What are the DSM (Diagnostic and Statistical Manual of Mental Disorders) criteria for diagnosing mental health conditions?

DSM Criteria for Mental Health Diagnosis

General Diagnostic Framework

All DSM-5 mental health diagnoses require that symptoms cause clinically significant distress or functional impairment in social, occupational, or academic functioning—normal developmental variations without impairment do not qualify for diagnosis. 1

The DSM-5 represents a fundamental shift from DSM-IV by moving away from rigid categorical distinctions toward a more unified, dimensional approach that better reflects the spectrum nature of psychiatric conditions 2.

Core Requirements Across Disorders

Every mental health diagnosis in DSM-5 must satisfy several universal criteria:

• Excessive symptoms that are developmentally inappropriate and out of proportion to actual circumstances or threat 1
• Duration criterion of at least 6 months for most disorders in adults, though this varies by specific condition 1
• Functional impairment that significantly interferes with normal routine, occupational functioning, or social relationships 2, 1
• Exclusion of alternative explanations including substance/medication-induced symptoms, medical conditions mimicking psychiatric symptoms, and other mental disorders that better account for the presentation 1, 3

Substance Use Disorders: The DSM-5 Model

DSM-5 eliminated the DSM-IV distinction between abuse and dependence, combining them into a single "substance use disorder" diagnosis requiring 2 or more of 11 criteria within a 12-month period. 2

Diagnostic Threshold and Severity

• Mild disorder: 2-3 criteria met 2
• Moderate disorder: 4-5 criteria met 2
• Severe disorder: 6 or more criteria met 2

This change resolved major problems with DSM-IV, including poor reliability of the abuse diagnosis, diagnostic orphans (patients with 2 dependence criteria but no diagnosis), and the incorrect assumption that abuse always preceded dependence 2.

Critical Exception for Medical Use

When psychoactive substances (stimulants, opioids, sedative-hypnotics, cannabis) are used under medical supervision, tolerance and withdrawal alone do not constitute a substance use disorder diagnosis—these represent normal physiological adaptations. 2

Remission Specifiers

• Early remission: ≥3 months but <12 months without meeting criteria (except craving) 2
• Sustained remission: ≥12 months without meeting criteria (except craving) 2

The 3-month threshold was selected because data demonstrated better outcomes for patients retained in treatment at least this duration 2.

Anxiety Disorders: Specific Diagnostic Criteria

Specific Phobia

Diagnosis requires marked, intense fear of a specific object or situation that almost invariably provokes immediate fear response, with active avoidance or endurance with intense distress, and fear out of proportion to actual danger. 2, 1

Key criteria include:

• The phobic object or situation almost invariably provokes immediate fear (in children, may manifest as crying, tantrums, freezing, or clinging) 2
• The phobic situation is avoided or endured with intense anxiety or distress 2
• Duration of at least 6 months in individuals under 18 years 2
• Recognition that fear is excessive or unreasonable (this feature may be absent in children) 2

Panic Disorder

Before diagnosing panic disorder, systematically rule out medical conditions that mimic panic symptoms: asthma, hyperthyroidism, hypoglycemia, cardiac arrhythmias, and migraines. 1

Assessment must include evaluation for commonly co-occurring conditions including major depressive disorder, other anxiety disorders, substance use disorders, and agoraphobia 1.

Agoraphobia

Agoraphobia can exist independently of panic attacks and should not be exclusively associated with panic disorder. 2, 1

The diagnosis requires excessive fear about being in situations where escape might be difficult or help unavailable should panic-like or overwhelming symptoms occur 1.

Substance-Induced Psychiatric Disorders

For substance/medication-induced disorders, the substance must be pharmacologically capable of producing the psychiatric symptoms, with symptoms occurring during intoxication, withdrawal, or within 4 weeks of cessation. 3

Critical Temporal Rule

If psychotic or psychiatric symptoms persist beyond 4 weeks after cessation of acute withdrawal or severe intoxication, this suggests an independent psychiatric disorder rather than a substance-induced condition. 3

This 4-week cutoff is diagnostically crucial and represents the standard expectation for symptom resolution in substance-induced conditions 3.

Diagnostic Process and Common Pitfalls

Systematic Evaluation Sequence

1. Assess level of consciousness and attention first—if impaired, consider delirium before other diagnoses 4
2. Obtain detailed substance/medication history, reviewing all medications (particularly anticholinergics, steroids, dopaminergic agents) and temporal relationship to symptoms 4
3. Rule out medical conditions through appropriate laboratory workup (CBC, CMP, urinalysis, toxicology screen) and neuroimaging (preferably MRI) 4
4. Evaluate for sensory deficits such as vision loss that could explain symptoms 4
5. Apply structured diagnostic interviews to confirm diagnosis according to DSM-5 criteria 1

Critical Pitfalls to Avoid

• Missing delirium doubles mortality risk—look for subtle disturbances in arousal and fluctuating course over the day 4
• Premature psychiatric diagnosis without ruling out ophthalmological and neurological causes 4
• Ignoring medication effects, particularly dopaminergic agents that can worsen hallucinations 4
• Diagnostic literalism—DSM criteria are fallible indices of disorders, not definitive definitions; they can be wrong and should be understood as tentative diagnostic constructs 5

Screening and Confirmation

• Use GAD-7 as initial screening for anxiety disorders, with scores ≥10 indicating moderate to severe anxiety requiring comprehensive diagnostic evaluation 1
• Structured diagnostic interviews should confirm diagnosis rather than relying solely on screening tools 1
• Systematic evaluation for comorbid conditions is mandatory, including major depressive disorder, other anxiety disorders, substance use disorders, PTSD, bipolar disorder, ADHD, OCD, and eating disorders 1

Key Conceptual Understanding

DSM criteria represent an indexical rather than constitutive relationship with disorders—criteria are fallible indicators of hypothetical diagnostic constructs, not absolute definitions. 5

This means criteria can be revised, symptoms outside the criteria may be diagnostically relevant, and clinical judgment remains essential in applying diagnostic guidelines 5. The criteria increase "pathosuggestiveness" through strategies including minimum duration requirements, frequency/intensity thresholds, disproportionality requirements, pervasiveness across contexts, and symptom combinations 6.