____________________________________________________________ A Clinician’s Guide to the DSM-5-TR
• A sense that life is meaningless without her mother • Emotional numbness and detachment from others • Bitterness and anger about the loss • Difficulty engaging in work and social activities These symptoms have persisted without significant improve- ment for over a year since the loss. Sarah reports that the inten- sity of her grief feels just as strong now as it did immediately after her mother’s death. Functional Impairment Sarah’s work performance has declined significantly. She has been reprimanded for excessive absences and missed deadlines. Her social relationships have deteriorated as she isolates her- self and avoids social gatherings. Sarah has also neglected her physical health, skipping meals and doctor’s appointments. Previous Treatment Sarah attended three grief counseling sessions shortly after her mother’s death but found them unhelpful and discontinued. She has been taking an SSRI antidepressant prescribed by her primary care doctor for the past six months with minimal effect on her symptoms. Diagnosis Based on the persistent and impairing nature of Sarah’s grief symptoms more than 12 months after her loss, she meets the criteria for prolonged grief disorder. Her symptoms go beyond customary cultural and religious norms for grief and are caus- ing significant functional impairment. Treatment Plan A comprehensive treatment approach is recommended, including: • Prolonged grief disorder-specific psychotherapy (e.g., complicated grief therapy) • Continued antidepressant medication with potential adjustment • Behavioral activation to increase engagement in meaningful activities • Grief support group to reduce isolation The goals are to help Sarah process her grief, find ways to maintain a healthy connection to her mother’s memory, and gradually re-engage in life. Regular monitoring of suicidal ideation is also warranted, given the elevated suicide risk associated with prolonged grief.
SYMPTOM CODE UPDATES: PRESENCE/ HISTORY OF SUICIDAL BEHAVIOR AND NSSI PRESENCE/HISTORY OF SUICIDAL BEHAVIOR The DSM-5-TR introduced significant changes regarding the documentation of suicidal behavior by adding new symptom codes to indicate both the presence and history of suicidal behavior [1]. This addition was part of a broader effort to improve the assessment and documentation of suicide risk in clinical practice. The DSM-5 had already included a Suicide Risk section in the text for most disorders to emphasize the importance of suicide risk assessment during clinical evalua- tions [2]. In the DSM-5-TR, these sections were expanded and renamed “Association with Suicidal Thoughts or Behavior.” The new symptom codes for suicidal behavior were added to the chapter “Other Conditions That May Be a Focus of Clini- cal Attention” in the DSM-5-TR. These codes allow clinicians to document current suicidal behavior (for both initial and subsequent encounters) as well as a history of suicidal behavior. Including these codes serves several important purposes: it helps improve the accuracy of clinical documentation, facili- tates better tracking and research on suicidal behavior, and encourages clinicians to assess for these behaviors as part of routine clinical practice. Importantly, these codes can be used without requiring any other mental health diagnosis, recogniz- ing that suicidal behavior can occur in various contexts. This change reflects a growing recognition of the need to address suicidal behavior as a distinct clinical concern, separate from, but often related to, other mental health conditions. NSSI The DSM-5-TR introduced new symptom codes for nonsui- cidal self-injury (NSSI), representing a significant update in the documentation and recognition of this clinically meaningful behavior [1]. This addition was part of a broader effort to improve the assessment and documentation of self-harming behaviors in clinical practice. The inclusion of these codes allows clinicians to document both current nonsuicidal self- injury and a history of nonsuicidal self-injury. The new symptom codes for NSSI were added to the “Other Conditions That May Be a Focus of Clinical Attention” chapter in the DSM-5-TR. These codes serve several important purposes: they help improve the accuracy of clinical documen- tation, facilitate better tracking and research on self-injurious behaviors, and encourage clinicians to assess for these behaviors as part of routine clinical practice. Importantly, these codes can be used without requiring any other mental health diagnosis, recognizing that NSSI can occur in various contexts and may not always be associated with a specific mental disorder. This change reflects a growing recognition of the need to address self-injurious behaviors as distinct clinical concerns, separate from, but often related to, other mental health conditions.
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