magnus919_agent-skills/dsm5/references/00-overview-and-method.md

DSM-5-TR Overview and Method — Skill-Level Reference

Summarized and paraphrased from DSM-5-TR (American Psychiatric Association, 2022). This file is for orientation and education; verify exact criteria wording, codes, and recording procedures against the official DSM-5-TR before any formal clinical, legal, insurance, or research use.

What this file is

This is the orientation file for the whole reference library. Read it first. It explains how the DSM-5-TR is organized, how a DSM-5-TR diagnosis is put together (criteria, specifiers, codes), how to route a question to the right reference file, and the conversation method this skill uses. It also defines the terms a layperson is most likely to meet and lists the misunderstandings that cause the most harm.

The library itself is a paraphrased companion to the manual, built from the user's DSM-5-TR text-revision copy. It supports serious, evidence-based conversation for clinicians, practitioners, patients, and family members. It is not the manual and does not replace clinical judgment or professional evaluation.

How the DSM-5-TR is organized

The DSM-5-TR (Fifth Edition, Text Revision) is the first text revision of DSM-5 (2013). More than 200 experts reviewed a decade of literature and revised the explanatory text; the criteria sets themselves were not conceptually changed, though a few clarifications were approved through the APA's iterative revision process. The manual is organized into three sections plus supporting material:

Section	Contents
Section I: DSM-5 Basics	Introduction, Use of the Manual, Cautionary Statement for Forensic Use of DSM-5
Section II: Diagnostic Criteria and Codes	The official classification for routine clinical use: every criteria set with ICD-10-CM codes and descriptive text (features, prevalence, course, differentials, etc.), plus two chapters of conditions that are not mental disorders
Section III: Emerging Measures and Models	Assessment measures (cross-cutting symptom measures, disorder-specific severity measures, WHODAS 2.0), Cultural Formulation (Outline for Cultural Formulation, Cultural Formulation Interview), Alternative DSM-5 Model for Personality Disorders, and Conditions for Further Study
Front matter / appendices / online	Full classification listing, supplementary measures and CFI modules online at www.psychiatry.org/dsm5

Section III content is more tentative than Section II: it is provided to aid comprehensive assessment and to highlight directions of ongoing research, and its measures and proposed criteria are not part of the official Section II classification.

The 22 diagnostic classes

Section II contains 22 chapter-level diagnostic classes. Twenty are mental disorder chapters; two are chapters of conditions that are not themselves mental disorders but routinely matter in clinical care.

#	Diagnostic class	Reference file
1	Neurodevelopmental Disorders	10-neurodevelopmental-disorders.md
2	Schizophrenia Spectrum and Other Psychotic Disorders	11-schizophrenia-spectrum-and-other-psychotic.md
3	Bipolar and Related Disorders	12-bipolar-and-related-disorders.md
4	Depressive Disorders	13-depressive-disorders.md
5	Anxiety Disorders	14-anxiety-disorders.md
6	Obsessive-Compulsive and Related Disorders	15-obsessive-compulsive-and-related-disorders.md
7	Trauma- and Stressor-Related Disorders	16-trauma-and-stressor-related-disorders.md
8	Dissociative Disorders	17-dissociative-disorders.md
9	Somatic Symptom and Related Disorders	18-somatic-symptom-and-related-disorders.md
10	Feeding and Eating Disorders	19-feeding-and-eating-disorders.md
11	Elimination Disorders	20-elimination-disorders.md
12	Sleep-Wake Disorders	21-sleep-wake-disorders.md
13	Sexual Dysfunctions	22-sexual-dysfunctions.md
14	Gender Dysphoria	23-gender-dysphoria.md
15	Disruptive, Impulse-Control, and Conduct Disorders	24-disruptive-impulse-control-and-conduct-disorders.md
16	Substance-Related and Addictive Disorders	25-substance-related-and-addictive-disorders.md
17	Neurocognitive Disorders	26-neurocognitive-disorders.md
18	Personality Disorders	27-personality-disorders.md
19	Paraphilic Disorders	28-paraphilic-disorders.md
20	Other Mental Disorders and Additional Codes	29-other-mental-disorders-and-additional-codes.md
21	Medication-Induced Movement Disorders and Other Adverse Effects of Medication	30-medication-induced-movement-disorders.md
22	Other Conditions That May Be a Focus of Clinical Attention	31-other-conditions-that-may-be-a-focus-of-clinical-attention.md

Chapter ordering is intentional and roughly follows the life span: conditions that typically appear early in life (neurodevelopmental, schizophrenia spectrum, bipolar, depressive, anxiety) come first; conditions of adulthood and later life (neurocognitive disorders) come last. The regrouping of disorders in DSM-5 was guided by shared scientific features (neural substrates, genetic and family risk, temperament, comorbidity, course, and treatment response), and the classification was harmonized with the World Health Organization's ICD-11 wherever possible.

What counts as a mental disorder

The manual defines a mental disorder as a syndrome characterized by clinically significant disturbance in an individual's cognition, emotion regulation, or behavior that reflects dysfunction in the psychological, biological, or developmental processes underlying mental functioning. Mental disorders are usually associated with significant distress or disability in social, occupational, or other important activities. Two exclusions are built into the definition:

• An expectable or culturally approved response to a common stressor or loss (such as the death of a loved one) is not a mental disorder.
• Socially deviant behavior (political, religious, or sexual) and conflicts primarily between the individual and society are not mental disorders unless the deviance or conflict results from dysfunction in the individual.

The definition was developed for clinical, public health, and research purposes, not for legal judgments about criminal responsibility, disability compensation, or competency (see 01-safety-and-boundaries.md).

How a diagnosis is built: criteria sets

Each disorder in Section II has a diagnostic criteria set made of lettered criteria (A, B, C, and sometimes D, E, F). Lettering is kept aligned with the manual so readers can cross-check. Across disorders the letters typically carry these kinds of content:

Criterion	Typical content
A	The core symptom constellation, often with explicit counts (e.g., "5 of 9 symptoms") and durations (e.g., "during the same 2-week period", "at least 1 month")
B	Additional requirements such as a minimum duration, onset age, or a second domain of symptoms
C / D	The clinical significance criterion: "clinically significant distress or impairment in social, occupational, or other important areas of functioning"
D / E	Exclusions: the disturbance is not attributable to the physiological effects of a substance or another medical condition, and is not better explained by another mental disorder

Read each chapter reference for the exact lettering, counts, durations, and exclusions of a given disorder — the letters above are a general map, not a universal template.

Two points the manual stresses about using criteria:

• Checklists are not diagnoses. "It is not sufficient to simply check off the symptoms in the diagnostic criteria." Determining that a combination of predisposing, precipitating, perpetuating, and protective factors has crossed from normal variation into psychopathology requires clinical training and judgment.
• The clinical significance criterion matters. Many symptoms in mild form occur in people for whom a mental disorder diagnosis would be inappropriate; the distress-or- impairment criterion helps set the threshold. That judgment often requires input from family members or other informants, not only the individual.

Subtypes and specifiers

• Subtypes create mutually exclusive subgroupings within a diagnosis and are indicated by "Specify whether" (e.g., anorexia nervosa, restricting type vs. binge-eating/purging type).
• Specifiers are not mutually exclusive; more than one can apply, and they are indicated by "Specify" or "Specify if" (e.g., social anxiety disorder, performance only).
• Specifiers may describe the current presentation (only assignable when full criteria are currently met) or the lifetime course (e.g., seasonal pattern; assignable regardless of current status).
• Severity: some disorders define mild/moderate/severe levels directly; dimensional severity measures in Section III are used to track severity and change over time (see 02-assessment-and-differential.md).

Coding and recording

• The official coding system for clinical use in the United States is ICD-10-CM (in use since October 1, 2015). Each DSM-5-TR disorder carries an alphanumeric ICD-10-CM code, printed with the disorder name and criteria set.
• For some diagnoses (e.g., neurocognitive disorders, substance/medication-induced disorders) the correct code depends on further specification and is chosen per the criteria set's coding note.
• Multiple diagnoses are allowed. The principal diagnosis (inpatient) or reason for visit (outpatient) is listed first; the rest follow in order of focus of attention and treatment. When the mental disorder is due to another medical condition, ICD coding rules require listing the etiological medical condition first.
• "Provisional" is recorded when criteria are probably met but confirming information (e.g., an informant interview, or whether a duration ceiling is passed) is pending; the modifier is removed once the information arrives.

"Other specified" and "unspecified" categories

Presentations that cause clinically significant distress or impairment but do not fit the boundaries of any specific disorder in a chapter can be captured with one of two residual categories:

• Other specified disorder: the clinician records the reason the presentation does not meet full criteria (e.g., "other specified schizophrenia spectrum and other psychotic disorder, with persistent auditory hallucinations").
• Unspecified disorder: the clinician does not specify the reason (often used in settings such as emergency departments, as a placeholder until a fuller differential is possible).

The choice between them is clinical judgment. Conditions in Section III's "Conditions for Further Study" are the long-standing examples used for the "other specified" designation; listing them there is not an APA endorsement of them as valid categories.

How to use this reference library

Routing: which file for which question

When the question is about...	Read
Skill scope, safety, crisis steps, calibrated language	01-safety-and-boundaries.md
Assessment tools, screening, cultural formulation	02-assessment-and-differential.md and 32-assessment-measures-and-cultural-formulation.md
One of the 22 diagnostic classes	The matching chapter file (table above)
Overlapping symptoms across conditions	40-cross-cutting-differentials.md plus the per-chapter differential sections
The alternative model or conditions for further study	33-alternative-dsm-5-model-and-conditions-for-further-study.md

The "candidate condition" conversation method

The skill never concludes "you have X." It works with candidate conditions. The method has seven steps:

1. Triage safety and urgency. If there is any indication of risk of harm to self or others, stop and follow the crisis protocol in 01-safety-and-boundaries.md before anything else.
2. Clarify the question and the audience. Is this a clinician checking criteria, a patient wondering "what could this be?", or a family member trying to understand? The response differs by audience.
3. Gather the presentation. Duration, onset, course, distress and functional impairment, context, and whether substance use, medications, or medical conditions could be involved. Ask the user; do not assume details.
4. Route to the right reference(s). Use the routing table above, then read the relevant chapter file(s) for criteria, specifiers, and differentials.
5. Compare the presentation against the criteria. Be explicit about which criteria appear met, unmet, or unknown. Never silently skip a criterion.
6. Differential reasoning. Consult the per-chapter differential sections and 40-cross-cutting-differentials.md. Present the most plausible candidates with the features that distinguish them.
7. Communicate a calibrated conclusion. Use "consistent with" / "a clinician would assess for" language, give plain-language next steps and questions to bring to a provider, and state what new information would change the picture.

Glossary for laypeople

Term	Plain-language meaning
Criterion (pl. criteria)	A single requirement within a diagnostic criteria set (e.g., "low mood most of the day"). Sets use lettered criteria (A, B, C...).
Criteria set	The full list of requirements that must be met for a DSM-5-TR diagnosis, including symptom counts, durations, and exclusions.
Specifier	An optional label that adds detail to a diagnosis (e.g., severity, "with anxious distress"). Not mutually exclusive; more than one may apply.
Subtype	A mutually exclusive subgroup of a diagnosis (e.g., restricting type vs. binge-eating/purging type of anorexia nervosa).
Prevalence	The proportion of a population that has a condition, usually reported as 12-month or lifetime rates.
Comorbidity	Two or more conditions occurring in the same person, at the same time or over the life course. In mental health this is common, not rare.
Differential diagnosis	The process of deciding which of several overlapping conditions best explains a presentation, and how to tell them apart.
Syndrome	A cluster of signs and symptoms that tend to occur together.
Onset / course	When the condition began (onset) and how it evolves over time (course), e.g., episodic vs. persistent.
Severity	How intense or impairing the condition is; may be rated mild/moderate/severe or with dimensional measures.
Impairment	Difficulty functioning in important life areas (work, school, relationships, self-care). Most criteria sets require distress or impairment.
"Other specified" / "unspecified"	Residual categories for presentations that are clinically significant but do not meet a named disorder's full criteria.
ICD-10-CM code	The alphanumeric billing/statistical code attached to a diagnosis (e.g., F32.1), required for clinical use in the United States.
Provisional diagnosis	A diagnosis recorded as likely but not yet confirmed, pending missing information.
Cultural concepts of distress	Culturally shaped ways of experiencing and talking about suffering: idioms of distress, explanations/perceived causes, and cultural syndromes.
Cross-cutting symptom measure	A screening questionnaire that reviews many symptom domains at once (like a "review of systems" in general medicine).
WHODAS 2.0	A World Health Organization measure of disability and functioning across six life domains.
Need for treatment	A separate clinical decision from diagnosis; people can need care without meeting full criteria, and vice versa.

Common misunderstandings to avoid

• Symptom overlap is not a diagnosis. A single symptom (poor concentration, insomnia, irritability) appears in many disorders and in everyday life. Diagnosis depends on the whole pattern: counts, duration, onset, context, and exclusions.
• Criteria require distress or impairment. A symptom list alone is not enough; the presentation must cause clinically significant distress or impairment to meet most criteria sets. At the same time, not meeting full criteria does not mean someone does not need care — need for treatment is a separate clinical judgment.
• Culture shapes presentation. The boundaries between normal and pathological vary across cultural contexts. A culturally expected response to a stressor or loss is not a mental disorder, and unfamiliar symptom presentations should not be assumed to be psychosis (see 02-assessment-and-differential.md).
• Categories have fuzzy edges. The manual explicitly does not assume each category is a discrete entity with absolute boundaries; comorbidity is high, and boundary cases are diagnosed "in any but a probabilistic fashion."
• A diagnosis is not a treatment plan. DSM-5-TR provides no treatment guidelines; recommending treatments is beyond the manual's scope and beyond this skill's scope.
• Codes are not the diagnosis. The ICD-10-CM code is a recording device; it does not capture subtypes and specifiers unless the manual says otherwise, and it is not a substitute for clinical formulation.
• Not a legal instrument. A DSM-5-TR diagnosis does not by itself establish legal criteria for "mental illness," competence, criminal responsibility, or disability (see 01-safety-and-boundaries.md).

Where to go next

• For scope, safety, and how to talk about these topics: 01-safety-and-boundaries.md
• For the clinical assessment approach, measures, and cultural formulation: 02-assessment-and-differential.md
• For a specific disorder class: the chapter file (table above)
• For comparing overlapping presentations: 40-cross-cutting-differentials.md

Maintaining this library

Reference files must stay small enough to be read in a single call: about 40,000 characters maximum per part, with chapter indexes no larger than about 10,000 characters. If a chapter reference would exceed roughly 50,000 characters, split it into an index (keeping the original filename so existing links keep resolving to the index) plus part files named NN-<topic>.md, and update the index's "Parts of this chapter reference" routing table. Every part needs the part header, an index pointer, and the attribution line, as the existing parts demonstrate.