What DSM-5-TR changes are on the ASWB Clinical exam?

Prolonged grief disorder as a new diagnosis, symptom codes for suicidal behavior (T14.91XA initial, T14.91XD subsequent) and nonsuicidal self-injury, the restored unspecified mood disorder category, stimulant-induced mild neurocognitive disorder, clarified criteria across 70+ disorders, and expanded text on how racism and discrimination shape presentation. ASWB began testing DSM-5-TR in January 2024.

What are the criteria for prolonged grief disorder?

Persistent intense longing or preoccupation with the deceased plus identity disruption, avoidance, and functional impairment lasting at least 12 months in adults (6 months in children and adolescents), exceeding cultural norms. It can be diagnosed alongside MDD if both criteria sets are met. On the exam, a death trigger plus a 12-month timeline with longing at the center beats MDD even with overlapping depressive symptoms.

Are T14.91 and NSSI codes diagnoses?

No. T14.91XA/XD flags current suicidal behavior (initial vs subsequent encounter) and NSSI codes flag self-injury history under Other Conditions That May Be a Focus of Clinical Attention. They document risk and focus of care, not disorders. The exam uses them to test documentation and risk vignettes — pick them when asked what to add alongside a diagnosis, never as the diagnosis itself.

How does the exam test racism and discrimination?

Through vignettes where guarded behavior, somatic complaints, or anger reflect lived experience of oppression rather than pathology. The correct sequence is cultural formulation first, environmental causes second, adjusted MSE interpretation third, conservative diagnosis last. Answers that assign paranoid or oppositional traits before considering context are wrong; answers that name the impact and choose collaboration are right.

NSSI vs suicide attempt — how do I tell them apart?

Intent decides. NSSI involves deliberate self-damage with no intent to die, serving functions like affect regulation — assess function, teach DBT distress-tolerance skills, monitor. An attempt involves at least some intent to die inferred from behavior or circumstances — assess plan, means, and intent and protect accordingly. History of either raises future risk and must be documented.

DSM-5-TR for Clinical: New T/Z Codes, Racism Impact, Suicidal Behavior Codes

ASWB began testing DSM-5-TR in January 2024, and Clinical candidates feel it most. The exam now expects you to know prolonged grief disorder, the new suicidal-behavior and NSSI codes, and — most tested of all — how racism and discrimination shape diagnosis.

This guide covers only what changed, so you can patch your DSM-5 notes instead of relearning everything. Drill it with an ASWB Clinical practice test focused on Assessment and Planning.

What Changed in DSM-5-TR

Change	What it is	How the exam tests it
Prolonged grief disorder added	Persistent intense grief beyond 12 months (adults) with identity disruption, avoidance, intense longing	Differentiate from MDD and adjustment disorder by trigger (death of close person) plus duration
Suicidal behavior T14.91 + Z codes	T14.91 current attempt; Z91.5 personal history of self-harm; R45.851 suicidal ideation	Documentation and risk vignettes — these are codes, not diagnoses
NSSI Z91.5 clarified	Non-suicidal self-injury history code; NSSI disorder remains in Section III	Distinguish NSSI (no intent to die) from attempt by intent, lethality, planning
Racism and discrimination impact statements	Text added across disorders on how oppression shapes presentation and assessment	Vignettes where the correct answer avoids pathologizing adaptive mistrust or grief
Gender and culture language updates	Revised terminology, cultural formulation emphasis	MSE interpretation questions — adjust for culture before diagnosing

T14.91, Z91.5, R45.851: Codes, Not Diagnoses

The single most tested trap: a vignette asks for the diagnosis and lists a T or Z code among the options. Codes describe factors influencing care, not disorders. Pick them only when the question asks what to document or add alongside a diagnosis — for example, MDD with T14.91 after an attempt, or Z91.5 on a returning client with NSSI history to flag risk.

T14.91: suicide attempt, current — use during the encounter when an attempt occurred
Z91.5: personal history of self-harm — history flag, drives safety planning
R45.851: suicidal ideation — symptom code when ideation is the focus of care
Z91.81: personal history of military trauma and other psychosocial risk codes — exam loves these as distractors

Prolonged Grief vs MDD vs Adjustment

Feature	Prolonged grief disorder	Major depression	Adjustment disorder
Trigger	Death of a close person	Any or none	Identifiable stressor within 3 months
Core feeling	Longing, yearning, preoccupation with the deceased	Anhedonia, worthlessness, pervasive low mood	Disproportionate distress or impairment tied to stressor
Duration	12+ months adults, 6+ months children	2+ weeks	Resolves within 6 months of stressor ending
Self-view	Identity disruption tied to loss	Global worthlessness and guilt	Varies, tied to stressor

Exam cue: if grief is the center and the timeline passes 12 months with functional impairment, prolonged grief beats MDD even when depressive symptoms overlap.

How Racism and Discrimination Show Up

Expect at least one vignette where a client's guarded behavior, somatic complaints, or anger reflects lived experience of discrimination rather than pathology. The correct move follows a fixed order:

Apply the cultural formulation — consider identity, stressors, supports, and clinician-client differences before labeling.
Rule out environmental causes — housing, policing, workplace discrimination, immigration stress.
Adjust the MSE — guarded in context is adaptive; flat affect across contexts is clinical.
Diagnose conservatively and document cultural factors influencing presentation.

Wrong answers pathologize first (paranoid traits, oppositional traits) or ignore culture entirely. Right answers name the impact and choose collaboration: ask, validate, adapt.

5-Minute Drill

For each differential you miss this week, write one line: trigger, duration, core feature. Grief needs a death plus 12 months. MDD needs 2 weeks of anhedonia or low mood plus 4 more symptoms. Adjustment needs a stressor within 3 months. NSSI needs no intent to die. Attempt needs intent plus action. That card alone answers most DSM questions on the Clinical exam.

DSM-5-TR for Clinical: New T/Z Codes, Racism Impact, Suicidal Behavior Codes

What Changed in DSM-5-TR

T14.91, Z91.5, R45.851: Codes, Not Diagnoses

Prolonged Grief vs MDD vs Adjustment

How Racism and Discrimination Show Up

5-Minute Drill

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