Jul 10, 2014 | Article, Volume 4 - Issue 3
Stephanie F. Dailey, Carman S. Gill, Shannon L. Karl, Casey A. Barrio Minton
Regardless of theoretical orientation or work setting, professional counselors should have a thorough understanding of the American Psychiatric Association’s (APA) fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). This article includes an overview of the most recent revision process and identification of key structural and philosophical changes in the DSM-5. The authors conclude with a summary of practice implications for counselors, including specific guidance for recording diagnoses, using diagnostic specifiers and incorporating emerging assessment measures.
Keywords: DSM-5, diagnosis, diagnosis specifiers, assessment, American Psychiatric Association
By definition, counseling is a professional relationship between client and counselor based on empowerment, rooted in diversity, and committed to accomplishing mental health, wellness, education and career goals of individuals, families and groups (Kaplan, Tarvydas, & Gladding, in press). To accomplish these goals, counselors often include diagnosis as an essential component of the counseling process. Even counselors who work in settings where they are not traditionally responsible for diagnostic assessment must possess a comprehensive understanding of diagnostic nosology and nomenclature. Such an understanding helps providers recognize diagnostic concerns and participate in interdisciplinary discussions and treatment decisions regarding consumers who experience distress or disability. Despite competitors such as the ICD-10 Classification of Mental and Behavioural Disorders (World Health Organization [WHO], 1992), the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5; APA, 2013) is the world’s standard reference for evaluation and diagnosis of mental disorders (Eriksen & Kress, 2006; Hinkle, 1999; Zalaquett, Fuerth, Stein, Ivey, & Ivey, 2008).
The purpose of this article is to present major structural and philosophical changes within the DSM-5 (APA, 2013) in order to make those changes more accessible to counselors. We, the authors, describe how these changes translate to current counseling practice and how they will help counselors utilize the revised nomenclature system. To better understand these changes, we believe it is important to first review development of the DSM and the most recent revision process.
History of the DSM
The original DSM was psychiatry’s first attempt to standardize mental illness classification. Published in 1952 by the APA, the DSM represented an alternative to the WHO’s sixth edition of the ICD that included a section on mental disorders for the first time (APA, 2000). Focused on clinical utility, the first DSM was grounded in psychodynamic formulations of mental disorders (Sanders, 2011). Emphasizing Adolf Meyer’s psychobiological view, this version of the manual claimed that mental illness represented “reactions” of the personality to psychological, social or biological aspects of client functioning (APA, 2000). A particularly noteworthy characteristic of the DSM’s first edition is that of the 106 conditions it included, only one diagnosis—adjustment reaction of childhood/adolescence—was relevant to youth (Sanders, 2011).
The APA published the next iteration, the DSM-II, in 1968. This version included 11 diagnostic categories and 182 disorders (APA, 1968). Reflecting significant changes in theoretical ideology, the focus of the manual shifted from psychopathology (i.e., reactions) to psychoanalysis (i.e., neuroses and psychophysiological disorders; Sanders, 2011). Authors of the DSM-II maintained a narrative focus when describing disorders.
APA began working on the DSM-III in 1974 and published it in 1980. This iteration differed significantly from previous editions and represented a dramatic shift to a more medically focused model (APA, 1980; Wilson, 1993). Authors of the DSM-III stressed use of empirical evidence to develop diagnoses and claimed theoretical neutrality, signaling a clear attempt to separate the DSM from its psychoanalytic origins (Maser, Kaelber, & Weise, 1991). A new multiaxial system included attention to biopsychosocial conceptualization. For the first time, the DSM-III contained descriptive diagnoses with a focus on positivistic, operationally defined and explicit diagnostic criteria (Wilson, 1993); narrative text also included information such as familial patterns, cultural considerations and gender (Sanders, 2011). The age of empirically based treatments had arrived, and widespread use of the DSM-III became commonplace.
Intended at first only to include minor changes, the APA published substantial modifications to text and diagnostic criteria within the DSM-III-R (1987); as a result, a number of scholars criticized the document intensely (APA, 2000; Blashfield, 1998; Scotti & Morris, 2000). Expanding to 297 diagnoses, Axis I descriptions nearly exceeded 300 pages, while attention to Axes IV and V remained limited to just a few pages. Many scholars continued to question the multiaxial system and validity of field trials (Rogler, 1997).
Heavy critique of the DSM-III and the DSM-III-R led to relatively mild changes to the DSM-IV, published in 1994 (APA, 2000). At nearly seven times the length of the original DSM, this version totaled 365 diagnoses in 886 pages. A text revision (DSM-IV-TR) published in 2000 included wording modifications to ensure nonstigmatizing, person-first language (Scotti & Morris, 2000). The APA also included empirically based information for each diagnosis and diagnostic code modifications to maintain consistency with the ICD-9 (APA, 2000). Like its predecessors, the DSM-IV-TR was heavily critiqued by scholars due to a heavy emphasis on a medical model and rigid classification systems (Eriksen & Kress, 2006; Ivey & Ivey, 1998; Scotti & Morris, 2000). Issues of comorbidity, questionable reliability, controversial diagnoses and excessive use of not otherwise specified (NOS) diagnoses were hot topics among critics (Beutler & Malik, 2002). APA identified these issues as driving forces for structural and philosophical changes in the DSM-5 (APA, 2013).
The DSM-5 Revision Process
Beginning in 1999, one year before the APA published the DSM-IV-TR, the APA began working on a new edition, which would be more scientifically based, increase clinical utility and maintain continuity with previous editions (APA, 2014a). APA released an initial research agenda focused on nomenclature, neuroscience, developmental science, personality disorders, and the relationship between culture and psychiatric diagnoses (APA, 2000; Kupfer, First, & Regier, 2002). The APA, the National Institute of Mental Health (NIMH), and the WHO held 13 conferences between 2004 and 2008 in which stakeholders discussed relevant diagnostic questions and solicited feedback regarding potential changes in nosology. Resulting themes facilitated the research base and fueled the agenda of the DSM-5 working groups (see Kupfer et al., 2002 for the full DSM-5 research agenda).
In 2007, the APA officially commissioned the DSM-5 Task Force, made up of 29 members including David J. Kupfer, M.D., Chair; and Darrel A. Regier, M.D., M.P.H., Vice-Chair (APA, 2014a). Kupfer and Regier provided clear direction to eradicate the use of NOS diagnoses, eliminate functional impairment as necessary components of diagnostic criteria, and use empirically based evidence to justify diagnostic revisions (Gever, 2012; Reiger, Narrow, Kuhl, & Kupfer, 2009). With these marching orders, each working group proposed draft criteria and justification for changes.
Between April 2010 and June 2012, the DSM-5 Task Force facilitated three rounds of public comment and two field trials (Clarke et al., 2013; Jones, 2012a; Narrow et al., 2013; Regier et al., 2013). The APA Board of Trustees reviewed final revisions in December 2012 and published the DSM-5 in May 2013. Although no professional counselors were invited to serve on the DSM-5 Task Force, several professional counseling associations served as important advocates during the revision process (Dailey, Gill, Karl, & Barrio Minton, 2014).
Major Structural Changes
The general format of the DSM-5 (APA, 2013) is quite different from that of the DSM-IV-TR (APA, 2000). Although roughly the same number of disorders is included in both editions, structural similarities end here. The DSM-5 (APA, 2013) includes three major sections, revised chapter organization, cross-cutting symptom and severity measures, adoption of a nonaxial system and enhanced coverage of cultural considerations (Dailey et al., 2014). As with previous versions, the text includes a number of appendices related to terminology and coding.
Section I: DSM-5 Basics
Section I of the new manual includes an introduction to the DSM-5 (APA, 2013) and general instructions on how to use the updated manual, including attention to nonaxial diagnosis and coding considerations. Counselors who diagnose in accordance with the DSM-IV-TR (2000) may be surprised to see that the APA eliminated both the multiaxial classification system and the Global Assessment of Functioning (GAF) scale. Never required for diagnosis, the APA removed the multiaxial system on the premise that it may lead to inaccurate, oversimplified conceptualization regarding complexities of physical, biological and emotional concerns. Furthermore, removal of the GAF was due to claims of insufficient clinical utility and reliability.
Less radical structural changes discussed in Section I include harmonization of language with the forthcoming ICD-11. The DSM-5 (APA, 2013) incorporates two sets of ICD codes: ICD-9 codes (for immediate use, presented in black print) alongside ICD-10 codes (for use upon nationwide conversion to ICD-10-CM coding expected October 1, 2015, presented in parentheses and in gray print). In addition, authors address consideration for implementing new other specified and unspecified disorder criteria, which present more specific alternatives to previous NOS diagnoses.
Section II: Diagnostic Criteria and Codes
Section II includes 20 diagnostic classifications or chapters, four more than the DSM-IV-TR (2000), and a significantly revised organization with attention to development and etiology in hopes of enhancing clinical utility (Brown & Barlow, 2005; Kupfer et al., 2002). For example, classifications more frequently diagnosed in childhood and believed to have similar root causes, such as neurodevelopmental disorders (most of which were formerly known as disorders usually diagnosed in infancy, childhood or adolescence), appear first. Diagnostic classifications more commonly seen in older adults and believed to have similar root causes, such as neurocognitive disorders (most of which were formerly known as delirium, dementia, and amnestic and other cognitive disorders), appear much later in the text.
The DSM-5 Task Force reorganized disorders into new chapters based on research regarding etiology as well as similarity in symptom experience or manifestation. For example, anxiety disorders, which were previously grouped together, now appear in three distinct chapters: “Anxiety Disorders,” “Obsessive-Compulsive and Related Disorders,” and “Trauma- and Stressor-Related Disorders.” Extrication of trauma- and stressor-related disorders allows diagnoses that result from traumatic external events or triggers to be grouped together in a more meaningful way (APA, 2013). Because they are diagnostically unique yet often triggered by traumatic events, the chapter “Dissociative Disorders” immediately follows the chapter “Trauma- and Stressor-Related Disorders.”
The DSM-5 Task Force also attended to etiology and development when choosing the order of diagnoses within chapters. This represents a shift from presenting more highly specified disorders first in previous editions of the manual. For example, the chapter “Feeding and Eating Disorders” opens with diagnostic criteria for pica, rumination disorder and avoidant/restrictive food intake disorder (previously classified as disorders usually first diagnosed in infancy, childhood and adolescence) before covering disorders more classically associated with adolescence and adulthood (e.g., anorexia nervosa, bulimia nervosa, binge-eating disorder).
Section III: Emerging Measures and Models
Counselors should not overlook the third and final section of the DSM-5 (Dailey et al., 2014). Section III includes a variety of measures and models in development, including assessment measures, cultural formulation tools, a proposed personality disorders model and conditions for further study (e.g., Internet gaming disorder, nonsuicidal self-injury). Section III does not represent formal changes in nosology or diagnostic processes; rather, most elements are included to enhance clinical use by clinicians and fuel investigations by researchers.
Proposed assessment measures comprise a major component of Section III. Level 1 cross-cutting symptom measures are tools designed to screen for a broad range of presenting concerns in adults (13 domains) and children (12 domains). In turn, Level 2 cross-cutting symptom measures facilitate more focused assessment of Level 1 domains flagged as concerning. The print version of the DSM-5 also includes a sample dimensional assessment related to psychosis and a reprinting of the WHODAS 2.0, a tool to assess disability and impairment. Most proposed assessment measures are not included in the print version of the DSM-5. For example, the DSM-5 website currently includes many Level 2 cross-cutting symptom measures and disorder-specific severity measures intended to be used as dimensional assessments for some of the most frequently diagnosed concerns. Counselors can find more information about these tools and additional dimensional assessment tools not included in the print version of the DSM-5 by viewing Online Assessment Measures (APA, 2014b) and reading resources provided by Jones (2012b) and Narrow et al. (2013).
Finally, authors of the DSM-5 (APA, 2013) devoted special attention to diverse ways in which individuals experience and describe distress. This fosters accurate communication so that counselors may better differentiate pathology from nonpathology when working with diverse clients (Dailey et al., 2014). As we will discuss below, counselors may use the cultural formulation interview to talk with clients about symptoms, cultural understanding of concerns and implications for treatment. The DSM-5 Appendix also includes a glossary of cultural concepts of distress.
Major Philosophical Changes
Two major philosophical changes will modify the ways in which counselors approach diagnosis, assessment and communication with other professionals when using the DSM-5 (Dailey et al., 2014). The first is movement away from a purely descriptive diagnostic model (i.e., a traditional medical perspective) toward a neurobiological model. This approach is grounded in client functioning as opposed to strict pathology, and includes research in genetics, neuroimaging, cognitive science and pathophysiology (Kupfer et al., 2002). The second philosophical change is a shift away from a strictly categorical classification system toward a more dimensional approach to nosology (Dailey et al., 2014).
A Neurobiological Perspective
The first major philosophical change involves a shift in focus from phenomenological interpretations toward identifiable pathophysiological origins (Dailey et al., 2014; Kupfer et al., 2002). Simply stated, the traditional medical model focuses on treating the problem, and the newer functional model focuses on treating and better understanding the problem. Diagnostic assessment has shifted from what to what and why. Previous iterations of the DSM based disorders purely on symptom identification and behavioral observations. As mentioned previously, APA reordered this iteration of the manual to align more clearly with a pathophysiological model that includes attention to etiology, neuroscientific evidence and functional changes associated with or resulting from disease or injury. This shift is consistent with national priorities for deeper understanding of mental illness (Kupfer & Reiger, 2011).
The DSM-5 Task Force incorporated text regarding neurobiology throughout the document, including standing descriptions of genetic and physiological risk factors, prognostic indicators and biological markers that may impact one’s experience with disorder. As noted previously, the lack of clear differentiation between mental and physical disorders served as a major reason for removal of the multiaxial system. The DSM-5 also includes several semantic changes that are philosophical, and possibly strategic, in nature. Whereas the DSM-IV-TR included reference to general medical conditions, the DSM-5 references disorders due to another medical condition. This implies that mental health concerns are, in essence, medical concerns. These seemingly innocuous philosophical shifts send a powerful message regarding the nature of a disorder and, in turn, assumptions about treatment.
As noted in the section regarding structural changes, some diagnostic classifications that were combined previously due to analogous symptomology now stand alone because of research regarding disorder etiology. Aside from the previously mentioned division of anxiety disorders into three separate classifications, mood disorders have been divided into two distinct chapters: “Bipolar and Related Disorders” and “Depressive Disorders.” This philosophical and in some cases structural modification is intended to reflect an emphasis on improved clinical utility and to “encourage further study of underlying pathophysiological processes that give rise to diagnostic comorbidity and symptom heterogeneity” (APA, 2013, p. 13). An example of “underlying pathophysiological processes” is the previous placement of attention-deficit/hyperactivity disorder (ADHD) as a disruptive behavior disorder within the first chapter of the DSM-IV-TR. Given abundant genetic links to ADHD (Rowland, Lesesne, & Abramowitz, 2002), it did not make sense for ADHD to continue as a disruptive disorder alongside oppositional defiant disorder and conduct disorder. ADHD is now classified within the neurodevelopmental disorders chapter of the DSM-5.
In accordance with a neurobiological perspective, the DSM-5 Task Force eliminated the chapter “Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence” and replaced it with a neurodevelopmental disorders chapter. Disorders not considered neurodevelopmental in nature are no longer included in this chapter. For example, reactive attachment disorder, which originates from gross pathological care during infancy, is now located within the chapter “Trauma- and Stressor-Related Disorders.” There also were other reasons for removing the chapter on disorders usually first diagnosed in infancy, childhood, or adolescence, such as the erroneous insinuation that these disorders manifest only in early development (Dailey et al., 2014).
Despite these changes, the impact of this shift was not as significant as neurobiologists would have hoped (Dailey et al., 2014). The DSM-5 Task Force did not fully accept or incorporate the biological perspective, and critics claimed that clinicans might dismiss important sociocultural variations, especially given the elimination of the multiaxial assessment (Mannarino, Loughran, & Hamilton, 2007).
Dimensional Versus Categorical Nomenclature
The second major philosophical change involves attention to dimensional assessment and documentation as opposed to strictly categorical diagnosis. Categorical assessment is based on the assumption that diagnostic criteria represent independent, discrete phenomena (First, 2010; Jones, 2012b). In reality, client symptoms occur on a continuum rather than as part of a dichotomy (Dailey et al., 2014).
As noted previously, dimensional assessment scales are designed to assess frequency, duration, severity or other characteristics of a specific diagnosis (Jones, 2012b). Near the beginning of the revision process, the DSM-5 Task Force proposed dimensional assessment measures for nearly every disorder in the manual. Following widespread concern regarding questionable psychometric data, the APA included only one dimensional assessment tool, clinician-rated dimensions of psychosis symptom severity, in the print version of the DSM-5 (APA, 2013). The APA, however, has provided supplemental assessment tools online (APA, 2014b).
Like the neurobiological perspective, the shift toward dimensional conceptualization was neither universal nor complete. The DSM-5 (APA, 2013) included new severity specifiers for most disorders, and it shifted forward dimensional conceptualization for several key diagnostic classifications. For example, in the DSM-5, DSM-IV-TR substance abuse and substance dependence disorders were collapsed into one new substance use disorder with severity indicators ranging from mild to severe based on the number of criteria presented by the client. Counselors are to diagnose clients who meet two or three criteria as having a mild disorder, those who meet four or five criteria as moderate, and those who have six or more criteria as severe. Counselors will find similar conceptualizations throughout the DSM-5, including in the newly conceptualized persistent depressive disorder, which combines dsythymia and chronic instances of major depressive disorder and includes 18 possible specifiers.
A more radical reflection of the dimensional approach in the DSM-5 is the presentation of spectrum disorders rather than distinct disorders. One umbrella diagnosis—autism spectrum disorder—replaced DSM-IV-TR (APA, 2000) disorders of autism, Asperger’s disorder, childhood disintegrative disorder, and pervasive developmental disorder. Autism spectrum disorder includes severity specifiers based on whether a client meets operationalized criteria for “requiring very substantial support, requiring substantial support, or requiring support” in social communication and restricted, repetitive behaviors domains (APA, 2013, p. 52). Similarly, the new chapter “Schizophrenia Spectrum and Other Psychotic Disorders” retains discrete diagnoses, but introduces the probability that brief psychotic disorder, schizophreniform disorder, and schizophrenia exist on a continuum. The APA (2013) claimed that the purpose of this change is to improve diagnostic efficacy, accuracy and consistency; however, critics conceptualized this as more of a philosophical shift (Dailey et al., 2014).
The APA has indicated intent to continue incorporating dimensional approaches in to future iterations of the DSM. For example, Section III includes a framework for diagnosing personality disorders using a hybrid categorical and dimensional model (APA, 2013). This model is based on the premise that personality dysfunction is a range of trait variations “with normal personality functioning on one end and abnormal personality functioning on the other” (Dailey et al., 2014, p. 309). Individuals who adopt the alternative model for clinical or research purposes will conceptualize clients as presenting impairment related to identity, self-direction, empathy and intimacy as they relate to five trait domains (i.e., negative affectivity, detachment, antagonism, disinhibition, psychoticism) and 25 more specific trait facets (APA, 2013). It is unclear whether the more complex dimensional model will be adopted fully in the next iteration of the DSM (Dailey et al., 2014).
Practice Implications for Counselors
Although many voiced concerns that the DSM-5 would lead to drastic shifts in counselors’ conceptualization of mental disorders, assessment procedures and diagnostic thresholds, this version of the “psychiatric bible” (Kutchins & Kirk, 1997, p. 1) looks remarkably similar to other iterations (Dailey et al., 2014). Despite similarities, the DSM-5 (APA, 2013) provides groundwork for future iterations to more closely represent neurobiological and dimensional conceptualizations of mental illness. Given the professional identity of counselors, and a scope of practice that “serves to promote wellness across the lifespan . . . [including] preventing and treating mental disorders” (Kraus, 2013, p. 1), strictly neurobiological interpretations may lead consumers to ignore essential interactions between individuals and their environments. Counselors who operate from strength-based wellness approaches will likely reject the notion that all mental illness has biological foundations (Dailey et al., 2014), especially as it is a short leap from assuming biological foundations to assuming that one must treat all disorders biologically. Counselors recognize that a biological orientation could lead to erroneous diagnosis, unwarranted medications and the selection of inappropriate treatment approaches. Although one cannot deny that life experiences have powerful impacts on neurobiological systems (e.g., Badenoch, 2008; Cozolino, 2010), there is concern that too heavy a focus on neurobiology may detract from the humanistic roots of counseling (Montes, 2013).
Certainly, counselors will continue to explore ways in which these philosophical shifts will affect the practice. In the following pages, we provide concrete recommendations for rendering diagnoses consistent with the DSM-5. These include recommendations for using other specified and unspecified disorders, procedures for recording diagnoses, insurance transitions and possibilities for incorporating attention to assessment tools.
Other Specified and Unspecified Disorders
A primary goal of the DSM-5 Task Force was the removal of NOS diagnoses from the DSM (Gever, 2012; Regier et al., 2009). This removal was based on perceived overuse of NOS by clinicians, especially when clients did not meet clear diagnostic criteria for more specific disorders (Jones, 2012b). Critics claimed that NOS diagnoses were a result of heavy reliance on “psychodynamic, a priori hypotheses” rather than “external, empirical indicators” (Kupfer & Regier, 2011, p. 672). By turning attention to more flexible dimensional diagnoses, creators of the DSM-5 hope to provide avenues for more flexible, yet more accurate labeling of mental disorders.
Counselors now have two options when working with individuals who do not meet full criteria for a specific diagnosis: other specified and unspecified. Use of other specified allows counselors to indicate, by using either specifiers assigned to that particular diagnosis or a descriptive narrative, the specific reason a client does not meet criteria for a more specific mental disorder (APA, 2013). When more specific information is not available or counselors do not feel comfortable providing additional detail, they may select an unspecified disorder. Each chapter of the DSM-5 includes at least one set of these disorders (e.g., other specified elimination disorder, unspecified elimination disorder).
Some diagnostic categories, such as bipolar and related disorders and depressive disorders, include specific examples of other specified disorders. For example, a client who meets all the criteria for a major depressive disorder except the time requirement may be diagnosed with 311 other specified depressive disorder, short-duration depressive episode. Counselors are not limited to using only these examples, as other reasons may warrant an other specified diagnosis (Dailey et al., 2014).
Recording Procedures
Nonaxial recording. Technically, DSM-IV-TR consumers were never required to present diagnoses using a multiaxial format (APA, 2013). Those who are used to the multiaxial system will simply combine previous Axis I (mental disorders and other conditions that may be a focus of treatment), Axis II (personality disorders and mental retardation), and Axis III (general medical conditions) diagnoses into one nonaxial diagnosis. Counselors also might note psychosocial stressors, environmental concerns, and impairments or disability as a brief narrative explanation relevant to the client’s mental health diagnoses if these are not (a) already indicated by the diagnosis, (b) included as a diagnostic subtype or (c) indicated by a unique specifier or severity indicator for the disorder. Counselors may list V codes or 900 codes (conditions associated with neglect or sexual, physical, and psychological abuse) as stand-alone diagnoses or alongside other diagnoses as long as these are relevant to clients’ presenting concerns and course of treatment. Although the DSM-5 does not include directions for formatting, counselors should keep explanations brief and use terminology appropriate for multidisciplinary communication (Dailey et al., 2014).
Counselors who see dual-diagnosis clients, individuals with medical conditions, and those who have psychosocial and environmental concerns may be overwhelmed by how to prioritize diagnoses. One solution is to list diagnoses in order of priority and scope of the presenting problem (APA, 2013; Dailey et al., 2014). When these are different, such as an adult referred for bereavement but found to have suicidal ideation and meet criteria for major depressive disorder, the APA (2013) advised users to include a parenthetical notation differentiating between the diagnosis and reason for visit. An example diagnosis might be 296.23 major depressive disorder, single episode, severe (principal diagnosis) and V62.82 uncomplicated bereavement (reason for visit).
Counselors also may need to prioritize presentation of diagnoses when clients have relevant medical diagnoses in addition to mental health concerns. For example, a client who experiences a manic episode, uses alcohol excessively and is not able to control a preexisting thyroid disorder because of the disturbance may receive a diagnosis of: F31.13 bipolar disorder I, current episode manic, severe; F10.10 alcohol use disorder, mild; and E06 chronic lymphocytic thyroiditis. We chose to list alcohol use disorder second because the client appears to be most impaired by the severe manic episode, and we suspect that a pattern of alcohol use and difficulty managing chronic medical conditions are both related to the bipolar disorder.
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 conditions and for mental health professionals who work in interdisciplinary settings where medical diagnoses are a matter of record (Dailey et al., 2014). 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 gathered via official medical record or consultation. Counselors may consider including mention of client-reported medical conditions elsewhere on the clinical record or qualify medical conditions as self-reported.
ICD coding. Since publication of the DSM-III, ICD-9 codes have appeared next to each diagnostic classification (APA, 1980). Originally created for statistical tracking of diseases, not reimbursement, most medical systems within the United States use these codes for billing purposes. These codes are also required for use by medical insurance organizations by the Health Insurance Portability and Accountability Act of 1996 (HIPAA). In the DSM-5 (APA, 2013), ICD-9 codes are in black print, appear first, and typically include three digits or begin with V. In contrast, ICD-10 codes are gray in print, appear in parentheses, and generally begin with the letter F or, if representing psychosocial or environmental factors, with the letter Z. The reason for including both coding sets in the DSM-5 is that all practitioners must align with HIPAA, which requires use of ICD-10-CM (clinical modification) codes no later than October 1, 2015. Complete ICD-9 and ICD-10 codes can be found in the Appendix of the DSM-5, listed alphabetically and numerically.
The implication of this modification is relatively minor for counselors. Counselors should be aware that the initial printing of the DSM-5 contained several coding errors, and not all terminology used within the DSM-5 matches ICD-10 exactly. Counselors can obtain a printable desk reference with coding updates by visiting the DSM-5 coding update section on the website (APA, n.d.).
Specifiers and subtypes. In keeping with a dimensional philosophy, the DSM-5 (APA, 2013) contains an expanded listing of specifiers and subtypes for disorders listed throughout the manual. As noted previously, this update may include a greatly expanded number of options to denote experience within a diagnosis. For example, counselors may now add the specifier with panic attacks to any diagnosis within the DSM-5. Other important changes include an expanded listing of specifiers for bipolar and related disorders and depressive disorders, such as with catatonia, with anxious distress, and with mixed features. These specifiers are intended to account for experiences that are often present in both types of disorders, such as elements of anxiety, but may not be part of the general criteria for the disorders (APA, 2013).
Counselors should note all relevant specifiers for each diagnosis. For more information regarding specifiers and subtypes, professional counselors can refer to the DSM-5 for specific coding instructions and examples (APA, 2013). Despite these changes, most situations will require counselors to use the same diagnostic codes regardless of subtypes and specifiers assigned (APA, 2013; Dailey et al., 2014). There are some exceptions, however, such as when recording substance-related disorders.
Insurance Transitions
The APA (2013) 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). Counselors may begin using diagnostic criteria as soon as they are ready to do so. Insurance companies, other third-party payers and mental health agencies, however, may take additional time to adjust their reporting systems from ICD-9 to ICD-10. This is especially true for the transition from a multiaxial to a nonaxial format (Dailey et al., 2014).
Although many counselors used the multiaxial system for diagnostic decisions, conversations and reimbursement, elimination of this system should not impact treatment decisions or reimbursement. Many third-party billing systems and government agencies collected data regarding a specific diagnosis only (previously Axis I, II and III); therefore, with the transition they should simply be reporting the same type of information.
Some insurance panels and reimbursement systems may have previously required more information, such as a GAF score, when determining eligibility for services. Given the expansion of severity indicators and specifiers contained throughout the DSM-5, functional impairments or specific disabilities may be noted within the nonaxial diagnosis. If this is not the case, as mentioned previously, counselors may use narrative notations alongside diagnostic labels. To the extent that functional impairment or disabilities are not listed and would previously have been indicated in the multiaxial system, counselors will need to work closely with associated parties to identify revised reporting requirements (Dailey et al., 2014). Counselors also can use the WHODAS 2.0, found in Section III of the DSM-5 or at www.psychiatry.org/dsm5, to more clearly indicate an individual’s level of functioning (APA, 2013).
The APA initially predicted that the insurance industry would transition to DSM-5 by December 31, 2013. This estimate was overly optimistic, however, as most third-party billing systems and government agencies have been slow to switch over to the DSM-5 and likely will not do so until the nationwide mandate for the use of ICD-10 codes goes into effect on October 1, 2015. Counselors can check with their employers and third-party payers to ensure a smooth transition to the DSM-5 in a manner consistent with local administrative procedures. The APA also is making implementation and transition updates available via their website.
Emerging Assessment Measures
As discussed previously, the DSM-5 includes a variety of cross-cutting assessment measures, disorder-specific severity measures and interview tools for clinicians. The APA (2013) qualified all print and online assessments, including the WHODAS 2.0 and Personality Inventories, as “emerging measures” intended for further research and exploration in clinical practice. Counselors may do well to integrate attention to screening of cross-cutting symptoms and monitoring of diagnostic severity in practice.
In most cases, the tools provided by the APA are clear, direct and ready to use; however, these online assessments vary widely in format, quality and rigor of psychometric validation (Jones, 2012b). For example, the severity measure for depression is the Patient Health Questionnaire–9 (APA, 2014b; Kroenke, Spitzer, & Williams, 2001). This well-developed instrument is in the public domain, and psychometric data are easy to access and indicate a strong degree of psychometric integrity. On the other hand, the Severity Measure for Panic Disorder–Adult (Shear et al., 2001) has limited validation and few publicly available references regarding development procedures and psychometric considerations (Keough et al., 2012). From an ethical perspective, counselors who use these measures are responsible for ensuring that they do so in a manner that is within their scope of practice and includes appropriate attention to instrument validity and administration procedures. Professional counselors must adhere to ethical standards (American Counseling Association [ACA], 2014; National Board for Certified Counselors [NBCC], 2012) and best practice guidelines (Association for Assessment in Counseling, 2003) when administering and interpreting diagnostic assessments.
A potentially useful tool to enhance clinical understanding of a client’s cultural worldview, the cultural formulation interview (CFI) is the APA’s attempt to address critics’ claims that the DSM has not historically included culture as part of diagnostic assessment (Dailey et al., 2014). Whereas the DSM-IV-TR (2000) included some cultural characteristics within its diagnostic classifications, it was clear that consumers needed more attention to psychosocial and environmental factors (Smart & Smart, 1997). The DSM-5 has continued this trend by updating diagnostic classification to include culture-related diagnostic issues for most disorders, supplemental information about cultural concepts and inclusion of the CFI.
The CFI is a 15–20 minute semi-structured interview consisting of 16 key questions (APA, 2013). With its coverage of numerous topics related to cultural perceptions of the presenting problem, the CFI helps counselors facilitate conversations about domains such as etiological origin, specific circumstances, interpersonal support systems, and coping and help-seeking behavior. Twelve additional modules, to be used as supplements to the CFI or independent of the CFI, are provided by the APA. These modules address topics or specific populations, such as immigrants and refugees; coping and help seeking; and spiritual, religious, or moral traditions. These modules can provide a firm foundation for culturally sensitive counselors to build competence and better understand a client’s worldview from a diagnostic perspective. Even if counselors simply find the CFI a helpful tool for facilitating conversations about culture, the inclusion of the CFI in the DSM-5 is an important step forward in helping professionals improve their understanding of cultural competence as essential to diagnostic assessment.
Perhaps most importantly, counselors do not have to use assessment measures or interview tools associated with the DSM-5 unless those assessment measures are integrated into standard operating procedures with insurance panels or agency policies. We encourage counselors to be selective and discerning as they incorporate emerging tools into practice. Because we expect the APA to continue to release new dimensional assessment and supplemental practice tools on a rolling basis, counselors may wish to visit the DSM-5 website and continue to assess the degree to which the recommended tools may enhance their practice.
Conclusion
Professional counselors comprise one of the largest bodies of DSM consumers (Frances, 2011). Regardless of background, training or theoretical orientation, counselors are responsible for understanding diagnostic practices and using them responsibly (ACA, 2014; NBCC, 2012). Counselors who are aware of recent modifications to the DSM position themselves for continued advancement of care systems that support “diverse individuals, families, and groups to accomplish mental health, wellness, education, and career goals” (Kaplan et al., in press). In this article, we attended to higher-level philosophical and structural changes within the DSM so that counselors may deepen their understanding regarding underlying foundations and motivations for DSM-5 revisions, even as they adopt more concrete diagnostic practices. We hope this historical and philosophical context helps counselors better advocate for a seat at the table in future DSM revision processes. In the meantime, counselors may use this information to make informed decisions about whether and how they will use the DSM-5.
Conflict of Interest and Funding Disclosure
The author reported no conflict of interest or funding contributions for the development of this manuscript.
References
American Counseling Association. (2014). 2014 ACA code of ethics. Alexandria, VA: Author.
American Psychiatric Association. (n.d.). DSM-5 coding update. Retrieved from http://dsm.psychiatryonline.org/DSM5CodingSupplement
American Psychiatric Association. (1968). Diagnostic and statistical manual of mental disorders (2nd ed.). Washington, DC: Author.
American Psychiatric Association. (1980). Diagnostic and statistical manual of mental disorders (3rd ed.). Washington, DC: Author.
American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text rev.). Washington, DC: Author.
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: Author.
American Psychiatric Association. (2014a). DSM-5 overview: The future manual. Retrieved from http://www.dsm5.org/about/Pages/DSMVOverview.aspx
American Psychiatric Association. (2014b). Online assessment measures. Retrieved from http://www.psychiatry.org/practice/dsm/dsm5/online-assessment-measures
Association for Assessment in Counseling. (2003). Responsibilities of users of standardized tests (RUST; 3rd ed.). Retrieved from http://aarc-counseling.org/assets/cms/uploads/files/rust.pdf
Badenoch, B. (2008). Being a brain-wise therapist: A practical guide to interpersonal neurobiology. New York, NY: W. W. Norton.
Beutler, L. E., & Malik, M. L. (Eds.). (2002). Rethinking the DSM: A psychological perspective. Washington, DC: American Psychological Association.
Blashfield, R. K. (1998). Diagnostic models and systems. In A. S. Bellack & M. Herson (Series Eds.), & C. R. Reynolds (Vol. Ed.), Comprehensive clinical psychology: Volume 4. Assessment (pp. 57–80). doi:10.1016/B0080-4270(73)00225-X
Brown, T. A., & Barlow, D. H. (2005). Dimensional versus categorical classification of mental disorders in the fifth edition of the diagnostic and statistical manual of mental disorders and beyond: Comment on the special section. Journal of Abnormal Psychology, 114, 551–556. doi:10.1037/0021-843X.114.4.551
Clarke, D. E., Narrow, W. E., Regier, D. A., Kuramoto, S. J., Kupfer, D. J., Kuhl, E. A., . . . Kraemer, H. C. (2013). DSM-5 field trials in the United States and Canada, Part I: Study design, sampling strategy, implementation, and analytic approaches. American Journal of Psychiatry, 170, 43–58.
Cozolino, L. (2010). The neuroscience of psychotherapy: Healing the social brain (2nd ed.). New York, NY: W. W. Norton.
Dailey, S. F., Gill, C. S., Karl, S. L., & Barrio Minton, C. A. (2014). DSM-5 learning companion for counselors. Alexandria, VA: American Counseling Association.
Eriksen, K., & Kress, V. E. (2006). The DSM and the professional counseling identity: Bridging the gap. Journal of Mental Health Counseling, 28, 202–217.
First, M. B. (2010). Clinical utility in the revision of the diagnostic and statistical manual of mental disorders (DSM). Professional Psychology: Research and Practice, 41, 465–473. doi:10.1037/a0021511
Frances, A. J. (2011, June 3). Who needs DSM-5? A strong warning comes from professional counselors. Psychology Today. Retrieved from http://www.psychologytoday.com/blog/dsm5-in-distress/201106/who-needs-dsm-5
Gever, J. (2012, May 10). DSM-5: What’s in, what’s out. Retrieved from http://www.medpagetoday.com/MeetingCoverage/APA/32619
Health Insurance Portability and Accountability Act of 1996, 42 U.S.C.A. § 1320d et seq. (West 1996).
Hinkle, J. S. (1999). A voice from the trenches: A reaction to Ivey and Ivey (1998). Journal of Counseling & Development, 77, 474–483. doi:10.1002/j.1556-6676.1999.tb02475.x
Ivey, A. E., & Ivey, M. B. (1998). Reframing DSM-IV: Positive strategies from developmental counseling and therapy. Journal of Counseling & Development, 76, 334–350. doi:10.1002/j.1556-6676.1998.tb02550.x
Jones, K. D. (2012a). A critique of the DSM-5 field trials. The Journal of Nervous and Mental Disease, 200, 517–519.
Jones, K. D. (2012b). Dimensional and cross-cutting assessment in the DSM-5. Journal of Counseling & Development, 90, 481–487. doi:10.1002/j.1556-6676.2012.00059.x
Kaplan, D. M., Tarvydas, V. M., & Gladding, S. T. (in press). 20/20: A Vision for the Future of Counseling: The new consensus definition of counseling. Retrieved from http://www.counseling.org/docs/david-kaplan’s-files/consensus-definition-of-counseling.docx?sfvrsn=2
Keough, M. E., Porter, E., Kredlow, M. A., Worthington, J. J., Hoge, E. A., Pollack, M. H., . . . & Simon, N. M. (2012). Anchoring the panic disorder severity scale. Assessment, 19, 257–259. doi:10.1177/1073191112436668
Kraus, K. (2013). 20/20 A vision for the future of counseling: Endorsement letter. Alexandria, VA: American Counseling Association. Retrieved from http://www.counseling.org/docs/david-kaplan’s-files/endorsement-letter.docx?sfvrsn=2
Kroenke, K., Spitzer, R. L., & Williams, J. B. W. (2001). The PHQ-9 validity of a brief depression severity measure. Journal of General Internal Medicine, 16, 606–613.
Kupfer, D. J., First, M. B., & Regier, D. A. (Eds.). (2002). A research agenda for DSM-V. Washington, DC: American Psychiatric Publishing.
Kupfer, D. J., & Regier, D. A. (2011). Neuroscience, clinical evidence, and the future of psychiatric classification in DSM-5. The American Journal of Psychiatry, 168, 672–674.
Kutchins, H., & Kirk, S. A. (1997). Making us crazy: DSM: The psychiatric bible and the creation of mental disorders. New York, NY: Free Press.
Mannarino, M. B., Loughran, M. J., & Hamilton, D. (2007, October). The professional counselor and the diagnostic process: Challenges and opportunities for education and training. Program presented at the annual Association for Counselor Education and Supervision Conference, Columbus, OH.
Maser, J. D., Kaelber, C., & Weise, R. E. (1991). International use and attitudes toward DSM-III and DSM-III-R: Growing consensus in psychiatric classification. Journal of Abnormal Psychology, 100, 271–279. doi:10.1037/0021-843X.100.3.271
Montes, S. (2013, November 1). Facing a rising tide of personality disorders. Counseling Today, 56(5), 33–39.
Narrow, W. E., Clarke, D. E., Kuramoto, S. J., Kraemer, H. C., Kupfer, D. J., Greiner, L., & Regier, D. A. (2013). DSM-5 field trials in the United States and Canada, Part III: Development and reliability testing of a cross-cutting symptom assessment for DSM-5. The American Journal of Psychiatry, 170, 71–82.
National Board for Certified Counselors. (2012). NBCC code of Ethics. Greensboro, NC: Author.
Regier, D. A., Narrow, W. E., Clarke, D. E., Kraemer, H. C., Kuramoto, S. J., Kuhl, E. A., & Kupfer, D. J. (2013). DSM-5 field trials in the United States and Canada, Part II: Test-retest reliability of selected categorical diagnoses. The American Journal of Psychiatry, 170, 59–70.
Regier, D. A., Narrow, W. E., Kuhl, E. A., & Kupfer, D. J. (2009). The conceptual development of DSM-V. The American Journal of Psychiatry, 166, 645–650.
Rogler, L. H. (1997). Making sense of historical changes in the diagnostic and statistical manual of mental disorders: Five propositions. Journal of Health and Social Behavior, 38, 9–20.
Rowland, A. S., Lesesne, C. A., & Abramowitz, A. J. (2002). The epidemiology of attention-deficit/hyperactivity disorder (ADHD): A public health view. Mental Retardation and Developmental Disabilities Research Reviews, 8, 162–170. doi: 10.1002/mrdd.10036
Sanders, J. L. (2011). A distinct language and a historic pendulum: The evolution of the diagnostic and statistical manual of mental disorders. Archives of Psychiatric Nursing, 25, 394–403. doi:10.1016/j.apnu.2010.10.002
Scotti, J. R., & Morris, T. L. (2000). Diagnosis and classification. In M. Hersen & R. T. Ammerman (Eds.), Advanced abnormal child psychology (2nd ed., pp. 15–32). Mahwah, NJ: Lawrence Erlbaum.
Shear, M. K., Rucci, P., Williams, J., Frank, E., Grochocinski, V., Vander Bilt, J., . . . & Wang, T. (2001). Reliability and validity of the Panic Disorder Severity Scale: Replication and extension. Journal of Psychiatric Research, 35, 293–296.
Smart, D. W., & Smart, J. F. (1997). DSM-IV and culturally sensitive diagnosis: Some observations for counselors. Journal of Counseling & Development, 75, 392–398. doi:10.1002/j.1556-6676.1997.tb02355.x
Wilson, M. (1993). DSM-III and the transformation of American psychiatry: A history. The American Journal of Psychiatry, 150, 399–410.
World Health Organization. (1992). The ICD-10 classification of mental and behavioural disorders: Clinical descriptions and diagnostic guidelines. Geneva, Switzerland: World Health Organization.
Zalaquett, C. P., Fuerth, K. M., Stein, C., Ivey, A. E., & Ivey, M. B. (2008). Reframing the DSM-IV-TR from a multicultural/social justice perspective. Journal of Counseling & Development, 86, 364–371. doi:10.1002/j.1556-6678.2008.tb00521.x
Jul 9, 2014 | Article, Volume 4 - Issue 3
Gary G. Gintner
The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) includes numerous alterations to specific disorders, as well as fundamental conceptual and organizational changes. The purpose of this article is to review three fundamental conceptual changes in DSM-5: the harmonization of the manual with the International Statistical Classification of Diseases and Related Health Problems, the introduction of spectrum disorders and dimensional ratings, and the new organization of the manual. For each change, potential benefits and shortcomings are discussed in terms of innovation, limitations and clinical implications.
Keywords: DSM-5, ICD-10, classification, diagnosis, spectrum disorders
The DSM is probably one of the most widely referenced texts in the mental health field. Considering this scope of influence, the release of its latest edition, DSM-5 (American Psychiatric Association [APA], 2013), has garnered considerable interest among professionals, patient advocacy groups and the public alike (Paris, 2013). Reactions have ranged from enthusiastic support (McCarron, 2013) to concern (Welch, Klassen, Borisova, & Clothier, 2013) and even calls to reject the manual’s use outright (Frances, 2013; Frances & Widiger; 2012). The strength of this reaction—both positive and negative—reflects the scope of change. DSM-5 attempts to integrate almost 20 years of burgeoning research in psychopathology, classification and treatment outcomes that have emerged since the publication of DSM-IV (APA, 1994), the last major revision of the manual’s criteria sets. While DSM-5 has made numerous alterations to specific disorders, fundamental conceptual and organizational changes have had the most substantial impact on reshaping the manual (APA, 2013; Regier, Kuhl, & Kupfer, 2013).
The purpose of this article is to review three of these fundamental conceptual changes: the harmonization of the manual with the ICD, the introduction of spectrum disorders and dimensional ratings, and the new organization of the manual. For each of these innovations, three questions will be addressed. First, what was the basis for introducing the change as an innovation to the manual? Here the rationale and potential contribution of the change will be discussed. Special attention will be paid to issues such as enhanced diagnostic accuracy, coverage and clinical utility. Second, does the innovation have any potential drawbacks or limitations? For example, to what extent could the innovation contribute to over or underdiagnosis, limit access to treatment, or pose some harm like increased stigmatization? Third, what are the practical consequences of the innovation relative to how clinical mental health counselors provide care for their clients? This section considers the impact on day-to-day practice and how the diagnostic process itself may be transformed. The conclusion section ties these three threads of innovations together and discusses implications for mental health practice in the 21st century.
DSM and ICD Harmony
There are two major classification systems for mental disorders: the DSM, used primarily in North America, and the ICD, used worldwide under the auspices of the World Health Organization (WHO). The ICD is a much broader classification encompassing causes of death, illness, injury and related health issues with one chapter dedicated to mental and behavioral disorders (Stein, Lund, & Nesse, 2013). As part of the United Nations Charter, countries around the world have agreed to use the ICD codes to report mortality, morbidity and other health information so that uniform statistics can be compiled. In the United States, the ICD codes are the official codes approved by the Health Insurance Portability and Accountability Act (HIPAA), which are used by insurance companies, Medicare, Medicaid and other health-related agencies (Goodheart, 2014). The code numbers that the DSM has always used are derived from whatever the official version of ICD is at that time. Currently, the ninth revision of the ICD (ICD-9; WHO, 1979) is the official coding system in the United States. The 10th revision of the ICD (ICD-10; WHO, 1992/2010) is scheduled to go into effect on October 1, 2015.
The DSM and ICD classifications of mental disorders have a number of similarities, but also have important differences. Both are descriptive classifications that categorize mental disorders based upon a constellation or syndrome of symptoms and signs. Symptoms are the client’s reports of personal experiences such as feeling sad, anxious or worried. Signs, on the other hand, are observable client behaviors such as crying, rapid speech, and flat affect. Structurally, both manuals group related mental disorders into either chapters (DSM) or diagnostic blocks (ICD). The names and diagnostic descriptions for many of the mental disorders in the ICD are similar to those in the DSM, a consequence of collaboration over the years and a shared empirical pool from which both have drawn.
Despite these similarities, there are significant disparities. First, DSM criteria are very specific and detailed, while the ICD relies more on prototype descriptions with less detailed criteria and minimal background information to guide the diagnostic process (First, 2009; Paris, 2013; Stein et al., 2013; WHO, 1992). Second, since DSM-III (APA, 1980), the DSM has used a multiaxial system that notes not only relevant mental and medical disorders, but also other diagnostic information such as environmental factors (Axis IV) and level of functioning (Axis V). The ICD, on the other hand, has always employed a nonaxial system that simply lists medical disorders, mental disorders, and other health conditions. These differences in complexity reflect the constituencies that each manual is designed to serve: The DSM is primarily used by licensed mental health professionals with advanced degrees, while the ICD needs to be accessible to a range of health care professionals worldwide with a broad range of educational backgrounds (Kupfer, Kuhl, & Wulsin, 2013; WHO, 1992).
A third discrepancy is that the names and descriptions for many disorders differ, which at times reflects marked conceptual differences (First, 2009). For example, in ICD-10 (WHO, 1992) bulimia nervosa has to be characterized by a “morbid dread of fatness” (p. 179), a concept akin to anorexia, while DSM-IV-TR (Text Revision; APA, 2000) requires that self-evaluation be “influenced” (p. 549) by only body shape or weight. As another example, the definition of the type of trauma that qualifies for post-traumatic stress disorder (PTSD) is much broader in ICD-10 (allowing for events that are exceptionally threatening or catastrophic) than in DSM-IV-TR (requiring that the event must be associated with actual or threatened death, serious injury, or threat to the physical integrity). These ICD-DSM disparities have led to difficulties comparing research results, collecting health statistics, communicating diagnostic information and reaching similar diagnostic decisions (APA, 2013; First, 2009; Widiger, 2005). Like conversing in two different languages, the diagnosis has often been lost in translation.
Innovation
From the outset of the DSM-5 development process there was a concerted effort to address these disparities. Joint meetings of representatives from APA and WHO met regularly throughout the process in an effort to make the manuals more compatible (APA, 2013; Regier et al., 2013). The goal was to find ways of harmonizing structural, conceptual and disorder-specific differences. The results of this process have had immediate effects on the look of DSM-5 and will have long-term effects on the harmonization of DSM-5 with the upcoming ICD-11, expected to be released in 2017 (APA, 2013; Goodheart, 2014).
The most significant impact of the harmonizing effort is the discontinuation of the multiaxial system in DSM-5. Axes I–III, the diagnostic axes (APA, 2000), are now collapsed into a nonaxial system, consistent with the ICD format. Psychosocial and environmental problems (formerly Axis IV) can be noted using ICD-10’s codes for problems and situations that influence health status or reasons for seeking care. These are usually referred to as Z codes and were formerly termed V codes in DSM-IV-TR. Axis V’s Global Assessment of Functioning (GAF) has been removed and replaced by an ICD measure for disability, the World Health Organization Disability Assessment Schedule (WHODAS) 2.0 (APA, 2013). Unlike the GAF, however, this rating is not required and serves only as an ancillary tool.
The following is an example of how a DSM-5 diagnosis might be listed using ICD-9’s nonaxial system in ICD-9:
296.42 Bipolar I disorder, current episode manic, moderate severity, with mixed features
307.83 Borderline personality disorder
V62.29 Other problem related to employment
The order of diagnoses would indicate that the bipolar disorder was the principal diagnosis and either the focus of treatment or reason for visit. In this example, borderline personality disorder is a secondary diagnosis. The V code is noted because it is an important area to target in the treatment plan.
There were three major reasons for abandoning the multiaxial system. First, health professionals in general medicine found it difficult to use because it was so different from the ICD format (Kupfer et al., 2013). Second, the multiaxial system contributed to the idea that mental disorders were qualitatively different from medical disorders, a dated dualistic distinction between mind and body (APA, 2013; Kupfer et al., 2013; Lilienfeld, Smith, & Watts, 2013). Third, research had shown that distinctions between Axes I and II were artificial and did not reflect that these axes actually overlapped considerably (Lilienfeld et al., 2013). Thus, the multiaxial system seemed to create artificial distinctions that did not seem valid (Lilienfeld et al., 2013). The ICD, on the other hand, offered a more simplified system that allowed a diverse group of health professionals to code disorders using a similar format.
Substantial harmonization of the manuals, however, will happen in the future. Not much could be done with harmonizing ICD-10 (WHO, 1992), a manual of the DSM-IV (APA, 1994) era, the organization and conceptual framework of which were well established (APA, 2013; Goodheart, 2014). The forthcoming ICD-11 will adopt much of DSM-5’s organizational restructuring (discussed below) and include a number of the new DSM-5 disorders (APA, 2013; Goodheart, 2014).
Limitations
Despite the potential contribution of this harmonization, there are three major drawbacks to consider. First, the loss of the multiaxial system may compromise the richness of the diagnostic assessment. In a sense, the multiaxial system was holistic in that it provided a way of noting prominent psychiatric conditions, maladaptive personality functioning, medical conditions, relevant stressors and environmental problems, and overall functioning. What will prompt clinicians to consider these important domains remains unclear. Noting V codes and assessing disability using the WHODAS 2.0 may be an alternative. However, these tasks are not required in the diagnostic workup and, if history is any guide, will probably be underutilized.
A second consideration is that consilience with the ICD clearly makes the DSM-5 a “medical classification” (APA, 2013, p. 10) and as David Kupfer, the Task Force Chair of DSM-5, has put it, “psychiatric disorders are medical disorders” (Kupfer et al., 2013, p. 388). The DSM espouses that it is atheoretical (APA, 2013; Lilienfeld et al., 2013), but the momentum is clearly swinging toward the central role of biological factors. This risks a reductionistic conceptualization of mind as simply brain. Alternative perspectives that recognize the importance of contextual, psychological, developmental and cultural factors, fundamental to the mental health counseling tradition (Gintner & Mears, 2009), may suffer as a result. The picture is more ominous considering the National Institute of Mental Health’s initiative, Research Domain Criteria (RDoC), designed to develop the next generation of psychiatric classification based upon underlying etiology of “brain disorders” (p. 749) and the identification of biomarkers (e.g., laboratory tests) to direct treatment selection (Insel et al., 2010). The direction in which the diagnostic train is heading is clear. The question is whether the track can be altered to one that is more balanced and biopsychosocial.
A third concern is that efforts to harmonize the manuals do not address many of the disparities between DSM-5 and ICD-9 or ICD-10. This is particularly true of the new disorders that DSM-5 has added, which lack clear ICD-9 or ICD-10 counterparts. The ICD codes that have been selected often do not map well onto these disorders. For example, the code for DSM-5’s hoarding disorder translates to ICD-9’s and ICD-10’s obsessive-compulsive disorder (OCD). Ironically, hoarding disorder was added because research showed that 80% of the time individuals with this condition did not meet criteria for OCD. As another example, binge eating disorder was added to DSM-5 to recognize individuals who had a pattern of maladaptive bingeing episodes, but did not have the compensatory behaviors (e.g., purging) characteristic of bulimia nervosa. The ICD code selected for this disorder was, nevertheless, bulimia nervosa. Because ICD is updated annually, it may be that more appropriate codes will be made available in future years. Thus, while ICD-DSM consilience has occurred, at least to this point, it has been superficial and restricted to the nonaxial formatting of the diagnosis. Clearly, it may enhance the curb appeal of DSM-5 to the medical community, but the real interior renovation is yet to occur, awaiting ICD-11.
Clinical Implications
The demise of the multiaxial system means that mental health counselors must be more intentionally biopsychosocial in their diagnostic assessments. More meat can be put on the bare-bones nonaxial system by systematically assessing these biological, psychological and sociocultural factors. This can be accomplished by always assessing whether any important contextual factors can be noted using the V codes, which will be termed Z codes when ICD-10 goes into effect. The WHODAS 2.0, the retired GAF, and other functioning measures can be recruited to assess impairment. While these measures are not part of the formal diagnosis, they can be noted in the chart and inform treatment planning.
Many insurance companies require a multiaxial diagnosis. The GAF score was often used to justify level of care. At the time of this writing, it is not clear what insurance companies will do with these modifications. The decision here will be important. What insurance companies require, for better or worse, often has profound impact on what clinicians do and the kind of clinical care they deliver.
Spectrum Disorders and Dimensionality
Both the DSM and ICD classify mental disorders into discrete categories. Clinicians make a yes-no decision about whether or not an individual has a disorder, based upon the particular criteria. But it has long been known that this categorical approach is fraught with problems (First & Westen, 2007; Widiger, 2005). First, comorbidity is common and there is some question as to whether comorbid conditions such as depression and anxiety are distinct or are really different expressions of some shared underlying dysfunction (Lilienfeld et al., 2013). Second, clinicians have used the not otherwise specified (NOS) category 30–50% of the time, indicating that a sizable proportion of phenomena have a varied presentation that existing categories do not capture (Widiger, 2005). This is problematic because NOS is not particularly informative in terms of describing the condition or making decisions about treatments. Finally, a categorical system assumes that each disorder is homogenous and that disorder occurs at the particular cut point. There is no recognition of subthreshold symptoms, and there is the assumption that those who do fulfill the criteria are qualitatively similar. This view is at odds with data showing that symptoms vary considerably in terms of severity and accompanying features (First & Tasman, 2004). In this sense, categorical assignment loses potentially useful clinical information about the condition and about what treatment strategies might be indicated.
Innovation
DSM-5 attempts to address this issue by introducing dimensionality to supplement the categorical approach (APA, 2013). While categories indicate differences in kind, dimensions describe variations in degree (Lilienfeld et al., 2013). From this perspective, mental disorders are considered to lie on a continuum, like blood pressure. Theoretically, the spectrum can run from optimal functioning to significant impairment. Markers of morbidity or adverse outcome determine where on the spectrum the cut point for disorder is drawn. In the case of blood pressure, for example, it is 140/90. This dimensionality allows for more fine-grained determination of not only severity or impairment, but also improvement or deterioration. Over the past 30 years, research has shown that many mental disorders appear to be more dimensional and heterogeneous than suggested by ICD’s or DSM’s purely categorical system (First & Westen, 2007; Helzer, 2011; Paris, 2013).
Dimensionality is incorporated into DSM-5 in three general ways. First, DSM-5 has added several formal spectrum disorders, which combine highly related disorders. Autism spectrum disorder merges together DSM-IV-TR’s autism disorder, Asperger’s disorder, childhood disintegrative disorder and pervasive developmental disorder NOS. Research has shown that these four conditions share many common symptoms, and the differences are more a matter of degree (APA, 2013; Tsai & Ghaziuddin, 2014). Another spectrum disorder is substance use disorder, which blends the former categories of abuse and dependence. The somatic spectrum is captured by somatic symptoms disorder, which merges what was formerly somatization disorder, pain disorder and undifferentiated somatoform disorder. For each of these spectrum disorders, DSM-5 provides a severity rating as well as other specifiers to note degree of impairment and complicating features.
A second way that dimensionality is infused into DSM-5 is that severity ratings and an expanded list of specifiers have been placed within the existing categories. In a sense, DSM-5 tries to dimensionalize the category. While this was done to some extent in previous editions, DSM-5 broadens this effort throughout the manual. For example, a number of new specifiers were added to describe mood episodes such as anxious distress (presence of comorbid anxiety), mixed features (presence of symptoms from the opposite mood pole), and peripartum onset (onset of symptoms sometime during pregnancy through one month post-delivery). The addition of these notations can be helpful in making treatment-planning decisions (First & Tasman, 2004). For example, severity ratings are an important consideration in deciding whether to use psychotherapy or medication for the treatment of major depressive disorder (APA, 2010). Feature specifiers like anxious distress and mixed features have been shown to increase suicide risk and portend a more complicated treatment regime (APA, 2013; Vieta & Valentí, 2013).
A third way that dimensionality is being promoted in DSM-5 is through the availability of a variety of online assessment measures (APA, 2014). These are rating scales that fall into three general categories. First, there are disorder-specific measures that correspond closely to the diagnostic criteria. These measures could be used to buttress the more clinical assessment that relies on the diagnostic criteria. They could also provide a means of assessing the client’s baseline and response to treatment over time. Measures are available for a range of disorders including depression, many of the anxiety disorders, PTSD, acute stress disorder and dissociative symptoms. Versions are available for adults as well as children aged 11–17. Most of these are self-completed but some are clinician-rated. A second type of measure is the WHODAS 2.0, discussed earlier, which assesses domains of disability in adults 18 and older. A third type of measure is referred to as cross-cutting symptom measures (CCSM). Similar to a broadband assessment of bodily systems in medicine, these measures assess common psychiatric symptoms that may present across diagnostic boundaries and may be clinically significant to note in the overall treatment plan. Level 1 CCSM is a brief survey of 13 domains of symptoms (e.g., depression, anxiety, psychosis, obsessions, mania). A more in-depth Level 2 assessment measure is available for a domain that indicates a significantly high rating. These measures can be reproduced and used freely by researchers and clinicians and can be downloaded at http://www.psychiatry.org/practice/dsm/dsm5/online-assessment-measures. Use of these types of measure is hoped to add surplus information that can aid diagnosis, case monitoring and treatment planning.
Limitations
Dimensions are not only intuitively appealing, but also seem to be a better reflection of nature (Lilienfeld et al., 2013). Notwithstanding, serious concerns have been raised. First, determining the appropriate cut point on these dimensions is critical in terms of determining true psychopathology. If the bar is set too low, there is a danger of pathologizing normal behavior. If set too high, those who need treatment may be excluded and denied services. At this point, data suggest that at least for autism spectrum disorder and substance use disorder, the bar might be set too high. For both, DSM-5 criteria tend to miss people on the more benign end of the spectrum. For example, those who formerly might have been diagnosed with mild to moderate Asperger’s, pervasive developmental disorder NOS, or substance abuse may no longer qualify for a diagnosis (Beighley et al., 2013; Mayes, Black, & Tierney, 2013; Peer et al., 2013; Proctor, Kopak, & Hoffmann, 2013). On the other hand, Frances (2013) has suggested that the threshold for somatic symptoms disorder is set too low, pathologizing many with normal worry about their medical illnesses.
A second concern is that lumping mild and more severe disorders into a unitary spectrum disorder can have unintended social effects, especially for people on the more benign end of the spectrum. For example, those who formerly were diagnosed with Asperger’s disorder will now be labeled with autism spectrum disorder. A college student who was diagnosed with alcohol abuse using DSM-IV-TR criteria will now carry the same diagnosis as someone who is considered an alcoholic and dependent (Frances, 2013). One unanswered question is the impact of these types of name changes on perceived stigma and consequent help seeking.
A final concern is that the dimensional measures were released prematurely without adequate testing and without sufficient guidelines for their use (Jones, 2012; Paris, 2013). While some of the measures are well established (e.g., Patient Health Questionnaire [PHQ]-9; APA, 2014), others have little to no psychometric support (e.g., Clinician-Rated Severity of Autism Spectrum and Social Communication Disorders). Scoring guidelines are made available, but information about the measure’s psychometric properties and norming are lacking. There also is no information on who is qualified to use these measures and what type of training they should have. Thus, while dimensionality may be an important innovation in the development of the DSM classification system, there are significant challenges ahead in calibrating these dimensions, refining the measures and considering social consequences.
Clinical Implications
Will dimensionality help or hinder the diagnostic process? On one level, the additional information about the condition may shift counselors’ fundamental way of thinking about treatment from “curing” clients (dichotomous) to helping them move toward more optimal points on the spectrum (dimensional). The availability of dimensional measures has the potential of improving diagnostic accuracy and providing a measure of treatment outcome (Segal & Coolidge, 2007). It may open the door to more measurement-based care, in which these ratings can be used to assess more precisely the need for care and the extent to which clients are profiting from treatment. This process may be more feasible to administer, score and record if these measures can be stored on tablets or mobile applications.
In terms of using these dimensional measures, however, the unanswered question is—at what cost? Clinicians are already busy, and anything that encumbers that process even more will be resisted (Paris, 2013). Criteria sets are now a bit more complex to navigate because of the added severity rating and feature specifiers. It will take considerable time to learn and master the range of measures that have been posted online, much less research their psychometric appropriateness for the situations in which they will be used. The wild card is whether managed care will require these types of measures as a way of documenting need for treatment and response to provided services. At this point, clinicians would be best served to proceed cautiously, ensuring that the measures they use are reliable and valid for the client population intended.
The New Organization of DSM-5
How was it decided in previous editions of the DSM which chapters to include and which disorders to place in each of them? While some research guided this process, tradition and clinical consensus were the primary sources that informed the organization of these earlier manuals (First & Tasman, 2004; Regier et al., 2013; Widiger, 2005). DSM-5 took a radically different approach, drawing upon research that examined how disorders actually cluster together. In this section, the new framework is examined and potential benefits and costs discussed.
Innovation
The DSM-5 manual is divided into three major sections. Section I provides an introduction, a discussion of key concepts such as the definition of a mental disorder, and guidelines for recording a diagnosis. Section II is the meat of the manual and contains all the mental disorders and other conditions that can be coded with their diagnostic criteria and background information. Section III includes tools for enhancing the diagnostic process, such as some of the dimensional measures discussed earlier, the WHODAS 2.0, and a Cultural Formulation Interview designed to assess the impact of culture on the clinical presentation. This section also includes a list of proposed mental disorders that require further study (e.g., Internet gaming disorder) and an alternative system for diagnosing personality disorders.
Table 1 lists DSM-5’s major categories (chapters) of mental disorders. Two general principles determined the sequence of chapters and the placement of disorders within chapters. First, disorders were grouped into similar clusters based upon shared underlying vulnerabilities, risk factors, symptoms presentation, course and response to treatment (APA, 2013). Groups that are positioned next to each other share more commonalities than those placed further apart. For example, bipolar disorder follows schizophrenia spectrum because they share a number of vulnerability factors (APA, 2013). Next to bipolar disorder is the chapter on depressive disorders. However, the sequence of chapters indicates that depressive disorders are more distantly related to schizophrenia spectrum. Next, internalizing disorders characterized by depression, anxiety and somatic symptoms are listed in adjacent chapters because of common risk factors, treatment response and comorbidity (APA, 2013). Externalizing disorders, noted by their impulsivity, acting out and substance use, are placed in the latter part of the manual.
Table 1
DSM-5 Classification
|
Sequence of Chapters in Section II
|
| Neurodevelopmental DisordersSchizophrenia Spectrum and Other Psychotic DisordersBipolar and Related DisordersDepressive DisordersAnxiety Disorders
Obsessive-Compulsive and Related Disorders
Trauma- and Stressor-Related Disorders
Dissociative Disorders
Somatic Symptom and Related Disorders
Feeding and Eating Disorders
Elimination Disorders
Sleep-Wake Disorders
Sexual Dysfunctions
Gender Dysphoria
Disruptive, Impulse Control, and Conduct Disorders
Substance-Related and Addictive Disorders
Neurocognitive Disorders
Personality Disorders
Paraphilic Disorders
Other Mental Disorders
Medication-Induced Movement Disorders and Other Adverse Effects of Medication
Other Conditions That May Be a Focus of Clinical Attention |
This shared commonality principle is also evident in the placement of disorders within chapters. As a result, a number of disorders have been transferred to different chapters. For example, DSM-IV-TR’s chapter on sexual and gender identity disorders contained sexual dysfunctions (e.g., premature ejaculation), paraphilias (e.g., exhibitionism) and gender identity disorder. Research showed that these three were not highly related, so they have been moved into different chapters, each of which is more proximally located to related disorders (APA, 2013). As another example, DSM-IV-TR’s anxiety disorders chapter has been divided into three separate chapters: anxiety disorders that are more fear-based (e.g. phobias); obsessive-compulsive and related disorders, which are characterized by preoccupations and repetitive behaviors (e.g., body dysmorphic disorder); and trauma- and stressor-related disorders. The latter is akin to a stress-response spectrum that ranges from severe reactions like PTSD to milder reactions characteristic of an adjustment disorder. It is hoped that these organizational changes will help clinicians locate disorders as well as identify related comorbidities (APA, 2013).
A second organizational principle is that the DSM-5 framework reflects a life-span perspective, both across and within chapters. Neurodevelopmental disorders (e.g., autism spectrum disorder, attention-deficit/ hyperactivity disorder [ADHD]) are listed first because they typically emerge early in life. Schizophrenia spectrum disorders also frequently have antecedents that manifest themselves in childhood (APA, 2013). Next are disorders that usually appear in adolescence and early adulthood, such as bipolar disorders, depressive disorders and anxiety disorders. In the middle and back of the manual are disorders that emerge in adulthood or late adulthood, such as personality disorders and neurocognitive disorders (e.g., dementia related to Alzheimer’s disease).
A developmental perspective also is infused into the organization of each chapter. DSM-IV-TR’s chapter on disorders of infancy, childhood and adolescence has been eliminated, and these disorders have been redistributed throughout the manual into relevant chapters. Each chapter is developmentally organized with disorders that emerge in childhood listed first, followed by those that appear in adolescence and adulthood. For example, oppositional defiant disorder and conduct disorder have been moved to the beginning of the chapter on disruptive, impulse control and conduct disorders. In addition, the criteria sets now include developmental manifestations of symptoms. For example, the ADHD criteria set includes both child and adult examples of the various symptoms. There also is an expanded section on development and course for each of the disorders, which explains how symptoms typically unfold over the life span. It is hoped that these types of changes will help clinicians recognize age-related manifestations of symptomatology (Kupfer et al., 2013; Pine et al., 2011).
The intent of the DSM-5 initiative was to develop a more valid organizational structure grounded in research. In the end it also may help to uncover common etiological factors—the holy grail of classification efforts (Insel et al., 2010; Stein et al., 2013). Certainly, these changes will help with differential diagnosis. The organization provides a better map of the relationship between disorders and how the diagnostic landscape may change over the life span.
Limitations
The new organization of the DSM-5 has been generally well received (Stein et al., 2013). One major concern that has been raised, however, is the decision to dismantle the chapter on child and adolescent disorders (Pine et al., 2011). Now there is not one place where the range of childhood disorders is listed. The neurodevelopment disorders—the remnant of the former child and adolescent chapter—is largely limited to disorders that manifest with early developmental delays and problems with language, learning, motor behavior, thinking or attention. Missing, however, are a broader range of behavior problems and anxiety disorders that the former chapter included. The problem is that many of these disorders can co-occur. For example, about 30–50% of children with conduct disorder have a specific learning disorder (Gintner, 2000). The wide separation of conditions such as these in the manual may interfere with accurate detection, especially among those who are not familiar with child and adolescent disorders.
Clinical Implications
Mental health counselors have a new organization to master. Anecdotally, probably one of the most common comments I hear about the new manual is, “Where do I find X now?” Understanding the new organization of the manual will require more than simply looking over the new structure. It will be critical to read the manual to understand why disorders were grouped in a particular chapter. Chapters that are either newly introduced in the manual or that were significantly altered will certainly need to be carefully reviewed. These include the chapters on neurodevelopmental disorders, obsessive-compulsive and related disorders, trauma- and stressor-related disorders, substance-related and addictive disorders, and neurocognitive disorders.
Importantly, the new DSM-5 message is that the structure is designed to indicate relationships within chapters and between chapters. This is a different way of thinking diagnostically. For example, in considering possible diagnostic alternatives, the clinician can first ask this broad question: Is this on the internalizing or externalizing spectrum? If the condition seems more internalizing, then the possible chapters have been winnowed down, and progressively more specific questions can be asked to locate the disorder in the particular chapter. The organization also alerts the diagnostician that adjacent chapters may hold comorbid conditions or even unexplained subthreshold symptoms. To take advantage of this diagnostic aid, however, it will be critical for mental health counselors to learn their way around this new framework.
Conclusions
These conceptual changes define the new look of DSM-5. ICD’s consilience, dimensionality and the organizational restructuring have fundamentally transformed DSM-5 into a 21st-century document that reflects the current state of knowledge in the mental health profession. The good news is that these changes may make the manual a better reflection of nature (i.e., research has shown it to be more valid) compared to previous editions. As a result, the way counselors diagnose and how they think about mental disorders is changing. Hopefully, such change will not only result in better care, but will also help researchers identify the deeper etiological substrates of mental disorders.
In science, progress also can have a dark side. While the DSM-5 incorporates the latest research, the entire development process and critical review highlight the primitive state of knowledge in the profession. While the spectrums and dimensions will no doubt transform the way mental health professionals diagnose, at this point they are crude and may help certain client populations, but hurt others. Harmonization with the ICD will probably take the DSM-5 to a broader audience of health providers. But it also further medicalizes the DSM-5 and will steer it perilously close to a biologically-based classification system. It will be up to mental health counselors and allied mental health professionals to help correct the course and find the middle way exemplified in the biopsychosocial model. Until then, DSM-5’s advances will be tempered by these potential limitations.
Conflict of Interest and Funding Disclosure
The author reported no conflict of interest or funding contributions for the development of this manuscript.
References
American Psychiatric Association. (1980). Diagnostic and statistical manual of mental disorders (3rd ed.). Washington, DC: Author.
American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: Author.
American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text rev.). Washington, DC: Author.
American Psychiatric Association. (2010). Practice guideline for the treatment of patients with major depressive disorder (3rd ed.). Retrieved from http://psychiatryonline.org/content.aspx?bookid=28§ionid=1667485
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.
American Psychiatric Association. (2014). Online assessment measures. Retrieved from
http://www.psychiatry.org/practice/dsm/dsm5/online-assessment-measures
Beighley, J. S., Matson, J. L., Rieske, R. D., Jang, J., Cervantes, P. E., & Goldin, R. L. (2013). Comparing challenging behavior in children diagnosed with autism spectrum disorders according to the DSM-IV-TR and the proposed DSM-5. Developmental Neurorehabilitation, 16, 375–381. doi:10.3109/17518423.2012.760119
First, M. B. (2009). Harmonisation of ICD–11 and DSM–V: Opportunities and challenges. The British Journal of Psychiatry, 195, 382–390. doi:10.1192/bjp.bp.108.060822
First, M. B., & Tasman, A. (2004). DSM-IV-TR mental disorders: Diagnosis, etiology & treatment. Chichester, England: John Wiley & Sons.
First, M. B., & Westen, D. (2007). Classification for clinical practice: How to make ICD and DSM better able to serve clinicians. International Review of Psychiatry, 19, 473–481. doi:10.1080/09540260701563429
Frances, A. (2013). Essentials of psychiatric diagnosis: Responding to the challenge of DSM-5. New York, NY: Guilford Press.
Frances, A. J., & Widiger, T. (2012). Psychiatric diagnosis: Lessons from the DSM-IV past and cautions for the DSM-5 future. Annual Review of Clinical Psychology, 8, 109–130.
Gintner, G. G. (2000). Conduct disorder and chronic violent offending: Issues in diagnosis and treatment selection. In D.
S. Sandhu & C. B. Aspy (Eds.), Violence in American schools: A practical guide for counselors (pp. 335–351).
Alexandria, VA: American Counseling Association.
Gintner, G. G., & Mears, G. (2009). Mental health counseling. In W. G. Emener, M. A. Richard, & J. J. Bosworth. (Eds.), A guidebook to human service professions: Helping college students explore opportunities in the human services field (2nd ed., pp. 154–165). Springfield, IL: Charles C. Thomas.
Goodheart, C. D. (2014). A primer for ICD-10-CM users: Psychological and behavioral conditions. Washington, DC: American Psychological Association.
Helzer, J. E. (2011). A proposal for incorporating clinically relevant dimensions into DSM-5. In D. A. Regier, W. E. Narrow, E. A. Kuhl, & D. J. Kupfer (Eds.), The conceptual evolution of DSM-5 (pp. 81–96). Washington, DC: American Psychiatric Association.
Insel, T., Cuthbert, B., Garvey, M., Heinssen, R., Pine, D. S., Quinn, K., . . . Wang, P. (2010). Research domain criteria (RDoC): Toward a new classification framework for research on mental disorders. The American Journal of Psychiatry, 167, 748–751. doi:10.1176/appi.ajp.2010.09091379
Jones, K. D. (2012). Dimensional and cross-cutting assessment in the DSM-5. Journal of Counseling and Development,
90, 481–487. doi:10.1002/j.1556-6676.2012.00059.x
Kupfer, D. J., Kuhl, E. A., & Wulsin, L. (2013). Psychiatry’s integration with medicine: The role of DSM-5. Annual Review of Medicine, 64, 385–392. doi:10.1146/annurev-med-050911-161945
Lilienfeld, S. O., Smith, S. F., & Watts, A. L. (2013). Issues in diagnosis: Conceptual issues and controversies. In W. E.
Craighead, D. J. Miklowitz, & L. W. Craighead (Eds.), Psychopathology: History, diagnosis, and empirical
foundations (2nd ed., pp. 1–35). Hoboken, NJ: John Wiley & Sons.
Mayes, S. D., Black, A., & Tierney, C. D. (2013). DSM-5 under-identifies PDDNOS: Diagnostic agreement between the DSM-5, DSM-IV, and checklist for autism spectrum disorder. Research in Autism Spectrum Disorders, 7, 298–306. doi:10.1016/j.rasd.2012.08.011
McCarron, R. M. (2013). The DSM-5 and the art of medicine: Certainly uncertain. Annals of Internal Medicine, 159, 360–361. doi:10.7326/0003-4819-159-7-201310010-00688
Paris, J. (2013). The intelligent clinician’s guide to the DSM-5. New York, NY: Oxford University Press.
Peer, K., Rennert, L., Lynch, K. G., Farrer, L., Gelernter, J., & Kranzler, H. R. (2013). Prevalence of DSM-IV and DSM-5 alcohol, cocaine, opioid, and cannabis use disorders in a largely substance dependent sample. Drug & Alcohol Dependence, 127, 215–219. doi:10.1016/j.drugalcdep.2012.07.009
Pine, D. S., Costello, E. J., Dahl, R., James, R., Leckman, J. F., Leibenluft, E., . . . Zeanah, C. H. (2011). Increasing the developmental focus in DSM-5: Broad issues and specific potential applications in anxiety. In D. A. Regier, W. E. Narrow, E. A. Kuhl, & D. J. Kupfer (Eds.), The conceptual evolution of DSM-5 (pp. 305–321). Washington, DC: American Psychiatric Publishing.
Proctor, S. L., Kopak, A. M., & Hoffmann, N. G. (2013). Cocaine use disorder prevalence: From current DSM-IV to proposed DSM-5 diagnostic criteria with both a two and three severity level classification system. Psychology of Addictive Behaviors. Advance Online Publication. doi:10.1037/a0033369
Regier, D. A., Kuhl, E. A., & Kupfer, D. J. (2013). The DSM-5: Classification and criteria changes. World Psychiatry, 12, 92–98. doi:10.1002/wps.20050
Segal, D. L., & Coolidge, F. L. (2007). Structured and semistructured interviews for differential diagnosis: Issues and applications. In M. Hersen, S. M. Turner, & D. C. Beidel (Eds.), Adult psychopathology and diagnosis (5th ed., pp. 79–100). Hoboken, NJ: John Wiley & Sons.
Stein, D. J., Lund, C., & Nesse, R. M. (2013). Classification systems in psychiatry: Diagnosis and global mental health in
the era of DSM-5 and ICD-11. Current Opinion in Psychiatry, 26, 493–497.
doi:10.1097/YCO.0b013e3283642dfd
Tsai, L. Y., & Ghaziuddin, M. (2014). DSM-5 ASD moves forward into the past. Journal of Autism and Developmental Disorders, 44, 321–330. doi:10.1007/s10803-013-1870-3
Vieta, E., & Valentí, M. (2013). Mixed states in DSM-5: Implications for clinical care, education, and research. Journal of Affective Disorders, 148, 28–36. doi:10.1016/j.jad.2013.03.007
Welch, S., Klassen, C., Borisova, O., & Clothier, H. (2013). The DSM-5 controversies: How should psychologists respond? Canadian Psychology, 54, 166–175. doi:10.1037/a0033841
Widiger, T. A. (2005). Classification and diagnosis: Historical development and contemporary issues. In J. E. Maddux & B. A. Winstead (Eds.), Psychopathology: Foundations for contemporary understanding (pp. 69–91). Mahwah, NJ: Lawrence Erbaum Associates.
World Health Organization. (1979). International statistical classification of diseases and related health problems (9th rev.). Geneva, Switzerland: Author.
World Health Organization. (1992). International statistical classification of diseases and related health problems (10th rev.). Geneva, Switzerland: Author.
World Health Organization. (2010). International statistical classification of diseases and related health problems (10th rev.). Retrieved from http://apps.who.int/classifications/icd10/browse/2010/en
The role of sexuality in the mental health profession can be somewhat blurry for both the novice and the trained counselor. Stephanie Buehler, MPW, PsyD, and certified sex therapist skillfully tackles this issue in her book, What Every Mental Health Professional Needs to Know about Sex. She demystifies the role of sex in therapy by expanding mental health professionals’ knowledge of common sexual issues through outlining stereotypes, appropriate language, sexual anatomy, sexual health and sexual problems, as well as assessment and treatment.
Dr. Marsha Linehan, creator of Dialectical Behavioral Therapy (DBT), has developed a valuable DVD that illustrates how impactful the DBT approach can be when working with clients who present with challenging issues (e.g., suicidality, borderline personality disorder). Dr. Linehan explains the basics of DBT while demonstrating and describing this unique approach in a clear and concise way. This DVD is designed to help the viewer understand the key components of this efficacious treatment modality.
Psychotherapy for Chronic PTSD: A Vietnam Vet’s Journey is a 2-hour and 47-minute training DVD appropriate for a classroom and/or training seminar. The DVD features three individuals: Dr. Victor Yalom (serving as the interviewer), Dr. Frank Ochberg (the clinician with expertise in post-traumatic stress disorder [PTSD]), and Terry (Dr. Ochberg’s client who has struggled with PTSD following his experiences in the Vietnam War). One unique aspect of this DVD is that Dr. Yalom candidly interviews both the clinician and the client about the work that occurs between them; their comments demonstrate the tremendous impact of both the therapeutic relationship and the specific techniques that the DVD highlights.