# 02 - Use of the Manual

# Use of the Manual

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Use of the Manual
This text is designed to provide a practical guide to using DSM-5, particularly in clinical
practice.
Approach to Clinical Case Formulation
The primary purpose of DSM-5 is to assist trained clinicians in the diagnosis of mental disorders
as part of a case formulation assessment that leads to an informed treatment plan for each
individual. The case formulation for any given individual should involve a careful clinical
history and concise summary of the social, psychological, and biological factors that may have
contributed to developing a given mental disorder. It is not sufficient to simply check off the
symptoms in the diagnostic criteria to make a mental disorder diagnosis. A thorough evaluation
of these criteria may assure more reliable assessment (which may be aided by the use of
dimensional symptom severity assessment tools); the relative severity and salience of an
individual’s signs and symptoms and their contribution to a diagnosis will ultimately require
clinical judgment. Diagnosis requires clinical training to recognize when the combination of
predisposing, precipitating, perpetuating, and protective factors has resulted in a
psychopathological condition in which the signs and symptoms exceed normal ranges. The
ultimate goal of a clinical case formulation is to use the available contextual and diagnostic
information in developing a comprehensive treatment plan that is informed by the individual’s
cultural and social context. However, recommendations for the selection and use of the most
appropriate evidence-based treatment options for each disorder are beyond the scope of this
manual.
Elements of a Diagnosis
Diagnostic criteria are offered as guidelines for making diagnoses, and their use should be
informed by clinical judgment. Text descriptions, including introductory sections of each
diagnostic chapter, can help support diagnosis (e.g., describing the criteria more fully under
“Diagnostic Features”; providing differential diagnoses).
Following the assessment of diagnostic criteria, clinicians should consider the application of
disorder subtypes and/or specifiers as appropriate. Most specifiers are only applicable to the
current presentation and may change over the course of the disorder (e.g., with good to fair
insight; predominantly inattentive presentation; in a controlled environment) and can be given
only if full criteria for the disorder are currently met. Other specifiers are indicative of the
lifetime course (e.g., with seasonal pattern, bipolar type in schizoaffective disorder) and can be
assigned regardless of current status.

When the symptom presentation does not meet full criteria for any disorder and the
symptoms cause clinically significant distress or impairment in social, occupational, or other
important areas of functioning, the “other specified” or “unspecified” category corresponding to
the predominant symptoms should be considered.
Subtypes and Specifiers
Subtypes and specifiers are provided for increased diagnostic specificity. Subtypes define
mutually exclusive and jointly exhaustive phenomenological subgroupings within a diagnosis
and are indicated by the instruction “Specify whether” in the criteria set (e.g., in anorexia
nervosa, Specify whether restricting type or binge-eating/purging type). In contrast, specifiers are
not intended to be mutually exclusive or jointly exhaustive, and as a consequence, more than one
specifier may be applied to a given diagnosis. Specifiers (as opposed to subtypes) are indicated
by the instruction “Specify” or “Specify if” in the criteria set (e.g., in social anxiety disorder,
“Specify if: performance only”). Specifiers and subtypes provide an opportunity to define a more
homogeneous subgrouping of individuals with the disorder who share certain features (e.g.,
major depressive disorder, with mixed features) and to convey information that is relevant to the
management of the individual’s disorder, such as the “with other medical comorbidity” specifier
in sleep-wake disorders. Although the fifth character within an ICD-10-CM code is sometimes
designated to indicate a particular subtype or specifier (e.g., “0” in the fifth character in the
F02.80 diagnostic code for major neurocognitive disorder due to Alzheimer’s disease, to indicate
the absence of a behavioral disturbance versus a “1” in the fifth character of the F02.81
diagnostic code for major neurocognitive disorder due to Alzheimer’s disease to indicate the
presence of a behavioral disturbance), the majority of subtypes and specifiers included in DSM5-TR are not reflected in the ICD-10-CM code and are indicated instead by recording the
subtype or specifier after the name of the disorder (e.g., social anxiety disorder, performance
type).
Use of Other Specified and Unspecified Mental Disorders
Although decades of scientific effort have gone into developing the diagnostic criteria sets for
the disorders included in Section II, it is well recognized that this set of categorical diagnoses
does not fully describe the full range of mental disorders that individuals experience and present
to clinicians on a daily basis throughout the world. Hence, it is also necessary to include “other
specified” or “unspecified” disorder options for presentations that do not fit exactly into the
diagnostic boundaries of disorders in each chapter. Moreover, there are settings (e.g., emergency
department) where it may only be possible to identify the most prominent symptom expressions
associated with a particular chapter (e.g., delusions, hallucinations, mania, depression, anxiety,
substance intoxication, neurocognitive symptoms). In such cases, it may be most appropriate to
assign the corresponding “unspecified” disorder as a placeholder until a more complete
differential diagnosis is possible.
DSM-5 provides two diagnostic options for presentations that do not meet the diagnostic
criteria for any of the specific DSM-5 disorders: other specified disorder and unspecified
disorder. The other specified category is provided to allow the clinician to communicate the

specific reason that the presentation does not meet the criteria for any specific category within a
diagnostic class. This is done by recording the name of the category, followed by the specific
reason. For example, with an individual with persistent hallucinations occurring in the absence of
any other psychotic symptoms (a presentation that does not meet criteria for any of the specific
disorders in the chapter “Schizophrenia Spectrum and Other Psychotic Disorders”), the clinician
would record “other specified schizophrenia spectrum and other psychotic disorder, with
persistent auditory hallucinations.” If the clinician chooses not to specify the reason that the
criteria are not met for a specific disorder, then “unspecified schizophrenia spectrum and other
psychotic disorder” would be diagnosed. Note that the differentiation between other specified
and unspecified disorders is based on the clinician’s choice to indicate or not the reasons why the
presentation does not meet full criteria, providing maximum flexibility for diagnosis. When the
clinician determines that there is enough available clinical information to specify the nature of
the
presentation, the “other specified” diagnosis can be given. In those cases where the clinician
is not able to further specify the clinical presentation (e.g., in emergency room settings), the
“unspecified” diagnosis can be given. This is entirely a matter of clinical judgment.
It is a long-standing DSM convention for conditions included in the “Conditions for Further
Study” chapter in Section III to be listed as examples of presentations that can be specified using
the “other specified” designation. The inclusion of these conditions for further study as examples
does not represent endorsement by the American Psychiatric Association that these are valid
diagnostic categories.
Use of Clinical Judgment
DSM-5 is a classification of mental disorders that was developed for use in clinical, educational,
and research settings. The diagnostic categories, criteria, and textual descriptions are meant to be
employed by individuals with appropriate clinical training and experience in diagnosis. It is
important that DSM-5 not be applied mechanically by individuals without clinical training. The
specific diagnostic criteria included in DSM-5 are meant to serve as guidelines to be informed by
clinical judgment and are not meant to be used in a rigid cookbook fashion. For example, the
exercise of clinical judgment may justify giving a certain diagnosis to an individual even though
the clinical presentation falls just short of meeting the full criteria for the diagnosis as long as the
symptoms that are present are persistent and severe. On the other hand, lack of familiarity with
DSM-5 or excessively flexible and idiosyncratic application of DSM-5 criteria substantially
reduces its utility as a common language for communication.
Clinical Significance Criterion
In the absence of clear biological markers or clinically useful measurements of severity for many
mental disorders, it has not been possible to completely separate normal from pathological
symptom expressions contained in diagnostic criteria. This gap in information is particularly
problematic in clinical situations in which the individual’s symptom presentation by itself
(particularly in mild forms) is not inherently pathological and may be encountered in those for

whom a diagnosis of “mental disorder” would be inappropriate. Therefore, a generic diagnostic
criterion requiring distress or disability has been used to establish disorder thresholds, usually
worded “the disturbance causes clinically significant distress or impairment in social,
occupational, or other important areas of functioning.” Assessing whether this criterion is met,
especially in terms of role function, is an inherently difficult clinical judgment. The text
following the definition of a mental disorder acknowledges that this criterion may be especially
helpful in determining an individual’s need for treatment. Use of information from the individual
as well as from family members and other third parties via interview or self- or informantreported assessments regarding the individual’s performance is often necessary.
Coding and Recording Procedures
The official coding system in use in the United States since October 1, 2015, is the International
Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM), a version of the
World Health Organization’s ICD-10 that has been modified for clinical use by the Centers for
Disease Control and Prevention’s National Center for Health Statistics (NCHS) and provides the
only permissible diagnostic codes for mental disorders for clinical use in the United States. Most
DSM-5 disorders have an alphanumeric ICD-10-CM code that appears preceding the name of the
disorder (or coded subtype or specifier) in the DSM-5-TR Classification and in the
accompanying criteria set for each disorder. For some diagnoses (e.g., neurocognitive disorders,
substance/medication-induced disorders), the appropriate code depends on further specification
and is listed within the criteria set for the
disorder with a coding note, and in some cases is further clarified in the text section “Recording
Procedures.” The names of some disorders are followed by alternative terms enclosed in
parentheses.
The use of diagnostic codes is fundamental to medical record keeping. Diagnostic coding
facilitates data collection and retrieval and compilation of statistical information. Codes also are
often required to report diagnostic data to interested third parties, including governmental
agencies, private insurers, and the World Health Organization. For example, in the United States,
the use of ICD-10-CM codes for disorders in DSM-5-TR has been mandated by the Health Care
Financing Administration for purposes of reimbursement under the Medicare system.
Principal Diagnosis/Reason for Visit
The general convention in DSM-5 is to allow multiple diagnoses to be assigned for those
presentations that meet criteria for more than one DSM-5 disorder. When more than one
diagnosis is given in an inpatient setting, the principal diagnosis is the condition established after
study to be chiefly responsible for occasioning the admission of the individual. When more than
one diagnosis is given for an individual in an outpatient setting, the reason for visit is the
condition that is chiefly responsible for the ambulatory medical services received during the
visit. In most cases, the principal diagnosis or the reason for visit is also the main focus of
attention or treatment. It is often difficult (and somewhat arbitrary) to determine which diagnosis
is the principal diagnosis or the reason for visit. For example, it may be unclear which diagnosis

should be considered “principal” for an individual hospitalized with both schizophrenia and
alcohol use disorder, because each condition may have contributed equally to the need for
admission and treatment. The principal diagnosis is indicated by listing it first, and the remaining
disorders are listed in order of focus of attention and treatment. When the principal diagnosis or
reason for visit is a mental disorder due to another medical condition (e.g., major neurocognitive
disorder due to Alzheimer’s disease, psychotic disorder due to malignant lung neoplasm), ICD
coding rules require that the etiological medical condition be listed first. In that case, the
principal diagnosis or reason for visit would be the mental disorder due to the medical condition,
the second listed diagnosis. For maximum clarity, the disorder listed as the principal diagnosis or
the reason for visit can be followed by the qualifying phrase “(principal diagnosis)” or “(reason
for visit).”
Provisional Diagnosis
The modifier “provisional” can be used when there is currently insufficient information to
indicate that the diagnostic criteria are met, but there is a strong presumption that the information
will become available to allow that determination. The clinician can indicate the diagnostic
uncertainty by recording “(provisional)” following the diagnosis. For example, this modifier
might be used when an individual who appears to have a presentation consistent with a diagnosis
of current major depressive disorder is unable to give an adequate history, but it is expected that
such information will become available after interviewing an informant or reviewing medical
records. Once that information becomes available and confirms that the diagnostic criteria were
met, the modifier “(provisional)” would be removed. Another use of “provisional” is for those
situations in which differential diagnosis depends exclusively on whether the duration of illness
does not exceed an upper limit as required by the diagnostic criteria. For example, a diagnosis of
schizophreniform disorder requires a duration of at least 1 month but less than 6 months. If an
individual currently has symptoms consistent with a diagnosis of schizophreniform disorder
except that the ultimate duration is unknown because the symptoms are still ongoing, the
modifier “(provisional)” would be applied and then removed if the symptoms remit within a
period of 6 months. If they do not remit, the diagnosis would be changed to schizophrenia.
Notes About Terminology
Substance/Medication-Induced Mental Disorder
The term “substance/medication-induced mental disorder” refers to symptomatic presentations
that are due to the physiological effects of an exogenous substance on the central nervous
system, including symptoms that develop during withdrawal from an exogenous substance that is
capable of causing physiological dependence. Such exogenous substances include typical
intoxicants (e.g., alcohol, inhalants, hallucinogens, cocaine), psychotropic medications (e.g.,
stimulants; sedatives, hypnotics, anxiolytics), other medications (e.g., steroids), and
environmental toxins (e.g., organophosphate insecticides). Editions of DSM from DSM-III to
DSM-IV referred to these as “substance-induced mental disorders.” To emphasize that
medications and not just substances of abuse can cause psychiatric symptoms, the term was

changed to “substance/medication-induced” in DSM-5.
Independent Mental Disorders
Historically, mental disorders were divided into those that were termed “organic” (caused by
physical factors) versus those that were “nonorganic” (purely of the mind; also referred to as
“functional” or “psychogenic”), terms that were included in DSM up through DSM-III-R.
Because these dichotomies misleadingly implied that the nonorganic disorders have no
biological basis and that mental disorders have no physical basis, DSM-IV updated this
terminology as follows: 1) the terms “organic” and “nonorganic” were eliminated from DSM-IV;
2) the disorders formerly called “organic” were divided into those due to the direct physiological
effects of a substance (substance-induced) and those due to the direct physiological effects of a
medical condition on the central nervous system; and 3) the term “nonorganic mental disorders”
(i.e., those disorders not due to either substances or medical conditions) was replaced by
“primary mental disorder.” In DSM-5, this terminology was further refined, replacing “primary”
with “independent” (e.g., Criterion C in substance/medication-induced anxiety disorder starts
with “the disturbance is not better accounted for by an anxiety disorder that is not substanceinduced. Evidence of an independent anxiety disorder could include . . .” [italics added for
reference]). This was done to reduce the potential for confusion given that the term “primary”
has historically had other meanings (e.g., it is sometimes used to indicate which disorder among
several comorbid disorders was the first to occur). The use of “independent mental disorder”
should not be construed to mean that the disorder is independent of other potential causal factors
such as psychosocial or other environmental stressors.
Other Medical Conditions
Another dichotomy adopted by prior editions of DSM that reflected mind-body dualism was the
division of disorders into “mental disorders” and “physical disorders.” In conjunction with the
elimination of organic/nonorganic terminology, DSM-IV replaced the “mental disorder” versus
“physical disorder” dichotomy with a “mental disorder” vs. “general medical condition”
dichotomy, based on chapter location within the International Classification of Diseases (ICD).
Medical conditions in ICD have been divided into 17 chapters based on a variety of factors,
which include etiology (e.g., Neoplasms [Chapter 2]), anatomical location (e.g., Diseases of the
ear and mastoid process [Chapter 8]), body system (e.g., Diseases of the circulatory system
[Chapter 9]), and context (e.g., Pregnancy, childbirth and the puerperium [Chapter 15]). In the
ICD framework, mental disorders are those located in Chapter 5, and general medical conditions
are those located within the other 16 chapters. Because of concerns that the term “general
medical condition” could be conflated with general practice, DSM-5 uses the term “another
medical condition” to emphasize the fact that mental disorders are medical conditions and that
mental disorders can be precipitated by other medical conditions. It is important to recognize that
“mental
disorder” and “another medical condition” are merely terms of convenience and should not be
taken to imply that there is any fundamental distinction between mental disorders and other
medical conditions, that mental disorders are unrelated to physical or biological factors or

processes, or that other medical conditions are unrelated to behavioral or psychosocial factors or
processes.
Types of Information in the DSM-5-TR Text
The DSM-5-TR text provides contextual information to aid in diagnostic decision-making. The
text appears immediately following the diagnostic criteria for each disorder and systematically
describes the disorder under the following headings: Recording Procedures, Subtypes, Specifiers,
Diagnostic Features, Associated Features, Prevalence, Development and Course, Risk and
Prognostic Factors, Culture-Related Diagnostic Issues, Sex- and Gender-Related Diagnostic
Issues, Diagnostic Markers, Association With Suicidal Thoughts or Behavior, Functional
Consequences, Differential Diagnosis, and Comorbidity. In general, when limited information is
available for a section, that section is not included.
Recording Procedures provides guidelines for reporting the name of the disorder and for
selecting and recording the appropriate ICD-10-CM diagnostic code. It also includes
instructions for applying any appropriate subtypes and/or specifiers.
Subtypes and/or Specifiers provide brief descriptions of applicable subtypes and/or
specifiers.
Diagnostic Features provides descriptive text illustrating the use of the criteria and includes
key points on their interpretation. For example, within the diagnostic features for
schizophrenia, it is explained that some symptoms that may appear to be negative symptoms
could instead be attributable to medication side effects.
Associated Features includes clinical features that are not represented in the criteria but
occur significantly more often in individuals with the disorder than those without the
disorder. For example, individuals with generalized anxiety disorder may also experience
somatic symptoms that are not contained within the disorder criteria.
Prevalence describes rates of the disorder in the community, most often described as 12month prevalence, although for some disorders point prevalence is noted. Prevalence
estimates are also provided by age group and by ethnoracial/cultural group when possible.
Sex ratio (prevalence in men vs. women) is also provided in this section. When international
data are available, geographic variance in prevalence rates is described. For some disorders,
especially those for which there are limited data on rates in the community, prevalence in
relevant clinical samples is noted.
Development and Course describes the typical lifetime patterns of presentation and
evolution of the disorder. It notes the typical age at onset and whether the presentation may
have prodromal/insidious features or may manifest abruptly. Other descriptions may include
an episodic versus persistent course as well as a single episode versus a recurrent episodic
course. Descriptors in this section may address duration of symptoms or episodes as well as
progression of severity and associated functional impact. The general trend of the disorder
over time (e.g., stable, worsening, improving) is described here. Variations that may be
noted include features related to developmental stage (e.g., infancy, childhood, adolescence,
adulthood, late life).
Risk and Prognostic Factors includes a discussion of factors thought to contribute to the

development of a disorder. It is divided into subsections addressing temperamental factors
(e.g., personality features); environmental factors (e.g., head trauma, emotional trauma,
exposure to toxic substances, substance use); and genetic and physiological factors
(e.g., APOE4 for dementia, other known familial genetic risks); this subsection may address
familial patterns (traditional) as well as genetic and epigenetic factors. An additional
subsection for course modifiers includes factors that may incur a deleterious course, and
conversely factors that may have ameliorative or protective effects.
Culture-Related Diagnostic Issues includes information on variations in symptom
expression, attributions for disorder causes or precipitants, factors associated with
differential prevalence across demographic groups, cultural norms that may affect level of
perceived pathology, risk of misdiagnosis when evaluating individuals from socially
oppressed ethnoracial groups, and other material relevant to culturally informed diagnosis.
Prevalence rates in specific cultural/ethnic groups are located in the Prevalence section.
Sex- and Gender-Related Diagnostic Issues includes correlates of the diagnosis that are
related to sex or gender, predominance of symptoms or the diagnosis by sex or gender, and
any other sex- and gender-related diagnostic implications of the diagnosis, such as
differences in the clinical course by sex or gender. Prevalence rates by gender are located in
the Prevalence section.
Diagnostic Markers addresses objective measures that have established diagnostic value.
These may include physical examination findings (e.g., signs of malnutrition in
avoidant/restrictive food intake disorder), laboratory findings (e.g., low CSF hypocretin-1
levels in narcolepsy), or imaging findings (e.g., regionally hypometabolic FDG PET imaging
for neurocognitive disorder due to Alzheimer’s disease).
Association With Suicidal Thoughts or Behavior provides information about disorderspecific prevalence of suicidal thoughts or behavior, as well as risk factors for suicide that
may be associated with the disorder.
Functional Consequences discusses notable functional consequences associated with a
disorder that are likely to have an impact on the daily lives of affected individuals; these
consequences may affect the ability to engage in tasks related to education, work, and
maintaining independent living. These may vary according to age and across the life span.
Differential Diagnosis discusses how to differentiate the disorder from other disorders that
have some similar presenting characteristics.
Comorbidity includes descriptions of mental disorders and other medical conditions (i.e.,
conditions classified outside of the Mental and Behavioral disorders chapter in ICD-10-CM),
likely to co-occur with the diagnosis.
Other Conditions and Disorders in Section II
In addition to providing diagnostic criteria and text for DSM-5 mental disorders, Section II also
includes two chapters for other conditions that are not mental disorders but may be encountered

by mental health clinicians. These conditions may be listed as a reason for a clinical visit in
addition to, or in place of, the mental disorders in Section II. The chapter “Medication-Induced
Disorders and Other Adverse Effects of Medication” includes medication-induced
parkinsonism, neuroleptic malignant syndrome, medication-induced acute dystonia, medicationinduced acute akathisia, tardive dyskinesia, tardive dystonia/tardive akathisia, medicationinduced postural tremor, antidepressant discontinuation syndrome, and other adverse effect of
medication. These conditions are included in Section II because of their frequent importance in
1) the management by medication of mental disorders or other medical conditions, and 2) the
differential diagnosis with mental disorders (e.g., anxiety disorder vs. medication-induced acute
akathisia).
The chapter “Other Conditions That May Be a Focus of Clinical Attention” includes
conditions and psychosocial or environmental problems that are not considered to be mental
disorders but otherwise affect the diagnosis, course, prognosis, or treatment of an individual’s
mental disorder. These conditions are presented with their corresponding codes from ICD-10CM (usually Z codes). A condition or problem in this chapter may be coded with or without an
accompanying mental disorder diagnosis 1) if it is a reason for the current visit; 2) if it helps to
explain the need for a test, procedure, or treatment; 3) if it plays a role in the initiation or
exacerbation of a mental disorder; or 4) if it constitutes a problem that should be considered in
the overall management plan. These include suicidal behavior and nonsuicidal self-injury; abuse
and neglect; relational problems (e.g., Relationship Distress With Spouse or Intimate Partner);
educational, occupational, housing, and economic problems; problems related to the social
environment, interaction with the legal system, and other psychosocial, personal, and
environmental circumstances (e.g., problems related to unwanted pregnancy, being a victim of
crime or terrorism); problems related to access to medical and other health care; circumstances of
personal history (e.g., Personal History of Psychological Trauma); other health service
encounters for counseling and medical advice (e.g., sex counseling); and additional conditions or
problems that may be a focus of clinical attention (e.g., wandering associated with a mental
disorder, uncomplicated bereavement, phase of life problem).
Online Enhancements
DSM-5-TR is available in online subscriptions at PsychiatryOnline.org, as well as an e-book that
reflects the print edition. The online version provides a complete set of supporting in-text
citations and references not available in print or e-book; it is also updated periodically to reflect
any changes resulting from the DSM-5 iterative revision process, described in the Introduction.
DSM-5 will be retained online in an archived format at PsychiatryOnline.org, joining prior
versions of DSM.
Clinical rating scales and measures in the print edition and e-book (see “Assessment
Measures” in Section III) are included online along with additional assessment measures used in
the field trials (www.psychiatry.org/dsm5), linked to the relevant disorders. From the Section III
chapter “Culture and Psychiatric Diagnosis,” the Cultural Formulation Interview, Cultural
Formulation Interview—Informant Version (both included in print and e-book), and

supplementary modules to the core Cultural Formulation Interview are all available online at
www.psychiatry.org/dsm5.