DSM-5-TR Diagnosis

The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR), published by the American Psychiatric Association in 2022, is the primary diagnostic classification system used in the United States for mental health disorders. Clinical social workers (LCSWs) must be proficient in using the DSM-5-TR for assessment, diagnosis, treatment planning, and insurance reimbursement.

DSM-5-TR Structure

The DSM-5-TR is organized into 20 diagnostic chapters arranged to reflect developmental considerations and related disorder groupings. Key structural features include:

• Dimensional approach: Many disorders are assessed on a severity spectrum (mild, moderate, severe) rather than as purely categorical (present or absent)
• Cross-cutting symptom measures: Standardized screening tools that assess symptoms across multiple diagnostic categories
• Cultural formulation: A framework for assessing how cultural factors influence the expression and experience of mental distress
• Specifiers and subtypes: Additional descriptors that provide greater clinical detail (e.g., "with anxious distress," "in partial remission")

Major Depressive Disorder (MDD)

Diagnostic Criteria: At least five of the following symptoms must be present during the same two-week period, with at least one being either depressed mood or loss of interest/pleasure:

1. Depressed mood most of the day, nearly every day
2. Markedly diminished interest or pleasure in activities (anhedonia)
3. Significant weight loss/gain or change in appetite
4. Insomnia or hypersomnia
5. Psychomotor agitation or retardation
6. Fatigue or loss of energy
7. Feelings of worthlessness or excessive guilt
8. Diminished ability to think, concentrate, or make decisions
9. Recurrent thoughts of death, suicidal ideation, or suicide attempt

Key Mnemonic — SIG E CAPS: Sleep, Interest, Guilt, Energy, Concentration, Appetite, Psychomotor changes, Suicidal ideation (plus depressed mood)

Specifiers: With anxious distress, with mixed features, with psychotic features, with peripartum onset, with seasonal pattern, in partial/full remission

Generalized Anxiety Disorder (GAD)

Diagnostic Criteria:

• Excessive anxiety and worry about multiple areas (work, health, family, etc.)
• Occurring more days than not for at least 6 months
• Difficulty controlling the worry
• Three or more of: restlessness, fatigue, difficulty concentrating, irritability, muscle tension, sleep disturbance
• Causes clinically significant distress or functional impairment

Differential Diagnosis: GAD must be distinguished from normal worry, panic disorder (discrete panic attacks), social anxiety disorder (fear of social evaluation), OCD (obsessive thoughts), and medical conditions (hyperthyroidism).

Post-Traumatic Stress Disorder (PTSD)

Diagnostic Criteria: Following exposure to a traumatic event (actual or threatened death, serious injury, or sexual violence), symptoms in four clusters lasting more than one month:

Substance Use Disorders

The DSM-5-TR classifies substance use disorders on a severity continuum based on the number of criteria met within a 12-month period:

The 11 Diagnostic Criteria (applied to each substance):

1. Taking the substance in larger amounts or for longer than intended
2. Wanting to cut down or stop but being unable to
3. Spending a great deal of time obtaining, using, or recovering from the substance
4. Craving the substance
5. Failing to fulfill major role obligations due to use
6. Continued use despite social or interpersonal problems
7. Giving up important activities because of use
8. Recurrent use in physically hazardous situations
9. Continued use despite knowledge of physical or psychological problems
10. Tolerance — needing more of the substance for the same effect
11. Withdrawal — experiencing symptoms when stopping or reducing use

Important Note: Tolerance and withdrawal alone do not indicate a substance use disorder if they occur as expected during prescribed medical treatment.

Personality Disorders

Personality disorders are enduring patterns of inner experience and behavior that deviate from cultural expectations, are pervasive and inflexible, have an onset in adolescence or early adulthood, and lead to distress or impairment. They are grouped into three clusters:

Borderline Personality Disorder (BPD) is particularly relevant for clinical social workers. Key features include:

• Frantic efforts to avoid abandonment (real or imagined)
• Pattern of unstable and intense interpersonal relationships (idealization/devaluation)
• Identity disturbance (unstable self-image)
• Impulsivity in at least two areas that are self-damaging
• Recurrent suicidal behavior, gestures, or self-harm
• Affective instability (intense episodic mood changes)
• Chronic feelings of emptiness
• Inappropriate, intense anger
• Transient, stress-related paranoid ideation or dissociative symptoms

Psychotic Disorders

Schizophrenia is characterized by two or more of the following present for a significant portion of time during a one-month period (at least one must be items 1, 2, or 3):

1. Delusions — fixed, false beliefs (persecutory, grandiose, referential)
2. Hallucinations — sensory experiences without external stimuli (most commonly auditory)
3. Disorganized speech — derailment, incoherence, tangentiality
4. Grossly disorganized or catatonic behavior
5. Negative symptoms — diminished emotional expression, avolition (lack of motivation), alogia (reduced speech), anhedonia, asociality

Duration: Continuous signs of disturbance for at least 6 months, with at least 1 month of active symptoms. Impairment in functioning must be present.

Neurodevelopmental Disorders

Key neurodevelopmental disorders include:

• ADHD: Persistent pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning. Can be predominantly inattentive, predominantly hyperactive-impulsive, or combined presentation.
• Autism Spectrum Disorder (ASD): Persistent deficits in social communication and restricted, repetitive behaviors. Now conceptualized as a spectrum with varying levels of support needed.
• Intellectual Disability: Deficits in intellectual and adaptive functioning with onset during the developmental period.