____________________________________________________________ A Clinician’s Guide to the DSM-5-TR
NEW DIAGNOSTIC ENTRIES IN DSM-5-TR ( Continued )
Diagnostic Entity Description
Key Features
No diagnosis or condition
The DSM-5-TR introduced a new code for “no diagnosis or condition” to address situations where a clinician needs to indicate that no mental disorder or condition is present. The code for “no diagnosis or condition” allows clinicians to document that a comprehensive diagnostic evaluation was conducted explicitly, but no mental disorder or condition warranting clinical attention was found. This code helps improve the accuracy of clinical documentation and provides a straightforward way to communicate that a mental health evaluation was conducted with a finding of no diagnosable condition. It is beneficial in contexts where the absence of a diagnosis needs to be formally recorded. The DSM-5-TR defines suicidal behavior as “potentially self-injurious behavior with at least some intent to die as a result of the action.” NSSI is defined as intentionally inflicting damage to one’s body that will “likely induce bleeding, bruising or pain.”
1. An individual undergoes a mental health assessment but does not meet the criteria or any mental disorder. 2. A clinician must indicate the absence of a mental health diagnosis for administrative or billing purposes. 3. There is a need to document that a thorough evaluation was performed, even though no diagnosis was made. 4. To differentiate between cases where no disorder is present versus cases with insufficient information to diagnose.
Suicidal behavior
1. Current suicidal behavior (initial encounter) 2. Current suicidal behavior (subsequent encounter) 3. History of suicidal behavior
Nonsuicidal self- injury (NSSI)
1. Current nonsuicidal self-injury 2. History of nonsuicidal self-injury
These new codes serve several important purposes: 1. They allow clinicians to document these behaviors without requiring other mental health diagnoses. 2. They help improve the accuracy of clinical documentation and risk assessment. 3. They facilitate better tracking and research on suicidal behavior and self-injury. 4. They encourage clinicians to assess these behaviors in routine clinical practice. The inclusion of these codes in the DSM-5-TR aims to draw attention to these critical issues in mental health care and improve the overall assessment and treatment of individuals at risk for suicide or self-harm. Source: [1] Table 1
• Importance for clinicians : These changes underscore the need for mental health professionals to stay updated with the latest version of the DSM to ensure they are using the most current and accurate diagnostic criteria. • Research implications : Clear criteria can produce more consistent research results across different studies and settings. It is important to note that while these modifications are significant for ensuring diagnostic accuracy, they are not as substantial as adding new disorders or significant revisions to existing ones. Clinicians are encouraged to review the specific changes relevant to their practice areas.
• Process : These changes underwent a formal review process, including approval by the DSM Steering Committee, the APA Board of Trustees, and the APA Assembly. • Clinical impact : While these modifications do not fundamentally alter the disorders, they may lead to more accurate and consistent diagnoses in clinical practice. • Examples : Typical clarifications might involve specifying time frames more precisely, clarifying the meaning of specific terms, or providing more detailed descriptions of symptoms.
23
EliteLearning.com/Social-Work
Powered by FlippingBook