Chapter 2
Structural, Philisophical, and Major Diagnostic Changes

In this chapter, we highlight major structural modifications of the DSM-5 (APA, 2013), including removal of the multiaxial system and changes to chapter order; philosophical changes, such as the proposed use of dimensional and new cross-cutting assessments; and major diagnostic changes from the DSM-IV-TR to the DSM-5. To help readers better understand the revision process and the philosophy behind it, we begin with a brief description of the historical background and evolution of the DSM.

History of the DSM

The original DSM, published by the APA in 1952, was psychiatry's first attempt to standardize the classification of mental disorders. Developed by the APA Committee on Nomenclature and Statistics, the DSM-I (APA, 1952) served as an alternative to the sixth edition of the ICD (WHO, 1949), which, for the first time, included a section for mental disorders (APA, 2000). Differing slightly from the ICD, which primarily served as an international system to collect health statistics, the DSM-I focused on clinical utility and was grounded in psychodynamic formulations of mental disorders (Sanders, 2011). This version highlighted prominent psychiatrist Adolf Meyer's (1866–1950) psychobiological view, which posited that mental disorders denoted “reactions” of the personality to biological, psychological, or social aspects of client functioning (APA, 2000). The DSM-I included three categories of psychopathology (organic brain syndromes, functional disorders, and mental deficiency) and 106 narrative descriptions of disorders in about as many pages. Only one diagnosis, adjustment reaction of childhood/adolescence, was applicable to children (Sanders, 2011).

Meyer's influence was abandoned in the initial revision of the DSM-II published in 1968. This version contained 11 categories and 182 disorders (APA, 1968). Similar to the previous version, the development of the DSM-II coincided with the development of the WHO's (1968) revised ICD-8. Although only incremental changes were evident, the focus of the manual shifted from causality to psychoanalysis, as evidenced by the removal of the word reactions and retention of terms such as neuroses and psychophysiologic disorders (Sanders, 2011). With the intent on reform, this shift was significant because separation meant removing unverified or speculative diagnoses from the manual. Critics, however, argued that actual separation of diagnostic labels from etiological origins would not actually occur until the next revision (Rogler, 1997).

Work on the third version, DSM-III, began in 1974 and continued until the edition was published in 1980. A considerable divergence from previous editions, the DSM-III represented a dramatic shift with inclusion of descriptive diagnoses and emphasis on the medical model (APA, 1980; Wilson, 1993). This profound reframing introduced a biopsychosocial model to diagnostic assessment with an emphasis on empirical evidence that represented a clear follow-through on previous attempts to separate the DSM from psychoanalytic origins. Supporters claimed “theoretical neutrality” of the DSM-III (Maser, Kaelber, & Weise, 1991, p. 271). As Rogler (1997) argued, “The DSM-III was an official attempt to abruptly, not gradually, reduce reliance on the vagaries of the diagnosticians' subjective understandings by specifying sets of diagnostic criteria” (p. 9).

With the publication of the DSM-III, mental health professionals repositioned themselves toward positivistic, operationally defined symptomatology based on specific descriptive measures (Wilson, 1993). This modification included the introduction of explicit diagnostic criteria (i.e., a checklist) as opposed to narrative descriptions. The DSM-III also introduced the multiaxial system and diagnostic classifications free from specific theoretical confines or etiological assumptions. This version integrated demographic information such as gender, familial patterns, and cultural features into diagnostic classifications (Sanders, 2011). On the basis of these philosophical changes, professional counselors began to emphasize the structured interview and insisted on empirically validating DSM-III diagnostic criteria. The age of empirically based treatments had arrived, and widespread use of the DSM-III, as opposed to the ICD-9 (WHO, 1975), became commonplace. Wilson (1993) wrote,

The biopsychosocial model [alone] did not clearly demarcate the mentally well from the mentally ill, and this failure led to a crisis in the legitimacy of psychiatry by the 1970s. The publication of DSM-III in 1980 represented an answer to this crisis, as the essential focus of psychiatric knowledge shifted from the clinically-based biopsychosocial model to a research-based medical model. (p. 399)

Intended only to be a minor change to the third version, the revised DSM-III-R (APA, 1987) renamed, added, and deleted categories; made changes to diagnostic criteria; and increased reliability by incorporating data from field trials and diagnostic interviews (APA, 2000; Blashfield, 1998; Scotti & Morris, 2000). Despite these innovations, the DSM-III and DSM-III-R were profoundly criticized. The manual had increased from 106 to 297 diagnoses (APA, 1987). Descriptions of Axis I disorders topped at 300 pages whereas explanations of Axis IV and V disorders totaled only two pages, leading many to question the multiaxial system (Rogler, 1997). Additionally, critics questioned field trials and claimed lack of objectivity among researchers, further contributing to strong criticism of the DSM-III and DSM-III-R.

Heavy critique of the DSM-III and its revision led to relatively mild changes to the DSM-IV, published in 1994. Despite few changes, the revision process was considerable and involved a steering committee, 13 work groups, work group advisors, extensive literature reviews, and numerous field trials to ensure clinical utility. The DSM-IV (APA, 1994) included 365 diagnoses; and at 886 pages, it was almost 7 times the length of the DSM-I. A “text revision” (DSM-IV-TR) was published in 2000 and included additional empirically based information for each diagnosis as well as changes to diagnostic codes for the purpose of maintaining consistency with the ICD (APA, 2000). In the DSM-IV-TR (APA, 2000), wording of the manual was modified in an attempt to differentiate people from their diagnoses. For example, phrases such as “a schizophrenic” were modified to read “an individual with schizophrenia” (Scotti & Morris, 2000).

Like their predecessors, the DSM-IV and DSM-IV-TR were heavily critiqued by helping professionals (Eriksen & Kress, 2006). Many felt the manual leaned too heavily on the medical model with its rigid classification system, despite claims of diagnostic neutrality (Eriksen & Kress, 2006; Ivey & Ivey, 1998; Scotti & Morris, 2000). Issues of comorbidity, questionable reliability, and controversial diagnoses were hot topics among critics; the multiaxial system continued to be controversial (Houts, 2002; Malik & Beutler, 2002). Because of the changing nature of how the DSM was being used and by whom, many practitioners began demanding that a more holistic or dimensional approach be used and that psychometrically sound assessments be included (Kraemer, 2007). Other critics, specifically those directly involved in writing the DSM-5, advocated for incorporating scientific advances from psychiatric research, genetics, neuroimaging, cognitive science, and pathophysiology (functional changes associated with or resulting from disease or injury) into diagnostic nosology (Kupfer & Regier, 2011).

Some counselors, in particular, believed that overreliance on DSM diagnoses can “narrow a counselor's focus by encouraging the counselor to only look for behaviors that fit within a medical-model understanding of the person's situation” (Eriksen & Kress, 2006, p. 204). In contrast to those who support the medical model, many counselors use diagnosis as only one aspect of understanding the client. Most counselors view individuals as having strengths and difficulties across myriad emotional, cognitive, physiological, social, occupational, cultural, and spiritual areas. Counselors recognize the whole person and nurture a strength-based approach to achieve wellness, not simply reduce symptomatology. Myers, Sweeney, and Witmer (2000) defined wellness as

A way of life oriented toward optimal health and well-being, in which body, mind, and spirit are integrated by the individual to live life more fully within the human and natural community. Ideally, it is the optimum state of health and well-being that each individual is capable of achieving. (p. 252)

The controversial issues of rigid classification, comorbidity, questionable reliability, and controversial diagnoses were the driving force of numerous structural and philosophical changes included in the DSM-5. Information regarding these major changes is provided in the next section.

DSM-5 Structural Changes

The DSM-5 includes approximately the same number of disorders as the DSM-IV-TR. This goes against a popular trend within health care to increase, rather than decrease, the number of diagnoses available to practitioners (APA, 2013). Despite being similar in number, several major changes affect the manual as a whole. Unlike the previous version that was organized by 16 diagnostic classes, one general section, and 11 appendixes, the DSM-5 is divided into three sections, 20 diagnostic classes, two general sections for medication-induced problems and other conditions that may be a focus of clinical attention, and seven appendixes. It also lists two sets of ICD codes, using ICD-9-CM (CDC, 1998) codes as the standard coding system with ICD-10-CM (CDC, 2014) codes in parentheses. ICD-10-CM codes are included because as of October 1, 2014, all practitioners must be in alignment with HIPAA, which requires use of ICD-10-CM codes. For more information, Part Four of this Learning Companion comprehensively reviews how diagnostic coding systems will change and implications of these modifications for counselors.

Section Overview

Section I of the DSM-5 provides a summary of revisions and changes as well as information regarding utilization of the revised manual. Section II includes all diagnoses broken into 20 separate chapters ordered by similarity to one another. Because comorbid symptoms are clustered together, counselors can now better differentiate between disorders that are distinctively different but have similar symptom characteristics or etiology (e.g., body dysmorphic disorder vs. obsessive-compulsive disorder; acute stress disorder vs. adjustment disorder). Section III includes conditions that require further research before they can be considered for adoption in an upcoming version of the DSM, dimensional assessment measures, an expanded look at how practitioners can better understand clients from a multicultural perspective, and a proposed model for diagnosing personality disorders.

Cultural Inclusion

Section III (see pp. 749–759 of the DSM-5) includes special attention to diverse ways in which individuals in different cultural groups can experience and describe distress. The manual provides a Cultural Formulation Interview (pp. 750–757 of the DSM-5) to help clinicians gather relevant cultural information. Expanding on information provided in the DSM-IV-TR, the Cultural Formulation Interview calls for clinicians to outline and systematically assess cultural identity, cultural conceptualization of distress, psychosocial stressors related to cultural features of vulnerability and resilience, cultural differences between the counselor and client, and cultural factors relevant to help seeking. The DSM-5 also includes descriptions regarding how different cultural groups encounter, identify with, and convey feelings of distress by breaking up what was formerly known as culture-bound syndromes into three different concepts. The first concept is cultural syndromes, a cluster of co-occurring symptomatology within a specific cultural group. The second is cultural idioms of distress, linguistic terms or phrases used to convey suffering within a specific cultural group. The third concept is cultural explanation or perceived cause, mental disorders unique to certain cultures that serve as the reason for symptoms, illness, or distress. This breakdown improves clinical utility by helping clinicians more accurately communicate with clients, so that they are able to differentiate disorders from nondisorders when working with clients from varied backgrounds.

Personality Disorders

Section III of the DSM-5 also provides an alternative model for diagnosing personality disorders. This model is a radical change from the current diagnostic structure, introducing a hybrid dimensional-categorical model, which evaluates symptomatology and characterizes five broad areas of personality pathology. As opposed to separate diagnostic criteria, this proposed model identifies six personality types with a specific pattern of impairments and traits. We review this model and the Cultural Formulation section in Part Four of this Learning Companion.

Adoption of a Nonaxial System

One of the most far-reaching structural modifications to the DSM-5 is the removal of the multiaxial system and discontinuation of the Global Assessment of Functioning (GAF) scale. Table 2.1 includes a comparison of the traditional multiaxial and the new nonaxial system. Axes I, II, and III are now combined with the assumption that there is no differentiation between medical and mental health conditions. Rather than list psychosocial and contextual factors affecting clients on Axis IV, counselors will now list V codes or 900 codes (used for conditions related to neglect, sexual abuse, physical abuse, and psychological abuse) as stand-alone diagnoses or alongside another diagnosis as long as the stressors are relevant to the client's mental disorder(s). An expanded listing of V codes is included in the DSM-5. Although the DSM-5 does not include direction for formatting, counselors may also use special notations for psychosocial and environmental considerations relevant to the diagnosis. Similarly, counselors will no longer note a GAF score on Axis V. Rather, the DSM-5 advises that clinicians find ways to note distress and/or disability in functioning, perhaps using the World Health Organization Disability Assessment Schedule 2.0 (WHODAS 2.0; WHO, 2010) as a dimensional assessment of functioning. Again, the manual does not include directions for formatting or presenting this assessment.

Table 2.1 Comparison of Multiaxial Versus Nonaxial Systems

DSM-III and DSM-IV Multiaxial System DSM-5 Nonaxial System
Axis I: Clinical disorders and other conditions that are the focus of treatment Combined attention to clinical disorders, including personality disorders and intellectual disability (i.e., mental retardation); other conditions that are the focus of treatment; and medical conditions continue to be listed as a part of the diagnosis.
Axis II: Personality disorders and intellectual disability (i.e., mental retardation)
Axis III: General medical conditions
Axis IV: Psychosocial and environmental stressors Special notations for psychosocial and contextual factors are now listed by using V codes or ICD-10-CM Z codes. An expanded list of V codes has been provided in the DSM-5. In rare cases where psychosocial and contextual factors are not listed, counselors can include the specific factor as it is related to the client's diagnosis.
Axis V: Global Assessment of Functioning (GAF) Special notations for disability are listed by using V codes or ICD-10-CM Z codes. The World Health Organization Disability Assessment Schedule 2.0 (WHODAS 2.0) has been included in Section III and is listed on APA's website (www.psychiatry.org) within the online assessment measures section.

Note

Counselors are not qualified to diagnose medical conditions. However, it is important to record all historical medical information. Counselors must work closely with medical professionals to identify any medical conditions.

Once ICD-10-CM is implemented (October 2014), all codes in the Other Conditions That May Be a Focus of Clinical Attention chapter of the DSM-5 will change. Z codes will replace V codes, and T codes will replace 900 codes. The only exception is V62.89 borderline intellectual functioning, in which the ICD-10-CM code is R41.83. (See APA, 2013, pp. 715–727.)

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The advantage to dropping the multiaxial system confirms what counselors from a wellness perspective have been claiming for decades—that differentiation among emotional, behavioral, physiological, psychosocial, and contextual factors is misleading and conveys a message that mental illness is unrelated to physical, biological, and medical problems. Combining these axes has the potential to be more inclusive, embracing more aspects of client functioning. However, practitioners will need to be intentional and systematic when incorporating more holistic assessments and notations into the diagnostic process so that their diagnoses do not become a simple listing of primary DSM-5 disorders.

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The DSM-5 has dropped the GAF scale because of a lack of clinical utility and reliability. The WHODAS 2.0 (WHO, 2010) has been included in Section III of the manual. This scale is used in the ICD as a standardized assessment of functioning for individuals diagnosed with mental disorders. The DSM-5 notes, however, that “it has not been possible to completely separate normal and pathological symptom expressions contained in diagnostic criteria” (APA, 2013, p. 21). Counselors who use the WHODAS 2.0 are responsible for ensuring they do so in accordance with the ACA Code of Ethics (ACA, 2014); this includes ensuring appropriateness of instruments through review of psychometric properties, appropriateness for client population, and appropriate use of interpretation. This is particularly important because the DSM-5 does not include information regarding the validity or reliability of the WHODAS 2.0.

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Critics of the multiaxial system argued that the system is cumbersome and ambiguous, thus providing poor clinical utility (Bassett & Beiser, 1991; Jampala, Sierles, & Taylor, 1986; Paris, 2013). Furthermore, many clinicians will agree that although the multiaxial system was well intentioned, client reports typically stopped at Axis I. In cases where Axis II was listed, some clients would feel stigmatized by their diagnostic label (Aviram, Brodsky, & Stanley, 2006; Fritz, 2012). Enhanced attention to V codes within the nonaxial system may also help counselors emphasize a client's entire worldview and systemic context in a way that informs the therapeutic process. If used intentionally, movement to a nonaxial system may help increase client understanding, remind counselors that medical and psychosocial issues are just as important as mental health diagnoses, and reduce stigma.

Challenges of moving to a nonaxial system include conceptual lack of clarity regarding how clinicians are going to implement the nonaxial system. If clinicians struggled to use holistic assessment within a multiaxial system that essentially required some attention to psychosocial and environmental issues and overall distress and disability, will they actually take the time to incorporate these elements into a more ambiguous format? We anticipate problems with interpretation, specifically regarding the combination of Axes I, II, and III, within the counseling profession and among interdisciplinary teams. Although counselors can include subjective descriptors next to the client's diagnosis, there is no telling whether these will carry over to the next clinician or if they will make sense to a different party. Other challenges include delays as insurance companies and governmental agencies update their claim forms and reporting procedures to accommodate DSM-5 changes. Major challenges for both counselors and clients are to be expected as helping professionals, insurance and service providers, and public or private institutions move toward nonaxial documentation of diagnosis.

With these new changes, diagnoses will be cited listing the primary diagnosis first, followed by all psychosocial, contextual, and disability factors. For example, a client presents with depressive symptoms during withdrawal of a severe cocaine use disorder. She has just revealed that she is being sexually abused by her husband who just kicked her out of her home. This client would receive a diagnosis of 292.84 cocaine-induced depressive disorder, with onset during withdrawal. An additional diagnosis of 304.20 severe cocaine use disorder would also be recorded, as well as 995.83 spouse violence, sexual, suspected, initial encounter and V60.0 homelessness. Any subsequent notations related to a mental health diagnosis would follow. More information regarding recording diagnoses can be found in Chapter 17 of this Learning Companion.

Chapter Organization

Overall organization of chapters within the DSM changed significantly to reflect a developmental approach to listing diagnoses. Diagnoses are now ordered in terms of similar symptomatology with presumed underlying vulnerabilities grouped together. This organization is indicative of the life-span (i.e., developmental) approach taken by the DSM-5 Task Force. Readers will notice that disorders more frequently diagnosed in childhood, such as intellectual and learning disabilities, are renamed as neurodevelopmental disorders and appear at the beginning of the manual. Diagnoses more commonly seen in older adults, such as neurocognitive disorders, appear at the end of the DSM-5. This modification more closely follows the ICD and was intended to increase practitioners' use of the manual for differential diagnosis.

Other structural changes include significant modifications to overall classification of disorders. The mood disorders section has been separated into two distinct classes: depressive disorders and bipolar and related disorders. Anxiety disorders have been broken out into three separate diagnostic chapters: anxiety disorders, obsessive-compulsive and related disorders, and trauma- and stressor-related disorders. In another large structural and philosophical change, the DSM-5 eliminated disorders usually diagnosed in infancy, childhood, or adolescence. Disorders within this section were incorporated into a new neurodevelopmental disorders chapter or, if not presumed to be neurodevelopmental in nature, relocated to other specific sections of the DSM-5. The DSM-5 Task Force justified this change because many of the disorders in this section are also seen in adulthood (e.g., ADHD; Jones, 2013), and many disorders seen in childhood may be precursors to concerns in adulthood. This section, originally created for convenience, led clinicians to erroneously believe there was a clear distinction between “adult” and “childhood” disorders. Critics felt this division was confusing and prevented clinicians from diagnosing children with “adult” disorders such as major depression or posttraumatic stress disorder (PTSD). Likewise, adults diagnosed with disorders such as ADHD have reported feeling stigmatized with limited treatment options (Katragadda & Schubiner, 2007). In terms of structure, diagnoses that were removed from this section, such as childhood feeding and eating disorders, can now be found within their associated sections, just later in the manual. For example, the feeding and eating disorders section of the DSM-5 now includes pica and rumination.

Other comprehensive structural changes include the removal of labeling disorders as not otherwise specified (NOS) so practitioners can be more specific and accurate in their diagnosis. As a replacement, the DSM-5 has two options for cases in which the client's presenting condition does not meet the criteria for a specific category: other specified disorder and unspecified disorder. The use of other specified disorder allows counselors to identify the specific reason why the client does not meet the criteria for a disorder. Unspecified disorder is used when a clinician chooses not to specify a reason for not diagnosing a more specific disorder or determines there is not enough information to be more specific. This is also supportive of dimensional, rather than categorical, classification (this idea is expanded on in the next section, DSM-5 Philosophical Changes). Finally, language throughout the DSM-5 changed so that medical conditions, previously referred to as general medical conditions, are renamed another medical condition. This change reflects the philosophical assumption that mental health disorders are medical conditions.

Note

Clinical judgment is the driving force for whether the client's presenting condition should be “other specified” or “unspecified.” APA is very clear in that the use of either is the decision of the clinician.

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Readers will also note that the DSM-5 includes both ICD-9-CM and ICD-10-CM codes. This inclusion is a response to a mandate from the U.S. Department of Health and Human Services that required all health care providers to use IDC-10-CM codes by October 2014. To ease this transition, the DSM-5 lists both code numbers in the Appendix section. This will aid in standardization among mental health care providers and will also allow for easier transition to the new ICD-10-CM codes and revised billing processes.

The following list is a summary of the major structural changes in the DSM-5:

  • removal of the multiaxial system;
  • modification to chapter order to reflect a developmental approach;
  • division into three sections: Section I: DSM-5 Basics; Section II: Diagnostic Criteria and Codes; and Section III: Emerging Measures and Models;
  • replacement of the first diagnostic chapter of the DSM-IV-TR, Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence, with a new Neurodevelopmental Disorders chapter;
  • inclusion of both ICD-9-CM and ICD-10-CM codes;
  • modifications to the classification of disorders: Bipolar and related disorders and depressive disorders are now stand-alone chapters; anxiety disorders was separated into three distinct categories (anxiety disorders, obsessive-compulsive and related disorders, and trauma- and stressor-related disorders); and
  • removal of NOS and inclusion of other specified and unspecified disorders.

Note

Whereas ICD code numbers were originally created for statistical tracking of diseases, not reimbursement, most medical systems within the United States use these codes for billing purposes. The DSM-III was coordinated with the development of the ICD-9. Other versions of the DSM continued to use the ICD-9 codes, despite that fact that the ICD-10 was first published in 1992.

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DSM-5 Philosophical Changes

Two philosophical changes, spearheaded by the DSM-5 Task Force, have modified the way in which counselors will approach diagnosis when using the DSM-5. The first philosophical change involves a shift in focus from phenomenological interpretations (i.e., symptom identification and behavioral observations—a medical model) to identifiable pathophysiological origins (i.e., functional changes associated with or resulting from disease or injury—a biological model). The second philosophical change involves the use of dimensions as opposed to diagnostic categories. Although these two changes are theoretically similar, each philosophy has a unique impact on the way in which counselors approach diagnosis, treatment planning, and interdisciplinary communication.

Regarding the first shift, the DSM-5 Task Force decided that using a bioecological perspective, as opposed to identifying symptomatology, was a more empirically sound way to approach diagnostic classifications (Kupfer & Regier, 2011). Neurobiologists believe that problems with growth and development of the brain or central nervous system adversely affect behavioral patterns, learning, and social interactions. Officially included in the DSM-5 Research Agenda (Kupfer, First, & Regier, 2002), the idea that disorders should be grouped by underlying neurobiological similarities rather than phenomenological observations (i.e., criteria) is not a new one (Kupfer & Regier, 2011). Supporters of a pathophysiologic (i.e., biological) approach to mental illness emphasize findings from genetics, neuroimaging, cognitive science, and pathophysiology need to drive psychiatric diagnosis. Followers claim the overuse of NOS diagnoses and problems with comorbidity as key indicators that previous versions of the DSM relied too heavily on “psychodynamic, a priori hypotheses” rather than “external, empirical indicators” (Kupfer & Regier, 2011, p. 672). Kupfer and Regier, respectively the chair and vice-chair of the DSM-5 Task Force, even proposed “keeping the DSM as a ‘living document' that can be readily updated to reflect changes in our understanding of neuroscience and pathophysiology in a world of (sometimes) rapid and dramatic neuroscience discovery” (Kupfer & Regier, 2011, p. 674).

The impact of this philosophical shift on the current DSM is not as significant as proponents would have hoped. With regard to grouping disorders by underlying pathophysiological similarities, Kupfer and Regier (2011) stated,

We realized from our Research Agenda conference series that we would not be able to accomplish by the DSM-5's deadline all of the things we set out to and, in fact, that portions of that agenda related to advances in neurosciences were already being addressed in other arenas . . . [which] will be very informative for subsequent versions: DSM-5.1, DSM-5.2, and beyond. (p. 673)

Although not as significant as some would have liked, this movement has affected the current DSM and will most certainly have an impact on future iterations of the manual. First, the way in which disorders are grouped, as previously mentioned, has changed. By listing diagnoses in terms of clinical expressions across the life span, the DSM-5 Task Force highlighted neurodevelopmental disorders such as autism and ADHD as having biological origins. This movement led the task force to eliminate the first section because they felt using a bioecological perspective to focus on the first 2 decades of life, when rapid changes in behavior, emotion, and cognition occur, was more empirically sound. Although critics claim that removal of disorders usually diagnosed in infancy, childhood, or adolescence points too heavily to a biological basis of behavior and deemphasizes sociocultural variations, this position is in alignment with the pathophysiologic movement adopted by the DSM-5 Task Force.

Within the narrative sections of the DSM-5, readers will notice inclusion of neurobiologic findings, such as genetic and physiologic risk factors, and life-span development and course alongside diagnostic criteria. Proponents claim this biological and life-span information, in conjunction with current criteria, will allow practitioners to better understand the role of genetic and physiologic risk factors, prognostic indicators, and biologic markers in shaping client risk and prognosis.

The DSM-5 Task Force did not fully accept or wholly incorporate classification of all mental illness from a neurodevelopmental and biological perspective. However, even the slightest movement toward adoption of this philosophy has had a significant impact on the current manual, as evidenced by the changes just described. Moreover, this movement has fueled another philosophical shift: recognition that categorical systems found within the DSM-IV-TR should be supplemented with dimensional models of assessment.

Although professional counselors may find themselves flipping through the DSM-5 in search of reorganized diagnoses, we suspect they may be most affected by the shift from categorical to dimensional assessment. The philosophical change and resulting implications are addressed throughout the remainder of this chapter. We begin the discussion with a historical overview of categorical and dimensional assessment along with explanation of philosophical challenges of dimensional assessment; we conclude by explaining dimensional assessments within the DSM-5.

From Categorical to Dimensional Assessment

In the 1960s and 1970s, scholars criticized psychiatric diagnosis for lack of diagnostic reliability, meaning there was little diagnostic agreement among helping professionals who evaluated the same individual (Spitzer & Fleiss, 1974). Revisions to the DSM, beginning with the DSM-III, provided practitioners and researchers with a more reliable common language for diagnostic criteria (Scotti & Morris, 2000). Rather than providing only narrative descriptions regarding manifestation of disorders, the DSM-III and DSM-IV included discrete clinical criteria that, when considered together, allowed professionals to identify the presence or absence of a disorder (APA, 2000; Jones, 2012a; Scotti & Morris, 2000). This system was intended to help users better understand complex and obscure phenomena of mental illness. In turn, creators of the system assumed a categorical approach would help mental health professionals find a common language for treatment, select empirically based interventions, calculate course and prognosis, and differentiate between clients who present with a mental health disorder and those who do not (First, 2010; Jones, 2012b). This philosophical shift resulted in etiologically based treatment options that integrated seemingly varied symptoms into a particular diagnosis (Millon, 1991). Even researchers were affected, as the DSM now serves as an important foundation for research conceptualization.

Several professionals have applauded modifications to this categorical classification system for allowing clinicians to plan treatments tailored to the special needs of the client (Bedell, Hunter, & Corrigan, 1997; Millon, 1991; Widiger & Frances, 1985). Categorical diagnoses have also assisted with accountability and record keeping, treatment planning, communication between helping professionals, and identification of clients with issues beyond one's areas of expertise (Hinkle, 1999). These revisions have been praised for including more empirically based criteria, thus allowing for what was assumed to be a more scientifically sound classification system (Maser et al., 1991). Although the categorical system was a vast improvement over the descriptive categories of DSM-I and DSM-II, the categorical approach poses several important limitations that DSM-5 Task Force members attempted to address.

Challenges to the Categorical Philosophy

Categorical diagnosis assumes that all individuals diagnosed with a given disorder have similar symptoms and attributes (First, 2010; Jones, 2012a). This system also presumes that mental disorders have little variation, that populations are relatively homogeneous, and that diagnoses are objective, discrete phenomena. However, the absoluteness of this yes/no approach has caused significant problems in terms of clinical utility among researchers and clinicians (Brown & Barlow, 2005; Demjaha et al., 2009; First, 2010). Critics of the categorical system point to significant limitations in terms of diagnostic agreement and dispute the assumption that there is a clear-cut line between having and not having a mental disorder (Kraemer, Noda, & O'Hara, 2004). Overuse of NOS diagnoses is sufficient evidence that the line between diagnosis and no diagnosis is not as clear as practitioners would like it to be. Specifically among counselors, there is excessive use of the NOS specifier when clients face significant distress or impairment but do not meet all criteria for a given disorder (Jones, 2012a).

Other problems with categorical diagnosis include disproportionate comorbidity among disorders and disputes regarding psychological constructs. For example, epidemiologic researchers argue that comorbidity between depressive and anxiety disorders is aberrantly high (Kessler et al., 1996; Mineka, Watson, & Clark, 1998). Magee, Eaton, Wittchen, McGonagle, and Kessler (1996) reported agoraphobia, simple phobia, and social phobia to be highly comorbid. Researchers also found that individuals with coexisting disorders experience more severe symptomatology. Diagnostic concurrence has also been identified between substance abuse and mood, anxiety, somatoform, personality, and eating disorders (Andrews, Slade, & Issakidis, 2002; Mineka et al., 1998; Subica, Claypoole, & Wylie, 2011; Widiger & Coker, 2003). In response to these findings, Jones (2012b) claimed, “It seems that diagnostic comorbidity is more the norm rather than the exception” (p. 482). Because the limitations of a purely categorical approach are widely documented, APA introduced dimensional assessments within the DSM-5.

Dimensional Assessments in the DSM-5

The DSM-5 has proposed specific assessment tools to help mental health professionals diagnose disorders. This philosophy, seen throughout the manual, moves beyond categorical description and considers etiological, biological, and behavioral dimensions of psychopathology. Dimensional assessments are a significant change to the philosophy of previous versions of the DSM in that the DSM-5 attempts to capture characteristics such as frequency, duration, and severity of individuals' experiences with disorders.

Although the categorical model has not been abandoned, dimensional assessments have been included in some areas to allow clinicians to evaluate clients on a full range of symptoms. This approach also allows clinicians to gather additional information to diagnose, create individualized treatment plans, and, as opposed to categorical models, evaluate client outcomes more effectively. Severity ratings for anxiety and depression as well as guidance for assessing suicide risk can now be found within the new manual. Beginning in Chapter 3, Depressive Disorders, of this Learning Companion, we provide several examples of assessments that measure severity (i.e., dimensional assessments). These can also be found on APA's website under Online Assessment Measures (www.psychiatry.org/practice/dsm/dsm5/online-assessment-measures).

Readers should note that the use of dimensional assessments is in its infancy. A dimensional approach to rating severity for the core symptoms of schizophrenia spectrum and other psychotic disorders, for example, is included in the DSM-5's Section III, Emerging Measures and Models. Under the previous categorical model followed in DSM-III and DSM-IV, a client diagnosed with schizophrenia who was experiencing severe positive symptoms such as persecutory hallucinations would have no way for this to be included as a part of his or her diagnostic classification. With the proposed rating system, counselors can indicate levels of severity on various criteria so that they can document concerns more effectively and determine the degree to which the client is experiencing decreases in symptomatology as a result of treatment (APA, 2013). Because disorders present with different degrees of severity and in the company of comorbid symptoms, the DSM-5 includes several standardized dimensional assessments proposed for future iterations of the manual. Similar to the idea of incorporating pathophysiological etiologies, these ideas need to evolve through research and continued advancements within psychiatry and counseling. To date, only one dimensional assessment is included in the DSM-5.

Critics of Dimensional Assessment

Some counselors speculate that introduction of dimensional assessments will bring about considerable potential for diagnostic inflation, claiming that APA-approved dimensional assessments are cumbersome, are difficult to administer, and lack rigorous psychometric validation (First, 2010; Jones, 2012a). Zimmerman and McGlinchey (2008) analyzed data from more than 300 psychiatrists and found that, despite the wide availability of assessments, fewer than 20% of the participants used depression scales to evaluate depression. Participants clearly identified three reasons why they did not administer a scale: (a) lack of confidence in scale utility, (b) lack of training, and (c) lack of time to administer an assessment. Although some studies have documented improvements in clinical care as a result of assessment (Trivedi et al., 2006), First (2010) expressed concerns that “clinicians are likely to view dimensional measures more as an administrative burden than as a clinically useful tool” (p. 471).

Critics also warn that severity specifiers already included in some DSM diagnoses lack clinical utility (First, 2010). For example, the DSM-III-R introduced severity and course specifiers for all but eight diagnoses. These specifiers were ignored by clinicians and, with the exception of specifiers for major depressive and manic episodes, were removed from the DSM-IV-TR. Research has provided little insight into why clinicians continue to ignore these specifiers (First, 2010; First et al., 2004). Given these criticisms and potential shortcomings of the DSM-5, we are intentional about highlighting dimensional components of diagnoses and incorporating implications in case studies and associated learning activities throughout this Learning Companion.

Cross-Cutting Assessments in the DSM-5

In addition to incorporating dimensional assessments for specific diagnoses, the DSM-5 has also included several cross-cutting assessment measures in Section III of the manual (APA, 2013, pp. 733–748). Although they are not required for use at this time, the measures are included for research and exploration purposes. These measures are not specific to any individual disorder, taking into consideration symptoms characteristic of clients in nearly all clinical settings (APA, 2013; Jones, 2012a). These assessments evaluate symptoms that are of high importance to all clinicians, such as suicidal ideation, depressed mood, sleep disturbance, and substance abuse. Cross-cutting assessment scales included in the DSM-5 were developed by the National Institutes of Health Patient-Reported Outcomes Measurement Information System and consist of two levels. The first level includes self-report measures that evaluate major clinical domains. Clients rate items on a Likert-type scale ranging from 0 (none–not at all) to 4 (severe–nearly every day). If any Level 1 area is considered clinically significant, counselors will follow up with a Level 2 measure. Level 2 measures provide a more detailed assessment of specific symptoms identified by the Level 1 measure. Like dimensional assessments, these measures are in their infancy; researchers do not yet know how use of the measures will influence diagnostic process and clinical utility. Still, it is likely that future editions of the DSM will include enhanced attention to cross-cutting assessments.

Critics of cross-cutting assessments claim there is a lack of psychometric data backing up some of these measures (Widiger & Samuel, 2008). A hot topic of debate, concerns over the utilization of cross-cutting assessments include lack of clinical utility due to the complexity and time-consuming nature of the assessments, need for extensive training for counseling professionals, and variance in validity and reliability of specific instruments (First, 2010; Jones, 2012a). These constraints, as well as the potential cost for procuring the assessments, fuel skepticism regarding the cross-cutting assessment approach.

We realize these structural and philosophical changes are significant. Readers will note that we include focused commentary regarding how philosophical shifts, structural changes, and specific diagnostic changes affect the counseling profession. In the next section, we highlight major diagnostic changes found within the DSM-5. Each of these changes will be explored in greater depth throughout this book.

Major Diagnostic Highlights

Although the following changes will be addressed comprehensively in subsequent chapters, we provide a general idea of the major changes readers should anticipate while reading this Learning Companion.

  1. Mental retardation is now referred to as intellectual disability (intellectual developmental disorder). Severity of disability is now determined by adaptive functioning rather than IQ score. New criteria include severity measures for mild, moderate, severe, and profound intellectual disability. Intellectual developmental disorder is placed in parentheses to reflect the term used in the ICD.
  2. Communication disorders have been restructured to include social communication disorder (SCD). SCD is intended to identify persistent difficulties in the social use of verbal and nonverbal communication. Individuals diagnosed under the DSM-IV-TR with pervasive developmental disorder NOS may meet criteria for SCD.
  3. Two diagnostic categories have been added to communication disorders: language disorder and speech disorder. Language disorder combines DSM-IV-TR expressive and mixed receptive-expressive language disorders.
  4. Phonological disorder is now referred to as speech sound disorder.
  5. Stuttering is now referred to as childhood-onset fluency disorder.
  6. Autism, Asperger's disorder, childhood disintegrative disorder, and pervasive developmental disorder have been replaced with one umbrella diagnosis: autism spectrum disorder. The purpose of this change is to improve diagnostic efficacy, accuracy, and consistency.
  7. Specific learning disorders have been expanded to represent distinct disorders that involve problems with the acquisition and/or use of one of more of the following skills: oral language, reading, written, and/or mathematical operations. Now referred to as specific learning disorder, this diagnosis is intended to combine reading disorder, mathematics disorder, disorder of written expression, and learning disorder NOS.
  8. Schizophrenia spectrum and other psychotic disorders remove special treatment of bizarre delusions and hallucinations involving conversations or commentary. Schizophrenia no longer includes attention to five subtypes.
  9. Disruptive mood dysregulation disorder is added with the intent of addressing overdiagnosis of bipolar disorder in children. Symptoms include persistent irritability and persistent outbursts three or more times a week for a year.
  10. Premenstrual dysphoric disorder is added to depressive disorders.
  11. The DSM-5 eliminates Criterion E, also known as the “grief exclusion,” for a major depressive episode. Individuals who have experienced the loss of a loved one can now be diagnosed with depression if they meet other criteria for a major depressive episode.
  12. Depressive and bipolar disorders include new specifiers such as with catatonia, with anxious distress, and with mixed features. These specifiers are intended to account for experiences often comorbid with mood disorders yet not part of standard criteria.
  13. Anxiety disorders include separate diagnostic categories for agoraphobia and panic disorder. Clients no longer need to experience panic to be diagnosed with agoraphobia.
  14. The anxiety disorders section includes diagnostic criteria for panic attacks. The specifier with panic attacks may now be used across all diagnostic categories of anxiety and within other sections of the DSM-5.
  15. A new chapter on obsessive-compulsive and related disorders groups disorders such as obsessive-compulsive disorder, body dysmorphic disorder, and trichotillomania together as opposed to having them scattered throughout the manual. It also includes several new disorders including excoriation (skin-picking) disorder and hoarding disorder. Hoarding disorder is characterized by persistent difficulty disposing of possessions, regardless of monetary or personal value.
  16. A new chapter on trauma- and stressor-related disorders groups disorders related to trauma and/or situational stress factors such as reactive attachment disorder, disinhibited social engagement disorder, PTSD, acute stress disorder, and adjustment disorder.
  17. PTSD was revised to include four distinct diagnostic clusters (as opposed to three in the DSM-IV-TR); the section includes considerable attention to developmentally appropriate criteria for children and adolescents.
  18. The feeding and eating disorders section includes a new disorder, binge eating disorder.
  19. The personality disorders section has not changed and will maintain the same 10 categories as the DSM-IV-TR. However, Section III on emerging measures and models includes a framework for diagnosing personality disorders using trait-specific methodology.
  20. The previous sexual and gender identity disorders section is now divided into three separate sections: sexual dysfunctions, gender dysphoria, and paraphilic disorders. Pedophilia disorder is now referred to as pedophilic disorder.
  21. The sleep-wake disorders section includes revisions with enhanced attention to biological indicators for diagnosis of many disorders.
  22. The substance-related and addictive disorders section is expanded to include addictive disorders; however, only gambling disorder falls in this category. Previous substance dependence and substance abuse criteria are combined into one overarching disorder: substance use disorders. Significant changes have been made to coding, recording, and specifiers for these disorders.
  23. The chapter on neurocognitive disorders (previously cognitive disorders) removes language regarding dementia, includes enhanced attention to a range of impairment as evidenced by incorporation of major and mild neurocognitive disorders, and includes additional attention to neurological assessment and basis of the condition.
  24. Section III includes several new disorders for study, such as attenuated psychosis syndrome (which describes individuals at high risk for psychosis who do not meet the criteria for a psychotic disorder), Internet gaming disorder, nonsuicidal self-injury, and suicidal-behavioral disorder.
  25. Section III also contains a detailed discussion of culture and diagnosis, including tools for in-depth cultural assessment and a description of some common cultural syndromes, idioms of distress, and causal explanations relevant to clinical practice.
  26. Within each diagnostic category, the NOS diagnosis has been replaced with other specified and unspecified diagnoses. The other specified category is used in situations in which the clinician chooses to communicate the specific reason that the presentation does not meet the criteria for the specific disorder.

Note

Readers will notice that only in Part One of this Learning Companion are other specified and unspecified diagnoses included. Readers can find more information on other specified and unspecified diagnoses in Chapter 17.

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Implications of the DSM-5

Implications for Clients

The DSM-5 changes outlined in this chapter and in the remainder of this Learning Companion are likely to have significant implications for clients who experience mental health concerns. While some believe the shift toward viewing mental illness as organic, with less focus on environmental precipitants of symptoms, could potentially reduce the stigma associated with mental disorders (Yang, Wonpat-Borja, Opler, & Corcoran, 2010), others wonder whether this philosophy will lead individuals to be viewed as fundamentally flawed rather than human beings who are struggling with developmental and environmental life tasks (Ben-Zeev, Young, & Corrigan, 2010; Frances, 2012b). In addition, the potential for dimensional criteria to lower diagnostic thresholds may increase the number of individuals diagnosed and boost false positives, increase labeling and associated stigma, and raise health care costs within the general population (Ben-Zeev et al., 2010; Frances, 2010; Jones, 2012a, 2013). Loosening criteria for diagnosis also raises the potential for an increase in unnecessary pharmaceutical treatment among those who seek first-line treatment from medical providers (First, 2011; Frances, 2010, 2012b). Thus, counselors need to be especially careful not to overpathologize symptoms that could be better explained by factors external to individuals (Jones, 2011). Conversely, some proponents of the DSM-5 believe a more dimensional system could normalize mental health concerns and facilitate help seeking and access to care among consumers (Andrews et al., 2007; Rosenbaum & Pollock, 2002).

Initial research on new diagnostic thresholds seems to indicate an increase in the rates of diagnosis for the general population, particularly in the areas of behavioral addictions and psychosis, as well as depressive, anxiety, eating, and neurocognitive disorders (Frances, 2010; Jones, Gill, & Ray, 2012; Mewton, Slade, McBride, Grove, & Teesson, 2011). For example, under the new combined substance use disorders, prevalence rates may increase to a staggering 12.4% (Jones et al., 2012). Similarly, lower diagnostic thresholds for ADHD have been noted as areas of concern among mental health professionals (British Psychological Society, 2011). Although these are all legitimate concerns, the reality of lower diagnostic thresholds remains to be seen.

In response to worries regarding loosened criteria, APA (2012) published documentation regarding reliability and prevalence of some diagnoses based on the field trials. However, this attempt at clarifying the anticipated increase in diagnoses has been met with strong criticism from scholars who believe the research is not adequate (Frances, 2011, 2012a; Jones, 2011). It is hoped implementation of the DSM-5 will result in data that help mental health professionals clarify usefulness of diagnostic thresholds for reaching consumers without artificially inflating diagnostic prevalence rates. Note that, throughout this DSM-5 Learning Companion, we provide information regarding diagnostic prevalence based on research using DSM-IV-TR criteria.

Concerns regarding potential increases in medications accompany concerns around the shift toward viewing mental illness as organic. In particular, many mental health professionals fear that lowering diagnostic thresholds and viewing symptoms as biological will end in more medications prescribed to newly diagnosed clients (Frances, 2010, 2012b; Jones, 2011). This is of particular concern given questions about financial relationships between task force members and pharmaceutical companies (Moisse, 2012). Although essential for some clients, the long- and short-term effects of medications are often unknown. For clients, the outcome could be an increase in the recommendation to take medications with less focus on other types of empirically supported treatments that are, by nature, less invasive. Finally, some frequently assigned disorders such as substance abuse, substance dependence, and disorders within NOS categories will no longer be included in the DSM-5, resulting in reevaluation and perhaps reassignment of long-standing diagnoses.

Implications for Counselors

Changes in the DSM-5 have potential widespread implications for counselors. Without understanding current diagnostic nomenclature, counselors may have trouble with reimbursement and thus suffer reduced credibility and potentially lose the opportunity to help clients. Whether counselors agree or disagree with the philosophy and nomenclature, there is no disputing the DSM “is the key to millions of dollars in insurance coverage for psychotherapy, hospitalization, and medications” (Kutchins & Kirk, 1997, p. 12).

The DSM-5 represents the first major structural change to the diagnostic classifications (including the layout, biopsychological model, and collapsing of the multiaxial system) since the publication of the DSM-III in 1980. As a result, there is a need for comprehensive training for counselors across settings. These radical changes affect seasoned counselors as well as new professionals, counselor educators, and counseling students (Jones, 2013).

Because of the pathophysiological model purported in the DSM-5, there are extant concerns regarding potential increases in psychopharmacological treatment (Mewton et al., 2011). The potential for a concomitant reduction in psychotherapeutic treatments may significantly affect provision of counseling services and holistic client care (First, 2011; Frances, 2010, 2012b). Because the psychiatric profession as a whole is trained in the medical model, the importance of retaining the efficacy of psychotherapy is critical. Counselors can and should advocate on community, state, and national levels in addition to actively engaging in research on evidenced-based practices.

A primary concern for counseling professionals is the lowering of diagnostic thresholds. The criteria for PTSD, acute stress disorder, ADHD, and substance use disorders have all been lowered (Frances, 2010; Jones et al., 2012; Mewton et al., 2011). There is concern that this could lead to vast overdiagnosis (Jones et al., 2012). According to Mewton et al. (2011), reducing the number of the criteria for diagnosis in the DSM-5 could increase prevalence rates of alcohol use disorders by 61.7%. As previously stated, however, the credibility of these studies remains to be seen as others have found low or no impact on prevalence rates (Beesdo et al., 2011; Pardini, Frick, & Moffitt, 2010). In response to these critiques, David Kupfer, chair of the DSM-5 Task Force, stated:

Charges that DSM-5 will lower diagnostic thresholds and lead to a higher prevalence of mental disorders are patently wrong. Results from our field trials, secondary data analyses, and other studies indicate that there will be essentially no change in the overall rates of disorders once DSM-5 is in use. For most disorders, including the addictive disorders that recently drew headlines, thresholds will remain the same or will increase. With other disorders, diagnostic criteria are being refined to hone specificity. The challenge is to balance specificity and sensitivity, to make sure that the language characterizes a disorder as accurately as possible. (Kupfer, 2012, p. 1)

There is also a concern of pathologizing normal behavioral patterns that lead to potential deleterious effects. The extant stigma of incurring a mental health diagnosis, including the cultural and spiritual impact it holds, should be carefully addressed across helping professions. The cost of treatment and ensuing medications can be burdensome as well. Because evidenced-based practices support the efficacy of psychotherapeutic treatment, medication can potentially be unnecessary and even dangerous (Olfson & Marcus, 2010). All of these factors hold specific implications for counselors across all levels of training.

Future of the DSM-5: Where Will It Go From Here?

Even as we work to understand implications of the DSM-5, others are already speculating on changes to upcoming iterations of the DSM. Research on the utility and efficacy of new diagnostic categories, cross-cutting and dimensional assessments, lowered threshold, and collapsing of the multiaxial system will affect the future direction of the manual. The ramifications of this, positive and negative, will not be fully understood until the DSM-5 is fully implemented across a multitude of settings. In the final section of this Learning Companion, we include a summary chapter regarding research and practice implications for counselors. We hope to provide avenues for counseling professionals to have an active voice in upcoming revisions to the DSM-5.

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