The Removal of the Multiaxial System in the DSM-5: Implications and Practice Suggestions for Counselors

Jul 8, 2014 | Article, Volume 4 - Issue 3

Victoria E. Kress, Casey A. Barrio Minton, Nicole A. Adamson, Matthew J. Paylo, Verl Pope

With the advent of the DSM-5 in 2013, the American Psychiatric Association eliminated the longstanding multiaxial system for mental disorders. The removal of the multiaxial system has implications for counselors’ diagnostic practices. In this article, the removal of the multiaxial system in the DSM-5 is discussed, and counselor practice suggestions related to each of the five Axes are provided. Additionally, ways in which counselors can sustain their current diagnostic skills while developing updated practices that align with the new streamlined system will be discussed.

Keywords: DSM-5, multiaxial system, diagnostic skills, mental disorders 

The American Psychiatric Association (APA) developed the original Diagnostic and Statistical Manual of Mental Disorders (DSM) in 1952 to create a uniform way to define mental health disorders. At the time, the manual contained narrative, psychodynamic descriptions regarding psychiatric disorders. Fueled by criticism regarding questionable foundations and lack of discrete diagnostic criteria, APA engaged in a comprehensive overhaul of the diagnostic system in preparation for the third edition of the manual (First, 2010). In 1980, the APA released the radically different DSM-III, a categorical nosological system with presumably atheoretical foundations and a multiaxial assessment system that ensured attention to biological, psychological and social elements related to mental disorders.

Although paradigm shifts were not as comprehensive as some might have hoped (First, 2010; Kupfer & Reiger, 2011), the most recent revision process resulted in the DSM-5 (APA, 2013) and the first major structural changes to diagnostic classifications and procedures since the DSM-III (APA, 1980). Key DSM-5 changes included reorganization of disorders into new categories on the basis of presumed etiological characteristics, movement toward dimensional conceptualization of disorders and discontinuation of the multiaxial system (Dailey, Gill, Karl, & Barrio Minton, 2014). Some revisions, such as a trend toward lower diagnostic thresholds (Frances, 2013; Miller & Prosek, 2013) and incorporation of complex, unvalidated assessment tools (First, 2010; Jones, 2012) received a great deal of public attention and comment. In contrast, removal of the multiaxial system happened quietly and with very little scholarly or public comment (Probst, 2014).

In this article, the title DSM will be used to refer to historic versions of the Diagnostic and Statistical Manual of Mental Disorders. References to specific editions will be clearly indicated with numerals or numbers in addition to the title. First, we provide a brief overview of the DSM and its use by counselors. Next, we describe the longstanding multiaxial system and discuss arguments in favor of and against removal of the multiaxial system. Throughout, we discuss implications for counselor diagnosis and practice.

Counselors’ Use of the DSM 

In order to understand the implications of the elimination of the multiaxial system, professional counselors must possess a preliminary understanding of the complex relationship between professional counseling and the DSM. Over time, the more general DSM system has come under critical review, especially by counselors who question how the diagnostic process fits with our professional identity and ethical obligations (Eriksen & Kress, 2006; Kress, Hoffman, & Eriksen, 2010; Zalaquett, Fuerth, Stein, Ivey, & Ivey, 2008). Eriksen and Kress (2005) detailed commonly cited limitations of the DSM and how it is used:

• Historically, some diagnostic labels have marginalized, stigmatized and harmed those who are different from the mainstream (e.g., homosexuality was once a DSM diagnosis).
• There is limited evidence of cross-cultural validity in diagnostic conceptualizations.
• Counselors who focus narrowly on diagnosis may only look for behaviors that fit within a medical or biological understanding of the person’s struggles (i.e., becoming reductionistic).
• The DSM system does not include sufficient emphasis on contextual factors (e.g., developmental struggles and transitions, culture, gender), strengths, resources, and uniqueness that may better explain the roots of client struggles and treatment implications.
• The DSM system cannot predict treatment outcomes or point to the etiology of mental disorders.
• Some people may use diagnosis to accept a self-fulfilling prophecy that their situation is hopeless and that they are sick.
• Diagnosing may preclude a focus on the client’s unique construction of his or her experience.
• There are flaws in the science behind DSM diagnoses; what is and is not classified as a mental disorder is often rooted in a political agenda and historical influences.

Limitations of the DSM require that counselors use it carefully, and thoughtfully consider challenges related to its use. Although Eriksen and Kress (2005) wrote in reference to the DSM-IV-TR, underlying assumptions and broad-based diagnostic processes have not changed in the DSM-5 (APA, 2013). We expect that these limitations will continue to be relevant to counselors.

In contrast to the reductionistic, medically oriented diagnostic model inherent within the DSM system (Eriksen & Kress, 2005), counselors emphasize strength-based and developmentally, culturally and contextually sensitive approaches (Kress & Paylo, 2014). Despite the best efforts of many counselors to establish and promote a professional identity that is distinct from other mental health professions, market demands frequently dictate aspects of clinical practice (Eriksen & Kress, 2006). Counselors are licensure-eligible in all 50 states and regularly recognized on insurance panels; as such, there is an expectation that mental health counselors will use the DSM for third-party reimbursement (Kress & Paylo, 2014). Thus, counselors may find themselves working to balance unique professional identities with realities of a diagnostic system created by and for physicians who have a primary focus on pathology.

Despite its limitations, the DSM system is useful in a number of ways (APA, 2013; Dailey et al., 2014; Eriksen & Kress, 2005, 2006; Kress & Paylo, 2014). Primarily, it serves as a way of communicating about client problems and struggles. Assuming that all client-related information is considered, it offers a vehicle for reducing complex information into a manageable form (Kress & Paylo, 2014). Through the categorization of psychological symptoms into disorders, the DSM system provides a means for counselors to select evidence-based treatments that correspond to said disorder. Some clients may benefit from receiving a diagnosis as it may help them to normalize and understand their experiences, sometimes even helping them to reduce the shame and self-blame that often relate to symptoms (Eriksen & Kress, 2005). Finally, categorization and identification of disorders allows researchers to study the etiology and treatment of various mental disorders. Such a process lends itself well to the development of prevention, early intervention and effective treatment measures that have very real impacts on clients’ lives (APA, 2013). The DSM-5 (APA, 2013) also provides systematic information about diagnostic features, associated features supporting diagnosis, subtypes and/or specifiers, prevalence, development and course, risk and prognostic factors, diagnostic measures, functional consequences, culture-related diagnostic issues of each diagnosis; this information may be helpful to counselors who are struggling to fully understand their clients’ experiences.

An understanding of clients’ contextual experience is essential for conceptualizing client concerns and planning counseling strategies that are relevant to clients and have a strong probability of success (Kress & Paylo, 2014). In the past, those who engaged in multiaxial diagnosis were cued to at least consider biopsychosocial elements of clients’ concerns, including mental disorders, medical conditions, psychosocial and environmental stressors, and overall functioning. In the following section, we attend to the rise and fall of the multiaxial system.

Rise and Fall of the Multiaxial System 

The APA first introduced the multiaxial system in the DSM-III (1980). A radical departure from the previous version of the document, the DSM-III introduced categorical, symptom-based diagnosis (First, 2010). In attempts to ensure clinical utility of information reported, the authors suggested, but did not require, that clinicians report diagnostic information on five distinct Axes. This tradition continued with only modest changes in the DSM-IV (APA, 1994) and DSM-IV-TR (APA, 2000).

The DSM-IV-TR (APA, 2000) multiaxial system involved documentation of diagnosis on five Axes. Axis I listed the primary or principal diagnoses that needed immediate attention; this included recording of clinical disorders as well as “Other Conditions That May Be a Focus of Clinical Attention” (e.g., life stressors, impairments in functioning; APA, 2000, p. 27). Axis II contained pervasive psychological issues such as personality disorders, personality traits and mental retardation (now intellectual disability disorder) that shaped responses to Axis I disorders. Axis III was intended to cue reporting of medical or neurological problems that were relevant to the individual’s current or past psychiatric problems. Axis IV required clinicians to indicate which of nine categories of psychosocial or environmental stressors influenced client conceptualization or care (e.g., recent divorce, death of partner, job loss). Finally, Axis V included the opportunity to provide a Global Assessment of Functioning (GAF) rating, a number between 0 and 100 intended to indicate overall level of distress or impairment.

Introduction of the multiaxial system was never without controversy or difficulty (Probst, 2014). Specific concerns included the degree to which Axes I and II were mutually exclusive and distinct (Røysamb et al., 2011), lack of clear boundaries between medical and mental health disorders (APA, 2013), inconsistent use of Axis IV for clinical and research purposes (Probst, 2014), and poor psychometric properties and clinical utility of the GAF (Aas, 2010; APA, 2013). Those most closely associated with APA noted concern that the multiaxial system was rarely used to its full potential and lacked clinical utility (APA, 2013; First, 2010). In 2004, APA first entertained a motion to explore elimination of the multiaxial system unless evidence was presented to suggest that the system enhanced patient care (First, 2010; Probst, 2014). Upon reviewing the literature, a 2005 committee recommended maintaining the system in the next iteration of the DSM and suggested that APA provide resources to support more widespread and consistent use (Probst, 2014). Nearly eight years later, the APA discontinued use of the multiaxial system, seemingly without public discussion or comment. Indeed, APA included just three paragraphs regarding this shift in the DSM-5, noting that “despite widespread use and its adoption by certain insurance and governmental agencies, the multiaxial system in DSM-IV was not required to make a mental disorder diagnosis” (2013, p. 16).

From Multiaxial to Nonaxial Assessment 

Clinicians who are accustomed to documenting diagnosis using a multiaxial system may wonder what DSM-5 assessment and diagnosis will look like. APA provided little concrete guidance, stating, “DSM-5 has moved to a nonaxial documentation of diagnosis (formerly Axes I, II and III), with separate notations for important psychosocial and contextual factors (formerly Axis IV) and disability (formerly Axis V)” (2013, p. 16). In the following sections, we explore evidence related to the shift and identify implications for counselors. 

Medical and Mental Health Conditions (Axes I, II and III)

Axes I, II and III have been eliminated in the DSM-5 (APA, 2013). Clinicians can simply list any disorders or conditions previously coded on these three Axes together and in order of clinical priority or focus (APA, 2013). Because many billing systems already used this system, this may not result in meaningful changes in terms of third-party billing.

This change removes the distinction of previous clinical disorders, personality disorders and intellectual disability disorder. Over time, clinicians have questioned whether Axis II personality disorders were qualitatively different from or any more stable than Axis I clinical disorders (Røysamb et al., 2011); one might also argue that certain developmental disorders (e.g., autism spectrum disorder, previously coded on Axis I) are just as longstanding and pervasive as intellectual disability disorder. Although there is some evidence that personality disorders are distinct from other clinical disorders, emerging evidence indicates that mental disorders do not factor cleanly into these classifications (Røysamb et al., 2011). It is possible that this subtle shift in coding may decrease the stigma often associated with personality disorders.

At the same time, this change in coding suggests that there is no differentiation between medical conditions and mental health disorders. Initially, APA released a definition in which it conceptualized mental disorders as “a behavioral or psychological syndrome or pattern that occurs in an individual” and “reflects an underlying psychobiological dysfunction [emphasis added]” (APA, 2012). The resulting controversy and dialogue regarding lack of evidence for the claim led to a more balanced definition of mental disorder as involving “a dysfunction in the psychological, biological, or developmental processes underlying mental functioning” (APA, 2013, p. 20). Still, clinicians will find that the previous DSM-IV-TR phrase “general medical condition” has been replaced with “another medical condition” throughout the DSM-5 (e.g., APA, 2013, p. 161). Together, these reinforce an assumption that mental disorders are rooted in biological causes.

Some have suggested that an increased emphasis on mental disorders as organic implies that environmental factors are less important, and this could reduce the stigma that many people with mental disorders feel (Yang, Wonpat-Borja, Opler, & Corcoran, 2010). Certainly, the DSM-5 (APA, 2013) includes evidence that some mental disorders have considerable genetic and neurological links, even if scientists have yet to identify clear laboratory markers for any DSM diagnosis (First, 2010). However, others have suggested that this approach could reinforce the notion that those with mental disorders are biologically flawed as opposed to being complex beings who traverse many complicated contextual factors that impact their functioning (Ben-Zeev, Young, & Corrigan, 2010).

This shift toward viewing mental disorders from a neurobiologically based perspective may result in increased use of psychopharmacotherapy, or medication therapy (Frances, 2013). Although many clients may benefit from or require psychotropic medications to function effectively, others with mental disorders do not require this type of intervention. The use of medications can invite serious side effects and financial costs and preclude participation in psychosocial therapies demonstrated to be successful in long-term management of many mental disorders. Counselors should be mindful of these changes as they advocate at the community, state and national levels to ensure clients are educated about medication options, understand effectiveness of psychosocial and counseling treatments, and have access to appropriate care (Dailey et al., 2014).

Even if somewhat arbitrary, removing the distinction between mental disorders and medical disorders has the potential of creating confusion within the helping professions as to the nature of the treatment provided. Counselors may struggle regarding their role in recording medical diagnoses that they are not qualified to diagnose, and should collaborate with medical professionals to offer a holistic treatment conceptualization. Counselors would do well to consider the body of evidence regarding etiology of mental disorders and evaluate ways in which they may make unique contributions to client change. 

Psychosocial and Contextual Factors (Axis IV)

Clinicians previously listed psychosocial and contextual factors that affect clients and are relevant to conceptualization on Axis IV:

Originally conceived in the third edition of the diagnostic manual as a way to rate and rank the severity of particular stressors, axis IV was simplified for the fourth edition because of the difficulty in reliably quantifying the etiologic contribution of specific stressors to mental disorder; instead, clinicians were asked to simply note salient environmental factors. (Probst, 2014, p. 123)

This included notation regarding concerns in nine key areas: primary support group, social environment, education, occupation, housing, economic, access to health care, legal system/crime and other (APA, 2000).

Although information listed on Axis IV was intended to supplement diagnoses on the first two Axes, clients who attended counseling for only an Axis IV diagnosis were not eligible to receive mental health coverage from insurance companies (APA, 2013). In fact, Probst (2014) provided evidence that APA was intentional in ensuring that Axis IV was not codable and optional for billing purposes in efforts to preserve a degree of client confidentiality. As such, the new nonaxial coding system might actually increase accessibility of services depending upon insurance companies’ individual responses (APA, 2013). Beginning with the DSM-5, clinicians are advised to make a separate notation regarding contextual information, rather than including it in axial notation. However, the APA (2013) did not provide guidance regarding how or where to do so.

Although there is no longer an Axis for contextual factors, it is imperative that counselors maintain a holistic focus that aligns with our unique identity (Hansen, 2009). Along with a humanistic, strength- and competency-based perspective, counselors are sensitive to contextual and cultural considerations. Context refers to the interrelated conditions in which clients’ experiences occur, or any factors that surround their experience and illuminate their situation. As previously discussed, many traditional understandings of mental disorders highlight a pathology- and deficit-based perspective. When considering clients’ situations from a contextual perspective, counselors are responsible for incorporating attention to culture, gender and various developmental factors. “Eliminating axis IV does not eliminate the need to consider context—unless it can be shown that genetic and neurochemical factors alone account for the emergence, variation, and trajectory of mental and emotional disorder” (Probst, 2014, p. 129). Thus, counselors are challenged to find new ways to communicate information previously provided in the multiaxial system.

A firm understanding of clients’ context may lead to a more compassionate and holistic conceptualization of symptoms that could be better explained by contextual factors or environmental stressors (Eriksen & Kress, 2005; Kress & Paylo, 2014). In addition, epidemiological research suggests that psychosocial and environmental problems have moderate predictive value for understanding prognosis of major depression, suicidality, anxiety disorders and substance use disorders (Gilman et al., 2013). Additionally, contextually sensitive counselors define some mental disorders as being a person’s functional attempts to adapt to or cope with a dysfunctional context (Ivey & Ivey, 1999). It is important that any diagnostic discussions integrate a focus on these contextual factors.

Culture is an exceptionally important contextual consideration; through culture, clients define, express and interpret their beliefs, values, customs and gender role expectations (Bhugra & Kalra, 2010). Multicultural considerations should enlighten counselors’ diagnostic decisions and ultimately the treatment process. Although it still has room for development, the DSM-5 (2013) includes systematic information regarding gender and culture for each diagnostic category. In some cases, this is limited to a simple accounting of the prevalence of disorders within certain groups; in other cases, APA provided information regarding the diverse presentation or understanding of disorders. Further, the American Counseling Association’s (ACA) Code of Ethics (2014) emphasizes that culture influences manifestation and understanding of problems; thus, counselors must consider culture throughout the counseling and treatment process.

Counselors can use formal or informal assessment to explore and understand clients’ context. The DSM-5 includes a Cultural Formulation Interview (CFI) that counselors can use to help them understand clients’ context and its impact on their experiences and symptoms. The CFI may help counselors obtain the most clinically useful information, develop a relational connection with clients and ultimately make accurate diagnoses. The CFI is included in Section III of the DSM-5 and is a semi-structured interview composed of 16 questions that address both individual experience and social context. The text is divided into two columns, with counselor-generated questions on the right and instructions for application on the left. Two versions of the interview are available, one for the individual and one for an informant (e.g., a caregiver or a parent). The interviews also are available online at the APA’s (2014) DSM-5 website. The CFI also includes 12 Supplementary Modules, which provide additional questions used to assess domains of the 16-item CFI (e.g., cultural identity) as well as questions that counselors can ask during the cultural assessment of particular groups (e.g., children and adolescents, older adults, immigrants and refugees, and caregivers).

Should counselors elect not to use this more formal interview format to assess culture, there are multiple additional formal and informal cultural assessments as well as assessment guidelines that they can apply. For example, Castillo (1997) provided the following guidelines for culturally sensitive diagnosis: (a) assess the client’s cultural identity; (b) identify sources of cultural information relevant to the client; (c) assess the cultural meaning of a client’s problem and symptoms; (d) consider the impacts and effects of family, work and community on the complaint, including stigma and discrimination that may be associated with mental illness in the client’s culture; (e) assess for counselor personal biases; and (f) plan treatment collaboratively. Castillo’s guidelines offer a comprehensive assessment that may inform diagnostic practices.

The ACA’s Code of Ethics (2014) also indicates that counselors should recognize social prejudices that lead to misdiagnosis and overpathologizing of certain populations. It is impossible to understand clients’ unique situations and how to best help them if cultural considerations are not addressed. An understanding of clients’ culture in relation to diagnosis includes understanding cultural explanations of their experiences, their help-seeking behavior, the cultural framework of clients’ identity, cultural meanings of healthy functioning and cultural aspects that relate to the counselor–client relationship (Eriksen & Kress, 2005).

Counselors can address, consider and convey contextual factors through use of V Codes and Z Codes, and by including attention to contextual factors within the treatment record and conceptualization process (Kress, Paylo, Adamson, & Baltrinic, in press). In the DSM-5, the APA greatly expanded the list of codes to provide a means for documenting “other conditions and problems that may be a focus of clinical attention or that may otherwise affect the diagnosis, course, prognosis, or treatment of a patient’s mental disorder” (2013, p. 715). These are included alongside mental disorders and medical conditions on the nonaxial diagnosis discussed previously. Examples of V/Z Codes in the DSM-5 include the following: difficulties rooted in interpersonal issues (e.g., parent–child, sibling, partner distress), issues with abuse and neglect (e.g., partner abuse, child abuse, maltreatment), education or occupational difficulties, problems with housing and finances, difficulties within their social environment (e.g., phase of life, acculturation, target of discrimination), legal issues and other personal circumstances (e.g., obesity, nonadherence to treatment, borderline intellectual functioning). For example, a client who presents with major depressive disorder and reports a recent marital separation that has resulted in homelessness might receive a diagnosis of: 296.22 (F32.1) major depressive disorder, single episode, moderate; V61.03 (Z63.5) disruption of family by separation; and V60.0 (Z59.0) homelessness.

The move toward eliminating the multiaxial system emphasizes the idea that mental disorders do not occur apart from physical considerations and contextual struggles. In some ways, this change is consistent with a professional counseling philosophy. However, because there is no longer an infrastructure to cue consideration of contextual concerns, counselors must be ever more vigilant in identifying systematic ways to assess this information and integrate it into treatment plans in meaningful ways. How counselors convey this information may vary across providers and contribute to some confusion in communicating this information. Thus, the elimination of this axis may provide more flexibility at the expense of clear communication. 

Functioning and Disability (Axis V)

Initially developed as the Health-Sickness Rating Scale, the GAF was introduced as Axis V of the DSM-III and DSM-IV (Aas, 2011). The scale called for clinicians to “consider psychological, social, and occupational functioning on a hypothetical continuum of mental health–illness. Do not include impairment in functioning due to physical (or environmental) limitations” (APA, 2000, p. 34). Over time, this single number scale came to be used to assist in payers’ determinations of medical necessity for treatment and in determining eligibility for disability compensation (Kress & Paylo, 2014). The APA discontinued use of the GAF in the DSM-5, and now suggests that clinicians use the World Health Organization Disability Assessment Schedule (WHODAS 2.0) as a measure of disability.

The GAF scale was removed from the DSM-5 because of perceived lack of reliability and poor clinical utility (APA, 2013). In a comprehensive review of literature regarding the GAF, Aas (2010, 2011) concluded insufficient reliability in clinical settings, lack of precision, inability to detect change and limited evidence of concurrent and predictive ability. One additional concern is the way in which the GAF combined attention to symptom severity and impairment. Hilsenroth et al. (2000) noted concern regarding overlap between previous Axis I and II diagnoses and GAF ratings, as evidenced by the APA’s continuing work to develop alternate measures of functioning such as the Global Assessment of Relational Functioning and the Social and Occupational Assessment Scale. Empirical evidence suggested that GAF scores relate to client and clinician perceptions of concerns (Bacon, Collins, & Plake, 2002; Hilsenroth et al., 2000) more so than with social adjustment or interpersonal problems (Hilsenroth et al., 2000). Others have expressed concern regarding the limits of use of the GAF with children (Schorre & Vandvik, 2004).

Ro and Clark (2009) argued that the construct of functioning is complex and multidimensional in a way that simple GAF ratings regarding symptom severity and impairment cannot capture. They stated that the World Health Organization’s (WHO) conceptualization of functioning as a component of health, and disability as impairment in functioning, was particularly helpful. Perhaps more importantly, Ro and Clark presented empirical evidence that functioning includes four key factors: well-being (including satisfaction, quality of life and personal growth), basic functioning in life demands, self-mastery, and interpersonal and social relationships. Certainly, this conceptualization fits well with an understanding of counseling as a profession dedicated to maximizing human development (Hansen, 2009).

Historically, payers approved the nature and extent of services based upon GAF scores, diagnosis, severity of symptoms, danger to self or others, and disability across life contexts. With the elimination of the multiaxial system, counselors will no longer note a GAF score, and will not have an assessment of functioning built into the documentation process. In the absence of GAF scores, the APA (2013) suggested that practitioners use alternative ways to note and quantify distress and disability in functioning. The APA also suggested that practitioners continue to assess for suicide and homicide risk and use available standardized assessments to assess for symptom severity and disability (APA, 2013).

The APA (2013) recommended the WHODAS 2.0 as a preferred measure for use in assessing clients’ functioning. The WHODAS 2.0 can be used with clients who have a mental or physical condition or disorder. The WHODAS 2.0 is a free assessment instrument that is provided in the DSM-5, included on the WHO’s website and available through the DSM-5 online assessment measures website (www.psychiatry.org/dsm5). A manual (Ustün, Kostanjsek, Chatteriji, & Rehm, 2010) also is available free of charge.

The WHODAS 2.0 is a 36-item measure that assesses disability in people 18 years and older. It assesses for disability across six different domains: self-care, getting around, understanding and communicating, getting along with people, life activities (e.g., work and/or school activities), and participation in one’s community/society. When completing the form, clients rate the six areas based on their functioning over the past 30 days. Respondents are asked to respond as follows: none (1 point), mild (2 points), moderate (3 points), severe (4 points), and extreme or cannot do (5 points). Scoring of the assessment measure involves either simple scoring (i.e., the scores are added up based on the items endorsed with a maximum possible score suggesting extreme disability as 180) or complex scoring (i.e., different items are weighted differently). The computer program that provides complex scoring can be found on the WHO’s website. The WHODAS 2.0 can be used to track changes in the client’s level of disability over time. It can be administered at specified intervals that are most relevant to the clients’ and counselors’ needs.

The WHODAS 2.0 has been decades in development, involving more than 65,000 participants in hundreds of studies conducted across 19 countries. Ustün et al. (2010) summarized psychometric evidence in support of the WHODAS as follows:

The WHODAS 2.0 was found to have high internal consistency (Cronbach’s alpha, α: 0.86), a stable factor structure; high test-retest reliability (intraclass correlation coefficient: 0.98); good concurrent validity in patient classification when compared with other recognized disability measurement instruments; conformity to Rasch scaling properties across populations, and good responsiveness (i.e., sensitivity to change). Effect sizes ranged from 0.44 to 1.38 for different health interventions targeting various health conditions. (p. 815)

The authors concluded that the instrument is robust and easy to use. Likewise, the assessment tool was tested in the DSM-5 field trials, and researchers suggested that it was sound and reliable in routine clinical evaluations (APA, 2013). Despite strong validity evidence, Kulnik and Nikoletou (2014) cautioned that the instrument seems to connect most cleanly to medical or physical elements of disability, sometimes at the expense of social aspects of disability. Similarly, the WHODAS 2.0 only assesses one of four areas of functioning identified by Ro and Clark (2009). Although counselors may find the WHODAS 2.0 helpful for understanding some elements of disability, they may do well to consider additional holistic and comprehensive opportunities to assess client functioning and strengths.

Discussion 

Counselors should be aware that the act of rendering a DSM diagnosis is only one part of a comprehensive assessment. What one reports in terms of diagnosis is just a snapshot of the client. It does not capture the totality of one’s understanding regarding client strengths and limitations, nor does it indicate how counselors go about constructing that understanding. Any thorough assessment must take into account an understanding of all relevant factors. These include, but are not limited to, psychosocial factors such as psychological symptoms, family interactions, developmental factors, contextual factors, functional abilities and longitudinal-historical information. 

Given elimination of the multiaxial system, we advise counselors to be especially alert to listing V or Z Codes as part of the diagnosis in order to maintain consideration for client context in addition to biology and symptomology. As with prior editions of the DSM, counselors can still use V or Z Codes as sole diagnoses or to augment other diagnoses. Counselors also should document contextual information in their records so that this information can be conveyed to others as appropriate and used to support clients’ treatment.

There are a number of models that can be used to guide counselors’ diagnostic, case conceptualization and treatment practices. One such model is the I CAN START model (Kress & Paylo, 2014), which follows:

• I (Individual) represents the individual counselor and his or her unique experiences, competencies, limitations and other personal factors;
• C (Context) relates to an understanding of the client’s unique context (e.g., culture, gender, sexual orientation, developmental level, religion/spirituality);
• A (Assessment and Diagnosis) represents the assessment of the client and his or her symptoms and the accompanying DSM-5 diagnosis;
• N (Necessary level of care) refers to the client’s required level of care (e.g., residential treatment, hospitalization, outpatient treatment, individual counseling, family therapy);
• S (Strengths) signifies the client’s strengths, resources, and capacities, which can be used in treatment to help him or her overcome his or her problems and thrive;
• T (Treatment) represents the utilization of an evidence-based treatment in addressing the presenting disorders or problems;
• A (Aims and objectives of treatment) denotes the development of clearly defined problems, with measurable goals and clear behavioral counseling objectives;
• R (Research-based interventions) refers to the use of counseling techniques that are based on research; and
• T (Therapeutic support services) involves the use of support services that may complement counseling interventions and treatments (e.g., case management, medication management, nutrition counseling, a physical exercise program, parent training, yoga, meditation).

The loss of the multiaxial system in the DSM-5 provides both opportunities and challenges to counselors. The exact outcome of how the new process will be implemented is not yet known, and only time will show the extent of its impact. With the loss of the multiaxial system, some of the structure associated with its use is also lost. Moving forward, counselors should continue to develop methods for assessing and documenting aspects of the multiaxial system that have been eliminated. With this change comes an opportunity to reaffirm holistic and integrated views of clients and to provide leadership for other mental health professions and professionals regarding how to incorporate this perspective into diagnostic practices.

Conflict of Interest and Funding Disclosure

The author reported no conflict of interest or funding contributions for the development of this manuscript.

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Victoria Kress, NCC, is a Professor at Youngstown State University. Casey A. Barrio Minton, NCC, is an Associate Professor and Counseling Program Coordinator at the University of North Texas. Nicole A. Adamson, NCC, is an Assistant Professor at the University of North Carolina at Pembroke.  Matthew J. Paylo is an Associate Professor at Youngstown State University. Verl T. Pope, NCC, is Chair and Professor of Counseling at Northern Kentucky University. Correspondence can be addressed to Victoria Kress, 1 University  Plaza, Youngstown, OH, 44555, victoriaekress@gmail.com.

Revising Diagnoses for Clients with Chronic Mental Health Issues: Implications of the DSM-5

Jul 5, 2014 | Article, Volume 4 - Issue 3

Laura E. Welfare, Ryan M. Cook

Major depressive disorder, bipolar I disorder and schizophrenia are chronic conditions, and adults who have these diagnoses often benefit from mental health treatment throughout their lives. The recent fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) included changes to many diagnoses. Consequently, counselors need to understand the changes and revise their diagnostic practices accordingly. Changes affect new clients being diagnosed for the first time as well as long-term clients who were initially diagnosed many years ago. This manuscript provides an explanation of changes to major depressive disorder, bipolar I disorder and schizophrenia. Case examples illustrate implications for counselors who work with clients who have these three serious and chronic mental illnesses. Counselors, following best practice guidelines and the American Counseling Association’s ethical mandate, can take advantage of this opportunity to ensure that clients understand their mental health conditions and that documented diagnoses are accurate and thorough.

Keywords: major depressive disorder, bipolar I disorder, schizophrenia, DSM-5, diagnoses, chronic mental illness 

Major depressive disorder, bipolar I disorder and schizophrenia are chronic mental health conditions. Adults who have these diagnoses often benefit from mental health treatment from counselors, psychiatrists and other clinicians throughout their lives. A new edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5; American Psychiatric Association [APA], 2013) has been released. The changes therein impact both new clients who present for initial assessment and also clients who have been in treatment for chronic conditions. A thorough understanding of the implications for revising existing diagnoses will help counselors provide quality services to clients who need ongoing support. Counselors also are responsible for helping clients understand their diagnoses, so the release of the DSM-5 is an opportunity to ensure that both new clients and clients in long-term treatment have an opportunity to ask questions about their conditions (American Counseling Association [ACA], 2014). Using the full terminology available in the DSM-5 (e.g., defined diagnoses instead of other specified umbrella diagnoses and including specifiers to highlight key features of the disorder) will help establish the new common language so that clinicians and clients can all communicate effectively about treatment. To illustrate how counselors can use the DSM-5 to best serve clients who have major depressive disorder, bipolar I disorder and schizophrenia, this article provides information about each disorder, a description of the changes from the DSM-IV-TR to the DSM-5, case examples and conclusions.

Major Depressive Disorder

Nearly 16 million adults in the United States experience a major depressive episode each year (Substance Abuse and Mental Health Services Administration [SAMHSA], 2013), as defined by the DSM-IV-TR (APA, 2000). Individuals who experience major depressive disorder suffer from impairment in every part of their lives, including relationships, functioning at work and self-care. When symptoms of depression increase, individuals may not feel motivated to spend time with others. They may feel no pleasure in previously enjoyable activities and experience interactions with others as draining. Similarly, a previously motivated and engaged employee may seem distracted or disconnected at work and absenteeism may become a problem. In addition to problems in relationships and at work, self-care also is impacted by major depression. Time and energy for healthy habits such as exercise and meal preparation may be lost. In severe cases, a lack of attention to basic hygiene may be observable. 

The severity and length of symptoms can vary tremendously for individuals with major depressive disorder. Some people never experience remission while others may enjoy years without symptoms (National Institute of Mental Health [NIMH], n.d.-a). The longer the period of remission, the lower the likelihood of a recurrence (APA, 2013). For those individuals who have more severe episodes, a history of multiple previous episodes, or were first diagnosed at a younger age, lifelong mental health treatment may be necessary to increase quality of life (APA, 2013).

Treatment. Almost 11 million people diagnosed with major depressive disorder sought treatment in 2012, which was approximately 68% of those diagnosed with the disorder (SAMHSA, 2013; based on DSM-IV-TR criteria). The most common forms of treatment are medications (e.g., antidepressants), psychotherapy/counseling or a combination of the two. In 2012, 45% of all individuals who had a major depressive episode used a combination of psychotherapy/counseling and medications, while 14.1% used psychotherapy/counseling only, and 6.6% used medication only (SAMHSA, 2013). More than half of the individuals who received medication for their major depressive episode did so from their general practitioner (SAMHSA, 2013). For those who sought psychotherapy/counseling, many accessed outpatient counseling at a mental health clinic or private practice in the community. About .8% reported they were hospitalized at some point in the year (SAMHSA, 2013). Others may have received treatment that included more intensive interventions such as case management to help with access to services and subsistence or day treatment to provide all-day support and supervision when needed. Because such a small percentage of clients seek psychotherapy/counseling alone (SAMHSA, 2013), it is likely that counselors who work with clients who have major depressive disorder do so as part of a treatment team. Counseling is an essential part of treatment, as there is ample empirical evidence for its effectiveness, particularly cognitive-behavioral and interpersonal techniques (e.g., Paradise & Kirby, 2005). 

Bipolar I Disorder

Bipolar I disorder affects roughly .6% of the population (APA, 2013). It is a lifelong disorder, as nearly all of the individuals who have one manic episode will have multiple episodes in their lifetime (APA, 2013). Symptoms of bipolar I disorder can be detrimental to relationships, daily functioning and financial stability of the individual who is diagnosed with the disorder. The cyclical nature of bipolar I disorder leads to instability, as the episodes of depression, mania and remission each have a different impact on the individual’s life. During episodes of depression, the impact is similar to that caused by major depressive disorder, as described above. In contrast, some individuals with bipolar I disorder report enjoying manic episodes as they escalate because of improved mood, energy and productivity. However, elevated mood often comes with dangerous grandiosity, distractibility and impulsivity. During periods of remission when symptoms are mild or absent, the person may attempt to repair the consequences of their manic episodes (e.g., excessive shopping) and depressive episodes (e.g., neglected chores). 

Few people seek treatment on their own during manic episodes. Initiating or expanding treatment during a manic episode is important to prevent irreparable damage and to ensure safety. Grandiosity combined with risky behaviors can lead to physical injuries and property damage, and the euphoria of elevated mood can quickly shift to anger and irritability. For more than half of individuals with bipolar I disorder, depressive episodes follow manic episodes (APA, 2013), which is especially dangerous to the individual if he or she is not in a secure treatment setting. 

Treatment. Roughly two-thirds of those diagnosed with bipolar I disorder receive treatment each year (Merikangas et al., 2007). The most common form of treatment is medication, including mood stabilizers, atypical antipsychotics and antidepressants (NIMH, n.d.-b). While many of these medications are effective in managing symptoms, some can have serious side effects resulting in additional medical risks such as liver or kidney issues. These risks, in addition to lack of insight into illness, preference for manic episodes, and comorbid personality or addictive disorders can lead to noncompliance (Colom et al., 2000). 

In treating bipolar I disorder, individual therapy and family counseling may be helpful in developing client interpersonal skills and increasing quality of life (NIMH, n.d.-b; Steinkuller & Rheineck, 2009). There is clear empirical evidence suggesting that individuals who participated in psychotherapy more frequently and for a longer duration in addition to using medication had a better prognosis than those who participated in fewer sessions over a shorter period of time (NIMH, n.d.-b.; Steinkuller & Rheineck, 2009). These individuals appeared to recover more quickly, have fewer relapses and require fewer hospitalizations. 

Schizophrenia

About 1% of Americans have schizophrenia (NIMH, n.d.-c). Only one in five people diagnosed with the disorder return to the level of functioning they had before onset. Therefore, schizophrenia is often a pervasive and lifelong disorder that can severely impair daily functioning. Individuals with schizophrenia may have difficulty completing tasks, focusing on assignments and processing information. Because onset of schizophrenia is typically in early adulthood, a person’s ability to make educational progress and develop necessary skills to obtain a job or receive a degree may be limited (NIMH, n.d.-c). The lack of income threatens stable housing and basic needs. Therefore, individuals diagnosed with schizophrenia are likely to require financial assistance from family or public funding sources. 

Treatment. The most common form of treatment for schizophrenia is medication. Antipsychotic medications focus on managing symptoms by reducing the severity and frequency of hallucinations and delusions. However, not all medications work for all individuals, and many can have significant side effects such as blurred vision, tremors, drowsiness, sensitivity to sunlight and tardive dyskinesia (NIMH, n.d.-c). Because of these side effects and the cognitive impairments inherent in the disorder, medication compliance is a problem, as individuals will sometimes skip doses or discontinue medications altogether. 

Other forms of treatment are recommended in conjunction with medication, such as counseling and psychoeducation to teach individuals skills for daily functioning, interacting with others, self-care and employment (NIMH, n.d.-c). Person-centered approaches may be effective, as a lack of insight into the illness may cause clients to become skeptical about treatment (Kreyenbuhl, Nossel, & Dixon, 2009; NIMH, n.d.-c). 

In summary, roughly one in 10 Americans will experience major depressive disorder, bipolar I disorder or schizophrenia each year, and two-thirds of those will seek treatment for their conditions (Merikangas et al., 2007; SAMSHA, 2013). Counselors who provide essential services to clients may have first made the diagnosis long ago and likely are part of a treatment team. With the release of the new version of the DSM, best practice is to review and revise diagnoses for all clients to ensure accuracy. Each change to major depressive disorder, bipolar I disorder and schizophrenia is described below.

Changes from DSM-IV-TR to DSM-5 

Major Depressive Disorder

The mood disorders section in the DSM-IV-TR began with criteria for mood episodes (e.g., depressive, manic, hypomanic; APA, 2000). The mood episodes were later included in the diagnostic criteria for mood disorders. The DSM-5 has a different format. The mood disorders are separated into two sections: depressive disorders, and bipolar and related disorders. In addition, the DSM-5 lists complete criteria for each disorder in one place, rather than separating the mood episodes from the rest of the criteria for each disorder (e.g., major depressive disorder). 

Major depressive disorder now includes a streamlined list of symptoms and examples of each so that clinicians may better understand the intended criteria. Part A of the diagnostic criteria did not change: “Five (or more) of the following symptoms have been present during the same 2-week period and represent a change from previous functioning; at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure” (APA, 2013, p. 160). The nine symptoms that follow are very similar to the symptoms listed in the DSM-IV-TR. The first symptom focuses on depressed mood and is the hallmark of the disorder. The example “hopeless” was added to increase clarity about the way clients may describe how they feel. The requirement of clinically significant distress did not change, nor did the verbiage about symptoms being caused by a medical condition or better explained by other disorders. 

A significant change was made to criterion E of DSM-IV-TR, often called the bereavement exclusion. The previous rule was that major depressive disorder could not be diagnosed following the death of a loved one or other loss unless the symptoms persisted for 2 months (as opposed to the typical 2-week required duration). The DSM-5 states that responses to loss may include feelings and behaviors that match those listed in the criteria for major depressive disorder. Although the reaction may be considered understandable given the recent loss, if criteria for the disorder are met, the diagnosis may be given regardless of the circumstances. Representatives from the depressive disorders work group explained their rationale for this change at the 2013 American Psychiatric Conference (Zisook, 2013). They noted that the criteria for diagnosis should be defined without regard to the cause of the symptoms. Many things can cause or exacerbate depressive symptoms. Most individuals who suffer losses (e.g., death of a loved one, divorce, unemployment) will not experience symptoms severe enough to merit diagnosis (Zisook, 2013). Severe depressive symptoms, such as those required for diagnosis of major depressive disorder, merit clinical attention regardless of external causes in the individual’s life. The DSM-5 gives the counselor the discretion to diagnose major depressive disorder in grieving clients if the symptoms have been met for 2 weeks, rather than requiring 2 months of suffering as noted in the DSM-IV-TR. 

Perhaps more relevant to those clients who have long been diagnosed with major depressive disorder, the DSM-5 included changes to the specifiers. Single episode, recurrent, mild, moderate and severe are again included with different numerical codes for each. One change is that psychotic features can now be added to mild, moderate or severe levels. Specifiers about seasonal pattern, catatonia, melancholia, and atypical features remain with expanded descriptors in some cases. Postpartum was changed to peripartum because symptoms often emerge during pregnancy, which would not fit the DSM-IV-TR specifier of postpartum, but is important nonetheless. The term peripartum means during the pregnancy or in the 4 weeks following delivery, so this specifier can be used in both cases. In addition, new specifiers were added: with anxious distress and with mixed features. Both are described below. 

The specifier with anxious distress is to be used when the client experiences two or more of the following symptoms most days: feels tense, feels unusually restless, worry disrupts concentration, fears something bad will happen, or worries about losing control of oneself. The severity of the anxious distress specifier also is noted, using mild, moderate, moderate-severe and severe. This specifier was added because clinicians frequently described the presence of some symptoms of anxiety in their clients who have major depressive disorder. Often, the threshold is not met for a comorbid anxiety disorder diagnosis but the symptoms are significant nonetheless. Clients with anxious distress are more likely to attempt suicide and may require more intensive treatment than those with depression alone; therefore, it is essential that counselors note these symptoms in the diagnosis (APA, 2013; Goldberg, 2013). 

The specifier with mixed features applies when clients have subthreshold hypomania most days in addition to symptoms of depression. For example, the criteria require three of the following symptoms to be present nearly every day during most of the days in the depressive episode: elevated mood, grandiosity, pressured speech, racing thoughts, increased energy, involvement in risky activities or decreased need for sleep. This specifier is important to note because clients who have major depressive disorder with mixed features are more likely to develop bipolar I or bipolar II disorder (Coryell, 2013). Because treatment for the bipolar disorders is often different from treatment for major depressive disorder, noting the mixed features is important to help clinicians track changes in the client’s symptoms closely. 

A final change in DSM-5 that affects multiple diagnoses, including major depressive disorder, is the inclusion of cross-cutting symptom measures (APA, 2013). The goals of these instruments are to help clinicians understand client symptoms more effectively, to identify co-morbidity of symptoms and to track changes in symptoms over time (Clarke, 2013). The Level 1 Cross-Cutting Symptom Measure–Adult is a self-report measure for adults to provide clinicians with information about the presence of symptoms. This measure also can be completed by an informant if the individual lacks the capacity to do so (APA, 2013). The measure consists of 23 questions related to 13 domains such as depression, anger and anxiety. To complete the measure, an individual rates the presence of symptoms over the past 2 weeks using a 5-point Likert scale (0 = none or not at all to 4 = severe or nearly every day). For most of the domains, a rating of mild or greater on any item is an indicator for a clinician to conduct a more detailed assessment (APA, 2013). However, for suicidality, psychosis and substance use, endorsement of any symptoms necessitates further investigation. Further assessment may include the use of the level 2 cross-cutting symptom measures. These domain-specific instruments are not included in DSM-5, but are available online at http://psychiatry.org/practice/dsm/dsm5/online-assessment-measures (APA, 2014). The cross-cutting measures can be administered numerous times for initial and ongoing assessment. Clinical trials revealed that the measures are easy to use and incorporate into daily practice and provide meaningful information (Clarke, 2013). Clients who participated in the clinical trials felt better understood by their clinicians when they used these measures (Clarke, 2013). Therefore, cross-cutting measures in the DSM-5 can be excellent information-gathering tools that counselors can use to make informed diagnostic and treatment decisions. 

Bipolar I Disorder

As described above, bipolar I disorder is now included in a separate section for bipolar and related disorders, and the complete diagnostic criteria list is found in one place (i.e., APA, 2013, p. 123). The core prerequisite for bipolar I disorder continues to be the presence of at least one manic episode, and several of the criteria for the manic episode were revised to increase clarity.

For example, criterion A for a manic episode in the DSM-IV-TR describes “a distinct period of abnormally and persistently elevated, expansive, or irritable mood, lasting at least 1 week (or any duration if hospitalization is necessary)” (APA, 2000, p. 362). In the DSM-5, the phrase “and present most of the day, nearly every day” was added to clarify how frequently the mood state must be present (APA, 2013, p. 124). Similarly, in criterion B, the DSM-5 specifies that the elevated, expansive or irritable mood must “represent a noticeable change from usual behavior” (APA, 2013). In the list of seven symptoms under criterion B, two were revised for greater clarity. The DSM-5 notes that distractibility can be either reported or observed. Psychomotor agitation is defined as “purposeless non-goal-directed activity” (APA, 2013, p. 124).

Criterion C from the DSM-IV-TR states that the episode in question must truly be a manic episode, not a mixed one. Mixed episodes were removed entirely from the DSM-5 as they were exceedingly rare, and instead a specifier denoting mixed features was added (Coryell, 2013). Additionally, the exclusion for manic-like episodes caused by antidepressant treatment was also removed. That is, in the DSM-IV-TR, if the manic symptoms follow antidepressant treatment such as medication, light therapy or electroconvulsive treatment, they are not considered symptoms of a true manic episode. In the DSM-5, that exclusion is removed. If a client displays symptoms that meet the criteria for a manic episode, the diagnosis can be given regardless of previous antidepressant treatment.

Additional descriptors also were added to the criteria for a hypomanic episode, although the diagnosis continues to describe individuals who display manic symptoms, but do not show clinically significant impairment. The elevated, expansive or irritable mood must be present for 4 consecutive days and for most of the day. The antidepressant exclusion also is removed from the hypomanic episode criteria, but clinicians are cautioned not to interpret irritability or agitation as sufficient for diagnosis. Bipolar I specifiers for severity and course remain the same, except that the psychotic features specifier is now coded separately from severity, as described above in major depressive disorder. Similarly, the specifiers with anxious distress and with mixed features were added to the bipolar disorders.

Schizophrenia

How schizophrenia is conceptualized did not change from the DSM-IV-TR to the DSM-5, but the criteria for the diagnosis did change significantly. In the DSM-IV-TR, criterion A stated that two or more of the following symptoms must be present for at least 1 month unless successfully treated: delusions, hallucinations, disorganized speech, grossly disorganized or catatonic behavior, or negative symptoms. An additional note permitted diagnosis with only one symptom of delusions or hallucinations if bizarre or persistent. The DSM-5 increases the diagnostic threshold by requiring the presence of delusions, hallucinations or disorganized speech (as opposed to the diagnosis being possible based on disorganized behavior and negative symptoms alone) and removing the single symptom option for meeting criterion A. The duration requirement remains the same as in DSM-IV-TR: at least 1 month of active symptoms in a time period of at least 6 months of impairment. Criterion D remains the schizoaffective disorder and mood disorder exclusion, but the text was revised to define how frequently manic or depressive symptoms must be present in order to meet full criteria. The DSM-5 specifies that mood symptoms must be present for at least half of the total duration of active and residual psychotic phases in order to be considered (APA, 2013).

The specifiers about the episodic or continuous symptoms and remission were changed in the DSM-5 and the subtypes were removed entirely. Course specifiers were revised for clarity and now include descriptors for first episode, multiple episodes, continuous or unspecified. These specifiers are not used until the disorder has been present for 1 year. In the DSM-5, the subtypes are not included as part of the diagnosis. For example, DSM-IV-TR language such as 295.30 schizophrenia, paranoid type is no longer used. The types are still described under the delusional disorder criteria, but the differentiated types of schizophrenia are no longer endorsed. Almost all schizophrenia diagnoses are now coded 295.90 schizophrenia, except for those individuals who have catatonia, and their diagnoses are coded 293.89. In the DSM-5, the Clinician-Rated Severity of Psychosis Symptoms Severity scale was added (APA, 2013). The rating scale and other instruments are available online at http://psychiatry.org/practice/dsm/dsm5/online-assessment-measures. Clinicians are instructed to rate the presence of symptoms over the previous 7 days across eight dimensions. The dimensions, rated from 0 (no presence) to 4 (severe and present), are hallucinations, delusions, disorganized speech, abnormal psychomotor behavior, negative symptoms, impaired cognition, depression and mania. During a presentation on the DSM-5 (Malaspina, 2013), representatives from the schizophrenia spectrum and other psychotic disorders work group explained that symptoms for individuals with schizophrenia can change over time. Therefore, the scale was designed to help clinicians note their detailed observations of the client and track changes in symptoms across time.

Case Examples 

Some of the changes previously described are minor and do not result in revisions to the core diagnoses of clients with these disorders. However, some changes might impact diagnoses, and others might alter the way we describe the disorder or the name of the disorder itself. As with the conversion from the DSM-III-R (APA, 1987) to the DSM-IV (APA, 1994), the process will be ongoing. The cases below illustrate possible changes that counselors, supervisors and counselor educators can make immediately in their practices. 

Martha: Major Depressive Disorder

Martha is a 47-year-old married mother of two. She works part-time as a real estate agent and is active in her Episcopal church. Her husband spends long hours at work and is often required to travel out of town. Her two adult children live nearby. Her father is deceased and her mother’s health is unstable, although she lives at a local assisted living facility. 

Martha’s depression was first recognized by her family doctor when she was 23. He was not familiar with the DSM (DSM-III-R at that time), but recognized symptoms of sadness, hopelessness, emptiness and fatigue. He began prescribing her a relatively new drug called Prozac. Martha experienced improvement immediately. For the next 6 years Martha’s family doctor managed her depression with occasional dosage increases and biannual checkups. Just before her 30th birthday, Martha experienced her first severe depressive episode and attempted suicide. She had delivered her second child three weeks prior, and her husband found her after she cut her wrists. 

Martha was hospitalized and received her first full mental health evaluation. Using the DSM-IV criteria, she was diagnosed with 296.33 major depressive disorder, recurrent, severe without psychotic features, with postpartum onset. Recurrent was given because of her self-reported symptom and treatment history. Her present symptoms far exceeded the minimum required for diagnosis, so the episode was considered severe. Martha was coherent, denied hearing voices or seeing images, and showed no evidence of delusions, so no psychotic features were noted. The suicide attempt occurred 3 weeks after delivery and depressive symptoms had been present for at least a week at that point; therefore, Martha met criteria for the postpartum onset specifier. Martha also experienced anxiety about caring for her children and managing her life but did not meet criteria for an anxiety disorder. Following discharge from the hospital, Martha continued to see the psychiatrist she met while hospitalized and began seeing a licensed professional counselor. Martha worked well in counseling and experienced long periods of remission and several more moderate depressive episodes in the 17 years that followed. She maintained regular appointments with her psychiatrist for medication management and sought counseling at times of increased depression or stress. 

Presently, Martha has just resumed seeing a licensed professional counselor. She describes sadness, low energy, hopelessness, limited pleasure, insomnia, and stressors related to aging, her family relationships and her mother’s failing health. Her psychiatrist adjusted her medication and suggested that she resume counseling for additional support. Although the counselor has worked with Martha previously, the resumption of services is a great opportunity to revisit her diagnosis. 

At this time, Martha’s core diagnosis of major depressive disorder, recurrent remains appropriate. Upon further exploration of Martha’s symptoms, the counselor finds that seven symptoms are present; therefore, Martha’s depressive episode is considered moderate. The new specifier with moderate anxious distress is also appropriate for inclusion because of Martha’s reported stressors. Martha feels tense and restless nearly every day. She worries about her children, her health, and her mother, and has difficulty focusing on her work and household tasks. She describes the feelings of depression as present all day, every day, and the stress, worry, and tension as present nearly every day, particularly when she attempts to “face reality” and engage with others or accomplish tasks around the house. A review of Martha’s history shows that anxious distress may have always been present during her depressive episodes. It was noted during her hospitalization and during previous counseling services, but had not reached the severity level necessary for an anxiety disorder diagnosis. Noting these important symptoms using the specifier may help Martha get the treatment she needs. Using the cross-cutting symptom measures to track her symptoms of depression and anxiety may be helpful as the counselor works to find the most effective ways to facilitate progress on Martha’s goals. 

During Martha’s 24 years of treatment, she has had several slightly different diagnoses. Her first unspecific depression diagnosis from the family physician was further identified by the evaluation she had while an inpatient using the DSM-IV criteria for 296.33 major depressive disorder, recurrent, severe without psychotic features, with post-partum onset. Martha’s current diagnosis of 296.32 major depressive disorder, recurrent, moderate, with moderate anxious distress is reflective of both her history and current presentation. 

Bo: Bipolar I Disorder

Bo is a 32-year-old single male. He lives alone with the support of his mother and brother. He has held numerous entry-level jobs for short time periods. Presently, he is unemployed and receiving Social Security Disability benefits. He receives treatment through a local mental health center. His current treatment program is called Program of Assertive Community Treatment (PACT; National Alliance on Mental Illness, 2014) and includes psychiatry, counseling, case management and vocational rehabilitation services. Some services occur at the local mental health center and some occur in his home or in the community. 

Bo was first diagnosed (per the DSM-IV-TR) with 296.90 mood disorder, not otherwise specified when he was 24. During adolescence, Bo had a history of drug and alcohol use, academic and behavioral problems at school, and minor legal infractions. At age 22, Bo had a stable job, one year of sobriety, and lived alone for the first time. After 3 days of no returned phone calls, Bo’s brother began a search and finally found him in an apparent manic state. He was rambling enthusiastically about a new business in media promotions. He had drawings and notes scattered across his apartment with what appeared to be logos for the business. Bo told his brother that he would make millions of dollars with his connections in the music industry. Bo’s brother was concerned given that Bo had no such relationships. With just a little prodding, Bo revealed he had already spent his life savings and sold his motorcycle to get the business started and needed to borrow more money to “make it happen.” He became furious and destructive when his brother challenged his ideas. Bo’s brother was alarmed and took him to the local emergency room for an evaluation. 

The emergency clinician met with Bo and determined that although some of his symptoms matched those for a manic episode, his vague symptom history and relatively short duration of illness precluded diagnosis of bipolar I disorder at that time. Bo was diagnosed with 296.90 mood disorder, not otherwise specified and referred to a crisis stabilization program for treatment and further evaluation. Bo was resistant to treatment because he did not believe his behavior to be inappropriate. After 4 days in crisis stabilization, Bo’s mood changed dramatically and he entered a major depressive episode. He expressed suicidal intent and was hospitalized. His diagnosis was revised to 296.53 bipolar I disorder, most recent episode depressed, severe without psychotic features (per DSM-IV-TR at the time).

Over the next 10 years Bo received ongoing psychiatric and mental health services from the community mental health center. His engagement in treatment waxed and waned, as did his symptoms. He had several six- to eight-month periods of remission and was hospitalized five additional times for severe manic or depressive episodes. Presently, Bo has been unemployed for 5 years and receiving Social Security Disability benefits for 3 years. After his most recent hospitalization, Bo was referred to the PACT team. His mother and brother continue to be supportive and are delighted to have the more intensive program to help Bo achieve stability again. In the PACT program, client services are reviewed every 120 days. Bo’s review is due, which is an opportunity to check his diagnosis for compliance with the new DSM-5 criteria.

Bo has stabilized somewhat since discharge from the hospital but continues to have attenuated manic symptoms. At the time of hospitalization, Bo’s symptoms were present most of the day, every day, so he exceeded the clarified requirement for diagnosis in the DSM-5. Among other symptoms, Bo demonstrated distractibility, but his grandiosity precluded him from acknowledging that. However, clinicians observed the distractibility in session; therefore, the criterion was met. Bo did not demonstrate mixed features or experience psychosis so those revisions in the DSM-5 are not pertinent here. He has received antidepressant treatment in the past but not in recent months; therefore, no extra consideration is necessary to ensure that criterion F is met. Given this presentation, Bo’s diagnosis remained bipolar I disorder, most recent episode manic.

Because of the improvement Bo has achieved since hospital discharge, in partial remission can be added to the diagnosis at his 120-day review. Therefore, his complete diagnosis is 296.45 bipolar I disorder, most recent episode manic, in partial remission. Bo’s improvement is tenuous, however, and requires ongoing medication compliance and supportive counseling. The PACT team is designed to provide this long-term support and counselors are an essential part of that program (Salyers & Tsemberis, 2007). Given the complexity and variability of Bo’s symptoms, a counselor may find it helpful to administer regularly the Level 1 Cross-Cutting Symptom Measure to track changes over time. The counselor also could use the more specific Level 2 assessment to track symptoms in a particular domain such as mania. 

Saul: Schizophrenia

Saul is a 20-year-old unemployed male. He currently lives in the home he grew up in with his mother, father and 14-year-old brother. Since graduating from high school, Saul has worked a part-time job while taking classes at a local community college. 

Saul was first hospitalized at age 18 after he began to tell his family that he was a messenger from God. Saul’s family had a difficult time understanding what Saul was telling them, as it was uncharacteristic of him, but initially they were not concerned. However, Saul’s parents became more alarmed as they noticed he was increasingly more preoccupied with the belief. They also observed that his grades began to suffer and he was spending more time reading religious material online rather than socializing with his friends. After a couple of months of this and no signs of improvement, Saul’s parents contacted the local community mental health center for help. 

Saul was voluntarily hospitalized because of uncharacteristic behavior. While in the hospital, he received a mental health evaluation from a psychiatrist. The psychiatrist noted that there was no evidence of disorganized speech, catatonia or negative symptoms. Additionally, Saul denied auditory and visual hallucinations and the psychiatrist did not observe Saul responding to internal stimuli. Saul reported that his mood was good and the psychiatrist noted no evidence of mania or depression. However, Saul routinely told the psychiatrist he was a messenger from God and often perseverated on the topic. He also reported the detrimental impact that his work as God’s messenger was having on his life. Saul and his family both denied any history of substance use, and a toxicology screen was negative for common street drugs, which could have led to the sudden change in behavior. In sum, there was no medical explanation for the change in behavior. 

Using the DSM-IV-TR, the psychiatrist diagnosed Saul with 295.30 schizophrenia, paranoid type. He cited evidence of a bizarre delusion, thus requiring only one symptom to meet criterion A. The psychiatrist noted paranoid type, which was appropriate given Saul’s preoccupation with the religious themes and the grandiose nature of the delusions. The psychiatrist prescribed an antipsychotic medication for Saul and encouraged him to follow up with a counselor and psychiatrist in the community for outpatient care. 

After discharge from the hospital, Saul received outpatient treatment from a licensed professional counselor and a psychiatrist. Saul took his medication each day with the assistance of his parents, who monitored his compliance. Saul was able to complete high school and started courses at a community college and worked part-time. However, when Saul was 20 years old, his psychiatrist noted a concern in his blood work, which was likely a side effect of the medication he was taking. Saul’s psychiatrist changed his medication because of this concern. 

Quickly, Saul’s preoccupation with his role as a messenger from God returned. Saul again began to have difficulty with course work and dropped out of school. He was fired from his job because his boss became frustrated that Saul was frequently late, took too long to complete tasks at work and appeared disengaged. There also were reports that he was scaring customers by asking about their religious faith and commitment to God. When Saul stopped showering, his parents requested that he be evaluated again and he was hospitalized for a second time. 

During his second hospitalization, Saul received another mental health evaluation from a psychiatrist. Saul continued to insist that he was a messenger from God and he perseverated on religious themes. Saul said he felt compelled to act on God’s commands, which he now heard as a deep male voice. The psychiatrist noted that Saul’s responses in session were delayed, he frequently asked for questions to be repeated and he seemed to be responding to his hallucinations. Using the DSM-5, the psychiatrist diagnosed Saul with 295.90 schizophrenia, multiple episodes, currently in acute episode. There was evidence of at least two symptoms for criterion A: evidence of delusions, auditory hallucinations and diminished emotional expression. Saul reported feeling sad or down at times, but through Saul’s report and the treatment team’s observations, it appeared that this occurred less than half the time during an active psychotic phase, which ruled out schizoaffective disorder. 

Saul’s psychiatrist also completed a quantitative severity assessment using the Clinician-Rated Dimensions of Psychosis Symptom Severity from the DSM-5 (APA, 2013). Saul’s psychiatrist rated the impairment in the past seven days for the eight areas of functioning using a scale ranging from 0 (no presence) to 4 (present and severe). The psychiatrist rated hallucinations as 4 because Saul was frequently responding to voices, which limited his ability to track their conversation and impaired his functioning. Delusions were rated 3 because of pressure to follow God’s commands. This pressure caused Saul to isolate from others, research religious themes, neglect his personal hygiene and pester customers about their beliefs, which cost him his job. Disorganized speech was rated 0 as the psychiatrist noted Saul’s speech was normal. The psychiatrist did not observe any abnormal psychomotor behavior; therefore, it was scored 0 as well. Negative symptoms were rated 3 as Saul displayed moderate decrease in facial expressiveness. Impaired cognition was rated 3 as Saul was unable to take classes and concentrate at work. Thus his functioning was significantly below what would be expected from an individual of Saul’s age and socioeconomic status. Depression was rated as 1 because Saul reported feeling sad or down some of the time, but did not appear preoccupied with sadness. Mania was rated as 0 because there was no evidence of elevated or expansive mood.

The Clinician-Rated Dimensions of Psychosis Symptom Severity scale may be repeated at hospital discharge or during subsequent treatment in order to track Saul’s progress. Additionally, Saul’s counselor may find it useful to track his symptoms using the Level 1 Cross-Cutting Symptom Measure. While in the hospital, Saul endorsed sadness on some of the past seven days. If Saul were to respond to an item on the depression domain as mild or greater, the counselor could also use the Level 2 Cross-Cutting Symptom Measure for depression to gather additional information. 

Saul’s case is unique in that his initial presentation 2 years ago would not have met full criteria for schizophrenia had it occurred after the DSM-5 was released. At the time of his second hospitalization, when the DSM-5 was in use, the additional symptoms made it clear that schizophrenia was the appropriate diagnosis for Saul. Ongoing treatment may help Saul achieve stability and improve his quality of life, and the repeated use of the severity scale may help track his progress.

Conclusion 

These scenarios illustrate which changes from DSM-IV-TR to DSM-5 had an impact on preexisting client diagnoses. Note the core diagnoses did not change, only some of the terminology and specifiers. Why then is it important for counselors to learn about the changes and review existing client diagnoses? Consider the following reasons for careful diagnostic practice. 

Section E.5 of the ACA Code of Ethics (ACA, 2014) mandates that counselors maintain careful, culturally sensitive diagnostic practices. Section A.2.b further requires counselors to take steps to explain the diagnosis and its implications to their clients. Some clients, particularly those who were previously diagnosed, may not have had the opportunity to discuss the meaning of their diagnosis or its implications with a mental health professional. They may have little knowledge at all or longstanding misconceptions. Some clients, like Martha, may have been first diagnosed by a primary care physician who was not familiar with the DSM and the specific features of depression that it details. The release of the DSM-5 is an opportunity to check in and use counseling and advocacy skills to help clients develop an accurate and healthy understanding of their diagnoses. The cross-cutting symptom measures provide a stimulus to engage in a dialogue about the client’s symptoms and treatment needs. Use of these instruments gathers valuable information and helps clients feel better understood (Clarke, 2013). Counselors can have a tremendous influence on how clients conceptualize their mental health, so taking advantage of this opportunity to shape it in a positive way is a great service to the client. 

Additionally, converting to DSM-5 criteria and terminology is essential to meet the common language goal that inspired the initial creation of the DSM. Each edition of the DSM has included revisions that changed the criteria or titles used to describe disorders, but instant conversion to the new terms does not happen in practice. For example, manic-depressive disorder became bipolar I disorder in the third revision of the DSM almost 35 years ago (APA, 1980) and yet some people still use the antiquated term today. Attending to the changes and discussing them with colleagues and clients will speed adoption of the new common language. Modeling ethical, careful, current diagnostic practices may have a positive ripple effect on colleagues as well. If counselors, supervisors and counselor educators all use the terms and criteria set forth by DSM-5, we can more easily communicate within our profession and across treatment teams. 

In fact, the DSM-5 authors made a special call for all clinicians to use the DSM-5 language as carefully and specifically as possible. For example, authors asked clinicians to avoid using the catchall diagnoses at the end of each section (i.e., not otherwise specified in the DSM-IV-TR, other specified and unspecified in the DSM-5; Phillips, 2013). These diagnoses are sometimes necessary in the short term (as in the case of Bo above), but with additional information a more defined diagnosis is often possible. The DSM-5 authors also called on clinicians to attend carefully to the use of specifiers (e.g., Coryell, 2013; Goldberg, 2013). Many of the revisions to specifiers were made because of the potential impact on client treatment. For example, the presence of anxious distress (as in Martha above) complicates the treatment of depression. Noting the anxious distress in the diagnosis itself brings attention to those symptoms and reduces the likelihood that they will be overlooked. For Martha, it seems that when she is able to rise up out of her depression enough to engage in life, her anxiety surges and discourages her from attempting engagement again. It may be that her anxiety needs to be addressed before she can effectively work on her depression. 

The DSM-5 authors also cautioned clinicians that one of the limitations of the DSM-IV-TR was that too many diagnostic criteria overlapped, leading to what is called “artificial co-morbidity” (Tandon, 2013). Individuals may be diagnosed with multiple disorders because of shared criteria. For example, a client’s irritability, social withdrawal and anger outbursts may have underlying depression, mania, delusional thinking or anxiety. These are features of bipolar disorder, major depressive disorder, schizoaffective disorder and post-traumatic stress disorder, and the convolution can lead to overdiagnosis and, ultimately, improper treatment. Arriving at more accurate diagnoses quickly will lead to better care for clients, and DSM-5 includes a new tool to help counselors do just that. The Cross-Cutting Symptoms Measures allow a counselor to assess for the presence of symptoms that are related to multiple diagnoses and consider whether a specifier or comorbid diagnosis is appropriate (APA, 2013). 

Accurate diagnoses also are essential to ongoing research on these and other mental health conditions. Medical record research is increasingly common, particularly with the adoption of electronic medical records and the conglomeration of large managed care companies. That means that the diagnoses counselors record on billing documentation or enter into client medical records are likely to become part of a behind-the-scenes research project. Often these projects use data points such as diagnosis, number of hospitalizations, frequency of outpatient sessions and medication dosages to conduct large-scale analyses of trends or outcomes in treatment. Research like this does not require client or clinician consent because the existing data is anonymized and permission is granted en masse by the organization. Important evidence-based practice recommendations come from this type of study; therefore, using the most accurate documentation, whether the counselor intends to participate in research or not, is important for valid studies. 

In sum, the DSM-5 has set forth changes in criteria and terminology used to describe major depressive disorder, bipolar I disorder and schizophrenia. Counselors can take advantage of this opportunity to help clients develop a healthy, accurate understanding of their diagnoses. The release of the DSM-5 also is an opportunity to revise diagnoses, paying careful attention to specifiers, in order to adhere to the common language it establishes. Thorough, accurate diagnoses support the selection of effective treatments and ongoing research on the treatment of these conditions. All counselors, supervisors and counselor educators can work together as we address these important goals.

Conflict of Interest and Funding Disclosure

The author reported no conflict of interest or funding contributions for the development of this manuscript.

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Laura E. Welfare, NCC, is an Associate Professor at Virginia Polytechnic Institute and State University. Ryan M. Cook is a doctoral student at Virginia Polytechnic Institute and State University. Correspondence can be addressed to Laura E. Welfare, 309 E. Eggleston Hall (0302), Blacksburg, VA 24061, welfare@vt.edu.

The Expansion and Clarification of Feeding and Eating Disorders in the DSM-5

Jul 4, 2014 | Article, Volume 4 - Issue 3

Maureen C. Kenny, Mérode Ward-Lichterman, Mona H. Abdelmonem

The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) introduced a chapter titled “Feeding and Eating Disorders,” which takes a life-span approach to diagnosing eating disorders and contains all related diagnoses. Rather than appearing throughout the text, all eating disorders are now contained within their own chapter for ease of review and comparison. Changes to the feeding and eating disorders include diagnostic revisions and the addition of several new disorders, including avoidant/restrictive food intake disorder and binge-eating disorder. While pica and rumination disorder remain unchanged, anorexia nervosa and bulimia nervosa experience some criteria changes. There is now a system for classifying the severity of several eating disorders (mild, moderate and severe) and an emphasis on body mass index for the diagnosis of anorexia nervosa. The DSM-5 also attempted to address the number of cases of eating disorders that did not meet criteria in any one category (e.g., eating disorder not otherwise specified), and the authors discuss the result of this attempt in examining two new disorders. This paper examines these changes and addresses clinical implications, while alerting counselors to important diagnostic information.

Keywords: eating disorders, DSM-5, pica, anorexia nervosa, bulimia nervosa, binge eating

With the publication of the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5; American Psychiatric Association [APA], 2013a) in May 2013 came structural changes to the categorization of disorders as well as criteria changes to a variety of disorders. One diagnostic category that experienced multiple changes is eating disorders. As stated in the DSM-5, “feeding and eating disorders are characterized by a persistent disturbance of eating or eating-related behavior that results in the altered consumption or absorption of food and that significantly impairs physical health or psychosocial functioning” (APA, 2013a, p. 329). Previously spread throughout several chapters in the DSM, these disorders are now self-contained in a single, more comprehensive chapter titled “Feeding and Eating Disorders.” This revised diagnostic category includes several new disorders and reflects changes to the criteria and wording of some existing diagnoses. While some of the changes are minor, all are noteworthy (Hartmann, Becker, Hampton, & Bryant-Waugh, 2012) and warrant examination. This article seeks to highlight the changes to this category and assist counselors in a greater understanding of these updated diagnoses.

Prevalence of Eating Disorders

One study by Hudson, Hiripi, Pope, and Kessler (2007) used data from the National Comorbidity Survey Replication to generate estimates of the prevalence of anorexia nervosa (AN), bulimia nervosa (BN) and binge-eating disorder (BED) among adults in the United States. The researchers based these estimates on the criteria found in the DSM-IV (Hudson et al., 2007). The authors report the following lifetime prevalence rates for AN, BN and BED, respectively: 0.9% among females and 0.3% among males, 1.5% among females and 0.5% among males, and 3.5% among females and 2.0% among males (Hudson et al., 2007). Of note is that BED, a new diagnosis in the DSM-5 (but one for which criteria appeared in the appendices of DSM-IV-TR), is by far the most prevalent of these three eating disorders. Also worth noting is the fact that the statistics for women, specifically for women under age 20, indicate that eating disorders are common among this subset of the population; young women appear to be afflicted at dramatically higher rates than the population at large. Using the DSM-5 criteria, Stice, Marti, and Rohde (2013) found a lifetime prevalence of 13.1% among this population, concluding that “one in eight young women” (p. 455) will have some form of diagnosable eating disorder. 

Not represented in the figures above is the fact that in the past, the most common eating disorder diagnosis has been the DSM-IV and the DSM-IV-TR category eating disorder not otherwise specified (EDNOS; Fairburn & Cooper, 2011; Machado, Gonҫalves, & Hoek, 2013). EDNOS cases may represent as many as 60% of eating disorder diagnoses (Fairburn et al., 2007). As Smink, van Hoeken, and Hoek (2012) pointed out, a “major goal” (p. 407) of the revisions reflected among eating disorders in DSM-5 was to decrease significantly the number of EDNOS or unspecified diagnoses. The addition of BED and the changes to AN and BN (which resulted in generally less stringent criteria) reflect this aim (Smink et al., 2012). Studies concluded that the DSM-5 criteria will, in fact, reduce the number of EDNOS diagnoses considerably (Allen, Byrne, Oddy, & Crosby, 2013; Fairburn & Cooper, 2011; Machado et al., 2013). The authors in all three studies determined, however, that the number of cases that will not meet the revised DSM-5 criteria for AN, BN or BED is still sizable (Allen et al., 2013; Fairburn & Cooper, 2011; Machado et al., 2013). 

While the prevalence of AN and BN are reasonably well established, the DSM-5 cites the prevalence of pica as unclear (APA, 2013a). It is predominantly recognized among children, most notably those with intellectual disabilities (Mash & Wolfe, 2013); pregnant women (Geissler, Mwaniki, Thiong’o, & Friis, 1998; Khan et al., 2009); adults with iron deficiency (Moore & Sears, 1994); and institutionalized persons (McAlpine & Singh, 1986). The prevalence of rumination disorder is also inconclusive, but believed to be higher in individuals with intellectual disabilities than the general population (APA, 2013a). Similarly, there are no reported prevalence rates for avoidant/restrictive food intake disorder (APA, 2013a).

Overview of Changes in DSM-5 

Before the current edition of the DSM, feeding and eating disorders were in two main sections of the manual: (1) Disorders Usually First Diagnosed in Infancy, Childhood or Adolescence and (2) Eating Disorders (APA, 2013a). The former no longer appears in the DSM-5. With the removal of a separate section describing disorders that were most likely to occur in childhood or adolescence, the DSM-5 now contains chapters for each diagnostic category, which include both disorders that may first manifest during youth and others that may not surface until adulthood. In line with one objective of the DSM-5, the placement of eating and feeding disorders in their own chapter ensures that diagnoses are applicable across the life span (Bryant-Waugh & Kreipe, 2012), and helps bring attention to the development and presentation of symptoms at various points in the life span; this reflects what some refer to as the age and stage approach (Bryant-Waugh, 2013). The childhood section that was removed had previously contained several eating disorders (e.g., pica and rumination). The new chapter in the DSM-5 now contains eight eating disorders (APA, 2013a), including several new disorders, among which are avoidant/restrictive food intake disorder (which replaces, but significantly expands on, feeding disorder of infancy or early childhood) and BED. The diagnoses of other specified feeding or eating disorders and unspecified feeding or eating disorders are new and replace the diagnosis of EDNOS. The already existing disorders of pica, rumination disorder, AN and BN reflect some minor changes as well. While many feeding and eating disorders share symptoms or behaviors, it is important to note that an individual can receive only one diagnosis (Dailey et al., 2014). The feeding and eating disorders diagnostic criteria are mutually exclusive, meaning that if a client is diagnosed with one disorder in this chapter, the client cannot be diagnosed with another (with pica as the only exception). The DSM-5 wants to ensure differentiation of each disorder and help counselors plan treatment that targets the unique features of a disorder (APA, 2013a). See Table 1 for a review of DSM-IV-TR and DSM-5 classification of eating disorders.

Table 1

Past and Current Feeding and Eating Disorder Diagnoses

Specific Changes to Eating Disorder Diagnoses 

Pica and Rumination Disorder

Pica and rumination disorder are two eating disorders that often receive less clinical attention from counselors than other eating disorders. This is probably due to the fact that these disorders are likely to be observed in institutionalized settings, and that treatment may necessitate the expertise of behavioral analysts or therapists highly trained in working with developmental disabilities (Williams & McAdam, 2012). Only the locations of pica and rumination have changed in the DSM-5: These disorders now appear in the chapter on feeding and eating disorders. With this change, these diagnoses are now applicable to individuals across the life span. The criteria for these disorders did not change.

Pica is the ingestion of non-nutritive substances (e.g., hair, chalk, paint chips) over at least a one-month period. Availability and the age of the affected individual often determine what substances a person will consume (Hartmann et al., 2012). Some reports have included individuals eating paper, tissues, wood, metal, small rocks, carpet and soap (Matson, Belva, Hattier, & Matson, 2011). The eating of these non-food substances is deemed to be inappropriate to the developmental level of the individual and is not part of a cultural or socially accepted practice (APA, 2013a). Generally, clinicians see this disorder in children with intellectual disabilities (Mash & Wolfe, 2013). However, the fourth criterion of the diagnosis notes that if this condition does occur within the context of a developmental or intellectual disability, it should be sufficiently severe to warrant clinical attention.

Children with pica eat normal foods as well as non-nutritive foods. In most cases, the disorder remits on its own, or will cease with improved environmental conditions or added infant stimulation (Mash & Wolfe, 2013). One common thought is that this disorder presents in children who do not have sufficiently stimulating environments. Hartmann et al. (2012) reported that some clinicians regard pica as a form of self-soothing behavior, employed when one’s arousal reaches a certain level. However, for children with intellectual disabilities, it may be life-threatening (Matson et al., 2011). Ingestion of metal or other items with high toxicity pose a threat to the developing child (Hartmann et al., 2012). There are multiple treatments available for such individuals including punishment, overcorrection, restraint, positive reinforcement, psychopharmacology and time out (Matson et al., 2013). There is some literature that discusses the presence of pica in pregnant women, which may cause lead poisoning or other health issues for the developing fetus (Thihalolipavan, Candalla, & Ehrlich, 2013).

There were no major changes to the diagnosis of rumination disorder in the DSM-5. Rumination disorder is repeated regurgitation (e.g., spewing up or spitting up of food) for a period of at least one month (APA, 2013a). This regurgitation of food is not attributable to any related medical or gastrointestinal condition. Thus, the regurgitation is voluntary and distinguished from vomiting or gastroesophageal reflux. Similar to pica, the fourth criterion of this diagnosis notes that if this condition does occur within the context of a developmental or intellectual disability, it is sufficiently severe to warrant clinical attention. Some individuals with rumination disorder appear to engage in the behavior for self-soothing effects, while for others it is habitual and a difficult behavior to reduce (Hartmann et al., 2012). Certainly, this disorder reduces the social functioning of an individual, as it is a socially undesirable behavior.

The DSM-5 reports that both pica and rumination disorder are generally first observable in infancy, but onset can occur in childhood, adolescence or adulthood. Another commonality of these diagnoses in DSM-5 is that they both now have a specifier of in remission. This is reserved for individuals who may have previously met the criteria of the disorder, but have not “for a sustained period of time” (APA, 2013a, p. 330). Additionally, pica and rumination disorder are concurrently diagnosable. Another commonality of these disorders is that they often occur in secret and are difficult to detect (Hartmann et al., 2012). Individuals are not likely to disclose their engagement in these behaviors. For young children, parental report is critical in assessment. 

Avoidant Restrictive Food Intake Disorder

An interesting addition to the DSM-5 is the diagnosis of avoidant restrictive food intake disorder (ARFID). The essence of this disorder is a disturbance in eating or feeding characterized by inadequate food intake (Bryant-Waugh & Kreipe, 2012). This inadequacy may mean that the individual does not meet necessary energy intake needs for the day (i.e., by consuming too few calories from food), or has an insufficient nutritional diet, or both. This disorder replaces feeding disorder of infancy or early childhood, but also adds significant new criteria. As Kreipe and Palomaki (2012) stated, “Although it has somewhat awkward phrasing, the name captures the key clinical features of non-eating disorder eating disturbances: avoiding (not necessarily ‘refusing’) foods for a variety of reasons, and restricting intake in the amount and/or range of foods eaten” (p. 428). In the DSM-IV-TR (APA, 2000), feeding disorder of infancy or early childhood primarily emphasized the child’s persistent failure to eat adequately, with significant failure to gain weight or significant loss of weight over at least one month. The primary symptom was a disturbance in eating or feeding not attributable to an associated medical or gastrointestinal condition, and the disorder was required to have an onset before six years of age. With the addition of ARFID, those criteria remain the same, but there is the additive criterion of significant nutritional deficiency, and dependence on enteral feeding (i.e., tube feeding) or oral nutritional supplements. The diagnosis is more specific in stating that the eating or feeding disturbance may be related to the sensory characteristics of food or a concern about aversive consequences of eating (e.g., nausea). The second criterion (a new addition) also mentions that a lack of available food or an associated, culturally sanctioned practice cannot account for the disturbance. The other criteria remain the same (e.g., ARFID cannot occur during the course of AN or BN; the condition cannot be related to a medical condition). It is, however, likely to co-occur with autism spectrum disorder or other neurodevelopmental disorders. Similar to other disorders in the DSM-5, one can apply in remission here if the individual previously met the full criteria for the disorder, but now has not met these criteria for a sustained period. 

Sometimes the individual with ARFID restricts certain foods, and at other times, there is an inadequate intake of vitamins and minerals. The inadequacy of energy intake may result in a child’s poor growth, weight loss or low weight. In their study on picky eating among children, Jacobi, Schmitz, and Agras (2008) pointed out that the longer the duration of the pickiness, the more avoidant the child becomes to trying new foods. However, children with ARFID are more than just picky eaters, as they suffer from failure to meet nutritional and/or energy needs that may result in weight loss. As the criteria imply, some of these individuals must rely on enteral feeding. 

The clinical presentation of ARFID is quite variable (Bryant-Waugh & Kreipe, 2012). Over time, there may be evidence that subgroups of the disorder are present, requiring further classification. Bryant-Waugh and Kreipe (2012) describe several presentations that include some of the ARFID symptoms. For example, some children (and some adults) eat only certain-colored foods or foods with a particular texture, thus ingesting only a narrow range of foods. Others may avoid certain foods based on past negative experiences with them, usually gastrointestinal problems. While there is no specific assessment for ARFID, careful clinical interviewing, including parental observations and a medical evaluation, are necessary for diagnosis. Because ARFID and AN share many common symptoms in childhood and young adulthood (e.g., low weight, food avoidance), differential diagnosis may be difficult (APA, 2013a). The DSM-5 reminds counselors that in AN, the individual has a persistent fear of becoming fat and/or gaining weight, which is not present in ARFID. We refer readers to Bryant-Waugh (2013) for a case study of a child with ARFID, including assessment questions and treatment. 

Anorexia Nervosa

The DSM-5 diagnostic criteria for AN reflect several significant changes from the criteria outlined in DSM-IV-TR. There are two particularly noteworthy changes to the first criterion for an AN diagnosis in DSM-5. The first of these is that what was described as “refusal to maintain body weight” in the DSM-IV-TR (APA, 2000, p. 589) has been reframed as “restriction of energy intake relative to requirements” in the DSM-5 (APA, 2013a, p. 338). The removal of the word refusal, which has negative connotations, results in a more neutrally worded criterion. Moreover, the new phrasing of this criterion in DSM-5 focuses specifically on the central behavioral component of AN (i.e., restriction of intake), rather than upon the results of this behavior (i.e., body weight). 

The second key change to this first criterion is that the specific guideline provided in DSM-IV-TR as a definition of a less than “minimally normal” body weight (i.e., below “85% of that expected”; APA, 2000, p. 589) no longer appears in the DSM-5. The new criterion instead highlights the essential role of context (e.g., age, sex, developmental status) in determining whether a particular individual is at a “significantly low weight” for his or her own body (APA, 2013a, p. 338). This change is particularly important because, while the DSM-IV-TR clarifies that 85% is intended as a guideline, once incorporated into the criteria, it became in many cases a requirement for insurance reimbursement (Hebebrand & Bulik, 2011). 

The second criterion for AN previously included only the cognitive symptom of “intense fear of gaining weight or becoming fat” (APA, 2000, p. 589). That same language appears in the DSM-5, but the new criterion includes a behavioral component as well. Moreover, because the word or is used rather than and, the behavioral manifestation of this criterion can actually stand in for other, more overt expressions of the cognitive component. In other words, according to the DSM-5, an individual engaging in “persistent behavior that interferes with weight gain” (APA, 2013a, p. 338) can now meet this second criterion even if he or she does not explicitly communicate anxiety around weight gain. This change may have particular relevance in pediatric cases, because some children with AN have not yet developed the cognitive abilities required either to have or to express this intense fear (Bravender et al., 2010; Reierson & Houlihan, 2008; Workgroup for Classification of Eating Disorders in Children and Adolescents, 2007).

The third criterion in the DSM-5 is very similar to that of the previous edition, aside from one notable distinction. In the new DSM, the phrase “persistent lack of recognition” (APA, 2013a, p. 339) replaces “denial” (APA, 2000, p. 589) in describing the anorexic individual’s perspective on the risks posed by his or her underweight status. As with the change to criterion one, the result of this rewording is more value-neutral (like refusal, the word denial has negative connotations). The resulting criterion may also be more accurate, in that the focus is on an inability of the anorexic individual to recognize the inherent dangers of his or her condition, rather than a conscious repudiation of the truth. 

Although these small linguistic changes may not seem especially significant, the outcome is a set of criteria that is, on the whole, less stigmatizing. This is important because research indicates that many clinicians have negative biases toward individuals with eating disorders. This may be especially true in the case of those with AN, and the stigma appears to impact the availability of quality treatment for the disorder (Thompson-Brenner, Satir, Franko, & Herzog, 2012). 

The fourth criterion for AN, which appears in the previous edition, was removed altogether from the DSM-5, so that there are now only three criteria for a diagnosis of AN. This previous criterion, amenorrhea (the cessation of menstruation), applied only to females who had achieved menarche (APA, 2000). By definition, then, this criterion inherently excluded all males, as well as pre-pubertal and post-menopausal females. Also excluded were females taking hormonal contraceptives (APA, 2013b). The removal of amenorrhea therefore results in a more inclusive set of criteria, reflective of the APA’s (2013a) stated goal of avoiding “overly narrow” diagnostic categories (p. 12), which in the past have contributed to an excess of EDNOS diagnoses (Fairburn & Cooper, 2011; Machado et al., 2013). 

As in the DSM-IV-TR, the criteria for AN in the DSM-5 include specifiers of restricting or binge-eating/purging types (APA, 2000, 2013a). The language in the new edition is similar to that of the previous edition, but clarifies that the specifier applies to the last 3 months (APA, 2013a), rather than the DSM-IV-TR’s more vaguely stated “current episode” (APA, 2000, p. 589). This change is relevant because the empirical evidence indicates that crossover between subtypes is frequent (Eddy et al., 2008). The DSM-5 reflects this research, and the text in the manual cautions that because such crossover occurs, “subtype description should be used to describe current symptoms rather than longitudinal course” (APA, 2013a, p. 339). It may be worth noting that some in the field have concluded that these diagnostic subtypes of AN are not actually clinically relevant (e.g., Eddy et al., 2008), although clearly the DSM-5 does not reflect this thinking.

Like other disorders in the DSM-5, the diagnostic criteria for AN now include additional specifiers regarding remission status (partial or full) and severity (APA, 2013a). The remission specifier may be especially useful for clinicians working with individuals with eating disorders, AN in particular. For example, with regard to the weight criterion, an individual who reaches “normal” weight will no longer meet the full criteria for an AN diagnosis, but may still be struggling with other key components of the disorder (e.g., intense fear of weight gain). Such a scenario may be particularly likely with this disorder, especially because a change in weight status can be the result of outside intervention rather than internal motivation (Nicholls, Lynn, & Viner, 2011).

Finally, the DSM-5 includes a severity specifier that uses the individual’s body mass index (BMI). There are three levels of severity: extreme (BMI < 15 kg/m²), severe (BMI 15–15.99 kg/m²), moderate (BMI 16–16.99 kg/m²) and mild (BMI > 17 kg/m²). As the manual states, the ranges are from the World Health Organization categories for thinness in adults. For children and adolescents, clinicians are encouraged to use the BMI percentiles. These levels of severity help indicate the clinical symptoms, the potential need for supervision and the degree of functional disability (APA, 2013a).

Bulimia Nervosa

The diagnosis of BN remains largely the same in the DSM-5, although there are some modifications to the criteria. BN is characterized by repeated, uncontrollable binge-eating episodes (criterion A) accompanied by ongoing compensatory behaviors to avoid weight gain (criterion B). These behaviors to avoid weight gain include “self-induced vomiting; misuse of laxatives, diuretics, or other medications; fasting; or excessive exercise” (APA, 2013a, p. 345). The DSM-5 brings no changes to these first two criteria from the DSM-IV-TR. Also unchanged in the new edition is the fourth criterion, the following key cognitive symptom: “self-evaluation is unduly influenced by body shape and weight” (APA, 2013a, p. 345). 

The major change to BN in the DSM-5 is in criterion C, the frequency of the compensatory behaviors required for diagnosis. In the DSM-5, this frequency has been reduced from an average of twice weekly to an average of only once per week. The required duration of these behaviors, however, remains the same in DSM-5: three months. Research indicates that individuals who display these behaviors at this new, lower threshold of once per week experience similar levels of pathology and distress (Wilson & Sysko, 2009). This decrease in frequency is likely to result in more diagnoses of BN; as stated, “increased prevalence rates are the result of a general lowering of diagnostic thresholds for eating disorders” (Dailey et al., 2014, p. 180). 

A secondary change to the BN criteria is the removal of the specifier regarding purging and nonpurging types of BN (APA, 2000). In the past, these specifiers described the type of compensatory behavior used by the individual. In the DSM-5, the criterion for compensatory behavior includes both types, so no further specifier is necessary. This change reflects the research indicating that many individuals with BN regularly engage in both purging and nonpurging compensatory behaviors, making this specifier insignificant (Ekeroth, Clinton, Norring, & Birgegård, 2013; Vaz, Peñas, Ramos, López-Ibor, & Guisado, 2001). 

BN, like the other disorders in the DSM-5, now has severity specifiers. For this diagnosis, the assessment of severity depends upon the frequency of inappropriate compensatory behaviors (e.g., the average number of times an individual purges in a given week). Depending on the frequency of compensatory behaviors per week, a case may be categorized as one the following: mild (1–3 episodes), moderate (4–7 episodes), severe (8–13 episodes) or extreme (14 or more episodes) (APA, 2013a). Finally, as with other disorders in the DSM-5, clinicians can apply the specifiers of partial or full remission to BN. 

Binge-Eating Disorder
The diagnosis of BED is new to the DSM-5. First mentioned in the DSM-IV (Striegel-Moore & Franko, 2008), the disorder appeared in that edition and the subsequent text revision under EDNOS, with research criteria outlined in the appendices (APA, 2000). With the publication of the DSM-5, BED was promoted from “criteria sets . . . for further study” (APA, 2000, p. 759) to being a full-fledged diagnosis. This addition is highly significant because BED is likely to be the most prevalent eating disorder (Striegel-Moore & Franko, 2008).

BED shares the binge-eating criterion of BN (i.e., consuming an objectively large quantity of food in a relatively short time while experiencing a loss of control). The disorder differs from BN, however, in that individuals with BED do not engage in compensatory behaviors (e.g., vomiting or laxative use) after binge eating. An additional distinction is that BED does not include a key cognitive criterion necessary for a diagnosis of BN—the undue influence of weight and shape on self-concept (APA, 2013a).

The second criterion for BED describes behaviors, emotions and cognitions associated with binge eating. The criterion includes five items and specifies that individuals must display a minimum of three to qualify for diagnosis. Examples are eating in the absence of physical hunger, eating unusually quickly and experiencing feelings of guilt and disgust around eating. Although a diagnosis of BN does require the presence of binge eating, that diagnosis does not include these additional criteria.

As is the case with other eating disorders, the diagnostic criteria for BED in the DSM-5 reflect reduced requirements for duration and frequency. Whereas the research criteria in the DSM-IV-TR specified that bingeing must take place at least two days a week for six months (APA, 2000), the DSM-5 diagnostic criterion is that binge eating must occur an average of once per week, for a minimum of three months (APA, 2013a). In the DSM-5, frequency is measured in times—rather than days—per week (for discussion, see DSM-IV-TR Appendix B, APA, 2000). In keeping with the other eating disorders, DSM-5 includes a severity specifier for BED, with, for example, between one and three episodes per week constituting mild BED, and 14 or more episodes per week qualifying as extreme (APA, 2013a). The addition of this severity rating is very helpful, as it will allow clinicians to determine the seriousness of the individual’s disorder in order to assist in treatment planning. Clinicians should also now specify whether an individual is in partial or full remission from BED. 

Obesity

The introduction to the chapter on feeding and eating disorders explicitly addresses the decision not to include obesity as a diagnosis in the DSM-5. This statement outlines the reasons that obesity itself does not constitute a mental disorder: “Obesity (excess body fat) results from the long-term excess of energy intake relative to energy expenditure. A range of genetic, physiological, behavioral, and environmental factors that vary across individuals contributes to the development of obesity” (APA, 2013a, p. 329). In other words, obesity is a physical condition caused by a number of contributing factors and is not, therefore, simply the embodiment of a psychological state. The introduction goes on to clarify, however, that there exist complex relationships between obesity and several psychiatric conditions. This section also refers to the connection between obesity and medications used to treat mental disorders (APA, 2013a). 

One of the disorders described by the DSM-5 as having a “robust association” with obesity is BED (APA, 2013a, p. 329). The relationship between obesity and BED is complicated. The manual specifies, on the one hand, that while some obese individuals suffer from BED, the majority do not. Moreover, individuals with BED are not necessarily obese; they may be overweight, or their weight may fall in the normal range (Striegel-Moore & Franko, 2008). On the other hand, obesity is a risk factor for BED (Decaluwé & Braet, 2003), and “the risk of presenting with BED increases with increasing obesity” (Hill, 2007, p. 151). One might assume that binge eating would precede obesity, but the relationship appears to move in the opposite direction (Decaluwé & Braet, 2003). Obesity also is a risk factor for the development of BN (Decaluwé & Braet, 2003; Hill, 2007). 

Other Specified Feeding or Eating Disorder and Unspecified Feeding or Eating Disorder

Whereas the DSM-IV-TR contained the catchall diagnostic category of EDNOS, this category no longer appears in the DSM-5. The EDNOS category previously was reserved for individuals who did not meet the full criteria for an eating disorder (e.g., a woman who meets all criteria for AN except that she has regular menses). It has been reported that this diagnosis was overly used by practitioners (Bryant-Waugh & Kreipe, 2012), so the changes in the DSM-5 attempt to address this problem. The literature indicates that many individuals who were being treated for an eating disorder received this diagnosis because they did not meet the stringent criteria for AN or BN (e.g., Sysko & Walsh, 2011). As mentioned previously, researchers have reported that EDNOS represented as many as 60% of all eating disorder diagnoses (Fairburn et al., 2007). 

In the DSM-5, two new diagnostic categories replace EDNOS: other specified feeding or eating disorder and unspecified feeding or eating disorder. Other specified feeding or eating disorder refers to individuals who present symptoms characteristic of a feeding or eating disorder that causes clinically significant impairment, but does not meet the full criteria for any of the disorders in this section. However, when applying this diagnosis, the clinician is able to specify or state the specific reason that the presentation does not meet the full criteria. Thus, the specific reason should follow the diagnosis. An example of this diagnosis would be BN (of low frequency and/or limited duration). In this example, the individual meets all of the criteria of BN except that the inappropriate compensatory behavior and binge eating occur at a frequency less than once a week and/or for less than 3 months. 

This diagnosis presents a contrast with another new diagnosis, unspecified feeding or eating disorder. In using this designation, the clinician is unable to provide the specific reason why the clinical presentation does not meet full criteria. This may be because of insufficient information from the client, such as may occur when a client obtains treatment in an emergency setting or a clinician fails to gather enough information during intake. In these cases, the client displays symptoms of an eating or feeding disorder that is causing clinically significant impairment, but does not meet the full criteria for any disorder.

Implications for Counselors 

Given the prevalence of some eating disorders, as well as their presence across the life span, counselors will likely encounter individuals suffering from a diagnosable eating disorder at some point in their career. In fact, research suggests that DSM-5 criteria will result in a rise in the prevalence of diagnosable eating disorders (Allen et al., 2013). This prediction underscores the importance of those in the counseling profession becoming well-informed regarding these revised criteria. New, broader criteria, when implemented by well-informed professionals, will likely increase the chances that a greater portion of the individuals suffering from these disorders will receive the help they need.

Feeding and eating disorders appear to exist on a continuum, with some related behaviors frequently occurring in the population at large. The skilled counselor will be able to differentiate between behaviors that would not be considered pathological (e.g., overeating or typical “dieting”), or are developmentally appropriate (e.g., picky eating), and those that are indicative of greater dysfunction (e.g., binge eating, dramatically restricting calories). Counselors should be aware, however, that clients with eating disorders may not be forthcoming about their symptoms, hide their behaviors and display resistance to seeking help (Abbate-Daga, Amianto, Delsedime, De-Bacco, & Fassino, 2013). Also, many individuals who are at risk for developing eating disorders or who have them may never seek help (Dailey et al., 2014). In addition, full recovery from eating disorders is the outcome in only about 50% of cases, while 20% of individuals make no improvement (Schlozman, 2002). Thus, many individuals have a lifelong battle with eating disorders and relapse is common. It is critical, therefore, that counselors screen all clients for potential eating disorders. Careful assessment of the client’s underlying thoughts, symptom presentation and impairment will help counselors make a correct diagnosis. 

Eating disorders can be damaging to one’s physical well-being, emotional health and interpersonal relationships (Dailey et al., 2014). These factors, coupled with the possible medical consequences and potential fatality of some eating disorders, highlight the need for counselors who work with these clients to have specialized training. If a counselor does not have the appropriate background in eating disorders, it is vital that he or she refer the client to an eating disorders specialist. Moreover, individuals with eating disorders must consult a physician for a comprehensive physical assessment and intervention (Piran, 2013). Given the complexity of the symptom presentation, treatment is likely to involve a multidisciplinary team approach for treatment of eating disorders (Dailey et al., 2014) and counselors would be wise to familiarize themselves with treatment resources in their community.

Conflict of Interest and Funding Disclosure

The author reported no conflict of interest or funding contributions for the development of this manuscript.

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Maureen C. Kenny, NCC, is a Professor at Florida International University. Mérode Ward-Lichterman is a graduate student at Florida International University. Mona H. Abdelmonem is an alumna of Florida International University. Correspondence can be addressed to Maureen C. Kenny, 11200 SW 8th Street, ZEB 247A, Miami, Florida 33199, kennym@fiu.edu.