Learning Objectives
By the end of this section, you will be able to:
- Explain the history of development of the DSM-5-TR
- Summarize how the DSM-5 is used in the diagnosis of mental disorders
- Outline the disadvantages of using the DSM-5 system of categorization of mental disorders
The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) provides a taxonomy, or system of classification, and diagnoses of mental disorders. According to the American Psychiatric Association (APA, 2022), the DSM-5 encompasses the “best available description of how mental disorders are expressed and can be recognized by trained clinicians” (xxiii). Therefore, it is the frame of reference used in health care to describe the various forms of mental disorders. The evidence-based approaches to treatment are formulated around the classifications of and diagnostic criteria for the conditions.
History of the Development of the DSM
The Diagnostical and Statistical Manual of Mental Disorders (DSM) was originally published in 1952 by the American Psychiatric Association to provide the standard criteria for the diagnosis and classification of mental disorders. The DSM has undergone several revisions and updates since its initial publication (Figure 13.3).
Structure and Organization of DSM-5-TR
The DSM-5-TR (Text Revision) was designed as a reference guide to clinical practice and is utilized as a common language for clinicians and researchers from many different backgrounds. The DSM-5-TR is also considered a tool for collecting and communicating accurate public health statistics on mental disorder frequency, morbidity, and mortality rates (APA, 2022). It is a tool for concise and explicit criteria for mental health disorders and is intended to facilitate objective assessment of symptom presentations.
The manual begins with an introduction that provides an overview of the purpose, goals, and intent of the DSM-5-TR, including its development process and updates from previous editions. The diagnostic criteria section outlines specific diagnostic criteria for various mental disorders. Each disorder is described in detail and is organized into chapters with related disorders. The DSM-5-TR includes an addition that describes various assessment measures and models that can be used in conjunction with diagnostic criteria. The DSM-5-TR recognizes the importance of cultural factors in understanding and diagnosing mental disorders. The appendices section includes information and resources, including a glossary of terms, codes for billing and reporting, a list of cultural concepts of distress, an alternative DSM-5 model for personality disorders, and conditions for further study.
Link to Learning
In this video, the American Psychiatric Association explains why prolonged grief disorder was added to the DSM-5-TR.
Relationship of the DSM-5 to the International Classification of Diseases
The International Classification of Diseases (ICD) is a standardized system used globally for classifying and coding diseases, disorders, injuries, and other health-related conditions. It is maintained by the World Health Organization (WHO) and provides a common language for health professionals, researchers, and policymakers to communicate and exchange health information. The ICD is currently in its tenth revision, known as ICD-10, published by the WHO in 1992. The DSM-5-TR criteria define disorders identified by the ICD diagnostic names and code numbers. In DSM-5-TR, both ICD-10-CM (Clinical Modification) and ICD-10-PCS (Procedure Coding System) codes are attached to the relevant disorders in the classification. The codes allow for medical insurance billing and reimbursement, as well as collection of health-care statistics. The DSM-5-TR structure corresponds with the organizational arrangement of disorders planned for the upcoming ICD-11 scheduled for release in the United States in the future.
Link to Learning
The APA published a supplement containing updated codes for neurocognitive disorders that also describes the corresponding changes to the ICD-10-CM codes.
Clinical Usage of the DSM-5-TR
In clinical practice, the DSM-5-TR provides a standardized framework for the classification and diagnosis of mental disorders. The DSM provides a comprehensive list of diagnostic criteria for various mental disorders, defines mental health conditions, and gives examples of identifying signs and symptoms. Mental health conditions are also categorized into groups. Clinicians use these criteria to assess and diagnose individuals presenting with mental health symptoms.
Nurses can use the DSM to help assess clients and build their care plan based on the criteria, presentations, and risks outlined in the DSM. The DSM also helps those doing research to have a common language and communication for collaboration.
Clinical Safety and Procedures (QSEN)
Teamwork: The Use of DSM-5 in Promoting Teamwork in the Care of Clients with a Psychiatric Disorder
The QSEN definition of teamwork and collaboration is to “function effectively within nursing and inter-professional teams, fostering open communication, mutual respect, and shared decision-making to achieve quality” (QSEN, n.d., table 2). During treatment team meetings, health-care professionals (psychiatrists, nurses, psychiatric nurse practitioners, clinical psychologists, social workers, and licensed professional counselors) may use the DSM-5 as a resource to collaborate with clients for the plan of care. The DSM information is shared to communicate the criteria for the medical diagnosis as well as risk factors for the disorder that relate to the client’s current clinical status and needs for care. It allows for interprofessional collaboration among all team members.
Conceptualizing Client Problems
The DSM aids nurses and health-care providers to conceptualize client issues. When conceptualizing the client problem, it is important to start by gathering important information about the client and their current presenting problem. For those with mental health disorders, this may take the form of a mental status exam, along with collecting any other relevant data. The nurse must identify any observable signs or symptoms indicating a problem and then define the problem statement with priority problem identification. The PMH nurse utilizes the DSM-5-TR medical diagnosis for reference to the pathology and helps to identify the client’s response to the health problem. The DSM-5-TR is helpful in providing a framework for helping individuals with specific diagnoses in ways that are evidence-based and culturally considerate.
Life-Stage Context
Diagnoses and Older Adults
Many older adults suffer from mental health disorders, but can have very different symptoms and need specific individualized interventions due to the changes with the aging process. Noted in the DSM-5-TR are several disorders that apply specifically to this age group. This includes major neurocognitive disorder when cognitive decline is noted. Many mental health disorders can be exacerbated by the experience of loss by the older adult. This can include death of a spouse or significant other, loss of mobility, and loss of inability to operate a motor vehicle, further isolating and leading to worsening mental health disorders. Depressive disorders may present differently than in younger individuals and may include sadness, loss of interest, changes in appetite or sleep, fatigue, and thoughts of death or suicide. Symptoms may present as irritability in young persons, rather than sadness. Anxiety disorders are also experienced by older adults. Substance-related disorders may occur in the older adult and may include alcohol, prescription medications, or illicit drugs, which may have serious implications for their physical and mental health.
Formulating Treatment Plans
The DSM helps nurses and care providers to assess and create treatment plans for mental health clients. Formulating a treatment plan begins with assessment of clinical findings. A physical and mental health exam, including a mental status exam, will help to guide the diagnosis. An evaluation of any test results may reveal a physical reason for their symptoms, such as thyroid abnormalities. It is important to rule out a physical and medical cause first. After assessment and diagnosis, the team creates a treatment plan. The treatment plan may include medications to treat symptoms as well as psychotherapy and other complementary therapies, such as deep breathing, mindfulness, and exercise.
Clinical Judgment Measurement Model
Nursing Priority Problem Identification: How Does It Relate to Medical Diagnosis?
Clinical judgment is a critical component of nursing practice, including the process of priority problem identification. Clinical judgment refers to application of the nursing process to an individual, family, or community’s response to actual or potential health problems or life processes. The nurse then prioritizes the identified problems and formulates nursing interventions. Once carried out, the nurse will evaluate the outcome of the interventions and make any revisions identified. Medical diagnosis focuses strictly on the classification of a specific disease or condition, based on signs and symptoms as well as diagnostic tests. Nursing problem identification differs in that it is a clinical judgment made by a registered nurse in response to a health problem and in partnership with the client. Nursing problem identification focuses on the client’s physical, psychological, sociocultural, and spiritual responses to an illness or disease and then determines the priority order of the problems.
Billing for Treatment
The DSM makes billing for treatment more efficient and, in many cases, possible. Billing for treatment of mental health disorders is completed by health-care providers, such as licensed social workers, physicians, and advanced practice nurses utilizing the DSM-5-TR as well as the ICD-10 diagnostic codes. Billing involves assigning a procedure code to the services provided to the client. This code is known as the Current Procedural Terminology (CPT) and is a standardized system of medical codes used to describe specific procedures or services. They are maintained and published by the American Medical Association.
Criticisms of the DSM-5
The DSM-5 has received both praise and criticism. A strength is that it is a widely used diagnostic tool in the field of mental health that identifies disorders, criteria, and risks. Criticisms include lack of scientific validity and subjectivity of symptoms and dependence on the practitioner’s clinical judgment. Critics have stated that the expansion of diagnostic criteria has led to overdiagnosis and labeling those with mild or temporary symptoms with a mental disorder that may stay with them for life. Other critics note that the DSM-5 relies on categories and mental disorders as distinct entities with clear boundaries, though many may exist on a continuum instead of within such boundaries. Some critics identify the undue influence of the pharmaceutical industry, and argue that expansion of criteria may lead to overmedication. Critics also point out a lack of cultural sensitivity in the DSM-5; the DSM-5-TR has attempted to address the experiences and expressions of mental distress in diverse cultural contexts.