If you made it this far in this Learning Companion, you may be wondering how the changes we presented will influence your work as a professional counselor. Although many advocates voiced concerns that the DSM-5 would lead to a rather drastic shift in conceptualization of mental disorders, assessment procedures, and diagnostic thresholds, this version of the “psychiatric bible” looks remarkably like its predecessor. First (2010b) predicted this lack of change when he noted that the DSM-5 would keep a descriptive categorical system and that “any future paradigm shift will have to await significant advances in our understanding of the etiology and pathophysiology of mental disorders” (p. 698). Still, those involved in revisions of the DSM-5 laid the groundwork for future shifts to neurobiological conceptualizations, removal of boundaries between medical and mental disorders, prescription of assessment measures in attempts to document complexities of mental illness, and how counselors will conceptualize schizophrenia spectrum and personality disorders. Indeed, the change from Roman to Arabic numerals is intended to allow for fluid revisions as new information becomes available (e.g., DSM-5.1, DSM-5.2).
In this chapter, we review philosophical implications for the counseling profession and address technical considerations such as how to use other specified and unspecified diagnoses, coding procedures, new assessment tools, and the Cultural Formulation Interview (CFI). We conclude the chapter with reflections regarding counselors' roles in the future of the DSM.
As a profession, counseling is uniquely focused on using an empowerment-based approach “to accomplish mental health, wellness, education, and career goals” (20/20: A Vision for the Future of Counseling, 2010, para. 2). Professional counselors should be familiar with philosophical foundations that include a commitment to normal human development; wellness as a primary paradigm (Myers, 1991); and an integrated understanding regarding systemic, social, and cultural foundations. Concerns about the degree to which diagnosis is consistent with a strong professional counseling identity are not new or unique to the DSM-5. Reflecting on risks and realities within DSM-IV (APA, 1994), Ivey and Ivey (1998) asked, “We want to define ourselves as concerned with normal development, but how can we face the reality of pathological and deficit models of child development, managed health care, and the omnipresent DSM-IV?” (p. 334). Zalaquett, Fuerth, Stein, Ivey, and Ivey (2008) explained,
It is important to note that this diagnostic nosology represents a medical model that stands in sharp contrast to many counselors' core values and beliefs. The medical model treats counseling concerns and behavioral symptoms as indicators of underlying diseases, emphasizes the client's deficits, leads to a top-down professional attitude, places the client in a passive (recipient) position, emphasizes individual origin of symptoms, and offers medications as the common mode of treatment. The counseling model, in contrast, treats such symptoms as responses to life challenges, emphasizes the client's strengths and assets in dealing with problems, leads to a more egalitarian relationship in the counseling setting, places the client in an active and engaged (agent) position in the treatment process, directs attention to environmental factors that may be linked to the individual's symptoms, and offers nonpsychopharmacological treatments. (p. 364)
Eriksen and Kress (2006) identified realities; potential benefits of diagnosis within the DSM; and key contradictions in values, assumptions, and philosophies and proposed strategies counselors may use to enhance understanding of developmental and contextual considerations in an ethical manner. Similarly, White Kress, Eriksen, Rayle, and Ford (2005) posed a series of questions regarding cultural considerations and formulation within the DSM-IV-TR, and more recently, Kress, Hoffman, and Eriksen (2010) addressed ethical dimensions of diagnosis within clinical mental health counseling. These balanced views address issues of professional identity and practice implications well and will continue to be of use to counselors who seek balance in the process. Although most concerns regarding diagnosis and professional identity will remain static, the DSM-5 presents two new challenges and opportunities as they relate to professional counseling identity: neurobiological foundations and movement to nonaxial diagnosis.
The revision process spawned conversations regarding what constitutes a mental disorder, including new conceptualizations regarding the line between medical and mental disorder. Initially, the DSM-5 Task Force proposed a reformulation in the definition of mental disorder to be “a behavioral or psychological syndrome or pattern that occurs in an individual” and “that reflects an underlying psychobiological dysfunction” (APA, 2012; italics added). The proposed revision generated a firestorm of controversy regarding the questionable foundation upon which APA could claim all mental disorders as having psychobiological roots. Ultimately, APA rejected the proposed revision in favor of a more balanced definition in which the disturbance “reflects a dysfunction in the psychological, biological, or developmental processes underlying mental functioning” (APA, 2013a, p. 20).
Still, the DSM-5 includes enhanced attention to neurobiological foundations as evidenced by reconceptualization of most disorders usually first diagnosed in infancy, childhood, and adolescence as neurodevelopmental disorders, and most cognitive disorders as neurocognitive disorders. APA (2013a) noted one purpose of the structural reorganization as to “encourage further study of underlying pathophysiological processes that give risk to diagnostic comorbidity and symptom heterogeneity” (p. 13). It is important to remember that this reorganization was not always clear-cut and without controversy. For example, ADHD is placed with the Neurodevelopmental Disorders chapter rather than relocated to the Disruptive Behavior Disorders chapter as previously conceptualized. Throughout the DSM-5, narrative descriptions include additional attention to genetic and physiological elements of disorders.
Subtle shifts in language also reflect movement toward biological explanations of disorder within the DSM-5. As we discuss below, removal of the multiaxial system means mental disorders will no longer be differentiated from medical disorders in diagnostic formulations. In addition, APA replaced general medical condition with another medical condition throughout the DSM-5. This subtle shift implies that mental disorders are medical disorders at their core.
Ivey and Ivey (1998) were astute in their observation that “developmental orientation, however, does not rule out biological factors—rather environment interacts with personal biology. The issue is finding balance between personal and environmental factors” (p. 336). Miller and Prosek (2013) advocated for renewed attention to the impact of this movement toward biological explanations of emotional problems, especially for vulnerable populations. Certainly, emerging neuroscience research holds much promise for facilitating understanding regarding complexities of the brain, experiences, and disorder. Still, overreliance on biological explanations without attention to the interaction with personal and environmental factors could lead to increased pathologizing, unnecessary pharmacological treatments, and unknown long-term effects on clients. There is also question within the counseling community that this focus may cause counselors to stray from the profession's humanistic roots (Montes, 2013).
For now, we urge professional counselors to seek additional training regarding neuroscience and implications for counseling and remain alert to opportunities and challenges for our profession. Scholars such as Badenoch (2008) and Siegel (2006, 2010, 2011) offer a number of trainings and readings regarding interpersonal neurobiology that are accessible to professional counselors, consistent with our professional foundations, and directly relevant to counseling practice.
Beginning with the DSM-III (APA, 1980), the multiaxial system was designed to ensure that mental health providers were conceptualizing clients in a biopsychosocial manner. Axes I and II included psychological disorders, Axis III provided space to note medical conditions, Axis IV required attention to psychosocial and environmental stressors, and Axis V provided space for rating degree of distress and impairment in functioning. In contrast, DSM-5 (APA, 2013a) simply includes a notation that “Axis III has been combined with Axes I and II. Clinicians should continue to list medical conditions that are important to the understanding or management of an individual's mental disorder(s)” (p. 16). In addition to listing all medical and mental health concerns as part of the diagnosis, DSM-5 users are advised to include separate notations regarding psychosocial stressors, environmental concerns, and impairments or disability.
As noted by APA (2013a), previous iterations of the DSM never required mental health providers to report diagnoses in a multiaxial manner. Still, multiaxial diagnosis quickly became part of everyday diagnostic decisions and conversations. Insurance companies frequently requested notations for each of the axes and sometimes determined level of care and progress based on Global Assessment of Functioning (GAF) ratings. Scholars concerned with cultural implications of DSM diagnosis, context of distress, and professional identity frequently pointed to Axis IV as a place where counselors could ensure attention to external influences on client wellness (e.g., Eriksen & Kress, 2006; Ivey & Ivey, 1998; White Kress et al., 2005; Zalaquett et al., 2008). Some even proposed developing an Axis VI in which practitioners could note theoretical foundations or conceptualizations (Eriksen & Kress, 2006).
Regardless of reporting formats recommended by APA, professional counselors would do well to remember that the DSM is a diagnostic guide rather than a theoretical framework or treatment manual. The removal of the multiaxial system in favor of nonaxial diagnosis need not affect how professional counselors make sense of or respond to client concerns. Rather, counselors can still conceptualize clients in manners consistent with our unique foundations, and we can still bring empowerment, strengths-based, and wellness-oriented approaches to all clients, even those who present with significant disruptions in functioning. Counselors who find the DSM-5 nonaxial diagnostic format incomplete may take steps to incorporate more holistic assessment in routine assessment and treatment planning practices. In the next two sections, we attend more specifically to logistics of coding and recording of diagnoses within the DSM-5.
A major goal of the DSM revision process was to reduce overreliance on NOS diagnoses, and the DSM-5 Task Force was successful in eliminating NOS from the DSM-5. Instead, clinicians who work with individuals who do not meet full criteria for more specific disorders within the DSM have options for issuing other specified and unspecified diagnoses. APA (2013a) noted that inclusion of these two options was designed to offer maximum flexibility. Time will tell whether this change in semantics and procedures will lead to enhanced diagnostic specificity over the previous NOS system.
Clinicians will use other specified diagnosis to record a concern within a specific diagnostic category and a reason why a more specific diagnosis is not provided. In some cases, the DSM-5 provides an exemplar list of other specified diagnoses, including conditions for further study. Other times, clinicians may simply indicate, in narrative form, the reason for the other specified diagnosis. For example, a client who met all criteria for bulimia nervosa except frequency requirements could receive a diagnosis of “F50.8 other specified feeding or eating disorder, bulimia nervosa of low frequency.”
Clinicians will use unspecified diagnoses when they are certain about the category of diagnosis but unable or unwilling to provide additional details. For example, a client who presents to an emergency room in an acutely psychotic state may not be able to provide the history necessary for an accurate diagnosis, and the clinician may not have access to information that might indicate if the disturbance was induced by a substance, medication, or another medical condition. In that case, one may render a diagnosis of “F29 unspecified schizophrenia spectrum and other psychotic disorder.”
APA (2013b) noted that the DSM-5 was “developed to facilitate a seamless transition into immediate use by clinicians and insurers to maintain a continuity of care” (p. 1). Clinicians may begin using the updated manual and diagnostic criteria as soon as they are ready to do so. However, insurance companies, other third-party payers, and community agencies in general may need time to adjust reporting systems from multiaxial to nonaxial formats. At the time the DSM-5 was published, APA predicted that the insurance industry would transition to DSM-5 by December 31, 2013. However, this estimate was optimistic, as most third-party billing systems and government agencies are unlikely to formally switch over to the DSM-5 until October 1, 2014, when a nationwide mandate for the use of ICD-10-CM codes goes into effect. This mandate is a result of a final rule, released January 16, 2009, by the Department of Health and Human Services, mandating nationwide conversion to ICD-10-CM coding by October 1, 2014.
In cases where organizations such as Medicare and Medicaid only collected single-access data regarding former Axes I, II, and III, this transition should be simple. In other instances, insurance companies will need to decide how they would like to categorize previous Axis IV and which, if any, new documenting procedures should be used in place of GAF to indicate symptom severity and functional impairment. Counselors need to check with their employers and third-party payers to ensure they are coordinating a transition to the DSM-5 in a manner consistent with local administrative procedures. APA will also make implementation and transition updates available via www.psychiatry.org/dsm.
The DSM-5 includes ICD-9-CM (CDC, 1998) codes for current billing use as well as ICD-10-CM (CDC, 2014) codes for use after the October 1, 2014, nationwide conversion to ICD-10 reporting for data collection, payment policy, and research purposes. In the DSM-5, ICD-9-CM codes appear first, are in black print, and generally include three digits or begin with V. In contrast, ICD-10-CM codes appear in parentheses, are in gray print, and generally begin with a letter (F); psychosocial and environmental factors often begin with Z. For example, generalized anxiety disorder includes a notation of coding as 300.02 (F41.1). Clinicians using ICD-9-CM codes would report 300.02, and clinicians using ICD-10-CM codes would report the disorder as F41.1. Similarly, an individual seeking services related to experiences as a victim of crime would be assigned an ICD-9-CM code of V62.89 or an ICD-10-CM code of Z65.4. APA (2013b) also noted that “because DSM-5 and ICD disorder names may not match, the DSM-5 diagnosis should always be recorded by name in the medical record in addition to listing the code” (p. 3). The initial printing of the DSM-5 contained several coding errors; counselors can obtain a printable desk reference with coding updates by visiting www.dsm5.org.
As readers may have noted, the transition to a more dimensional diagnostic system in the DSM-5 resulted in a greatly increased number of subtypes and specifiers throughout the manual. For example, a client who has 2 or more years of depressed mood, including the presence of major depressive episodes within the experience, a degree of anxiety, and intermittent panic attacks may be diagnosed with F34.1 persistent depressive disorder; with anxious distress; with panic attacks; late onset; with intermittent major depressive episodes, without current episode; moderate. This is quite a change from the DSM-IV-TR diagnosis: 296.35 major depressive disorder, recurrent, in partial remission and 300.00 anxiety disorder NOS.
In most cases, clinicians will include the same diagnostic code regardless of subtypes and specifiers assigned. There are some notable exceptions, especially regarding substance-related disorders. Although we included an outline of coding notes throughout this book, professional counselors should refer to the DSM-5 for coding instructions and examples. (Refer to Section I of the DSM-5 for additional details regarding elements of a diagnosis, including coding procedures.)
Counselors used to reporting diagnoses in a multiaxial format may wonder what nonaxial diagnosis may look like. In short, it can be quite simple. Official DSM-5 diagnoses will include codes for mental health diagnoses, clinically significant psychosocial and environmental concerns, and relevant medical diagnoses that are part of the official record. These will be reported in a line-by-line manner.
We assume counselors will list disorders or concerns in order of clinical priority or relevance, with the principal diagnosis and reason for visit listed first. When the principal diagnosis and reason for visit are different, APA (2013a) advised users to include a parenthetical notation regarding which is which. For example, a child who is referred for counseling because of numerous disciplinary problems at school and is found to meet criteria for ADHD may receive a diagnosis of
| F90.2 | attention-deficient/hyperactivity disorder, combined presentation, moderate (principal diagnosis) and |
| Z55.9 | academic or educational problem (reason for visit). |
In contrast, someone who meets criteria for depression, uses alcohol excessively, and is unable to control his diabetes as a result of the disturbance may receive a diagnosis of
| F32.2 | major depressive disorder, single episode, severe; |
| F10.10 | alcohol use disorder, mild; and |
| E11 | type 2 diabetes mellitus. |
The second example raises an important consideration regarding counselors' scope of practice. Diagnosis of medical conditions alongside mental health disorders makes sense for psychiatrists who are qualified to diagnose and treat both and for mental health professionals who work in interdisciplinary settings where medical diagnoses are a matter of record. Given that counselors are not qualified to diagnose medical conditions, it may be wise to refrain from including diagnostic mention of specific medical conditions unless information is obtained via official medical record or consultation. Instead, counselors may include mention of client-reported medical conditions elsewhere on the clinical record or qualify self-reported conditions as by client report.
The following points may serve as important reminders regarding rendering of nonaxial diagnoses:
As discussed previously, the DSM-5 no longer includes attention to Axis V GAF ratings regarding distress and impairment; however, the text includes directions that clinicians include “separation notations” for disability. To some degree, counselors will indicate degree of distress and impairment using new dimensional assessment severity ratings provided throughout the DSM-5. The DSM-5 also includes a more comprehensive assessment, the WHODAS 2.0 (WHO, 2010), as holding promise for documenting functional impairment. It is currently unknown whether insurance companies will require documentation of degree of concerns via the WHODAS 2.0 or another measure. Regardless of whether one adopts the WHODAS 2.0, counselors need to consider how to attend to impairment in routine assessment and case documentation practices.
Early in the revision process, it appeared as if the DSM-5 would include dimensional assessment measures intended for use with nearly every disorder in the manual. This raised widespread concerns regarding the unknown psychometric properties of the proposed instruments, many of which were constructed by work groups during the revision process. In the end, APA chose to include relatively few assessment tools in the print version of the DSM, qualified the assessments as “emerging measures” intended for further study, and provided supplemental assessment tools via www.psychiatry.org/practice/dsm/dsm5. Assessment tools of particular interest include cross-cutting symptom measures, disorder-specific severity measures, the WHODAS 2.0, and personality inventories. In all cases, APA described the purpose of the measures as “to enhance clinical decision-making and not as the sole basis for making a clinical diagnosis” (APA, 2013c, para. 3).
APA (2013a) noted that cross-cutting symptom measures were “modeled on general medicine's review of symptoms” (p. 733). It is best to think of Level 1 cross-cutting symptom measures as very general screening tools. The DSM-5 includes an adult measure and a child measure to be completed by a caregiver; the supplemental website also includes a self-report measure for children ages 11 to 17. For example, the adult version of the cross-cutting symptom measure includes 23 questions focused on 13 domains of broad concern to clinicians across settings. Domains include areas such as depression, anger, anxiety, and sleep problems. Clients or informants use a scale from 0 (none/not at all) to 4 (severe/nearly every day) to rate their concern over a 2-week time period. With the exception of suicidal ideation, psychosis, and substance abuse for which any endorsement warrants follow-up, clinicians are advised to further inquire about any domains in which a client endorses items at a level of mild/several days or greater.
To facilitate assessment, most Level 1 domains are associated with Level 2 cross-cutting symptom measures. Level 2 measures for adults include those focused on depression, anger, mania, anxiety, somatic symptoms, sleep disturbance, repetitive thoughts and behaviors, and substance use. These assessment tools and information regarding development, administration, and psychometric properties are available free of charge via the DSM-5 website. Although most Level 2 measures were developed using well-validated instruments, APA noted that not all formulations have been validated. For these reasons, counselors should use Level 1 and Level 2 measures with caution, considering them just one source of clinical information.
APA also provides a number of disorder-specific severity measures to be used with the DSM-5. These measures correspond to specific disorders or categories of disorders. Some are designed as self-report measures, and clinicians complete other measures following a diagnostic interview. With the exception of the Clinician-Rated Dimensions of Psychosis Symptom Severity Scale available in the printed version of the DSM-5, these scales are all available through the DSM-5 website. These scales vary widely in format, quality, and rigor of psychometric validation. For example, APA chose the Patient Health Questionnaire–9, a well-developed instrument in the public domain, as the severity measure for depression. Counselors can easily access information needed to use this scale with a strong degree of integrity. On the other hand, the Severity Measure for Panic Disorder–Adult has face validity but does not include reference to development and validation procedures. Finally, the Clinician-Rated Severity of Oppositional Defiant Disorder measure simply includes one item advising clinicians to rate severity on a 4-point scale based on number of settings in which concerns occur. Counselors who choose to use severity measures in practice are responsible for learning more about development, validation, and psychometric properties of the measures so they may ensure adherence to ethical (ACA, 2014) and best practice (Association for Assessment in Counseling, 2003) guidelines.
As noted before, GAF rating procedures are discontinued in the DSM-5, and the WHODAS 2.0 is included as an alternative method for assessing disability. The WHODAS 2.0 is a well-established assessment measure appropriate for use with diverse populations and captures the level of functioning in six domains of life:
In short, the WHODAS 2.0 may be completed by a client or informant and includes 36 items in which one rates concerns over the past 30 days on a scale ranging from 1 (none) to 5 (extreme). It takes approximately 5 to 20 minutes to complete and is appropriate for repeat administration. Extensive information regarding scoring, norms, psychometric properties, and the development process is provided in a manual available in the public domain (Üstün et al., 2010). A corresponding measure for children and adolescents is in development.
Finally, APA provides personality inventories designed to “measure maladaptive personality traits in five domains: negative affect, detachment, antagonism, disinhibition, and psychoticism” (APA, 2013c, para 4). Provided online, the measures include brief forms (25 items) and full forms (220 items) for adults and a brief form for children ages 11 to 17. The scales and subscales in the assessment tools are aligned with facets and domains conceptualized within the alternative model for personality disorders printed in Section III of the DSM-5. Individuals interested in using this assessment tool should refer to Krueger, Derringer, Markon, Watson, and Skodol (2012).
APA's provision of assessment tools corresponding to key constructs within the DSM-5 represents a shift in thinking from the DSM as a manual that simply describes experiences to one in which a degree of clinical practice is suggested or prescribed. As noted throughout this section, the measures provided in print and online vary widely in their rigor. The degree to which they are usable in everyday counseling practice is likely to vary in accordance with properties of the specific measure, the counselor's work setting and focus, and the counselor's theoretical orientation. The instruments are largely deficit based and grounded in a medical model, and it is not yet known whether counselors will find these instruments useful for practice and feasible in the world of managed care (Jones, 2012). Counselors operating from a wellness and strength-based model may wish to incorporate assessment tools reflective of this orientation in addition to or instead of the tools provided by the APA. To learn more about these assessments in general, refer to Jones (2012). In addition, APA will be releasing measures for further study on a rolling basis, so readers may wish to check back for updates on the DSM-5 website.
A key criticism of the DSM over time has been lack of attention to cultural considerations in diagnostic assessment. The DSM-IV was designed with additional attention to culture in mind and included a number of cultural upgrades, including descriptions of cultural features, a cultural formulation outline, and enhanced attention to psychosocial and environmental stressors (Smart & Smart, 1997). The DSM-5 includes continued attention to cultural considerations through updated diagnostic criteria, text regarding culture-related diagnostic issues for most disorders, additional information about cultural concepts, and a formal Cultural Formulation Interview, or CFI. The CFI was designed to answer questions regarding how one might bring integrated understanding of cultural considerations to assessment, diagnosis, and treatment planning. The CFI client and informant versions are provided on pages 752–757 of the DSM-5.
The CFI is a semistructured interview consisting of 16 questions covering domains such as cultural definition of the problem; cultural perceptions of cause, context, and support; cultural factors affecting self-coping and past help seeking; and cultural factors affecting current help seeking. Designed to be completed in about 15 to 20 minutes, the CFI provides concrete direction and tools for bringing culture into diagnostic assumptions. In addition, APA provides a series of 12 supplementary modules to be used as adjuncts to the CFI or independent of the CFI. Addressing topics and populations such as needs of immigrants and refugees; coping and help seeking; and spirituality, religion, and moral traditions, the modules provide a foundation upon which culturally sensitive counselors can build.
During a year-long field trial involving the CFI, Aggarwal, Nicasio, DeSilva, Bioler, and Lewis-Fernandez (2013) identified several barriers to implementing the CFI. From the client perspective, barriers included confusion about how the CFI was different from other assessments, reluctance to discuss the past, confusion over several items, rigidity in conversation, and difficulty participating given the nature of the client's illness. Interdisciplinary clinicians sometimes questioned conceptual connections between the CFI and presenting problems, wondered whether the entire interview was helpful, identified instances in which clients may not be able to participate, and worried about being overly structured in delivery of the interview. They also noted concerns regarding the amount of time needed to complete the entire CFI. Even if counselors simply find the CFI helpful as a guide to facilitating conversations about culture, the CFI provides a step forward in helping counselors move from multicultural awareness to skills when thinking diagnostically.
As we discussed in Chapters 1 and 2, the DSM is an evolving manual that reflects the particular time in which it was created. Over time, mental health professionals have witnessed the DSM shift from explicit psychodynamic foundations in the original document to an implicit supposedly atheoretical medical model in the third revision. APA made a strong statement when it moved from denoting new editions with Roman numerals (e.g., DSM-III, DSM-IV, DSM-IV-TR) to indicating editions with Arabic numbers (e.g., DSM-5, DSM-5.1, DSM-5.2). This shift indicates plans for ongoing revision of the document as new information becomes available.
Given expansion of national priorities regarding brain-based initiatives and neurobiological research on mental disorders, we expect continued efforts around understanding and classifying etiology of disorders rather than classification of symptom-based experiences (Kupfer & Regier, 2011). Certainly, the NIMH noted such a shift in focus when they endorsed the DSM-5 as the “contemporary consensus standard for how mental disorders are diagnosed and treated” (Insel & Lieberman, 2013, para. 2) and went on to express plans for “a new kind of taxonomy for mental disorders by bringing the power of modern research approaches in genetics, neuroscience, and behavioral science to the problem of mental illness” (para. 3).
As one of the largest consumers of the DSM (Frances, 2011), professional counselors are responsible for ensuring they understand and incorporate the latest advances in related professions while advocating for assessment, diagnostic, and treatment systems that best empower “diverse individuals, families, and groups to accomplish mental health, wellness, education, and career goals” in accordance with ACA's definition of counseling (20/20: A Vision for the Future of Counseling, 2010). In the years to come, professional counselors will need to decide whether to advocate for heightened inclusion in DSM revision processes or, deciding that the manual no longer enhances work within the counseling profession, adopt an alternative nosology that is consistent with the philosophical, theoretical foundations and the work that we do as professional counselors.