Regardless of background, training, or theoretical orientation, professional counselors need to have a thorough understanding of the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), published by the American Psychiatric Association (APA; 2013). The DSM-5 and its earlier editions have become the world's standard reference for client evaluation and diagnosis (Eriksen & Kress, 2006; Hinkle, 1999; Zalaquett, Fuerth, Stein, Ivey, & Ivey, 2008). Most important, the manual allows professional counselors to break down the complexity of clients' presenting problems into practical language for practitioners and clients alike. Sometimes referred to as the “the psychiatric bible” (Caplan, 2012; Kutchins & Kirk, 1997; Perry, 2012), the DSM is intended to be applicable in various settings and used by mental health practitioners and researchers of differing backgrounds and orientations.
Because of the prevalent use of the DSM, professional counselors who provide services in mental health centers, psychiatric hospitals, employee assistance programs, detention centers, private practice, or other community settings must be well versed in client conceptualization and diagnostic assessment using the manual. For those in private practice, agencies, and hospitals, a diagnosis using DSM criteria is necessary for third-party payments and for certain types of record keeping and reporting. Of the 50 states and the U.S. territories, including the District of Columbia, that have passed laws to regulate professional counselors, 34 include diagnosis within the scope of practice for professional counselors (American Counseling Association [ACA], 2012). Even professionals who are not traditionally responsible for diagnosis as a part of their counseling services, such as school or career counselors, should understand the DSM so they can recognize diagnostic problems or complaints and participate in discussions and treatment regarding these issues. Although other diagnostic nomenclature systems, such as the World Health Organization's (WHO; 2007) International Statistical Classification of Diseases and Related Health Problems (ICD), are available to professional counselors, the DSM is and will continue to be the most widely used manual within the field. For these reasons, the ability to navigate and use the DSM responsibly has become an important part of a professional counselor's identity.
By definition, counseling is a “professional relationship that empowers diverse individuals, families, and groups to accomplish mental health, wellness, education, and career goals” (ACA, 2013, para. 2). To accomplish this role, practitioners often incorporate diagnosis as one component of the counseling process. Therefore, it is not surprising that ethical guidelines for the profession and accreditation standards for counselor education programs encourage counselors to have an understanding of diagnostic nomenclature. For example, the ACA Code of Ethics (ACA, 2014) Section E.5.a., Proper Diagnosis, requires counselors to “take special care to provide proper diagnosis of mental disorders” (p. 11). The Council for Accreditation of Counseling and Related Educational Programs (CACREP; 2009) requires that counselors learn strategies for collaborating and communicating with other human service providers as part of their common core curricular experiences. Thus, learning outcomes for clinical mental health counselors require demonstrated knowledge regarding the most recent edition of the DSM. Ask any professional counselor and he or she is likely to agree that a thorough understanding of the DSM is an essential aspect of interdisciplinary communication.
Despite widespread guidance encouraging counselors to be familiar with the DSM, utilization of the manual is not without challenges and controversy. Many professional counselors feel unprepared or uncomfortable when faced with the task of assigning clients a diagnosis (Mannarino, Loughran, & Hamilton, 2007). Other professionals are conflicted about the DSM's focus on psychopathology and feel the mechanistic approach reduces “complex information about people into a few words . . . describing a person's parts (symptoms) as static” (Mannarino et al., 2007). As counselors are only too aware, clients cannot be encapsulated into fixed categories. Each client comes to counseling with numerous sociocultural issues that the counselor must consider prior to making a diagnosis and putting together an approach for treatment. This is also particularly important given a large body of research that provides support for the far-reaching impact of poverty and social class on psychological and emotional well-being (e.g., American Psychological Association, 2007; Belle & Doucet, 2003; Groh, 2006). For example, studies of children and adolescents from lower socioeconomic families report higher instances of emotional and conduct problems, including chronic delinquency and early onset of antisocial behavior (McLoyd, 1998). Low income has also been correlated to higher levels of family distress and discord as well as higher rates of parental mental illness.
Finally, many counselors believe the “medicalization” of clients ignores the strengths-based, developmental, wellness approach that is the hallmark of the counseling profession (see Chapter 16 of this Learning Companion for information on the wellness vs. the medical model). The introduction of the DSM-5 adds to this controversy, presenting counselors with a new challenge—the application of a new nomenclature system.
We wrote this Learning Companion to make the DSM-5 accessible to professional counselors by breaking down the complexity of the changes and additions found within the revised manual. Because the CACREP 2009 Standards require that programs “provide an understanding of the nature and needs of persons at all developmental levels and in multicultural contexts, . . . including an understanding of psychopathology and situational and environmental factors that affect both normal and abnormal behavior” (p. 9), we believe it essential that new and seasoned professional counselors, counselor educators, and counseling students have easily accessible and accurate information regarding the DSM-5 and implications of changes for current counseling practice.
To understand changes from the DSM-IV-TR (APA, 2000) to the DSM-5 (APA, 2013), we believe it is important for the reader to first understand the revision process. In the following section, we describe the revision process of the DSM-5 and the role counselors took in its inception. Readers will find a comprehensive description of structural and philosophical changes to the manual, including a history of the manual's iterations, in Chapter 2.
The DSM-5, after 14 years of debate and deliberation, was intended to be the most radical revision to date (Frances & First, 2011; Jones, 2012b; Miller & Levy, 2011). Beginning in 1999, a year before the DSM-IV-TR was published, APA began collaboration with the National Institute of Mental Health (NIMH) on a new edition. The intent of these meetings was to develop a more scientifically based manual that would increase clinical utility while maintaining continuity with previous editions (APA, 2012a). The process began with an initial DSM-5 Research Planning Committee Conference, held in 1999, in which APA and NIMH deliberated on a research agenda and priorities for the new manual. Additional conferences, sponsored by APA, NIMH, and WHO, took place in 2000 and resulted in the formation of six work groups. These initial work groups focused on nomenclature, neuroscience and genetics, developmental issues and diagnosis, personality and relational disorders, mental disorders and disability, and cross-cultural issues. In 2002, a series of six white papers was published with the intent of “providing direction and potential incentives for research that could improve the scientific basis of future classifications” (Kupfer, First, & Regier, 2002, p. xv). Two final manuscripts were published in 2007. One focused on mental disorders in infants, young children, and older persons and the other on gender, cultural, and spiritual issues.
After the release of the initial research agenda for the DSM-5, it became clear that further deliberation was needed with regard to nomenclature, neuroscience, developmental science, personality disorders, and the relationship between culture and psychiatric diagnoses (APA, 2000; Kupfer et al., 2002). Steered by APA, NIMH, and WHO, 13 conferences were held between 2004 and 2008 in which participants discussed relevant diagnostic questions and solicited feedback from colleagues and other professionals regarding potential changes. Findings from these conferences facilitated the research base for proposed revisions for the DSM-5 and fueled the agenda of the DSM-5 work groups (see Kupfer et al., 2002, for the full DSM-5 research agenda).
In 2007, APA officially commissioned the DSM-5 Task Force, made up of 29 members, including David J. Kupfer, MD, chair, and Darrel A. Regier, MD, MPH, vice-chair (APA, 2012a). The DSM-5 Task Force expanded the work groups from six to 13. These included attention-deficit/hyperactivity disorder (ADHD) and disruptive behavior disorders; anxiety, obsessive-compulsive spectrum, posttraumatic, and dissociative disorders; childhood and adolescent disorders; eating disorders; mood disorders; neurocognitive disorders; neurodevelopmental disorders; personality disorders; psychotic disorders; sexual and gender identity disorders; sleep-wake disorders; somatic symptoms disorders; and substance-related disorders. Although each of these work groups investigated specific disorders, cross-collaboration was common. Kupfer and Regier provided clear direction to the work groups to, among other things, eradicate the use of not otherwise specified (NOS) diagnoses within categories, do away with functional impairments as necessary components of diagnostic criteria, and use empirically based evidence to justify diagnostic classes and specifiers (Gever, 2012; Regier, Narrow, Kuhl, & Kupfer, 2009). With these marching orders, each work group proposed draft criteria and changes for the new manual.
Three rounds of public comment regarding proposed changes took place between April 2010 and June 2012. An estimated 13,000 mental health professionals commented on the proposed criteria (APA, 2012c, 2012d). Additionally, mental health professionals conducted field trials to “assess the feasibility, clinical utility, reliability, and (where possible) the validity of the draft criteria and the diagnostic-specific and cross-cutting dimensional measures being suggested for DSM-5” (APA, 2010, p. 1). Two field trial study designs were administered (APA, 2010, 2011b). The first trial, held between April 2010 and December 2011, took place in 11 large academic or medical centers and involved a total of 279 clinicians (APA, 2012b, 2012c). The second trial, which included solo or small group practices, took place between October 2010 and February 2012. APA recruited a volunteer sample of psychiatrists, psychologists, licensed clinical social workers, licensed counselors, licensed marriage and family therapists, and licensed psychiatric mental health nurses to participate in the second field trial (APA, 2012b, 2012c). Feedback from public comment periods and field trials was shared with work group members, who edited proposed criteria as indicated. The final version of the DSM-5 went before the APA Board of Trustees in December 2012 and was released in May 2013. The following outlines the complete timeline of the development of the DSM-5.
Timeline of DSM-5
| 1999–2001 | Development of the DSM-5 research agenda |
| 2002–2007 | APA/WHO/NIMH DSM-5/ICD-11 research planning conferences |
| 2006 | Appointment of DSM-5 Task Force |
| 2007 | Appointment of DSM-5 work groups |
| 2007–2011 | Literature review and data reanalysis |
| 2010–2011 | First phase field trials |
| 2010–2012 | Second phase field trials |
| July 2012 | Final draft of DSM-5 for APA review |
| May 2013 | DSM-5 released to the public |
Although no professional counselor was invited to serve on the DSM-5 Task Force, ACA served as an important advocate for professional counselors during the revision process. Through advocacy efforts of the ACA Professional Affairs Office and the ACA DSM-5 Revisions Task Force, two ACA presidents sent letters to APA indicating concern over proposed changes. The first was sent by Dr. Lynn E. Linde, ACA 2009–2010 president, to Dr. David J. Kupfer, DSM-5 Task Force chair. The letter indicated that ACA members had concerns regarding five areas of particular importance to professional counselors: (a) applicability across all mental health professions, (b) gender and culture, (c) organization of the DSM-5 multiaxial system, (d) lowering of diagnostic thresholds and combining diagnoses, and (e) use of dimensional assessments. The second letter was sent by Dr. Don W. Locke, ACA 2011–2012 president, informing Dr. John Oldham, APA president, that licensed professional counselors were the second largest group to routinely use the DSM-IV-TR. He noted uncertainty among professional counselors about the quality and credibility of the DSM-5 and included a prioritized list of concerns APA should consider before publishing the DSM-5. APA responded to this letter on November 21, 2011 (APA, 2011a).
In addition to feedback provided by ACA, several divisions of the American Psychological Association voiced concern about the writing process of the DSM-5 (Jones, 2012a). As a result, the Society for Humanistic Psychology, Division 32 of the American Psychological Association, sponsored a petition outlining its concerns and inviting other mental health professionals, including counselors, to sign this petition (for a review of these concerns, see British Psychological Society, 2011). It is important to note that nine out of 19 ACA divisions endorsed this petition, including the Association for Adult Development and Aging; Association for Creativity in Counseling; American College Counseling Association; Association for Counselor Education and Supervision; Association for Humanistic Counseling; Association for Lesbian, Gay, Bisexual and Transgender Issues in Counseling; American Rehabilitation Counseling Association; Association for Specialists in Group Work; and Counselors for Social Justice.
Professional counselors are responsible for understanding changes and using the DSM-5 in a manner consistent with the mission of our profession and the ACA Code of Ethics (ACA, 2014). A thorough understanding of the revision process, changes, rationale for changes, and impact of changes will help professional counselors decide how they would like to continue to use the DSM-5 in practice, consider possibilities for future revisions, and ensure advocacy so counselors have a greater voice in the next revision of the DSM.
In Chapter 2 of this Learning Companion, we outline major structural and philosophical changes adopted for the DSM-5, such as the elimination of the multiaxial system. We also outline major diagnostic changes, such as the removal of the bereavement clause from major depressive disorder. In addition, we discuss major changes that influence numerous chapters within the DSM-5, for example, the removal of NOS and the inclusion of other specified and unspecified disorders to replace all NOS diagnoses.
Following Chapter 2, this Learning Companion includes four separate parts, grouped by diagnostic similarity and relevance to the counseling profession. In each of the four parts, we provide a basic description of the diagnostic classification and an overview of the specific disorders covered, highlighting essential features as they relate to the counseling profession. We also provide a comprehensive review of specific changes, when applicable, from the DSM-IV-TR to the DSM-5. When specific or significant changes to a diagnostic category or diagnosis have not been made, we provide a general review of either the category or the diagnosis, but we refrain from providing the reader with too much detail because the purpose of this Learning Companion is to focus on changes from the DSM-IV-TR to the DSM-5. For example, we do not go into great detail about personality disorders, found in Part Four, because the diagnostic criteria for these disorders have not changed. What we do focus on, however, is the proposed model for diagnosing personality disorders that may significantly affect how counselors diagnose personality disorders in future versions of the DSM.
Readers will find, within each part of the book, individual chapters that highlight key concepts of each disorder (including differential diagnoses), new or revised diagnostic criteria, and implications for professional counseling practice. We provide “Notes” to highlight significant information and include case studies to assist counselors in further understanding and applying the new or revised diagnostic categories. All case studies are fictitious composites and do not depict real clients. Any similarity to any person or case is simply coincidental.
Readers should also note that we provide more detail for disorders that counselors are more likely to see in their clients. Therefore, because this Learning Companion is organized in order of diagnoses counselors are most likely to diagnose, each consecutive part of the book provides the reader with less specific detail about each diagnostic grouping. For example, Part One includes a detailed synthesis for key disorders, including cultural considerations, differential diagnosis, and special considerations for counselors. We have also included a description of other specified and unspecified diagnoses for each diagnostic class. Conversely, Part Three provides less detail about neurodevelopmental disorders because these diagnoses are typically made by other professionals.
Part One, Changes and Implications Involving Mood, Anxiety, and Stressor-Related Concerns, includes chapters regarding depressive disorders, bipolar and related disorders, anxiety disorders, obsessive-compulsive and related disorders, trauma- and stressor-related disorders, and gender dysphoria. We listed this section first because these disorders, both within and outside of the counseling profession, are some of the highest reported mental disturbances within the United States (Centers for Disease Control and Prevention [CDC], 2011). Readers will note that this is the only section in which other specified and unspecified diagnoses are listed.
Part Two, Changes and Implications Involving Addictive, Impulse-Control, and Specific Behavior-Related Concerns, includes chapters focused on behavioral diagnoses such as substance use and addiction disorders; impulse-control and conduct disorders; and specific behavioral disruptions consisting of feeding and eating, elimination, sleep-wake, sexual dysfunction, and paraphilic disorders. Similar to the disorders found in Part One, counselors are often exposed to the disorders listed in Part Two within clinical practice, but these disorders frequently manifest through more visible, external behavioral concerns rather than less visible, internal experiences (i.e., depression vs. sexual dysfunction). Moreover, counselors may or may not diagnose these disorders. This is not to say that counselors do not frequently diagnose substance use disorders. However, compared with depression and anxiety disorders, substance use disorders are more often diagnosed by a combination of counselors and other health professionals.
Part Three, Changes and Implications Involving Diagnoses Commonly Made by Other Professionals, includes chapters focused on neurodevelopmental, schizophrenia spectrum, and other psychotic, dissociative, neurocognitive, and somatic disorders. Many of these disorders, specifically neurodevelopmental and somatic issues, require highly specialized assessment or extensive medical examination by physicians or other qualified medical professionals. These chapters focus on helping professional counselors understand major changes and the potential impact of these changes on the clients counselors serve. We do not provide a detailed description of each disorder in this chapter; rather, we address major changes, if applicable, and considerations for counselors.
Part Four, Future Changes and Practice Implications for Counselors, addresses future changes to the DSM as well as clinical issues related to professional counseling. Whereas all parts of the book focus on professional counselors, this part highlights clinical utility of the DSM-5 as well as future changes that may affect the counseling profession. For example, Chapter 16 addresses the personality disorders section of the DSM-5. Although personality disorders did not change from the DSM-IV-TR to the DSM-5, proposed changes were included in Section III of the DSM-5. If these changes were implemented, they would significantly alter the way counselors diagnose and treat clients with these disorders.
Chapter 17 addresses issues such as the diagnostic interview, the nonaxial system, cultural inclusion, and assessment instruments such as the WHO Disability Assessment Schedule (Version 2.0; WHO, 2010). This chapter also contains information regarding diagnostic coding and changes counselors can expect with the October 2014 revision to the ICD-10-Clinical Modification (ICD-10-CM; CDC, 2014) coding required for Health Insurance Portability and Accountability Act of 1996 (HIPAA) purposes. We also explore ways in which counselors can continue to be an active part of future revisions of diagnostic nomenclature systems.