The DSM-5 Text Revision (DSM-5-TR)¹ is the first published revision of DSM-5 since its original publication in 2013. Like the previous text revision (DSM-IV-TR), the main goal of DSM-5-TR is to comprehensively update the descriptive text that is provided for each DSM disorder based on reviews of the literature since the release of the prior version. However, in contrast to DSM-IV-TR, in which updates were confined almost exclusively to the text², there are a number of significant changes and improvements in DSM-5-TR that are of interest to practicing clinicians and researchers. These changes include the addition of diagnostic entities, and modifications and updated terminology in diagnostic criteria and specifier definitions.

The updates to the diagnostic criteria and text in DSM-5-TR are the product of two separate but concurrent processes: the iterative revision process that allows the addition or deletion of disorders and specifiers as well as changes in diagnostic criteria to be made on an ongoing basis³, which commenced soon after the publication of DSM-5, and a complementary text revision process which began in 2019.

While most of the changes instituted since publication of DSM-5 and included in this text revision involve relatively minor changes and serve to correct errors, clarify ambiguities, or resolve inconsistencies between the diagnostic criteria and text, some are significant enough to have an impact on clinical practice⁴. Here we outline the main changes in DSM-5-TR, subdivided into four categories: addition of diagnostic entities and symptom codes; changes in diagnostic criteria or specifier definitions; updated terminology; and comprehensive text updates.

Diagnostic entities added to DSM-5-TR include Prolonged Grief Disorder, Unspecified Mood Disorder, and Stimulant-Induced Mild Neurocognitive Disorder.

Prolonged Grief Disorder is characterized by the continued presence, for at least 12 months after the death of a loved one, of intense yearning for the deceased and/or persistent preoccupation with thoughts of the deceased, along with other grief-related symptoms such as emotional numbness, intense emotional pain and avoidance of reminders that the person is deceased, that are sufficiently severe to cause impairment in functioning^{5, 6}.

Unspecified Mood Disorder is a residual category for presentations of mood symptoms which do not meet the full criteria for any of the disorders in either the bipolar or the depressive disorders diagnostic classes, and for which it is difficult to choose between Unspecified Bipolar and Related Disorder and Unspecified Depressive Disorder (e.g., acute agitation).

Stimulant-Induced Mild Neurocognitive Disorder has been added to the existing types of substance-induced mild neurocognitive disorders (alcohol, inhalants, and sedative, hypnotics or anxiolytic substances), in recognition of the fact that neurocognitive symptoms, such as difficulties with learning and memory and executive function, can be associated with stimulant use⁷.

Free-standing symptom codes have been added to the chapter Other Conditions that May Be a Focus of Clinical Attention, to indicate the presence (or history of) suicidal behavior (“potentially self-injurious behavior with at least some intent to die”) and nonsuicidal self-injury (“intentional self-inflicted damage to the body likely to induce bleeding, bruising, or pain in the absence of suicidal intent”)¹. These codes will allow the clinician to record these clinically important behaviors independent of any particular psychiatric diagnosis.

Changes in diagnostic criteria or specifier definitions have been implemented for more than 70 disorders. While most of these changes are relatively minor, a number are more significant, and address identified problems that could lead to misdiagnosis. Diagnostic criteria sets or specifier definitions with more significant changes include those to criterion A for Autism Spectrum Disorder; changes in severity specifiers for Manic Episode; addition of course specifiers to Adjustment Disorder; and changes to criterion A for Delirium.

Autism Spectrum Disorder is defined by persistent difficulties in the social use of verbal and nonverbal communication (criterion A) along with restricted repetitive patterns of behavior (criterion B). While the minimum threshold for the restricted repetitive behavior component was straightforward (at least two of four), the minimum required number of types of deficits in social communication was ambiguous. Specifically, the criterion A phrase “as manifested by the following” could be interpreted to mean “any of the following” (one of three) or “all of the following” (three of three). Since the intention of the DSM-5 Work Group was always to maintain a high diagnostic threshold by requiring all three, criterion A was revised to be clearer: “as manifested by all of the following”.

The “mild” severity specifier for Manic Episode (few, if any, symptoms in excess of required threshold; distressing but manageable symptoms, and the symptoms result in minor impairment in social or occupational functioning) was inconsistent with Manic Episode criterion C, which requires that the mood disturbance be sufficiently severe to cause marked impairment in social or occupational functioning, necessitate hospitalization, or include psychotic features. The severity specifiers from DSM-IV have now been adopted: “mild” if only minimum symptom criteria are met; “moderate” if there is a very significant increase in activity or impairment in judgment, and “severe” if almost continual supervision is required.

Specifiers indicating the duration of symptoms in Adjustment Disorder were inadvertently left out of DSM-5 and have now been reinstated: “acute” if symptoms have persisted for less than 6 months, and “persistent” if symptoms have persisted for 6 months or longer after the termination of the stressor or its consequences.

The essential cognitive features in Delirium are disturbances of attention and awareness of the environment. While the nature of the attentional disturbance – characterized in criterion A as a reduced ability to direct, focus, sustain, and shift attention – is clear, the characterization of the awareness component as “reduced orientation to the environment” is confusing, given that “disorientation” already appears as one of the “additional disturbances in cognition” listed in criterion C. Consequently, criterion A has been reformulated to avoid using “orientation”, so that it now reads “A disturbance in attention (i.e., reduced ability to direct, focus, sustain, and shift attention) accompanied by reduced awareness of the environment”.

DSM-5 terminology has been updated to conform to current preferred usage, and includes replacing “neuroleptic medications”, which emphasize side effects, with “antipsychotic medications or other dopamine receptor blocking agents”; replacing “intellectual disability” with “intellectual developmental disorder”; and changing “conversion disorder” to “functional neurological syndrome”. Reflecting the evolving terminology in the area of gender dysphoria, “desired gender” is replaced with “experienced gender”; “natal male/natal female” with “individual assigned male at birth” or “individual assigned female at birth”; and “cross-sex treatment regimen” with “gender-affirming treatment regimen”.

The updates to the text were the result of a three-year process involving over 200 experts, most of whom had participated in the development of DSM-5. There were 20 Review Groups to cover the Section II chapters, each headed by a Section Editor. Experts were asked to review the text to identify material that was out-of-date. This was supplemented by literature reviews that covered the period of the prior 10 years.

Three cross-cutting Review Groups (Sex and Gender, Culture, Suicide) reviewed every chapter, focusing on material involving their specific expertise. Revisions to the text also underwent a forensic review. Finally, an Ethnoracial Equity and Inclusion Work Group reviewed the entire text to ensure among other things that explanations of ethno-racial and cultural differences in symptomatic presentations and prevalence took into consideration the impact of experiences such as racism and discrimination.

Most disorder texts had at least some revisions, with the overwhelming majority having significant revisions. Text sections most extensively updated were Prevalence, Risk and Prognostic Factors, Culture-Related Diagnostic Features, Sex- and Gender-Related Diagnostic Features, Association with Suicidal Thoughts and Behaviors, and Comorbidity. The text sections with the fewest updates were Diagnostic Features and Differential Diagnosis.

The American Psychiatric Association continues to welcome empirically-grounded proposals for change. Guidelines for submitting such proposals can be found at www.dsm5.org.

DSM-5 文本修订版 (DSM-5-TR) ¹是 DSM-5 自 2013 年最初出版以来首次发布的修订版。与之前的文本修订版 (DSM-IV-TR) 一样，DSM-5 的主要目标-TR 将根据自上一版本发布以来的文献回顾，全面更新为每个 DSM 障碍提供的描述性文本。然而，与 DSM-IV-TR 相比，DSM-IV-TR 的更新几乎只限于文本²，在 DSM-5-TR 中有许多重要的变化和改进，这些变化和改进是临床医生和研究人员感兴趣的。这些更改包括诊断实体的添加，以及诊断标准和说明符定义中的修改和更新术语。

DSM-5-TR 中诊断标准和文本的更新是两个独立但同时进行的过程的产物：允许添加或删除疾病和说明符的迭代修订过程以及对诊断标准进行更改的迭代过程。 DSM-5 发布后不久开始的持续基础³，以及 2019 年开始的补充文本修订过程。

虽然自 DSM-5 发布以来进行的大多数更改以及包含在本文本修订中的更改都涉及相对较小的更改，并用于纠正错误、澄清歧义或解决诊断标准与文本之间的不一致，但有些更改足以影响临床实践⁴．在这里，我们概述了 DSM-5-TR 的主要变化，分为四类：添加诊断实体和症状代码；诊断标准或说明符定义的变化；更新的术语；和全面的文本更新。

添加到 DSM-5-TR 的诊断实体包括长期悲伤障碍、未指明的情绪障碍和兴奋剂诱发的轻度神经认知障碍。

长期悲伤障碍的特征是在亲人去世后至少 12 个月内持续存在对死者的强烈向往和/或持续专注于对死者的想法，以及其他与悲伤相关的症状，例如情绪麻木、强烈的情绪痛苦和避免提醒人们已经死亡，这些情况严重到足以导致功能受损^{5, 6}。

未指明的情绪障碍是情绪症状的残留类别，不符合双相或抑郁障碍诊断类别中任何疾病的完整标准，并且难以在未指明的双相和相关障碍之间进行选择，以及未指明的抑郁症（例如，急性躁动）。

兴奋剂诱发的轻度神经认知障碍已被添加到现有类型的物质诱发的轻度神经认知障碍（酒精、吸入剂和镇静剂、催眠剂或抗焦虑物质）中，以认识到神经认知症状，例如学习和记忆困难和执行功能，可与兴奋剂的使用⁷。

独立的症状代码已添加到“可能成为临床关注焦点的其他情况”一章中，以表明存在（或有过自杀行为）（“至少有某种死亡意图的潜在自残行为”）和非自杀性自伤（“在没有自杀意图的情况下，故意对身体造成的自我伤害，可能导致出血、瘀伤或疼痛”）¹ . 这些代码将允许临床医生独立于任何特定的精神病诊断记录这些临床上重要的行为。

已对 70 多种疾病实施了诊断标准或说明符定义的更改。虽然这些变化中的大多数相对较小，但其中一些变化更为重要，并解决了可能导致误诊的已识别问题。具有更显着变化的诊断标准集或说明符定义包括自闭症谱系障碍的标准 A；躁狂发作严重性说明符的变化；在调整障碍中添加课程说明符；并更改谵妄的标准 A。

自闭症谱系障碍的定义是语言和非语言交流的社会使用持续困难（标准 A）以及受限的重复行为模式（标准 B）。虽然限制重复行为组件的最低阈值很简单（至少四个中的两个），但社会交流中所需的最少类型缺陷的数量是模棱两可的。具体而言，标准 A 短语“如以下所示”可以解释为“以下任何一项”（三项之一）或“以下所有”（三项中的三项）。由于 DSM-5 工作组的意图始终是通过要求所有三项来保持较高的诊断阈值，因此对标准 A 进行了修订以更加清晰：“如以下所有内容所示”。

躁狂发作的“轻度”严重程度说明符（如果有的话，很少有超过所需阈值的症状；令人痛苦但可控的症状，并且这些症状会导致社交或职业功能的轻微损害）与躁狂发作标准 C 不一致，后者要求情绪障碍严重到足以导致社会或职业功能显着受损，需要住院治疗，或包括精神病特征。现在已采用 DSM-IV 中的严重性说明符：如果仅满足最低症状标准，则为“轻度”；如果活动显着增加或判断力受损，则为“中度”，如果需要几乎持续的监督，则为“严重”。

指示调整障碍症状持续时间的说明符无意中被排除在 DSM-5 之外，现在已恢复：如果症状持续不到 6 个月，则为“急性”，如果症状持续 6 个月或更长时间，则为“持续”压力源的终止或其后果。

谵妄的基本认知特征是注意力和环境意识的障碍。虽然注意障碍的性质——在标准 A 中被描述为引导、集中、维持和转移注意力的能力下降——是明确的，但将意识部分描述为“对环境的定向减少”是令人困惑的，因为“定向障碍”已经作为标准 C 中列出的“额外认知障碍”之一出现。因此，标准 A 已重新制定以避免使用“定向”，因此它现在读作“注意力障碍（即，降低指导能力、集中、维持和转移注意力）伴随着对环境的意识降低”。

DSM-5 术语已更新以符合当前的首选用法，包括将强调副作用的“神经安定药物”替换为“抗精神病药物或其他多巴胺受体阻断剂”；将“智力障碍”替换为“智力发育障碍”；并将“转换障碍”转变为“功能性神经综合征”。反映性别焦虑领域不断演变的术语，“期望的性别”被“经验的性别”取代；“本命男/本命女”与“个人指定出生男性”或“个人出生指定女性”；“跨性别治疗方案”与“性别肯定治疗方案”。

对文本的更新是历时三年过程的结果，涉及 200 多名专家，其中大多数人参与了 DSM-5 的开发。有 20 个审查小组负责第二部分的章节，每个小组由一位编辑负责。专家们被要求审查文本以确定过时的材料。涵盖过去 10 年期间的文献综述对此进行了补充。

三个交叉审查小组（性与性别、文化、自杀）审查了每一章，重点关注涉及其特定专业知识的材料。对文本的修订也经过了法医审查。最后，民族平等和包容工作组审查了整个文本，以确保除其他事项外，对症状表现和流行中的民族种族和文化差异的解释考虑到种族主义和歧视等经历的影响。

大多数无序文本至少有一些修改，绝大多数有重大修改。最广泛更新的文本部分是患病率、风险和预后因素、文化相关的诊断特征、性别和性别相关的诊断特征、与自杀念头和行为的关联以及合并症。更新最少的文本部分是诊断特征和鉴别诊断。

美国精神病学协会继续欢迎基于经验的变革建议。提交此类提案的指南可在 www.dsm5.org 找到。