Gender can inﬂuence illness in a variety of ways. First, it may exclusively determine whether an individual is at risk for a disorder (e.g., as in premenstrual dysphoric disor- der). Second, gender may moderate the overall risk for development of a disorder as shown by marked gender differences in the prevalence and incidence rates for selected mental disorders. Third, gender may inﬂuence the likelihood that particular symptoms of a disorder are experienced by an individual. Attention-deficit/hyperactivity disorder is an example of a disorder with differences in presentation that are most commonly expe- rienced by boys or girls. Gender likely has other effects on the experience of a disorder that are indirectly relevant to psychiatric diagnosis. It may be that certain symptoms are more readily endorsed by men or women, and that this contributes to differences in service pro- vision (e.g., women may be more likely to recognize a depressive, bipolar, or anxiety dis- order and endorse a more comprehensive list of symptoms than men).
Reproductive life cycle events, including estrogen variations, also contribute to gender differences in risk and expression of illness. Thus, a specifier for postpartum onset of mania for the onset of an illness episode. In the case of sleep and energy, alterations are often nor- mative postpartum and thus may have lower diagnostic reliability in postpartum women.
The manual is configured to include information on gender at multiple levels. If there are gender-specific symptoms, they have been added to the diagnostic criteria. A gender- related specifier, such as perinatal onset of a mood episode, provides additional informa- tion on gender and diagnosis. Finally, other issues that are pertinent to diagnosis and gen- der considerations can be found in the section ”Gender-Related Diagnostic Issues.”
Use of Other Specified and Unspecified Disorders
To enhance diagnostic specificity, DSM-5 replaces the previous NOS designation with two options for clinical use: other specified disorder and unspecified disorder. The other specified disorder category is provided to allow the clinician to communicate the specific reason that the presentation does not meet the criteria for any specific category within a diagnos- tic class. This is done by recording the name of the category, followed by the specific rea- son. For example, for an individual with clinically significant depressive symptoms lasting 4 weeks but whose symptomatology falls short of the diagnostic threshold for a major depressive episode, the clinician would record ”other specified depressive disorder, depressive episode with insufficient symptoms." If the clinician chooses not to specify the reason that the criteria are not met for a specific disorder, then ”unspecified depressive disorder” would be diagnosed. Note that the differentiation between other specified and unspecified disorders is based on the clinician’s decision, providing maximum ﬂexibility for diagnosis. Clinicians do not have to differentiate between other specified and unspec- ified disorders based on some feature of the presentation itself. When the clinician deter- mines that there is evidence to specify the nature of the clinical presentation, the other specified diagnosis can be given. When the clinician is not able to further specify and de- scribe the clinical presentation, the unspecified diagnosis can be given. This is left entirely up to clinical judgment.
For a more detailed discussion of how to use other specified and unspecified designa- tions, see ”Use of the Manual" in Section I.
The Multiaxial System
Despite widespread use and its adoption by certain insurance and governmental agencies, the multiaxial system in DSM-IV was not required to make a mental disorder diagnosis. A nonaxial assessment system was also included that simply listed the appropriate Axis I, II, and III disorders and conditions without axial designations. DSM-S has moved to a nonax- ial documentation of diagnosis (formerly Axes I, II, and III), with separate notations for