Moral, Religious, or Spiritual Problem: An Expanded Z Code Diagnostic Category in the DSM-5-TR

The DSM has made advances in helping clinicians address cultural factors important in psychiatric care, including the acknowledgement of religious and spiritual problems that impact a patient's mental health. However, moral problems have been under-recognized as a culturally contextualized source of negative consequences for occupational, social, and other areas of functioning.

To recognize the clinical significance of moral problems, an expanded DSM Z-code diagnostic category entitled "Moral, Religious, or Spiritual Problem" was recently approved.

In light of this development, this paper reviews the conceptual and empirical connections with regard to moral, religious, and spiritual problems. A definition of moral problems is presented in relationship to transgressions of an individual's moral identity, which may include moral dilemmas, moral distress, and moral injury.

Various differential diagnostic issues are raised related to this expanded Z-code, as well as potential implications for clinical practice, public health, and future research.