The time criteria that decide clinical items, the neighbor diagnoses the exam pairs them with, the rule-out order, and the TR changes you need.
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Create a free account or sign in ← Back to free toolsThe time criteria that decide clinical items, the neighbor diagnoses the exam pairs them with, the rule-out order, and the TR changes you need.
Download the PDF · 30 flashcards included Or read it on screen below. Print single-sided for the flashcards.Areas of Clinical Focus is twenty-nine percent of the exam, and the diagnosis items inside it are decided more often by a number than by a symptom. Two weeks or two years. Four days or seven. One month or six. The item writer gives you a presentation with a near neighbor and a duration that settles it, and candidates who read for symptoms alone pick the neighbor. This guide puts every tested duration in one table, walks the neighbor pairs, and ends with thirty cards that make the numbers automatic.
Read in the DSM's own order, which is also the order of the rule-outs. First, substances: what is the client using, how much and how recently, and could it produce this picture? Alcohol, stimulants, cannabis, benzodiazepines and prescribed medications can each imitate mood, anxiety and psychotic disorders, and a stem that mentions them is mentioning them for a reason. Second, medical conditions: thyroid disease, head injury, delirium, medication effects and pregnancy are the ones items use. Third, another mental disorder that better explains the symptoms. Only then the criteria themselves.
Within the criteria, read for four things in order: duration, how long has this been going on; count, how many of the listed symptoms are actually present in the stem; impairment, is there clinically significant distress or functional impairment, without which most diagnoses cannot be made; and specifiers, severity, course and features that the exam asks about separately. A stem that lists three depressive symptoms over ten days after a job loss has not described a major depressive episode no matter how sad it sounds, and the candidate who counts gets the item.
The DSM-5-TR is the current edition and the exam is written to it. Older study materials describe the multiaxial system and the GAF, both removed in 2013, and some describe eight content areas on the exam, which also no longer exist. If a source predates 2013 for diagnosis, use these pages instead.
These are the time criteria the exam tests. Most items use one of them as the deciding detail, and the table is worth memorizing as a whole because the neighbors sit beside each other in it.
| Diagnosis | Duration criterion | Neighbor it is tested against |
|---|---|---|
| Major depressive episode | 2 weeks, 5 of 9 symptoms, one is depressed mood or anhedonia | Adjustment disorder; persistent depressive disorder; bereavement |
| Persistent depressive disorder | 2 years adults (1 year children/adolescents), never symptom-free more than 2 months | Major depressive disorder |
| Disruptive mood dysregulation disorder | 12 months, outbursts 3+ per week, onset before 10, diagnosed 6–18 | Bipolar disorder in children; ODD |
| Manic episode | 1 week (or any duration if hospitalized), marked impairment | Hypomanic episode |
| Hypomanic episode | 4 consecutive days, no marked impairment, no psychosis | Manic episode |
| Cyclothymic disorder | 2 years (1 year youth) of hypomanic and depressive symptoms below threshold | Bipolar II |
| Generalized anxiety disorder | 6 months, more days than not, 3 of 6 symptoms (1 in children) | Adjustment disorder with anxiety; panic |
| Panic disorder | Recurrent unexpected attacks plus 1 month of worry or behavior change | Agoraphobia; specific phobia; medical causes |
| Specific phobia / social anxiety | 6 months typical | Panic disorder; agoraphobia |
| Separation anxiety disorder | 4 weeks children; 6 months adults | GAD; school refusal from other causes |
| Selective mutism | 1 month, not the first month of school | Social anxiety; language disorder |
| Acute stress disorder | 3 days to 1 month after trauma | PTSD; adjustment disorder |
| PTSD | More than 1 month after trauma | Acute stress disorder; adjustment disorder |
| Adjustment disorder | Onset within 3 months of stressor; resolves within 6 months after stressor ends | MDD; GAD; PTSD when the event is not a trauma |
| Prolonged grief disorder (TR) | 12 months after death (6 months children), daily yearning plus 3 of 8 symptoms | MDD; normal bereavement |
| Brief psychotic disorder | 1 day to 1 month, full return | Schizophreniform |
| Schizophreniform disorder | 1 to 6 months | Schizophrenia; brief psychotic |
| Schizophrenia | 6 months total, 1 month active symptoms | Schizophreniform; schizoaffective |
| Schizoaffective disorder | Mood episode concurrent with criterion A, plus 2 weeks of delusions/hallucinations without a mood episode | Bipolar or MDD with psychotic features |
| Delusional disorder | 1 month of delusions, functioning not markedly impaired | Schizophrenia |
| Anorexia nervosa | No duration; restriction, low weight, fear of gain or body-image disturbance | Bulimia; ARFID |
| Bulimia nervosa | Binge and compensate at least once a week for 3 months | Binge-eating disorder |
| Binge-eating disorder | Binges at least once a week for 3 months, no compensation | Bulimia |
| Insomnia disorder | 3 nights a week for 3 months | Adjustment; depression |
| Enuresis / encopresis | Twice a week for 3 months, age 5 / once a month for 3 months, age 4 | Medical causes |
| Oppositional defiant disorder | 6 months, 4 symptoms | Conduct disorder; DMDD |
| Conduct disorder | 12 months, 3 of 15 behaviors, 1 in past 6 months; childhood-onset before 10 | ODD; antisocial PD (requires 18+ and CD before 15) |
| ADHD | 6 months, 6 symptoms (5 at 17+), several present before age 12, two settings | Anxiety; bipolar; learning disorders |
| Substance use disorder | 12 months, 2 of 11 criteria; mild 2–3, moderate 4–5, severe 6+ | Intoxication; withdrawal |
| Personality disorders | Enduring pattern from adolescence/early adulthood; antisocial requires age 18 | Mood and anxiety disorders; each other |
| Delirium vs. major neurocognitive disorder | Delirium: hours to days, fluctuating attention. NCD: gradual, stable decline | Each other; depression (pseudodementia) |
Four depressive presentations are tested as a set. A major depressive episode requires two weeks of five of nine symptoms, one of which is depressed mood or loss of interest, with impairment. Persistent depressive disorder is the two-year low-grade course. Adjustment disorder with depressed mood begins within three months of an identifiable stressor, does not meet the criteria for another disorder, and resolves within six months of the stressor ending. Bereavement is not a disorder, but since DSM-5 removed the bereavement exclusion, a major depressive episode can be diagnosed during grief if the picture is depressive rather than grieving: pervasive low mood rather than waves of yearning, worthlessness rather than guilt about the deceased, self-focus rather than preoccupation with the lost person.
Prolonged grief disorder, new in the TR, requires twelve months in adults and six in children, with daily intense yearning or preoccupation and at least three of eight symptoms: identity disruption, disbelief, avoidance of reminders, intense emotional pain, difficulty reintegrating, numbness, meaninglessness and loneliness. Intense grief at month four is not prolonged grief disorder whatever its severity. Premenstrual dysphoric disorder requires symptoms in most cycles of the past year, confirmed prospectively over two cycles. Disruptive mood dysregulation disorder was created to stop children with chronic irritability from being diagnosed bipolar; it requires twelve months of severe outbursts three or more times a week with persistent irritability between them, onset before ten, and cannot coexist with ODD or bipolar disorder.
Bipolar is decided by the elevated episode. Mania lasts at least a week, or any duration if hospitalization is required, with marked impairment or psychosis; hypomania lasts at least four days with a clear change in functioning but no marked impairment and no psychosis. Bipolar I requires one manic episode and nothing else; a depressive episode is not required for the diagnosis. Bipolar II requires at least one hypomanic and one major depressive episode and no manic episode ever; a single manic episode converts the diagnosis to bipolar I permanently. Cyclothymia is two years of hypomanic and depressive symptoms that never meet full criteria. Items hide a past hypomanic episode in the history of a client presenting with depression, and the candidate who asks about it gets the item.
Generalized anxiety disorder is six months of excessive worry about several things, more days than not, with three of six associated symptoms: restlessness, fatigue, poor concentration, irritability, muscle tension and sleep disturbance; children need one. Panic disorder is recurrent unexpected attacks plus a month of worry about them or behavior change because of them; attacks alone, which are common, are not a disorder, and attacks cued by a specific situation point to a phobia instead. Agoraphobia is fear of two or more of five situations, public transport, open spaces, enclosed spaces, crowds or lines, and being outside the home alone, because escape might be difficult; since DSM-5 it is diagnosed separately from panic disorder. Social anxiety disorder is fear of scrutiny in social situations, with a performance-only specifier.
Obsessive-compulsive and related disorders left the anxiety chapter in 2013. OCD requires obsessions, compulsions or both that take more than an hour a day or cause impairment, with insight specifiers from good to absent. Body dysmorphic disorder, hoarding disorder, trichotillomania and excoriation disorder are its neighbors. Obsessive-compulsive personality disorder is the standard distractor: a pervasive pattern of perfectionism and control, egosyntonic, without true obsessions or compulsions. OCD is egodystonic, meaning the person recognizes the thoughts as unwanted.
The trauma chapter is decided by the clock and by criterion A. Acute stress disorder runs from three days to one month after a trauma; PTSD requires more than a month, with symptoms in four clusters: intrusion, avoidance, negative changes in cognition and mood, and changes in arousal and reactivity, with a dissociative subtype and a preschool subtype for children six and under. Adjustment disorder is the answer when the stressor does not meet criterion A's definition of trauma, exposure to actual or threatened death, serious injury or sexual violence, or when the symptoms do not reach PTSD. Reactive attachment disorder, withdrawn, and disinhibited social engagement disorder, indiscriminately friendly, both require a history of insufficient care and are diagnosed between nine months and five years.
The psychotic disorders are the clearest case of diagnosis by clock. Criterion A for schizophrenia is two or more of five symptoms for a significant portion of a month, delusions, hallucinations, disorganized speech, grossly disorganized or catatonic behavior, and negative symptoms, with at least one of the first three. Brief psychotic disorder is one day to one month with full return to functioning. Schizophreniform disorder is one to six months, and no decline in functioning is required. Schizophrenia is six months of continuous disturbance including at least one month of active symptoms, with prodromal and residual periods making up the rest, and functioning must be markedly below the prior level.
Schizoaffective disorder requires a major mood episode concurrent with criterion A symptoms, plus at least two weeks of delusions or hallucinations in the absence of a mood episode, with mood symptoms present for the majority of the illness. Its distractor is a mood disorder with psychotic features, in which psychosis occurs only during mood episodes. Delusional disorder is one or more delusions for a month without the other criterion A symptoms and without markedly impaired functioning; the subtypes, erotomanic, grandiose, jealous, persecutory and somatic, are tested by description. Substance- or medication-induced psychotic disorder and psychotic disorder due to another medical condition are the rule-outs that precede all of them.
Negative symptoms are the ones candidates forget: diminished emotional expression, avolition, alogia, anhedonia and asociality. Positive symptoms are additions to normal experience; negative symptoms are subtractions. A stem describing a flat, withdrawn, unmotivated client with poverty of speech could be describing negative symptoms or depression, and the history of psychosis decides. Catatonia is now a specifier that can attach to several disorders rather than a schizophrenia subtype, and the subtypes of schizophrenia, paranoid, disorganized and so on, were removed in 2013.
| Duration of psychotic symptoms | Diagnosis |
|---|---|
| 1 day to 1 month, full return | Brief psychotic disorder |
| 1 to 6 months | Schizophreniform disorder |
| 6 months or more (1 month active) | Schizophrenia |
| Mood episode plus 2 weeks psychosis without mood | Schizoaffective disorder |
| Psychosis only during mood episodes | MDD or bipolar with psychotic features |
| 1 month of delusions only, functioning intact | Delusional disorder |
ADHD requires six symptoms of inattention or hyperactivity-impulsivity, five at age seventeen and older, for six months, with several present before age twelve and in two or more settings, and the exam tests the age change from seven to twelve and the two-settings rule. Autism spectrum disorder requires persistent deficits in social communication and interaction plus restricted, repetitive behaviors, present from early development, with severity levels based on support needed; Asperger's disorder was folded into it in 2013. Intellectual developmental disorder, renamed in the TR, requires deficits in intellectual functioning and in adaptive functioning, with severity based on adaptive functioning, not IQ. Specific learning disorder has specifiers for reading, written expression and mathematics.
Substance use disorder is a single diagnosis per substance, replacing abuse and dependence in 2013, with eleven criteria over twelve months: two or three is mild, four or five moderate, six or more severe. The criteria group into impaired control, social impairment, risky use and pharmacological criteria, tolerance and withdrawal. Tolerance and withdrawal do not count toward the diagnosis when the substance is taken as prescribed. Gambling disorder is the only behavioral addiction in the chapter; internet gaming disorder sits in the conditions for further study. Intoxication and withdrawal are diagnosed separately and are the rule-outs for mood, anxiety and psychotic presentations.
Personality disorders are enduring, pervasive, inflexible patterns beginning by adolescence or early adulthood, and the exam tests them in three clusters. Cluster A, odd or eccentric: paranoid, schizoid, schizotypal. Cluster B, dramatic, emotional or erratic: antisocial, borderline, histrionic, narcissistic. Cluster C, anxious or fearful: avoidant, dependent, obsessive-compulsive. Antisocial personality disorder requires age eighteen and evidence of conduct disorder before fifteen. Schizoid wants no relationships and does not mind; avoidant wants relationships and fears rejection; that pair is the most common personality disorder item. Borderline is tested through splitting, fear of abandonment and self-harm, and dialectical behavior therapy is its keyed treatment.
Delirium is an acute disturbance of attention and awareness that develops over hours to days, fluctuates across the day, and is caused by a medical condition, a substance or withdrawal; it is a medical emergency and the keyed response is a medical evaluation, not a counseling intervention. Major neurocognitive disorder, formerly dementia, is a gradual, significant decline in one or more cognitive domains that interferes with independence; mild neurocognitive disorder is a modest decline that does not. Etiological subtypes include Alzheimer's disease, the most common, vascular, Lewy body, frontotemporal, traumatic brain injury and substance-induced.
Depression in older adults can present as cognitive complaint, historically called pseudodementia, and the differential is tested: depressed clients complain about memory and give "I don't know" answers, while clients with neurocognitive disorder often minimize deficits and confabulate. New memory loss in an older adult taking a sedative, a benzodiazepine or an anticholinergic is a medication question before it is a diagnostic one. Somatic symptom disorder, illness anxiety disorder, functional neurological symptom disorder and factitious disorder are tested as a set defined by the relationship between symptoms, distress and intent: factitious disorder involves deliberate falsification without obvious external reward, and malingering, which is not a mental disorder, involves falsification for an external gain.
Gender dysphoria is diagnosed by marked incongruence between experienced and assigned gender with distress or impairment, for six months, and the TR changed terminology to experienced gender, gender-affirming treatment and individuals assigned male or female at birth. Being transgender is not a disorder; the diagnosis names the distress. Paraphilic disorders are diagnosed only when the paraphilia causes distress or impairment or involves harm or a non-consenting person. These appear as ethics and attributes items as often as diagnostic ones, and the keyed answers use the TR's language.
Specifiers carry points of their own. Major depressive disorder takes severity, mild, moderate or severe, course, single episode or recurrent, remission status, and features: anxious distress, mixed features, melancholic, atypical, psychotic, catatonic, peripartum onset, with onset during pregnancy or within four weeks of delivery, and seasonal pattern. Bipolar disorders take rapid cycling, four or more episodes in a year. Substance use disorders take early remission, three to twelve months without criteria other than craving, sustained remission, twelve months or more, and in a controlled environment. OCD and body dysmorphic disorder take insight specifiers. PTSD takes the dissociative subtype and with delayed expression when full criteria are not met until six months after the event.
The TR's changes beyond prolonged grief disorder are small and tested: suicidal behavior and nonsuicidal self-injury received codes as conditions that may be a focus of attention, unspecified mood disorder returned for presentations that are clearly mood but not clearly unipolar or bipolar, intellectual disability became intellectual developmental disorder, the autism criteria wording was clarified so that all three social communication deficits are required, and the text on culture, racism and discrimination was revised throughout. ICD-10-CM codes are what the TR prints and what insurers require. The DSM provides criteria; the ICD provides the codes.
The Cultural Formulation Interview is the TR's tool for a diagnosis made in context: sixteen questions on the client's definition of the problem, causes, stressors and supports, the role of cultural identity, coping and past help-seeking, and current expectations. A presentation that is normative in the client's culture is not a symptom, and the exam tests that principle with religious experiences, grief practices and culturally patterned expressions of distress. Culture-related diagnostic issues and cultural concepts of distress replaced the older culture-bound syndromes.