DSM-5-TR Introduction

Brief History of Prior DSM Editions

• The first edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM) was published in 1952 by the American Psychiatric Association.
• The first edition introduced a glossary of descriptions of diagnostic categories and reflected Adolf Meyer's psychobiological view that mental disorders were reactions of the personality to psychological, social, and biological factors.
• The second edition (DSM-II) was developed in 1968, based on the mental disorders section of the eighth revision of the International Classification of Diseases (ICD-8).
• DSM-III was published in 1980, with development beginning in 1974, and was coordinated with the development of ICD-9.
• DSM-III introduced methodological innovations, including explicit diagnostic criteria and a descriptive approach neutral to theories of etiology of mental disorders.
• Robert L. Spitzer, M.D. directed the development of DSM-III.
• Inconsistencies in DSM-III led to the appointment of a Workgroup to Revise DSM-III.

Key Milestones

• 1952: Publication of DSM-I
• 1968: Implementation of DSM-II and ICD-8
• 1974: Development of DSM-III begun
• 1975: Publication of ICD-9
• 1978: Implementation of ICD-9
• 1980: Publication of DSM-III

DSM-5 Revision Process

• In 1999, the APA launched an evaluation of the strengths and weaknesses of DSM, coordinated with the WHO's Division of Mental Health, the World Psychiatric Association, and the NIMH.
• The evaluation effort was conducted through conferences, resulting in the 2002 monograph "A Research Agenda for DSM-V".
• Between 2003 and 2008, the APA and WHO convened 13 international DSM-5 research planning conferences, involving 400 participants from 39 countries.
• The conferences reviewed world literature in specific diagnostic areas and aimed to prepare for revisions in developing both DSM-5 and ICD-11.
• Reports from these conferences formed the basis for future DSM-5 Task Force reviews and set the stage for the new edition of DSM.

DSM-5 Task Force

• In 2006, the APA named David J. Kupfer, M.D., as Chair and Darrel A. Regier, M.D., M.P.H., as Vice-Chair of the DSM-5 Task Force.
• The task force was responsible for overseeing the development of DSM-5 and recommending chairs for the 13 diagnostic work groups with a multidisciplinary range of expertise.
• An additional vetting process was initiated by the APA Board of Trustees to disclose sources of income and avoid conflicts of interest by task force and work group members.

Disclosure of Income and Research Grants

• Members are required to disclose all income and research grants from commercial sources, including the pharmaceutical industry.
• An income cap from commercial sources and publication of disclosures on a website were imposed to enforce this requirement in the past 3 years.

Task Force and Work Groups

• The task force consisted of 28 members.
• Over 130 work group members were approved in 2007 and 2008.
• The task force involved over 400 advisors with no voting authority.
• These advisors participated in the classification of mental disorders.

Centralized Vision for Classification

• The classification of mental disorders was considered the next evolutionary stage.
• A clear concept of the classification emerged from the efforts of the task force and work groups.
• The vision for this classification was based on the history of DSM-IV, its strengths and limitations, and strategic directions for its revision.

6-Year Process for Revising Criteria

• The process for revising the criteria took 6 years to complete.
• It involved conducting literature reviews and secondary analyses, publishing research reports, developing draft diagnostic criteria, and posting preliminary drafts for public comment.
• Preliminary findings were presented at professional meetings, and field trials were performed to revise the criteria and text.

Participants Involved

• The 6-year process involved a wide range of participants, including health professionals, educational groups, physicians, psychologists, social workers, nurses, counselors, epidemiologists, statisticians, neuroscientists, neuropsychologists, individuals with mental disorders, families, lawyers, consumer organizations, and advocacy groups.

Proposed Revisions for DSM-IV Criteria

• Proposals for revising DSM-IV diagnostic criteria were developed by work group members.
• These proposals were based on rationale, scope of change, expected impact, strength of supporting research evidence, overall clarity, and clinical utility.

DSM-5 Field Trials

• Changes to diagnostic criteria in DSM-5 included adding new disorders, subtypes, and specifiers, and deleting existing disorders.
• Strengths and weaknesses in current criteria and nosology were identified, and novel scientific findings from the past two decades were considered.
• Four principles guided draft revisions:
  • DSM-5 is primarily for clinicians, and revisions must be feasible for routine clinical practice.
  • Recommendations for revisions should be guided by research evidence.
  • Continuity should be maintained with previous editions of DSM where possible.
  • No a priori constraints should be placed on the degree of change between DSM-IV and DSM-5.

Revision Process

• Work groups identified key issues within their diagnostic areas and examined broader methodological concerns.
• Concerns included contradictory findings, developing a refined definition of mental disorder, and considering cross-cutting issues relevant to all disorders.

Inclusion and Exclusion Criteria

• Proposals for revision were informed by consideration of advantages and disadvantages for public health and clinical utility, strength of evidence, and magnitude of change.
• New diagnoses and disorder subtypes and specifiers required demonstration of reliability (the degree to which two clinicians could independently arrive at the same diagnosis).
• Disorders with low clinical utility and weak validity were considered for deletion.

Conditions for Further Study

• Placement of proposed conditions in Section III was contingent on the amount of empirical evidence generated, diagnostic reliability or validity, presence of clear clinical need, and potential benefit in advancing research.

Field Trials

• The use of field trials to demonstrate reliability was a noteworthy improvement introduced in DSM-III.
• The DSM-5 Field Trials design and implementation strategy represented several improvements.

Changes from DSM-III and DSM-IV

• DSM-III and DSM-IV kappa reliability estimates were obtained in real-world clinical settings to assess precision.
• Two study designs were used: one in large, diverse medical-academic settings and another in routine clinical practices.
• The former design focused on large sample sizes to test hypotheses on reliability and clinical utility of diagnoses.
• The latter design contributed valuable information about revisions in everyday clinical settings among a diverse sample of DSM users.

Need for Future Research

• Future studies will focus on the validity of revised categorical diagnostic criteria and underlying dimensional features of disorders.
• The NIMH Research Domain Criteria initiative is exploring new areas.

Field Trials for DSM-5

• Field trials took place at 11 North American medical-academic sites from December 2010 to October 2011.
• The trials assessed the reliability, feasibility, and clinical utility of select revisions.
• Priority was given to revisions representing significant changes from DSM-IV or those with potential public health impact.
• Full clinical patient populations were screened for DSM-IV diagnoses or qualifying symptoms.
• Stratified samples of four to seven specific disorders were identified for each site.

Patient Consent and Interview Procedures

• Patients consented to the study and were randomly assigned for a clinical interview by a clinician blind to the clinical diagnosis.
• A second interview, occurring within two weeks, was conducted by a clinician unfamiliar with the first interviewer's diagnoses.
• Patients completed a computer-assisted inventory of cross-cutting symptoms in over a dozen psychological domains.
• A computer scored the inventory, and the results were provided to clinicians before they conducted a typical clinical interview without a structured protocol.

DSM-5 Diagnostic Criteria

• Clinicians used a computer-assisted DSM-5 diagnostic checklist to score the presence of qualifying criteria
• The checklist allowed clinicians to:
  • Determine diagnoses
  • Score the severity of the diagnosis
  • Upload data to a central repository

Inter-Rater Reliability

• The study design enabled calculation of inter-rater reliability using the Intraclass Kappa statistic
• Clinician-administered ratings were used to assess agreement on:
  • Cross-cutting and diagnosis-specific symptom severity (using intraclass correlation coefficients)
  • Self-reported cross-cutting symptoms
  • Personality traits
  • Disability
  • Diagnostic severity

Routine Clinical Practice Field Trials

• The trials recruited individual psychiatrists and other mental health clinicians from October 2011 to March 2012
• The volunteer sample consisted of:
  • Generalist and specialty psychiatrists
  • Psychologists
  • Licensed clinical social workers
  • Counselors
  • Marriage and family therapists
  • Advanced practice psychiatric mental health nurses
• The trials assessed the feasibility and clinical utility of proposed DSM-5 diagnoses and dimensional measures

Public and Professional Review

• The APA launched a website in 2010 to facilitate public and professional input into DSM-5
• The website posted draft diagnostic criteria and proposed changes for a 2-month comment period, receiving over 8,000 submissions
• The feedback was systematically reviewed by each of the 13 work groups, and revisions were made based on the feedback and field trial results
• A second posting occurred in 2011, and work groups considered feedback from both web postings and the results of the DSM-5 Field Trials

Expert Review and Final Approval of DSM-5

• 13 work groups, representing expertise in their respective areas, collaborated with advisors and reviewers to draft diagnostic criteria and accompanying text.
• The DSM-5 Task Force provided overall direction, supported by APA Division of Research staff and a network of text coordinators from each work group.
• The text editor coordinated the preparation of the text, working closely with the work groups and under the direction of the task force chairs.

Scientific Review Committee (SRC)

• The SRC was established to provide a scientific peer review process external to the work groups.
• The SRC consisted of a chair, vice-chair, and six committee members, reviewing the degree to which proposed changes from DSM-IV could be supported with scientific evidence.
• Each proposal for diagnostic revisions required a memorandum of evidence for change, accompanied by a summary of supportive data organized around validators.
• Validators included:
  • Antecedent validators (e.g., familial aggregation)
  • Concurrent validators (e.g., biological markers)
  • Prospective validators (e.g., response to treatment or course of illness)
• The SRC reviewed submissions and scored them according to the strength of the supportive scientific data.
• Justifications for change from clinical experience, need, or conceptual reframing of diagnostic categories were generally seen as outside the purview of the SRC.

Scores, Commentary, and Consideration

• Scores from different proposals were sent to the APA Board of Trustees and work groups for consideration and response.

Clinical and Public Health Committee (CPHC)

• The CPHC reviewed additional information for criteria, including clinical utility, public health, and logical clarification.
• These aspects were only considered if enough evidence was deemed sufficient to make changes.

DSM-IV Deficiency Review

• The review process was particularly important for DSM-IV disorders with known deficiencies.
• Proposed remedies for these disorders had neither been considered in the DSM revision process nor been subjected to replicated research studies.
• The disorders were evaluated by 4-5 external reviewers.
• The blinded results were reviewed by CPHC members who made recommendations to the APA Board of Trustees and work groups.

Forensic Review

• The APA Council on Psychiatry and Law conducted forensic reviews of diagnostic criteria and text for disorders appearing in forensic environments and ones with high potential for influencing civil and criminal judgments.
• Work groups also added forensic experts to complement expertise provided by the Council on Psychiatry and Law.

APA Assembly's Committee on DSM-5

• A final recommendation from the task force was provided to the APA Assembly's Committee on DSM-5 to consider some of the clinical utility and feasibility features of the proposed revisions.
• The Assembly represents the district branches and wider membership, composed of psychiatrists from throughout the United States, providing geographic, practice size, and interest-based diversity.
• The Committee on DSM-5 was composed of a diverse group of Assembly leaders.

Executive "Summit Committee"

• The executive "summit committee" convened to consolidate input from review.
• The committee included: Assembly committee chairs, task force chairs, a forensic advisor, and a statistical advisor.
• The committee conducted a preliminary review of each disorder for both the Assembly and the APA Board of Trustees executive committees.
• There was also a preliminary review by the full APA Board of Trustees.
• In November 2012, a vote took place to recommend that the Board approve the publication of DSM-5.

DSM-5 Revision Process

• The American Psychiatric Association has adopted an iterative improvement model for DSM revisions, enabled by advances in digital publishing.
• Revisions are based on specific scientific advances.

DSM Steering Committee

• The committee was established in Spring 2014, chaired by Paul S. Appelbaum, M.D.
• Ellen Leibenluft, M.D. and Kenneth Kendler, M.D. serve as Vice Chairs.
• The committee oversees the iterative revision process and manages a web portal (www.dsm5.org) for submitting proposals.

Submitting Proposals

• Proposed changes can include adding new disorders, modifying diagnostic criteria, or changing text.
• Submissions must include:
  • Reasons for the change
  • Magnitude of change
  • Data documenting improvements in validity across multiple validators
  • Evidence of reliability and clinical utility
  • Consideration of potential deleterious consequences

Validating Diagnostic Criteria

• Approaches to validation include:
  • Antecedent validators: Genetic markers, family traits, temperament, and environmental exposure
  • Concurrent validators: Neural substrates, biomarkers, emotional and cognitive processing, and symptom similarity
  • Predictive validators: Clinical course and treatment response
• New criteria for current disorders are adopted if they improve validity in some of these classes.
• New disorders are added to DSM if they demonstrate validity by a substantial subset of these validators.

DSM-5 Text Revision Process

• Validators must meet the criteria for a mental disorder and demonstrate clinical utility.
• Proposals are submitted to the DSM web portal and undergo an initial review by the Steering Committee.
• The Steering Committee determines whether the proposal appears likely to meet the criteria for approval based on the evidence provided.

Review Committee Process

• Approved proposals are referred to one of the five standing Review Committees, which cover broad domains of psychiatric diagnosis.
• The Review Committee considers the evidence in support of the proposed change and requests additional information if necessary.
• The Review Committee returns the proposal to the Steering Committee with recommendations for disposition and suggested modifications.

Public Comment and Approval

• The proposed revision is posted on the DSM-5 website for public comment if the Steering Committee concurs that sufficient evidence exists.
• The final stage involves making necessary adjustments based on the comments and forwarding the final version to the APA Assembly and Board of Trustees for approval.
• Once approved, the online version of the manual is updated to reflect the changes.

DSM-5-TR Development

• The DSM-5-TR development effort was started in Spring 2019 with Michael B. First, M.D., and Philip Wang, M.D., Dr.P.H., as Revision Subcommittee Co-Chairs, and Wilson M. Compton, M.D., and Daniel S. Pine, M.D., as Revision Subcommittee Vice Chairs.
• The development effort involved over 200 experts, who conducted literature reviews covering the past 10 years and reviewed the text to identify out-of-date material.
• A review of conflicts of interest for all proposed changes to the text was conducted to eliminate any possible compromise of the objectivity of the content.

DSM-5 Organizational Structure

• DSM is a medical classification of disorders, serving as a cognitive schema to organize clinical and scientific information for better comprehension and utility.

Regrouping of Disorders in DSM-5

• The DSM-5 diagnostic spectra study group examined the use of scientific validators to regroup related disorders within the existing categorical framework.
• The study group recommended 11 indicators to separate groups of psychiatric illness:
  • Neural substrates
  • Family traits
  • Genetic risk factors
  • Specific environmental risk factors
  • Biomarkers
  • Temperamental antecedents
  • Abnormalities of emotional or cognitive processing
  • Symptom similarity
  • Course of illness

DSM-5 Organizational Structure

• DSM is a medical classification of disorders, serving as a cognitive schema to organize clinical and scientific information for better comprehension and utility.

Regrouping of Disorders in DSM-5

• The DSM-5 diagnostic spectra study group examined the use of scientific validators to regroup related disorders within the existing categorical framework.
• The study group recommended 11 indicators to separate groups of psychiatric illness:
  • Neural substrates
  • Family traits
  • Genetic risk factors
  • Specific environmental risk factors
  • Biomarkers
  • Temperamental antecedents
  • Abnormalities of emotional or cognitive processing
  • Symptom similarity
  • Course of illness

Revising Diagnostic Manuals

• The Diagnostic and Statistical Manual of Mental Disorders (DSM) and the International Classification of Diseases (ICD) are being revised.
• The revision process aims to use shared treatment responses and comorbidity as empirical guidelines to inform decision-making in clustering disorders.

Criteria and Validations

• Validators were found to be useful in suggesting large groupings of disorders and validating proposed changes to diagnostic criteria through a series of papers in Psychological Medicine.
• The American Psychological Association (APA) and World Health Organization (WHO) considered improving clinical utility by rethinking the organizational structures of DSM and ICD.
• This was done to facilitate scientific investigation and explain apparent comorbidity.

Revision Approach

• The revision process was guided by emerging scientific evidence on relationships between disorder groups, taking a conservative, evolutionary approach to diagnostic reform.
• The goal was to stimulate new clinical perspectives and encourage researchers to identify cross-cutting factors that are not bound by strict categorical designations.

Harmonizing Classifications

• A shared organizational structure helped harmonize the classifications, with large sections of content falling into place easily.
• This reflects strengths in areas such as epidemiology, analyses of scientific information, and relationships between disorders.

Placement of ADHD in DSM-5

• ADHD's placement in DSM-5 has been debated due to its co-occurrence with other disorders.
• The classification of ADHD requires consideration of various factors, including symptoms, comorbidity, shared risk factors, and evidence.

Organisation of Disorders in DSM-5

• DSM-5 organizes disorders using a categorization framework that separates internalizing and externalizing disorders.
• Internalizing disorders are characterized by feelings of anxiety, depression, and somatic symptoms.
• Externalizing disorders are associated with impulsive, disruptive conduct, and substance use.
• Neurocognitive disorders affect cognitive functions like memory or attention.

Future Directions

• Research is needed to understand the underlying pathophysiological mechanisms contributing to comorbidity and symptom heterogeneity.
• DSM-5 aims to improve diagnosis by primary care physicians by organizing disorders based on clinical reality.
• Dimensional approaches to diagnosis may supplement or supersede categorical approaches in the future.
• These approaches will serve as a bridge for new diagnoses without disrupting existing practices.

Combining Developmental and Life Span Considerations

• DSM-5 is organized along developmental and life span trajectories.
• The manual begins with diagnoses that reflect early life developmental processes (e.g., neurodevelopmental disorders, schizophrenia spectrum and other psychotic disorders).
• Diagnoses that commonly manifest in adolescence and young adulthood (e.g., bipolar and related disorders, depressive disorders, anxiety disorders) follow.
• The manual concludes with diagnoses relevant to adulthood and later life (e.g., neurocognitive disorders).
• A similar approach has been taken within each chapter to facilitate the use of life span information in diagnostic decision-making.

Harmonization With ICD-11

• The goal of harmonizing DSM and ICD systems was to facilitate:
  • Collection and use of national health statistics
  • Design of clinical trials for new treatments
  • Global applicability of results by international regulatory agencies
• Two major classifications of mental disorders (DSM and ICD) hinder:
  • Replication of scientific results across national boundaries
  • Identification of identical patient populations
• DSM-IV and ICD-10 diagnoses did not always agree, even when intended to identify the same patient populations.
• Harmonization efforts were confined to the organizational structure, with no complete harmonization of diagnostic criteria due to differences in timing.

Definition of a Mental Disorder

• Each identified disorder in Section II of the manual, excluding Medication-Induced Movement Disorders and Other Adverse Effects of Medication, and Other Conditions That May Be a Focus of Clinical Attention, must meet the definition of a mental disorder.
• The definition of a mental disorder is not exhaustive, but it includes certain required elements.
• The DSM-5 definition of a mental disorder is applicable to all disorders in Section II, with a few exceptions.

Mental Disorder Definition

• A mental disorder is a syndrome characterized by a clinically significant disturbance in an individual's cognition, emotion regulation, or behavior.
• This disturbance reflects a dysfunction in the psychological, biological, or developmental processes underlying mental functioning.

Characteristics of Mental Disorders

• Mental disorders are usually associated with significant distress or disability in social, occupational, or other important activities.
• An expectable or culturally approved response to a common stressor or loss is not considered a mental disorder.
• Socially deviant behavior or conflicts between the individual and society are not mental disorders unless they result from a dysfunction in the individual.

Diagnosis of Mental Disorders

• A diagnosis of a mental disorder should have clinical utility, helping clinicians determine prognosis, treatment plans, and potential treatment outcomes.
• The diagnosis of a mental disorder does not necessarily mean a need for treatment.
• Factors considered in determining the need for treatment include symptom severity, symptom salience, individual distress, disability related to symptoms, risks and benefits of available treatments, and other factors.

Access to Care

• Clinicians may encounter individuals who do not meet full criteria for a mental disorder but still demonstrate a clear need for treatment or care.
• The fact that some individuals do not show all symptoms indicative of a diagnosis should not limit their access to appropriate care.

Purpose of the Definition

• The definition of mental disorder was developed for clinical, public health, and research purposes.
• Additional information is usually required beyond that contained in the DSM-5 diagnostic criteria to make legal judgments on issues such as criminal responsibility.

Categorical Approach to Diagnosis

• High rates of comorbidity among disorders, symptom heterogeneity within disorders, and the need for other specified and unspecified diagnoses are structural problems with the categorical design of DSM.
• The categorical approach does not capture clinical experience or important scientific observations.
• The boundaries between many disorder "categories" are more fluid over the life course than has been recognized.
• Many symptoms that make up the essential features of a particular disorder may occur, at varying levels of severity, in many other disorders.

Dimensional Approach to Diagnosis

• A dimensional approach classifies clinical presentations on the basis of quantification of attributes rather than the assignment to categories.
• Dimensional systems work best in describing phenomena that are distributed continuously and do not have clear boundaries.
• Dimensional systems increase reliability and communicate more clinical information.
• Dimensional systems report clinical attributes that might be subthreshold in a categorical system.
• Despite advantages, dimensional systems have serious limitations and have been less useful than categorical systems in clinical practice.

Numerical Dimensional Descriptions

• Numerical dimensional descriptions are less familiar and vivid than category names of mental disorders
• There is no agreement on the optimal dimensions to be used for classification purposes
• Dimensional approaches are likely to gain greater acceptance as a method of conveying clinical information and as a research tool
• DSM-5 combines categorical and dimensional elements to classify mental disorders into types based on criteria sets with defining features
• The categorical framework does not assume that each mental disorder is a completely discrete entity with absolute boundaries
• Individuals with the same mental disorder are likely to be heterogeneous in regard to the defining features of the diagnosis
• Boundary cases are difficult to diagnose in a non-probabilistic fashion

Cross-Cutting Symptom Measures

• Psychiatric pathologies are not reliably discrete with sharp boundaries from one another
• The DSM-5 Level 1 Cross-Cutting Symptom Measure was developed to help clinicians assess all major areas of psychiatric functioning
• The measure aims to uncover possible disorders, atypical presentations, subsyndromal conditions, and coexistent pathologies
• The measure assesses areas such as mood, psychosis, cognition, personality, and sleep

DSM-5 Level 1 Cross-Cutting Symptom Measure

• A tool used to identify latent disorders and symptoms in need of assessment or treatment
• Acts as an inventory of mental systems to help clinicians better understand their patients' issues
• Recommended as an important component of the psychiatric evaluation of individuals presenting for psychiatric care
• Endorsed by the American Psychiatric Association Practice Guidelines for the Psychiatric Evaluation of Adults as a first step in identifying and addressing symptoms across diagnostic categories
• Available online for clinical use at www.psychiatry.org/dsm5

Removal of the DSM-IV Multiaxial System

• DSM-IV offered a multiaxial system of recording diagnoses with assessments on several axes
• DSM-5 has moved to a nonaxial documentation of diagnosis
• Disorders and conditions formerly listed on Axis I, Axis II, and Axis III are now listed together without formal differentiation, typically in order of clinical importance
• Psychosocial and contextual factors are listed along with the diagnoses and conditions using Z codes in the chapter “Other Conditions That May Be a Focus of Clinical Attention”
• DSM-IV Axis V consisted of the Global Assessment of Functioning (GAF) scale, which has been replaced by the WHO Disability Assessment Schedule (WHODAS)

Cultural and Social Structural Issues

• Mental disorders are defined and recognized within the context of local sociocultural and community norms and values.
• Cultural contexts influence the experience and expression of symptoms, signs, behaviors, and thresholds of severity for diagnosis.
• Sociocultural contexts shape aspects of identity (e.g. ethnicity or race) that affect social positions and exposure to social determinants of health, including mental health.
• Cultural elements are transmitted, revised, and recreated within families, communities, and social systems and institutions, and change over time.

Impact of Cultural Norms and Practices

• The boundaries between normality and pathology vary across cultural contexts for specific behaviors.
• Thresholds of tolerance for symptoms or behaviors differ across cultural contexts, social settings, and families.
• The level at which an experience becomes problematic or is perceived as pathological differs depending on cultural norms.
• Cultural norms internalized by the individual and applied by others (including family members and clinicians) influence the judgment of whether a behavior requires clinical attention.

Cultural Concepts of Distress

• Historically, cultural psychiatry and psychology focused on the construct of culture-bound syndrome, but it has been replaced by three concepts that offer greater clinical utility since DSM-5.

Cultural Idiom of Distress

• Refers to a behavior, linguistic term, phrase, or way of talking about symptoms, problems, or suffering among individuals with similar cultural backgrounds.
• Used to express or communicate essential features of distress, e.g., stating "I feel so depressed" to express low mood or discouragement that does not meet the threshold for major depressive disorder.
• Does not necessarily imply specific symptoms, syndromes, or perceived causes.
• May be used to convey a wide range of discomfort, including everyday concerns, subclinical conditions, or suffering due to social circumstances rather than mental disorders.
• Most cultural groups have common bodily idioms of distress used to express a wide range of suffering and concerns.

Cultural Explanations

• A cultural explanation is a label or attribution that provides a culturally coherent concept of etiology or cause for symptoms, illness, or distress.
• Examples of cultural explanations include attributing psychopathology to "stress", spirits, or failure to follow culturally prescribed practices.

Cultural Syndromes

• A cultural syndrome is a cluster or group of co-occurring, distinctive symptoms found in specific cultural groups, communities, or contexts.
• An example of a cultural syndrome is ataque de nervios (attack of nerves).
• Cultural syndromes may or may not be recognized as an illness in the local cultural context.

Impact of Racism and Discrimination on Psychiatric Diagnosis

• Race is a social, not a biological construct, used to divide people into groups based on superficial physical traits such as skin color.
• There is no biological basis for the construct of race.
• Discriminatory practices based on race have profound effects on physical and mental health.
• Racialization is the social process by which specific categories of identity are constructed on the basis of racial ideologies and practices.
• Racialized identities are strongly associated with systems of discrimination, marginalization, and social exclusion.

Racism and its Effects

• Racism affects individuals and society as a whole.

Forms of Racism

• Personal Racism: internalized stereotypes and experiences of threat, devaluation, neglect, and injustice.
• Interpersonal Racism: explicit behaviors and microaggressions.
• Systemic/Institutional Racism: embedded in everyday practices of institutions and organizations.

Implicit Bias in Systemic Racism

• Systemic racism is maintained by implicit biases, habits, routines, and practices that result in misrecognition and inequity.
• Individuals can unknowingly contribute to systemic racism.

Social Structural Racism

• Manifested in the organization and norms of society and public policy.
• Perpetuates pervasive inequities in economic resources, power, and privilege.
• Impacts exposure to health risks and access to healthcare.

Consequences of Racism

• Negative effects on mental health, including hypertension, suicidal behavior, posttraumatic stress disorder, and psychosis.
• Racial stereotypes and attitudes affect the psychological development and well-being of racialized groups.
• Unequal access to care and clinician bias in diagnosis and treatment lead to misdiagnosis, e.g., schizophrenia among African Americans.

Addressing Cultural and Racial Biases in DSM-5-TR

• A Cross-Cutting Review Committee on Cultural Issues reviewed the DSM-5-TR texts to address cultural influences on disorder characteristics.
• The committee consisted of 19 experts in cultural psychiatry, psychology, and anthropology from the US and internationally.

Ethnoracial Equity and Inclusion Work Group

• A separate work group reviewed the texts to avoid perpetuating stereotypes and discriminatory clinical information.
• The work group consisted of 10 mental health practitioners from diverse ethnic and racialized backgrounds with expertise in disparity-reduction practices.

Language and Terminology

• DSM-5-TR avoids language that implies races are discrete and natural entities.
• The term "racialized" is used instead of "racial" to highlight the socially constructed nature of race.
• "Ethnoracial" combines ethnic and racialized identifiers, such as Hispanic, White, or African American, based on US Census categories.
• The term "Latinx" is used to promote gender-inclusive terminology, replacing "Latino/a".
• The term "Caucasian" is not used due to its outdated and erroneous views on European ethnicity.
• Terms like "minority" and "non-White" are avoided as they perpetuate social hierarchies.
• Study-specific labels are used for clarity in reporting epidemiological or other information.

Sex and Gender Differences

• Sex is determined by an individual's reproductive organs and chromosomes, which can be either XX or XY.
• Gender encompasses not only reproductive organs but also an individual's self-representation, including social, behavioral, and psychological consequences of their perceived gender.
• Research on psychiatric illnesses often relies on self-identified gender, particularly in the DSM-5-TR.
• The terms "women and men" or "boys and girls" are commonly used in the DSM-5-TR to refer to gender.

Importance of Sex Differences

• Sex differences are crucial in understanding topics like the metabolism of substances.
• These differences are also significant in instances where only one sex is affected, such as during specific life stages.

Sex and Gender Influence on Illness

• Sex determines risk for certain disorders, such as premenstrual dysphoric disorder, which is exclusively determined by sex.
• Sex and gender affect the overall risk for developing a disorder, resulting in differences in prevalence and incidence rates of mental disorders between men and women.
• Sex and gender influence the likelihood of experiencing specific symptoms of a disorder, for example, ADHD may manifest differently in boys and girls.

Sex and Gender Effects on Diagnosis

• Certain symptoms may be more readily endorsed by men or women, influencing how healthcare providers recognize and diagnose mental illnesses.
• Women are more likely to be diagnosed with depression, bipolar disorder, or anxiety disorder and may present a broader range of symptoms.
• Gender-based differences in symptom endorsement lead to variations in service provision.

Reproductive Life Cycle Events

• Changes in ovarian hormones during menstruation, pregnancy, and menopause contribute to sex-related differences in mental illness.
• The specifier "with peripartum onset" of an illness, such as brief psychotic disorder, indicates a time period where women are more susceptible to developing these mental illnesses.

Diagnostic Considerations

• Postpartum alterations in sleep and energy are common and may affect diagnosis reliability.
• The diagnostic manual contains information on sex and gender at multiple levels, including gender-specific symptoms.
• Specifiers, such as "with peripartum onset" of a mood episode, provide information on the relationship between sex and diagnosis.
• Prevalence estimates for each mental disorder are provided based on sex and gender.
• Further issues related to sex and gender are discussed in the "Sex and Gender-Related Diagnostic Issues" section of the manual.

Association With Suicidal Thoughts or Behavior

• No specific information provided, but it is related to the topic of sex and gender differences in mental illness.

DSM-5-TR Features

• The DSM-5-TR includes a new section called "Association With Suicidal Thoughts or Behavior" for each diagnosis, where relevant literature is available.
• This section provides information on the associations between suicidal thoughts or behavior and a particular diagnosis, based on studies that have demonstrated such links.

Suicide Risk Assessment

• Within a group of individuals with the same diagnosis, there can be a wide range in suicide risk, from none to severe, depending on individual psychopathology.
• Clinicians should use their clinical judgment, informed by known risk factors, to assess an individual's suicide risk, rather than relying solely on the presence of a diagnosis associated with suicidal thoughts or behavior.

Clinical Implications

• The "Association With Suicidal Thoughts or Behavior" section serves as an alert to clinicians to conduct further inquiry for an individual with a particular diagnosis.
• Clinical risk assessment requires an individualized assessment that goes beyond the formulation of a DSM-5 diagnosis and the scope of the manual, encompassing many factors.