinicians about the diagnosis, and a diagnostic system that yields unreliable results across most diagnostic categories is a significant problem. Thus, in 1974, only a few years after the publication of DSM-II, the decision was made to revise the DSM again, with Robert Spitzer as the chairman of the DSM-III task force. The primary goals for DSM-III were to make the DSM more consistent with the ICD, standardize diagnostic practices between the United States and other countries, and improve the standardization and validity of diagnoses. To make these improvements, the methods for establishing the diagnostic criteria for a disorder were changed. In previous versions of the DSM, diagnoses consisted of brief and sometimes vague descriptions of the disorder, with many descriptions being heavily influenced by theory rather than observable factors. In DSM-III, diagnoses were structured using the research diagnostic criteria and the Feighner criteria, which were published scientific reports for how a psychiatric diagnostic system should be structured [14,15]. It was here that many DSM diagnoses, like their current descriptions, began to fully appear, with the inclusion of diagnostic categories such as anxiety and affective disorders, schizophrenia, and antisocial personality disorder. When published in 1980, DSM-III contained 265 mental health diagnoses, which was a significant increase from DSM-II [16]. In addition to including more explicit diagnostic criteria, DSM-III introduced a multiaxial system that allowed for multiple facets of diagnosis and the notation of medical diagnoses, acknowledging that mental and physical health problems often co-occur. The multiaxial system also allowed attention to be given to more chronic disorders, with Axis II diagnoses including mental retardation and personality disorders. Finally, DSM-III also included more textual descriptions of theoretically neutral disorders dispensed with previous theoretically driven diagnoses. Many of these changes resulted in DSM-III being a far more reliable tool than DSM-II and facilitated better communication among professionals about the disorders they were treating.
| A) | 1995 | ||
| B) | 1997 | ||
| C) | 1999 | ||
| D) | 2001 |
Nineteen years elapsed between the publication of DSM-IV and the release of DSM-5. The revision process for DSM-5 began in 1999 and was a long one that involved substantial efforts by many key leaders in the field of psychopathology, considerable debate about what changes should or should not be made to diagnostic categories and criteria, and extensive field-testing of diagnoses for reliability [21]. In coordination with large health institutions, such as the National Institute of Mental Health and the World Health Organization, the APA began in 1999 to evaluate the strengths and weaknesses of DSM-IV. David Kupfer and Darrel Regier chaired the DSM-5 task force of 28 people, with 6 to 12 task force members assigned to each work group. Each work group was responsible for meeting in person and communicating frequently throughout the year to determine the changes that should be made for each assigned category (e.g., mood disorders, eating disorders, personality disorders). These work groups then drafted proposals for changes to each area, which were posted on the APA DSM-5 website (http://www.dsm5.org) for public evaluation and commentary. Field trials for potential DSM-5 diagnostic criteria began in 2011 to establish inter-rater reliability for all diagnoses. In December 2012, the APA Board of Trustees voted to approve DSM-5, published in May 2013. However, it is essential to remember that the DSM is a constantly evolving manual.
| A) | Chronic fatigue syndrome | ||
| B) | Internet gaming disorder | ||
| C) | Prolonged grief disorder | ||
| D) | Misophonia |
The DSM-5 was released in 2013, and nearly a decade later received a text revision, colloquially known as the DSM-5-TR [1]. The development of the DSM-5-TR involved over 200 experts, including many who had worked on the DSM-5, and took approximately three years to complete [22]. The revision process incorporated three main components: the original DSM-5 diagnostic criteria and text, updates made through an iterative revision process overseen by the DSM Steering Committee, and a comprehensive text update managed by the Revision Subcommittee. The DSM-5-TR introduced several changes, including a new diagnosis (prolonged grief disorder), clarifications to existing diagnostic criteria, updated terminology, and comprehensive text revisions [1]. Additionally, four cross-cutting review groups focused on culture, sex and gender, suicide, and forensic issues, while a Work Group on Ethnoracial Equity and Inclusion ensured appropriate attention to risk factors such as racism and discrimination [23]. The revision aimed to reflect current scientific literature, address inconsistencies, and improve the manual's utility for clinicians and researchers.
| A) | To completely restructure mental health diagnoses | ||
| B) | To provide updated information based on new research since DSM-5 | ||
| C) | To eliminate all previous diagnostic categories | ||
| D) | To reduce the number of mental health diagnoses |
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.
| A) | More than 50 | ||
| B) | More than 70 | ||
| C) | About 20 | ||
| D) | More than 100 |
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:
Nature of the changes: The modifications were mostly minor clarifications to wording, designed to resolve ambiguities or inconsistencies in the original DSM-5 criteria.
Purpose: These changes were intended to enhance the reliability and validity of diagnoses by making the criteria more precise and more accessible to interpret consistently across clinicians.
Scope: The modifications affected a wide range of disorders across multiple categories in the DSM, indicating a comprehensive review of the manual.
Process: These changes underwent a formal review process, including approval by the DSM Steering Committee, the APA Board of Trustees, and the APA Assembly.
Clinical impact: While these modifications do not fundamentally alter the disorders, they may lead to more accurate and consistent diagnoses in clinical practice.
Examples: Typical clarifications might involve specifying time frames more precisely, clarifying the meaning of specific terms, or providing more detailed descriptions of symptoms.
Importance for clinicians: These changes underscore the need for mental health professionals to stay updated with the latest version of the DSM to ensure they are using the most current and accurate diagnostic criteria.
Research implications: Clear criteria can produce more consistent research results across different studies and settings.
| A) | When symptoms meet the criteria for either bipolar disorder or major depressive disorder | ||
| B) | Only in emergency department settings where there is limited time for assessment | ||
| C) | When a patient has been previously diagnosed with a specific mood disorder but is currently in remission | ||
| D) | When symptoms do not meet the full criteria for any specific mood disorder, and it is difficult to choose between unspecified bipolar and unspecified depressive disorder |
NEW DIAGNOSTIC ENTRIES IN DSM-5-TR
| Diagnostic Entity | Description | Key Features | |||||||
|---|---|---|---|---|---|---|---|---|---|
| Prolonged grief disorder |
|
1. Intense yearning for the deceased or preoccupation with thoughts/memories of them 2. At least 3 of 8 additional symptoms, such as:
| |||||||
| Unspecified mood disorder |
|
| |||||||
| Stimulant-induced mild neurocognitive disorder |
|
| |||||||
| No diagnosis or condition |
|
| |||||||
| Suicidal behavior | The DSM-5-TR defines suicidal behavior as "potentially self-injurious behavior with at least some intent to die as a result of the action." |
| |||||||
| Nonsuicidal self-injury (NSSI) | NSSI is defined as intentionally inflicting damage to one's body that will "likely induce bleeding, bruising or pain." |
| |||||||
| |||||||||
| A) | Severe interference with daily activities | ||
| B) | Complete loss of cognitive function | ||
| C) | Requires more mental effort but maintains independence | ||
| D) | Only occurs during active stimulant use |
NEW DIAGNOSTIC ENTRIES IN DSM-5-TR
| Diagnostic Entity | Description | Key Features | |||||||
|---|---|---|---|---|---|---|---|---|---|
| Prolonged grief disorder |
|
1. Intense yearning for the deceased or preoccupation with thoughts/memories of them 2. At least 3 of 8 additional symptoms, such as:
| |||||||
| Unspecified mood disorder |
|
| |||||||
| Stimulant-induced mild neurocognitive disorder |
|
| |||||||
| No diagnosis or condition |
|
| |||||||
| Suicidal behavior | The DSM-5-TR defines suicidal behavior as "potentially self-injurious behavior with at least some intent to die as a result of the action." |
| |||||||
| Nonsuicidal self-injury (NSSI) | NSSI is defined as intentionally inflicting damage to one's body that will "likely induce bleeding, bruising or pain." |
| |||||||
| |||||||||
| A) | To reduce overdiagnosis of mental disorders | ||
| B) | To provide a billing code for insurance purposes | ||
| C) | To improve the accuracy of clinical documentation and provides a straightforward way to communicate that a mental health evaluation was conducted with a finding of no diagnosable condition. | ||
| D) | To replace the "diagnosis deferred" option from previous editions |
NEW DIAGNOSTIC ENTRIES IN DSM-5-TR
| Diagnostic Entity | Description | Key Features | |||||||
|---|---|---|---|---|---|---|---|---|---|
| Prolonged grief disorder |
|
1. Intense yearning for the deceased or preoccupation with thoughts/memories of them 2. At least 3 of 8 additional symptoms, such as:
| |||||||
| Unspecified mood disorder |
|
| |||||||
| Stimulant-induced mild neurocognitive disorder |
|
| |||||||
| No diagnosis or condition |
|
| |||||||
| Suicidal behavior | The DSM-5-TR defines suicidal behavior as "potentially self-injurious behavior with at least some intent to die as a result of the action." |
| |||||||
| Nonsuicidal self-injury (NSSI) | NSSI is defined as intentionally inflicting damage to one's body that will "likely induce bleeding, bruising or pain." |
| |||||||
| |||||||||
| A) | To align with new diagnostic categories | ||
| B) | To reflect current scientific understanding and promote more sensitive, accurate language | ||
| C) | To simplify the language for non-professionals | ||
| D) | To match terminology used in the ICD-11 |
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.
| A) | Preferred gender | ||
| B) | Chosen gender | ||
| C) | Identified gender | ||
| D) | Experienced gender |
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.
| A) | F43.20 | ||
| B) | F43.81 | ||
| C) | F43.8 | ||
| D) | Z63.4 |
Prolonged grief disorder was added with the code F43.8.
New symptom codes were introduced for:
Suicidal behavior (R45.851)
Nonsuicidal self-injury (R45.88)
Codes for homelessness were expanded:
Sheltered homelessness (Z59.01)
Unsheltered homelessness (Z59.02)
| A) | Cultural Competence Committee | ||
| B) | Work Group on Ethnoracial Equity and Inclusion | ||
| C) | Diversity in Diagnosis Task Force | ||
| D) | Race and Ethnicity Review Board |
A dedicated Work Group on Ethnoracial Equity and Inclusion was established to review the entire manual for the first time in DSM history. This group, composed of ten diverse mental health practitioners, ensured appropriate attention was given to risk factors such as racism and discrimination and that non-stigmatizing language was used throughout the text. This was a significant departure from the DSM-5, which had no comprehensive review process focused on these issues.
| A) | To diagnose culture-bound syndromes | ||
| B) | To assess language proficiency in non-native English speakers | ||
| C) | To gather culturally relevant information to inform diagnosis and treatment planning | ||
| D) | To determine a patient's racial and ethnic background |
The DSM-5-TR built upon the Cultural Formulation Interview (CFI) introduced in DSM-5 and provides more comprehensive guidance on assessing cultural factors in diagnosis and treatment planning. This expansion aims to improve clinicians' ability to consider cultural context in their assessments.
| A) | True | ||
| B) | False |
The manual explicitly highlighted the risk of misdiagnosis when evaluating individuals from socially oppressed ethnoracial groups. This acknowledgment of potential bias in diagnosis was not as prominently featured in the DSM-5.
| A) | Updates occur only every 20 years | ||
| B) | Changes can only be made by the APA board | ||
| C) | Allows for ongoing updates based on emerging research | ||
| D) | Requires complete manual revision for any changes |
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.
| A) | True | ||
| B) | False |
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:
Autism Spectrum Disorder: Criterion A was revised to require that all three deficits be present, stating "as manifested by all of the following."
Major Depressive Disorder: Criterion D was revised to allow diagnosis of MDD whether the current episode includes psychotic symptoms, if there was at least one major depressive episode without concurrent symptoms of another mental disorder in the patient's lifetime.
Manic Episode: The severity specifiers were revised in order to be consistent with the diagnostic criteria.
| A) | Symptoms lasting at least 6 months | ||
| B) | Symptoms lasting at least 12 months | ||
| C) | Symptoms lasting at least 18 months | ||
| D) | Symptoms lasting at least 24 months |
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.
| A) | 3 months | ||
| B) | 6 months | ||
| C) | 9 months | ||
| D) | 12 months |
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.
| A) | Intense yearning/longing for the deceased person | ||
| B) | Preoccupation with thoughts or memories of the deceased person | ||
| C) | Identity disruption (feeling as though part of oneself has died) | ||
| D) | Engagement with reminders that the person is dead |
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]:
Definition: PGD is characterized as a maladaptive grief reaction that persists for an extended period after the death of someone with whom the bereaved had a close relationship.
Time criteria (Criterion A):
For adults: At least 12 months must have passed since the death
For children and adolescents: At least six months must have passed since the death
Core symptoms (Criterion B): The person must experience at least one of the following nearly every day for at least the last month:
Intense yearning/longing for the deceased person
Preoccupation with thoughts or memories of the deceased person (for children/adolescents, this may focus on the circumstances of the death)
Additional symptoms (Criterion C): At least three of the following eight symptoms must be present nearly every day for at least the last month:
Identity disruption (feeling as though part of oneself has died)
Marked sense of disbelief about the death
Avoidance of reminders that the person is dead
Intense emotional pain related to the death
Difficulty moving on with life
Emotional numbness
Feeling that life is meaningless
Intense loneliness
Functional impairment (Criterion D): The disturbance must cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
Cultural considerations (Criterion E): The duration and severity of the grief reaction must clearly exceed expected social, cultural, or religious norms for the individual's culture and context.
Differential diagnosis (Criterion F): The symptoms are not better explained by another mental disorder.
| A) | Sleep disturbance | ||
| B) | Intense yearning for the deceased | ||
| C) | Weight loss | ||
| D) | Panic attacks |
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]:
Definition: PGD is characterized as a maladaptive grief reaction that persists for an extended period after the death of someone with whom the bereaved had a close relationship.
Time criteria (Criterion A):
For adults: At least 12 months must have passed since the death
For children and adolescents: At least six months must have passed since the death
Core symptoms (Criterion B): The person must experience at least one of the following nearly every day for at least the last month:
Intense yearning/longing for the deceased person
Preoccupation with thoughts or memories of the deceased person (for children/adolescents, this may focus on the circumstances of the death)
Additional symptoms (Criterion C): At least three of the following eight symptoms must be present nearly every day for at least the last month:
Identity disruption (feeling as though part of oneself has died)
Marked sense of disbelief about the death
Avoidance of reminders that the person is dead
Intense emotional pain related to the death
Difficulty moving on with life
Emotional numbness
Feeling that life is meaningless
Intense loneliness
Functional impairment (Criterion D): The disturbance must cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
Cultural considerations (Criterion E): The duration and severity of the grief reaction must clearly exceed expected social, cultural, or religious norms for the individual's culture and context.
Differential diagnosis (Criterion F): The symptoms are not better explained by another mental disorder.
| A) | True | ||
| B) | False |
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.
| A) | Major depressive disorder | ||
| B) | Acute stress reaction | ||
| C) | Panic attacks | ||
| D) | No diagnosis or condition |
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.
| A) | Codes for current suicide behavior only | ||
| B) | Codes for a history of NSSI only | ||
| C) | Codes for both current and historical suicidal behavior and NSSI | ||
| D) | No new codes were added. |
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."
| A) | Requires specific medication protocols | ||
| B) | Added new symptom codes for documentation | ||
| C) | Eliminated all previous suicide-related criteria | ||
| D) | Focuses only on prevention strategies |
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."
| A) | help improve the accuracy of clinical documentation. | ||
| B) | facilitate better tracking and research on self-injurious behaviors. | ||
| C) | encourage clinicians to assess for these behaviors as part of routine clinical practice. | ||
| D) | All of the above |
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.
| A) | Rigidity | ||
| B) | Transparency | ||
| C) | Research promotion | ||
| D) | Provisional recognition |
Section III Conditions for Further Study in the DSM serves several important purposes:
Research promotion: This section includes proposed diagnostic categories and criteria sets that require further research before they can be considered official diagnoses in the main sections of the DSM. The DSM encourages and stimulates additional research to validate these proposed disorders by including these conditions.
Provisional recognition: This provides provisional recognition for conditions with some empirical support but is not well-established enough to be included in formal diagnoses. This allows clinicians and researchers to have a common language for discussing these potential disorders.
Clinical utility testing: Including these conditions allows for testing their clinical utility in real-world settings. Clinicians can use these proposed criteria sets and provide feedback on their usefulness and validity.
Future development: This section serves as a developmental ground for future additions to the main diagnostic categories in subsequent DSM editions.
Addressing emerging issues: This allows the DSM to be responsive to emerging mental health issues and new research findings without prematurely including them as official diagnoses.
Continuity and evolution: It bridges current diagnostic practices and potential future directions in psychiatric nosology.
Transparency: The DSM demonstrates transparency in developing new diagnostic categories by including these proposed disorders.
Flexibility: This section allows for more flexibility in considering new diagnostic entities compared to the more established categories in the main sections of the manual.
| A) | By allowing for immediate diagnosis and treatment of schizophrenia | ||
| B) | By enabling early intervention before full psychotic symptoms develop | ||
| C) | By preventing all cases of APS from progressing to psychosis | ||
| D) | By replacing the need for antipsychotic medications |
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.
| A) | One day | ||
| B) | Two days | ||
| C) | Three days | ||
| D) | Four days |
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.
| A) | a fully recognized diagnostic category. | ||
| B) | a condition for further study. | ||
| C) | a subtype of stimulant use disorder. | ||
| D) | It is not included at all. |
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]:
A persistent desire or unsuccessful effort to control caffeine use
Continued use despite harm
Withdrawal symptoms
| A) | Two criteria | ||
| B) | Three criteria | ||
| C) | Four criteria | ||
| D) | Five criteria |
A problematic pattern of caffeine use leading to clinically significant impairment or distress, as manifested by at least three of the following criteria occurring within a 12-month period [1]:
A persistent desire or unsuccessful efforts to cut down or control caffeine use.
Continued caffeine use despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by caffeine.
Withdrawal, as manifested by either of the following:
The characteristic withdrawal syndrome for caffeine
Caffeine (or a closely related substance) is taken to relieve or avoid withdrawal symptoms
Caffeine is often taken in larger amounts or over a longer period than was intended.
Recurrent caffeine use resulting in a failure to fulfill major role obligations at work, school, or home (e.g., repeated tardiness or absences from work or school related to caffeine use or withdrawal).
Continued caffeine use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of caffeine (e.g., arguments with spouse about consequences of use, medical problems, cost).
Tolerance, as defined by either of the following:
A need for markedly increased amounts of caffeine to achieve the desired effect
Markedly diminished effect with continued use of the same amount of caffeine
A great deal of time is spent on activities necessary to obtain caffeine, use caffeine, or recover from its effects.
Craving or a strong desire or urge to use caffeine.
| A) | a fully recognized diagnostic category. | ||
| B) | a condition for further study. | ||
| C) | a subtype of stimulant use disorder. | ||
| D) | not included at all. |
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.
| A) | Three symptoms | ||
| B) | Four symptoms | ||
| C) | Five symptoms | ||
| D) | Six symptoms |
Persistent and recurrent use of the Internet to engage in games, often with other players, leading to clinically significant impairment or distress as indicated by five (or more) of the following in a 12-month period [1]:
Preoccupation with Internet games. (The individual thinks about previous gaming activity or anticipates playing the next game; Internet gaming becomes the dominant activity in daily life.) Note: This disorder is distinct from Internet gambling, which is included under gambling disorder.
Withdrawal symptoms when Internet gaming is taken away. (These symptoms are typically described as irritability, anxiety, or sadness, but there are no physical signs of pharmacological withdrawal.)
Tolerance—the need to spend increasing amounts of time engaged in Internet games.
Unsuccessful attempts to control the participation in Internet games.
Loss of interests in previous hobbies and entertainment as a result of, and with the exception of, Internet games.
Continued excessive use of Internet games despite knowledge of psychosocial problems.
Has deceived family members, therapists, or others regarding the amount of Internet gaming.
Use of Internet games to escape or relieve a negative mood (e.g., feelings of helplessness, guilt, anxiety).
Has jeopardized or lost a significant relationship, job, or educational or career opportunity because of participation in Internet games.
| A) | Gaming exclusively for monetary gain | ||
| B) | Gaming only during specific hours | ||
| C) | Persistent and recurrent use of Internet games | ||
| D) | Playing only specific types of games |
Persistent and recurrent use of the Internet to engage in games, often with other players, leading to clinically significant impairment or distress as indicated by five (or more) of the following in a 12-month period [1]:
Preoccupation with Internet games. (The individual thinks about previous gaming activity or anticipates playing the next game; Internet gaming becomes the dominant activity in daily life.) Note: This disorder is distinct from Internet gambling, which is included under gambling disorder.
Withdrawal symptoms when Internet gaming is taken away. (These symptoms are typically described as irritability, anxiety, or sadness, but there are no physical signs of pharmacological withdrawal.)
Tolerance—the need to spend increasing amounts of time engaged in Internet games.
Unsuccessful attempts to control the participation in Internet games.
Loss of interests in previous hobbies and entertainment as a result of, and with the exception of, Internet games.
Continued excessive use of Internet games despite knowledge of psychosocial problems.
Has deceived family members, therapists, or others regarding the amount of Internet gaming.
Use of Internet games to escape or relieve a negative mood (e.g., feelings of helplessness, guilt, anxiety).
Has jeopardized or lost a significant relationship, job, or educational or career opportunity because of participation in Internet games.
| A) | True | ||
| B) | False |
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].
| A) | Disruptive, Impulse-Control, and Conduct Disorders. | ||
| B) | Neurodevelopmental disorders. | ||
| C) | Suicidal Self-Injury Disorder. | ||
| D) | Conditions for Further Study. |
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.
| A) | Three days | ||
| B) | Four days | ||
| C) | Five days | ||
| D) | Six days |
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.
| A) | The DSM-5-TR includes too many biomarkers, leading to overdiagnosis. | ||
| B) | The lack of reliable biomarkers in the DSM-5-TR undermines its validity as a diagnostic tool. | ||
| C) | The DSM-5-TR relies too heavily on biomarkers, ignoring psychological factors. | ||
| D) | Biomarkers in the DSM-5-TR are not specific enough to differentiate between disorders. |
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.
| A) | HiTOP uses categorical diagnoses, while the DSM-5-TR uses dimensional ratings. | ||
| B) | HiTOP organizes symptoms into dimensional spectra, while DSM-5-TR primarily uses discrete categories. | ||
| C) | HiTOP is based on expert consensus, while DSM-5-TR is based on factor analysis. | ||
| D) | HiTOP includes more mental disorders than DSM-5-TR. |
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.
| A) | Categorical classification | ||
| B) | Dimensional, data-driven approach | ||
| C) | Expert consensus only | ||
| D) | Cultural factors exclusively |
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.
| A) | RDoC uses categorical diagnoses, while the DSM-5-TR uses dimensional ratings. | ||
| B) | 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. | ||
| C) | RDoC is based on expert consensus, while the DSM-5-TR is based on factor analysis. | ||
| D) | RDoC includes more mental disorders than the DSM-5-TR. |
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.
| A) | Three domains | ||
| B) | Four domains | ||
| C) | Five domains | ||
| D) | Six domains |
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.
| A) | Views disorders as discrete categories | ||
| B) | Focuses on underlying latent variables | ||
| C) | Views symptoms as directly influencing each other | ||
| D) | Emphasizes cultural factors only |
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.
| A) | Focus on discrete diagnostic categories | ||
| B) | Emphasis on standard processes across multiple disorders | ||
| C) | Exclusive use of biological markers | ||
| D) | Rejection of all psychological factors |
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.
| A) | Categorical diagnosis only | ||
| B) | Focus on progression of mental disorders over time | ||
| C) | Exclusive use of biological markers | ||
| D) | Rejection of all traditional diagnoses |
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.
| A) | Standardized diagnostic criteria only | ||
| B) | Categorical classification | ||
| C) | Individual biological, psychological, and social characteristics | ||
| D) | Cultural factors exclusively |
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.
| A) | Alternative DSM-5 model for personality disorders | ||
| B) | Cultural Formulation Interview | ||
| C) | Dimensional approach to diagnosis | ||
| D) | All of the above |
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.
| A) | 12 questions | ||
| B) | 14 questions | ||
| C) | 16 questions | ||
| D) | 18 questions |
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.