Back to Basics: Using the DSM-5 to Benefit Clients

Matthew R. Buckley

It is a pleasure to introduce this special DSM-5 edition of The Professional Counselor, which provides a solid primer regarding changes in the DSM-5 diagnosis process and how these changes will likely impact mental health professionals. Changes within the DSM-5 have prompted counselors to revisit the basics of diagnosis and consider the cessation of certain conventions (e.g., the multiaxial system) and what these changes mean to counselors as they perform their vital work for the benefit of clients. The unprecedented inclusion of various mental health professionals in the development of the DSM-5 is an inherent recognition of how this tool is being used across a wide range of professional disciplines that focus on psychopathology. I hope these articles not only inform, but encourage further research into the practical use of the DSM-5, “stimulate new clinical perspectives” in mental illness (American Psychiatric Association [APA], 2013, p. 10), and inspire continued professional dialogue around DSM nosology and the diagnostic processes.

Keywords: DSM-5, diagnosis, psychopathology, mental illness, multiaxial system

The fifth edition of the Diagnostic and Statistical Manual for Mental Disorders (DSM-5) is an update of a major diagnostic tool (APA, 2013). The manual was originally designed to help mental health professionals within a wide variety of disciplines assess and conceptualize cases in which people were suffering from mental distress. This conceptualization is important in that it facilitates an understanding in a common language toward the development of treatment planning to address complex and entrenched symptomology. The DSM has undergone numerous iterations and represents the current knowledge of mental health professionals about mental illness (APA, 2013). One of the primary aims of the DSM-5 workgroups was to align the manual with the current version of the International Classification of Diseases (ICD-9). In addition, political, social, legal and cultural dynamics influenced the development of the DSM-5—and not without controversy (Greenberg, 2013; Locke, 2011; Linde, 2010; Pomeroy & Anderson, 2013). As with any tool, concerns have emerged about the potential of misuse. It is the professional responsibility of skilled and ethical mental health counselors and other professionals to prevent misapplication of the manual (American Counseling Association [ACA], 2014, E.1.b, E.5.a–d). Walsh (2007) succinctly noted that “the primary goal of the DSM is to enhance the care of individuals with psychiatric disorders” (p. S3).

The introduction of the DSM-IV-TR states that the DSM has been used by numerous mental health practitioners (APA, 2000), with no mention of their investment as legitimate stakeholders in the process of DSM development. Well before the final revision of the DSM-5, various mental health professionals, organizations and other relevant collaborators helped formulate the manual in unprecedented capacities. In the introduction to the DSM-5 (APA, 2013) the authors intentionally state that numerous stakeholders were involved in DSM-5 development including counselors and “patients, families, lawyers, consumer organizations, and advocacy groups” (p. 6). Of particular note was the inclusion of national organizations such as the ACA in the form of a DSM-5 task force, which submitted position statements and recommendations to the APA. Various mental health professionals participated directly in the formulation of the DSM-5, primarily in field trials which “supplied valuable information about how proposed revisions performed in everyday clinical settings” (p. 8). Much of the data supports the use of more than 60 cross-cutting and severity symptom measures (see

Clinical Utility

First (2010) reported that utilizing broad and diverse populations of mental health professionals provides rigor for clinical utility. Achieving clinical utility within the DSM diagnostic processes meets the following four objectives:

to help clinicians communicate clinical information to other practitioners, to patients and their families, and to health care systems administrators;

to help clinicians implement effective interventions in order to improve clinical outcomes;

to help clinicians predict the future in terms of clinical management needs and likely outcomes; and

to help clinicians differentiate disorder from non-disorder for the purpose of determining who might benefit from disorder-based treatments. (First, 2010, p. 466)

Any changes to the DSM were framed within the context of how they might be utilized by all mental health professionals, including revisions to definitions of diagnoses and symptoms, proposed diagnostic categories, dimensional assessment (including cross-cutting), and a renewed emphasis on severity specifiers. Ultimately, the consideration was whether the revised manual would be accepted and utilized by the practitioners it proposed to serve (APA, 2013; First, 2010). First (2010) noted that no mandate exists requiring the use of the DSM by any professional, and that other tools used to arrive at an ICD diagnosis exist or are in development (e.g., the NIMH Research Domain Criteria initiative; APA, 2013; Nussbaum, 2013). The DSM-5 workgroups were challenged to revise the manual in order to make it user-friendly and maintain its relevance among mental health professionals. Even though the manual is an imperfect resource, the goal was to enhance clinical utility.

Determining a Differential Diagnosis

In his primer on diagnostic assessment focused on the DSM-5, Nussbaum (2013) offers six considerations in determining a differential diagnosis that serve as an important basis for practice. These considerations or steps include the following:

to what extent signs and symptoms may be intentionally produced;

to what extent signs and symptoms are related to substances;

to what extent signs and symptoms are related to another medical condition;

to what extent signs and symptoms are related to a developmental conflict or stage;

to what extent signs and symptoms are related to a mental disorder; and

whether no mental disorder is present.

Each of these process steps serves as important reminders for getting back to the basics of rendering diagnoses that help inform treatment. When working with clients, these steps function as points of reference to rule out potential factors influencing misdiagnosis. Additionally, client cultural factors are essential at capturing comprehensive context for assessment and diagnosis.

Consider to what extent signs and symptoms may be intentionally produced. Signs and symptoms may be purposely feigned on the part of a client for secondary gain (e.g., financial benefits, drug seeking, disability status, attention from others, reinforcement of an identity of pathology, avoiding incarceration). Counselors must recognize the context in which signs and symptoms occur and pay attention when something does not “fit” with how a client presents for treatment. Assessing prior mental health treatment (including outcomes), cultural factors and potential motives to fake an illness can assist counselors in making an accurate differential diagnosis.

Consider to what extent signs and symptoms are related to substances. A wise and influential professor and mentor during my graduate training said, “Always assess for substance use!” Clients can present with a variety of conditions that are induced by prescription or over-the-counter drugs, illicit substance, or herbal supplements (Nussbaum, 2013). An important emphasis within the DSM-5 is substance-use and substance-induced disorders, which are included in many relevant diagnostic criteria (APA, 2013). Counselors are well-advised to make this determination in the initial assessment and continue to assess throughout the course of treatment.

Consider to what extent signs and symptoms are related to another medical condition. Clients present with signs and symptoms that may be caused by or coincident with another medical condition in a variety of ways. Nussbaum (2013) defined possible manifestations including (a) medical conditions that directly or indirectly alter signs and symptoms, (b) treatments for medical conditions that alter signs or symptoms, (c)  mental disorders and/or treatments that may cause or exacerbate medical conditions, or (d)  both a mental disorder and a medical condition that are not causally related. Counselors should gather medical information from the client and appropriately follow up with medical personnel as needed to ensure proper and accurate diagnosis, which will lead to more targeted and effective treatment.

Consider to what extent signs and symptoms are related to a developmental conflict or stage. A primary strength of counseling professional identity is the focus on human development as a key factor in client distress and resiliency. The counseling practice of “meeting clients where they are” includes where they are developmentally. Counselors must recognize where incongruence exists between what clients present and the expected behaviors or characteristics of their particular developmental stage. Nussbaum (2013) stresses the importance of gathering a comprehensive psychosocial history to determine expected developmental milestones. Being on the lookout for developmental delays,  regressive behaviors of an earlier developmental period, primal defense mechanisms, or signs of “a developmental conflict in a particular relationship” (p. 201) will help ensure that all essential contextual factors are addressed when making a diagnosis.

Consider to what extent signs and symptoms are related to a mental disorder. The definition of mental disorder has not changed significantly from previous versions of the DSM: a mental disorder is “a syndrome characterized by clinically significant disturbance in…cognition, emotion regulation, or behavior that reflects a dysfunction in the psychological, biological, or developmental processes…[and] usually associated with significant distress or disability in social, occupational, or other important activities” (APA, 2013, p. 20). Identifying mental disorders, or the process of diagnosis, involves more than clear-cut observations and often includes the consideration of complex factors involving comorbidity, symptom clusters “that may be part of a more complex and unified syndrome that has been artificially split in the diagnostic system” (Nussbaum, 2013, p. 202), overlap between diagnostic criteria, genetic predisposition, and the mutual influence of two or more conditions. Counselors must be careful to consider the presence of these factors, consult when necessary, and take into account differential diagnosis to determine the most appropriate diagnosis given the verbal and observable data available.

Consider whether no mental disorder is present. Sometimes a client may present with symptoms that do not meet the full diagnostic criteria for a mental disorder, despite significant distress in social, occupational or other areas of functioning. In these cases, utilizing the not otherwise specified or unspecified diagnoses may be warranted in order to provide opportunities for deeper inquiry. For example, the symptoms of a disorder may be a secondary reaction to an identifiable social stressor that may justify a diagnosis of an adjustment disorder. The possibility exists that there may not be a diagnosis present (Nussbaum, 2013), and in these cases, counselors and other mental health professionals are challenged to make that decision in the face of pressures to diagnose.

Cultural Implications

It is imperative that counselors take their clients’ social and cultural influences into account when assessing and diagnosing. Culture impacts all aspects of diagnosis and treatment, including how and when treatment is sought; power differentials between clients and mental health professionals; the age, gender, ethnicity, race, religion, sexual orientation, and socioeconomic status of both clients and mental health professionals; how illness is defined by both; and how problems are conceptualized and addressed within the context of culture (Lewis-Fernández et al., 2014; Tomlinson-Clarke & Georges, 2014).

Two decades of experience using the Outline for Cultural Formulation (OCR), which was introduced in the DSM-IV (APA, 1994), evolved into the Cultural Formulation Interview (CFI) now contained in the DSM-5, comprised of 16 semi-structured questions designed to collect data in a more consistent and efficient manner. Like other dimensional, cross-cutting and severity measures developed specifically for the DSM-5, the CFI was field tested at 12 sites representing several countries to determine feasibility and usefulness (Lewis-Fernández et al., 2014). For the first time, culture in its varied manifestations has been intentionally incorporated into the DSM nosology through a specific assessment instrument. “The CFI follows a person-centered approach to cultural assessment…designed to avoid stereotyping, in that each individual’s cultural knowledge affects how he or she interprets illness experience and guides how he or she seeks help” (APA, 2013, p. 751). Counselors are encouraged to utilize the CFI as a way to understand their clients more meaningfully and to aid in clinical utility.

The TPC Special Issue: Counseling and the DSM-5 

Because the DSM-5 is a tool for mental health professionals to utilize in their conceptualization of client distress, understanding how to use the DSM effectively is at the heart of this special issue published by The Professional Counselor (TPC). Readers will find a variety of articles that will assist mental health professionals by providing important context for most of the salient changes within the DSM-5 (APA, 2013) from the perspective of professional counseling. Inherent in each of these contributions is the theme of getting back to the basics in not only understanding the DSM-5 conceptually, but also providing ideas for putting concepts into practice.

An essential element in understanding and using the DSM-5 effectively is exploring the foundational and historical roots of this complex nosology. Dailey, Gill, Karl, and Barrio Minton (2014); Gintner (2014); and Kress, Barrio Minton, Adamson, Paylo and Pope (2014) offer excellent overviews of salient changes within the DSM-5 that impact clinical practice, including how the DSM has evolved over time. While there is necessary redundancy on key points (e.g., elimination of the multiaxial format, implementation of cross-cutting symptom measures, closer alignment with the ICD coding system), each article provides an important and unique perspective. Dailey et al. (2014) offer important perceptions on changes within the DSM-5 including how changes evolved historically and the philosophical foundations behind those changes, especially those that clash with the philosophical underpinnings of counseling. The authors review the implications of such changes for professional counselors. Gintner (2014) provides an excellent context regarding the harmonization of the DSM-5 with the ICD, the inclusion of cross-cutting symptom measures and dimensional assessment, and how the manual is organized. The article focuses on how counselors might respond to these changes. Kress et al. (2014) offer an important perspective on the removal of the multiaxial convention used by mental health professionals for over three decades and the implications for counselors in the practice of assessment and diagnosis. These authors provide an important context for the decision to terminate the multiaxial system including advantages and disadvantages of DSM-5 changes.

King (2014) describes the practical application of diagnostic criteria and the use of cross-cutting dimensional assessments. This perspective offers a backdrop on which to compare current practice and how it may alter with use of the DSM-5. This article focuses on clinical utility and ensuring that the DSM-5 remains a guide to assessment, diagnosis and treatment. Schmit and Balkin (2014) give a comprehensive review of the cross-cutting, dimensional and severity measures from the perspective of psychometric instrumentation, including the practical application of validity and reliability. These authors underscore DSM-5 assessments as soft measures and provide important cautions to counselors using these instruments in their work with clients, including the importance of developing multiple data points.

Understanding specific diagnostic categories is essential to good clinical practice. Welfare and Cook (2014); Kenny, Ward-Lichterman and Abdelmonem (2014); and Jones and Cureton (2014) provide solid descriptions of specific diagnostic criteria and emphasize areas essential to our understanding of developmental and demographic strata. Welfare and Cook (2014) tackle chronic and persistent mental illness manifested in diagnoses within the following categories: schizophrenia spectrum and other psychotic disorders, bipolar and related disorders, and depressive disorders.  Clinical examples help contextualize the process of assessing and diagnosing these disorders and provide a detailed example of effectively utilizing each step of the diagnostic process. Kenny et al. (2014) provide a cogent overview of the changes made to the “Feeding and Eating Disorders” chapter, including the addition of binge eating and avoidant/restrictive food intake disorders, severity criteria for anorexia nervosa based on body mass indexes, and how the diagnosis of eating disorder not otherwise specified (EDNOS) has changed as a result. Jones and Cureton (2014) offer important perspectives on significant changes to the “Trauma- and Stressor-Related Disorders” chapter and how these changes may impact clinical practice. The authors discuss how diagnostic criteria have been developed for both children and adults and how cross-cutting symptoms (e.g., panic and dissociation) manifest in a range of disorders. Another significant change to this category is the acknowledgement of sexual abuse as a traumatic event; this takes post-traumatic stress disorder (PTSD) out of the often associated realm of combat veterans and into more common and insidious manifestations of trauma.

Counselors should consider the aforementioned changes to the DSM-5 in the context of their counselor identity. Maintaining professional identity and promoting a wellness- and strength-based perspective continues to be an important concern for the counseling profession and the training of counselors. Tomlinson-Clarke and Georges (2014) provide an overview of maintaining professional identity in the process of assessment and diagnosis within a system representing the medical model. A particular strength is the inclusion of how multicultural competency is crucial in using the DSM-5 effectively, which is an essential basic foundation to sound practice. Implications for counselor preparation also are a focus. Finally, Frances (2014) provides a critical commentary of how the DSM has been used by pharmaceutical companies to leverage significant profits at the cost to consumers of mental health services and our economy. As the former chair of the DSM-IV task force, Frances reminds counselors and other mental health professionals of their essential place within treatment and cautions counselors to use the DSM in a balanced manner. His comments are consistent with advocacy inherent in our profession for treatments that promote client resilience, and address psychosocial and environmental factors that impact client functioning.


This special TPC issue on counseling and the DSM-5 provides a compilation of articles covering the history of the DSM, structural and categorical changes, the process of diagnosis, implications for practice, and cautions and criticisms. These articles validate the unique and important perspective counselors bring to their work, and challenge all mental health professionals to use the DSM-5 accurately. The DSM continues to evolve, and its advocates have made significant strides in reaching out to a variety of professionals; one manifestation of this outreach is the development of the DSM-5 website (see Counselors have the opportunity to use the DSM-5, provide feedback directly to the APA, and help shape and influence future editions of this diagnostic tool. This is an important way counselors can advocate for their clients as well as their profession, and shape how the DSM is used to help treat those suffering from mental and emotional distress.


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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Matthew R. Buckley, NCC, is a faculty member in the Mental Health Counseling program at Walden University, Minneapolis, MN. Correspondence can be addressed to Matthew R. Buckley, Walden University, 100 Washington Avenue South, Suite 900, Minneapolis, MN 55401-2511,


Historical Underpinnings, Structural Alterations and Philosophical Changes: Counseling Practice Implications of the DSM-5

Stephanie F. Dailey, Carman S. Gill, Shannon L. Karl, Casey A. Barrio Minton

Regardless of theoretical orientation or work setting, professional counselors should have a thorough understanding of the American Psychiatric Association’s (APA) fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). This article includes an overview of the most recent revision process and identification of key structural and philosophical changes in the DSM-5. The authors conclude with a summary of practice implications for counselors, including specific guidance for recording diagnoses, using diagnostic specifiers and incorporating emerging assessment measures.

Keywords: DSM-5, diagnosis, diagnosis specifiers, assessment, American Psychiatric Association 


By definition, counseling is a professional relationship between client and counselor based on empowerment, rooted in diversity, and committed to accomplishing mental health, wellness, education and career goals of individuals, families and groups (Kaplan, Tarvydas, & Gladding, in press). To accomplish these goals, counselors often include diagnosis as an essential component of the counseling process. Even counselors who work in settings where they are not traditionally responsible for diagnostic assessment must possess a comprehensive understanding of diagnostic nosology and nomenclature. Such an understanding helps providers recognize diagnostic concerns and participate in interdisciplinary discussions and treatment decisions regarding consumers who experience distress or disability. Despite competitors such as the ICD-10 Classification of Mental and Behavioural Disorders (World Health Organization [WHO], 1992), the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5; APA, 2013) is the world’s standard reference for evaluation and diagnosis of mental disorders (Eriksen & Kress, 2006; Hinkle, 1999; Zalaquett, Fuerth, Stein, Ivey, & Ivey, 2008).

The purpose of this article is to present major structural and philosophical changes within the DSM-5 (APA, 2013) in order to make those changes more accessible to counselors. We, the authors, describe how these changes translate to current counseling practice and how they will help counselors utilize the revised nomenclature system. To better understand these changes, we believe it is important to first review development of the DSM and the most recent revision process.

History of the DSM 

The original DSM was psychiatry’s first attempt to standardize mental illness classification. Published in 1952 by the APA, the DSM represented an alternative to the WHO’s sixth edition of the ICD that included a section on mental disorders for the first time (APA, 2000). Focused on clinical utility, the first DSM was grounded in psychodynamic formulations of mental disorders (Sanders, 2011). Emphasizing Adolf Meyer’s psychobiological view, this version of the manual claimed that mental illness represented “reactions” of the personality to psychological, social or biological aspects of client functioning (APA, 2000). A particularly noteworthy characteristic of the DSM’s first edition is that of the 106 conditions it included, only one diagnosis—adjustment reaction of childhood/adolescence—was relevant to youth (Sanders, 2011).

The APA published the next iteration, the DSM-II, in 1968. This version included 11 diagnostic categories and 182 disorders (APA, 1968). Reflecting significant changes in theoretical ideology, the focus of the manual shifted from psychopathology (i.e., reactions) to psychoanalysis (i.e., neuroses and psychophysiological disorders; Sanders, 2011). Authors of the DSM-II maintained a narrative focus when describing disorders.

APA began working on the DSM-III in 1974 and published it in 1980. This iteration differed significantly from previous editions and represented a dramatic shift to a more medically focused model (APA, 1980; Wilson, 1993). Authors of the DSM-III stressed use of empirical evidence to develop diagnoses and claimed theoretical neutrality, signaling a clear attempt to separate the DSM from its psychoanalytic origins (Maser, Kaelber, & Weise, 1991). A new multiaxial system included attention to biopsychosocial conceptualization. For the first time, the DSM-III contained descriptive diagnoses with a focus on positivistic, operationally defined and explicit diagnostic criteria (Wilson, 1993); narrative text also included information such as familial patterns, cultural considerations and gender (Sanders, 2011). The age of empirically based treatments had arrived, and widespread use of the DSM-III became commonplace.

Intended at first only to include minor changes, the APA published substantial modifications to text and diagnostic criteria within the DSM-III-R (1987); as a result, a number of scholars criticized the document intensely (APA, 2000; Blashfield, 1998; Scotti & Morris, 2000). Expanding to 297 diagnoses, Axis I descriptions nearly exceeded 300 pages, while attention to Axes IV and V remained limited to just a few pages. Many scholars continued to question the multiaxial system and validity of field trials (Rogler, 1997).

Heavy critique of the DSM-III and the DSM-III-R led to relatively mild changes to the DSM-IV, published in 1994 (APA, 2000). At nearly seven times the length of the original DSM, this version totaled 365 diagnoses in 886 pages. A text revision (DSM-IV-TR) published in 2000 included wording modifications to ensure nonstigmatizing, person-first language (Scotti & Morris, 2000). The APA also included empirically based information for each diagnosis and diagnostic code modifications to maintain consistency with the ICD-9 (APA, 2000). Like its predecessors, the DSM-IV-TR was heavily critiqued by scholars due to a heavy emphasis on a medical model and rigid classification systems (Eriksen & Kress, 2006; Ivey & Ivey, 1998; Scotti & Morris, 2000). Issues of comorbidity, questionable reliability, controversial diagnoses and excessive use of not otherwise specified (NOS) diagnoses were hot topics among critics (Beutler & Malik, 2002). APA identified these issues as driving forces for structural and philosophical changes in the DSM-5 (APA, 2013).

The DSM-5 Revision Process 

Beginning in 1999, one year before the APA published the DSM-IV-TR, the APA began working on a new edition, which would be more scientifically based, increase clinical utility and maintain continuity with previous editions (APA, 2014a). APA released an initial research agenda focused on nomenclature, neuroscience, developmental science, personality disorders, and the relationship between culture and psychiatric diagnoses (APA, 2000; Kupfer, First, & Regier, 2002). The APA, the National Institute of Mental Health (NIMH), and the WHO held 13 conferences between 2004 and 2008 in which stakeholders discussed relevant diagnostic questions and solicited feedback regarding potential changes in nosology. Resulting themes facilitated the research base and fueled the agenda of the DSM-5 working groups (see Kupfer et al., 2002 for the full DSM-5 research agenda).

In 2007, the APA officially commissioned the DSM-5 Task Force, made up of 29 members including David J. Kupfer, M.D., Chair; and Darrel A. Regier, M.D., M.P.H., Vice-Chair (APA, 2014a). Kupfer and Regier provided clear direction to eradicate the use of NOS diagnoses, eliminate functional impairment as necessary components of diagnostic criteria, and use empirically based evidence to justify diagnostic revisions (Gever, 2012; Reiger, Narrow, Kuhl, & Kupfer, 2009). With these marching orders, each working group proposed draft criteria and justification for changes.

Between April 2010 and June 2012, the DSM-5 Task Force facilitated three rounds of public comment and two field trials (Clarke et al., 2013; Jones, 2012a; Narrow et al., 2013; Regier et al., 2013). The APA Board of Trustees reviewed final revisions in December 2012 and published the DSM-5 in May 2013. Although no professional counselors were invited to serve on the DSM-5 Task Force, several professional counseling associations served as important advocates during the revision process (Dailey, Gill, Karl, & Barrio Minton, 2014).

Major Structural Changes 

The general format of the DSM-5 (APA, 2013) is quite different from that of the DSM-IV-TR (APA, 2000). Although roughly the same number of disorders is included in both editions, structural similarities end here. The DSM-5 (APA, 2013) includes three major sections, revised chapter organization, cross-cutting symptom and severity measures, adoption of a nonaxial system and enhanced coverage of cultural considerations (Dailey et al., 2014). As with previous versions, the text includes a number of appendices related to terminology and coding. 

Section I: DSM-5 Basics

Section I of the new manual includes an introduction to the DSM-5 (APA, 2013) and general instructions on how to use the updated manual, including attention to nonaxial diagnosis and coding considerations. Counselors who diagnose in accordance with the DSM-IV-TR (2000) may be surprised to see that the APA eliminated both the multiaxial classification system and the Global Assessment of Functioning (GAF) scale. Never required for diagnosis, the APA removed the multiaxial system on the premise that it may lead to inaccurate, oversimplified conceptualization regarding complexities of physical, biological and emotional concerns. Furthermore, removal of the GAF was due to claims of insufficient clinical utility and reliability. 

Less radical structural changes discussed in Section I include harmonization of language with the forthcoming ICD-11. The DSM-5 (APA, 2013) incorporates two sets of ICD codes: ICD-9 codes (for immediate use, presented in black print) alongside ICD-10 codes (for use upon nationwide conversion to ICD-10-CM coding expected October 1, 2015, presented in parentheses and in gray print). In addition, authors address consideration for implementing new other specified and unspecified disorder criteria, which present more specific alternatives to previous NOS diagnoses. 

Section II: Diagnostic Criteria and Codes

Section II includes 20 diagnostic classifications or chapters, four more than the DSM-IV-TR (2000), and a significantly revised organization with attention to development and etiology in hopes of enhancing clinical utility (Brown & Barlow, 2005; Kupfer et al., 2002). For example, classifications more frequently diagnosed in childhood and believed to have similar root causes, such as neurodevelopmental disorders (most of which were formerly known as disorders usually diagnosed in infancy, childhood or adolescence), appear first. Diagnostic classifications more commonly seen in older adults and believed to have similar root causes, such as neurocognitive disorders (most of which were formerly known as delirium, dementia, and amnestic and other cognitive disorders), appear much later in the text. 

The DSM-5 Task Force reorganized disorders into new chapters based on research regarding etiology as well as similarity in symptom experience or manifestation. For example, anxiety disorders, which were previously grouped together, now appear in three distinct chapters: “Anxiety Disorders,” “Obsessive-Compulsive and Related Disorders,” and “Trauma- and Stressor-Related Disorders.” Extrication of trauma- and stressor-related disorders allows diagnoses that result from traumatic external events or triggers to be grouped together in a more meaningful way (APA, 2013). Because they are diagnostically unique yet often triggered by traumatic events, the chapter “Dissociative Disorders” immediately follows the chapter “Trauma- and Stressor-Related Disorders.” 

The DSM-5 Task Force also attended to etiology and development when choosing the order of diagnoses within chapters. This represents a shift from presenting more highly specified disorders first in previous editions of the manual. For example, the chapter “Feeding and Eating Disorders” opens with diagnostic criteria for pica, rumination disorder and avoidant/restrictive food intake disorder (previously classified as disorders usually first diagnosed in infancy, childhood and adolescence) before covering disorders more classically associated with adolescence and adulthood (e.g., anorexia nervosa, bulimia nervosa, binge-eating disorder). 

Section III: Emerging Measures and Models

Counselors should not overlook the third and final section of the DSM-5 (Dailey et al., 2014). Section III includes a variety of measures and models in development, including assessment measures, cultural formulation tools, a proposed personality disorders model and conditions for further study (e.g., Internet gaming disorder, nonsuicidal self-injury). Section III does not represent formal changes in nosology or diagnostic processes; rather, most elements are included to enhance clinical use by clinicians and fuel investigations by researchers. 

Proposed assessment measures comprise a major component of Section III. Level 1 cross-cutting symptom measures are tools designed to screen for a broad range of presenting concerns in adults (13 domains) and children (12 domains). In turn, Level 2 cross-cutting symptom measures facilitate more focused assessment of Level 1 domains flagged as concerning. The print version of the DSM-5 also includes a sample dimensional assessment related to psychosis and a reprinting of the WHODAS 2.0, a tool to assess disability and impairment. Most proposed assessment measures are not included in the print version of the DSM-5. For example, the DSM-5 website currently includes many Level 2 cross-cutting symptom measures and disorder-specific severity measures intended to be used as dimensional assessments for some of the most frequently diagnosed concerns. Counselors can find more information about these tools and additional dimensional assessment tools not included in the print version of the DSM-5 by viewing Online Assessment Measures (APA, 2014b) and reading resources provided by Jones (2012b) and Narrow et al. (2013). 

Finally, authors of the DSM-5 (APA, 2013) devoted special attention to diverse ways in which individuals experience and describe distress. This fosters accurate communication so that counselors may better differentiate pathology from nonpathology when work­ing with diverse clients (Dailey et al., 2014). As we will discuss below, counselors may use the cultural formulation interview to talk with clients about symptoms, cultural understanding of concerns and implications for treatment. The DSM-5 Appendix also includes a glossary of cultural concepts of distress.

Major Philosophical Changes

Two major philosophical changes will modify the ways in which counselors approach diagnosis, assessment and communication with other professionals when using the DSM-5 (Dailey et al., 2014). The first is movement away from a purely descriptive diagnostic model (i.e., a traditional medical perspective) toward a neurobiological model. This approach is grounded in client functioning as opposed to strict pathology, and includes research in genetics, neuroimaging, cognitive science and pathophysiology (Kupfer et al., 2002). The second philosophical change is a shift away from a strictly categorical classification system toward a more dimensional approach to nosology (Dailey et al., 2014). 

A Neurobiological Perspective

The first major philosophical change involves a shift in focus from phenomenological interpretations toward identifiable pathophysiological origins (Dailey et al., 2014; Kupfer et al., 2002). Simply stated, the traditional medical model focuses on treating the problem, and the newer functional model focuses on treating and better understanding the problem. Diagnostic assessment has shifted from what to what and why. Previous iterations of the DSM based disorders purely on symptom identification and behavioral observations. As mentioned previously, APA reordered this iteration of the manual to align more clearly with a pathophysiological model that includes attention to etiology, neuroscientific evidence and functional changes associated with or resulting from disease or injury. This shift is consistent with national priorities for deeper understanding of mental illness (Kupfer & Reiger, 2011).

The DSM-5 Task Force incorporated text regarding neurobiology throughout the document, including standing descriptions of genetic and physiological risk factors, prognostic indicators and biological markers that may impact one’s experience with disorder. As noted previously, the lack of clear differentiation between mental and physical disorders served as a major reason for removal of the multiaxial system. The DSM-5 also includes several semantic changes that are philosophical, and possibly strategic, in nature. Whereas the DSM-IV-TR included reference to general medical conditions, the DSM-5 references disorders due to another medical condition. This implies that mental health concerns are, in essence, medical concerns. These seemingly innocuous philosophical shifts send a powerful message regarding the nature of a disorder and, in turn, assumptions about treatment.

As noted in the section regarding structural changes, some diagnostic classifications that were combined previously due to analogous symptomology now stand alone because of research regarding disorder etiology. Aside from the previously mentioned division of anxiety disorders into three separate classifications, mood disorders have been divided into two distinct chapters: “Bipolar and Related Disorders” and “Depressive Disorders.” This philosophical and in some cases structural modification is intended to reflect an emphasis on improved clinical utility and to “encourage further study of underlying pathophysiological processes that give rise to diagnostic comorbidity and symptom heterogeneity” (APA, 2013, p. 13). An example of “underlying pathophysiological processes” is the previous placement of attention-deficit/hyperactivity disorder (ADHD) as a disruptive behavior disorder within the first chapter of the DSM-IV-TR. Given abundant genetic links to ADHD (Rowland, Lesesne, & Abramowitz, 2002), it did not make sense for ADHD to continue as a disruptive disorder alongside oppositional defiant disorder and conduct disorder. ADHD is now classified within the neurodevelopmental disorders chapter of the DSM-5.

In accordance with a neurobiological perspective, the DSM-5 Task Force eliminated the chapter “Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence” and replaced it with a neurodevelopmental disorders chapter. Disorders not considered neurodevelopmental in nature are no longer included in this chapter. For example, reactive attachment disorder, which originates from gross pathological care during infancy, is now located within the chapter “Trauma- and Stressor-Related Disorders.” There also were other reasons for removing the chapter on disorders usually first diagnosed in infancy, childhood, or adolescence, such as the erroneous insinuation that these disorders manifest only in early development (Dailey et al., 2014).

Despite these changes, the impact of this shift was not as significant as neurobiologists would have hoped (Dailey et al., 2014). The DSM-5 Task Force did not fully accept or incorporate the biological perspective, and critics claimed that clinicans might dismiss important sociocultural variations, especially given the elimination of the multiaxial assessment (Mannarino, Loughran, & Hamilton, 2007). 

Dimensional Versus Categorical Nomenclature

The second major philosophical change involves attention to dimensional assessment and documentation as opposed to strictly categorical diagnosis. Categorical assessment is based on the assumption that diagnostic criteria represent independent, discrete phenomena (First, 2010; Jones, 2012b). In reality, client symptoms occur on a continuum rather than as part of a dichotomy (Dailey et al., 2014). 

As noted previously, dimensional assessment scales are designed to assess frequency, duration, severity or other characteristics of a specific diagnosis (Jones, 2012b). Near the beginning of the revision process, the DSM-5 Task Force proposed dimensional as­sessment measures for nearly every disorder in the manual. Following widespread concern regarding questionable psychometric data, the APA included only one dimensional assessment tool, clinician-rated dimensions of psychosis symptom severity, in the print version of the DSM-5 (APA, 2013). The APA, however, has provided supplemental assessment tools online (APA, 2014b). 

Like the neurobiological perspective, the shift toward dimensional conceptualization was neither universal nor complete. The DSM-5 (APA, 2013) included new severity specifiers for most disorders, and it shifted forward dimensional conceptualization for several key diagnostic classifications. For example, in the DSM-5, DSM-IV-TR substance abuse and substance dependence disorders were collapsed into one new substance use disorder with severity indicators ranging from mild to severe based on the number of criteria presented by the client. Counselors are to diagnose clients who meet two or three criteria as having a mild disorder, those who meet four or five criteria as moderate, and those who have six or more criteria as severe. Counselors will find similar conceptualizations throughout the DSM-5, including in the newly conceptualized persistent depressive disorder, which combines dsythymia and chronic instances of major depressive disorder and includes 18 possible specifiers. 

A more radical reflection of the dimensional approach in the DSM-5 is the presentation of spectrum disorders rather than distinct disorders. One umbrella diagnosis—autism spectrum disorder—replaced DSM-IV-TR (APA, 2000) disorders of autism, Asperger’s disorder, childhood disintegrative disorder, and pervasive developmental disorder. Autism spectrum disorder includes severity specifiers based on whether a client meets operationalized criteria for “requiring very substantial support, requiring substantial support, or requiring support” in social communication and restricted, repetitive behaviors domains (APA, 2013, p. 52). Similarly, the new chapter “Schizophrenia Spectrum and Other Psychotic Disorders” retains discrete diagnoses, but introduces the probability that brief psychotic disorder, schizophreniform disorder, and schizophrenia exist on a continuum. The APA (2013) claimed that the purpose of this change is to improve diagnostic efficacy, accuracy and consistency; however, critics conceptualized this as more of a philosophical shift (Dailey et al., 2014).

The APA has indicated intent to continue incorporating dimensional approaches in to future iterations of the DSM. For example, Section III includes a framework for diagnosing personality disorders using a hybrid categorical and dimensional model (APA, 2013). This model is based on the premise that personal­ity dysfunction is a range of trait variations “with normal personality functioning on one end and abnormal personality functioning on the other” (Dailey et al., 2014, p. 309). Individuals who adopt the alternative model for clinical or research purposes will conceptualize clients as presenting impairment related to identity, self-direction, empathy and intimacy as they relate to five trait domains (i.e., negative affectivity, detachment, antagonism, disinhibition, psychoticism) and 25 more specific trait facets (APA, 2013). It is unclear whether the more complex dimensional model will be adopted fully in the next iteration of the DSM (Dailey et al., 2014).

Practice Implications for Counselors 

Although many voiced concerns that the DSM-5 would lead to drastic shifts in counselors’ conceptualization of mental disorders, assessment procedures and diagnostic thresholds, this version of the “psychiatric bible” (Kutchins & Kirk, 1997, p. 1) looks remarkably similar to other iterations (Dailey et al., 2014). Despite similarities, the DSM-5 (APA, 2013) provides groundwork for future iterations to more closely represent neurobiological and dimensional conceptualizations of mental illness. Given the professional identity of counselors, and a scope of practice that “serves to promote wellness across the lifespan . . . [including] preventing and treating mental disorders” (Kraus, 2013, p. 1), strictly neurobiological interpretations may lead consumers to ignore essential interactions between individuals and their environments. Counselors who operate from strength-based wellness approaches will likely reject the notion that all mental illness has biological foundations (Dailey et al., 2014), especially as it is a short leap from assuming biological foundations to assuming that one must treat all disorders biologically. Counselors recognize that a biological orientation could lead to erroneous diagnosis, unwarranted medications and the selection of inappropriate treatment approaches. Although one cannot deny that life experiences have powerful impacts on neurobiological systems (e.g., Badenoch, 2008; Cozolino, 2010), there is concern that too heavy a focus on neurobiology may detract from the humanistic roots of counseling (Montes, 2013). 

Certainly, counselors will continue to explore ways in which these philosophical shifts will affect the practice. In the following pages, we provide concrete recommendations for rendering diagnoses consistent with the DSM-5. These include recommendations for using other specified and unspecified disorders, procedures for recording diagnoses, insurance transitions and possibilities for incorporating attention to assessment tools. 

Other Specified and Unspecified Disorders

A primary goal of the DSM-5 Task Force was the removal of NOS diagnoses from the DSM (Gever, 2012; Regier et al., 2009). This removal was based on perceived overuse of NOS by clinicians, especially when clients did not meet clear diagnostic criteria for more specific disorders (Jones, 2012b). Critics claimed that NOS diagnoses were a result of heavy reliance on “psychodynamic, a priori hypotheses” rather than “external, empirical indicators” (Kupfer & Regier, 2011, p. 672). By turning attention to more flexible dimensional diagnoses, creators of the DSM-5 hope to provide avenues for more flexible, yet more accurate labeling of mental disorders. 

Counselors now have two options when working with individuals who do not meet full criteria for a specific diagnosis: other specified and unspecified. Use of other specified allows counselors to indicate, by using either specifiers assigned to that particular diagnosis or a descriptive narrative, the specific reason a client does not meet criteria for a more specific mental disorder (APA, 2013). When more specific information is not available or counselors do not feel comfortable providing additional detail, they may select an unspecified disorder. Each chapter of the DSM-5 includes at least one set of these disorders (e.g., other specified elimination disorder, unspecified elimination disorder). 

Some diagnostic categories, such as bipolar and related disorders and depressive disorders, include specific examples of other specified disorders. For example, a client who meets all the criteria for a major depressive disorder except the time requirement may be diagnosed with 311 other specified depressive disorder, short-duration depressive episode. Counselors are not limited to using only these examples, as other reasons may warrant an other specified diagnosis (Dailey et al., 2014). 

Recording Procedures

Nonaxial recording. Technically, DSM-IV-TR consumers were never required to present diagnoses using a multiaxial format (APA, 2013). Those who are used to the multiaxial system will simply combine previous Axis I (mental disorders and other conditions that may be a focus of treatment), Axis II (personality disorders and mental retardation), and Axis III (general medical conditions) diagnoses into one nonaxial diagnosis. Counselors also might note psychosocial stressors, environmental concerns, and impairments or disability as a brief narrative explanation relevant to the client’s mental health diagnoses if these are not (a) already indicated by the diagnosis, (b) included as a diagnostic subtype or (c) indicated by a unique specifier or severity indicator for the disorder. Counselors may list V codes or 900 codes (conditions associated with neglect or sexual, physical, and psychologi­cal abuse) as stand-alone diagnoses or alongside other diagnoses as long as these are relevant to clients’ presenting concerns and course of treatment. Although the DSM-5 does not include directions for formatting, counselors should keep explanations brief and use terminology appropriate for multidisciplinary communication (Dailey et al., 2014).

Counselors who see dual-diagnosis clients, individuals with medical conditions, and those who have psychosocial and environmental concerns may be overwhelmed by how to prioritize diagnoses. One solution is to list diagnoses in order of priority and scope of the presenting problem (APA, 2013; Dailey et al., 2014). When these are different, such as an adult referred for bereavement but found to have suicidal ideation and meet criteria for major depressive disorder, the APA (2013) advised users to include a parenthetical notation differentiating between the diagnosis and reason for visit. An example diagnosis might be 296.23 major depressive disorder, single episode, severe (principal diagnosis) and V62.82 uncomplicated bereavement (reason for visit). 

Counselors also may need to prioritize presentation of diagnoses when clients have relevant medical diagnoses in addition to mental health concerns. For example, a client who experiences a manic episode, uses alcohol excessively and is not able to control a preexisting thyroid disorder because of the disturbance may receive a diagnosis of: F31.13 bipolar disorder I, current episode manic, severe; F10.10 alcohol use disorder, mild; and E06 chronic lymphocytic thyroiditis. We chose to list alcohol use disorder second because the client appears to be most impaired by the severe manic episode, and we suspect that a pattern of alcohol use and difficulty managing chronic medical conditions are both related to the bipolar disorder. 

The second example raises an important consideration regarding counselors’ scope of practice. Diagnosis of medical conditions alongside mental health disorders makes sense for psychiatrists who are qualified to diagnose and treat both conditions and for mental health professionals who work in interdisciplinary settings where medical diagnoses are a matter of record (Dailey et al., 2014). Given that counselors are not qualified to diagnose medical conditions, it may be wise to refrain from including diagnostic mention of specific medical conditions unless information is gathered via official medical record or consultation. Counselors may consider including mention of client-reported medical conditions elsewhere on the clinical record or qualify medical conditions as self-reported. 

ICD coding. Since publication of the DSM-III, ICD-9 codes have appeared next to each diagnostic classification (APA, 1980). Originally created for statistical tracking of diseases, not reimbursement, most medical systems within the United States use these codes for billing purposes. These codes are also required for use by medical insurance organizations by the Health Insurance Portability and Accountability Act of 1996 (HIPAA). In the DSM-5 (APA, 2013), ICD-9 codes are in black print, appear first, and typically include three digits or begin with V. In contrast, ICD-10 codes are gray in print, appear in parentheses, and generally begin with the letter F or, if representing psychosocial or environmental factors, with the letter Z. The reason for including both coding sets in the DSM-5 is that all practitioners must align with HIPAA, which requires use of ICD-10-CM (clinical modification) codes no later than October 1, 2015. Complete ICD-9 and ICD-10 codes can be found in the Appendix of the DSM-5, listed alphabetically and numerically. 

The implication of this modification is relatively minor for counselors. Counselors should be aware that the initial printing of the DSM-5 contained several coding errors, and not all terminology used within the DSM-5 matches ICD-10 exactly. Counselors can obtain a printable desk reference with coding updates by visiting the DSM-5 coding update section on the website (APA, n.d.). 

Specifiers and subtypes. In keeping with a dimensional philosophy, the DSM-5 (APA, 2013) contains an expanded listing of specifiers and subtypes for disorders listed throughout the manual. As noted previously, this update may include a greatly expanded number of options to denote experience within a diagnosis. For example, counselors may now add the specifier with panic attacks to any diagnosis within the DSM-5. Other important changes include an expanded listing of specifiers for bipolar and related disorders and depressive disorders, such as with catatonia, with anxious distress, and with mixed features. These specifiers are intended to account for experiences that are often present in both types of disorders, such as elements of anxiety, but may not be part of the general criteria for the disorders (APA, 2013). 

Counselors should note all relevant specifiers for each diagnosis. For more information regarding specifiers and subtypes, professional counselors can refer to the DSM-5 for specific coding instructions and examples (APA, 2013). Despite these changes, most situations will require counselors to use the same diagnostic codes regardless of subtypes and specifiers assigned (APA, 2013; Dailey et al., 2014). There are some exceptions, however, such as when recording substance-related disorders. 

Insurance Transitions

The APA (2013) noted that the DSM-5 was “developed to facilitate a seamless transition into immediate use by clinicians and insurers to maintain a continuity of care” (p. 1). Counselors may begin using diagnostic criteria as soon as they are ready to do so. Insurance companies, other third-party payers and mental health agencies, however, may take additional time to adjust their reporting systems from ICD-9 to ICD-10. This is especially true for the transition from a multiaxial to a nonaxial format (Dailey et al., 2014). 

Although many counselors used the multiaxial system for diagnostic decisions, conversations and reimbursement, elimination of this system should not impact treatment decisions or reimbursement. Many third-party billing systems and government agencies collected data regarding a specific diagnosis only (previously Axis I, II and III); therefore, with the transition they should simply be reporting the same type of information. 

Some insurance panels and reimbursement systems may have previously required more information, such as a GAF score, when determining eligibility for services. Given the expansion of severity indicators and specifiers contained throughout the DSM-5, functional impairments or specific disabilities may be noted within the nonaxial diagnosis. If this is not the case, as mentioned previously, counselors may use narrative notations alongside diagnostic labels. To the extent that functional impairment or disabilities are not listed and would previously have been indicated in the multiaxial system, counselors will need to work closely with associated parties to identify revised reporting requirements (Dailey et al., 2014). Counselors also can use the WHODAS 2.0, found in Section III of the DSM-5 or at, to more clearly indicate an individual’s level of functioning (APA, 2013). 

The APA initially predicted that the insurance industry would transition to DSM-5 by December 31, 2013. This estimate was overly optimistic, however, as most third-party billing systems and government agencies have been slow to switch over to the DSM-5 and likely will not do so until the nationwide mandate for the use of ICD-10 codes goes into effect on October 1, 2015. Counselors can check with their employers and third-party payers to ensure a smooth transition to the DSM-5 in a manner consistent with local administrative procedures. The APA also is making implementation and transition updates available via their website. 

Emerging Assessment Measures

As discussed previously, the DSM-5 includes a variety of cross-cutting assessment measures, disorder-specific severity measures and interview tools for clinicians. The APA (2013) qualified all print and online assessments, including the WHODAS 2.0 and Personality Inventories, as “emerging measures” intended for further research and exploration in clinical practice. Counselors may do well to integrate attention to screening of cross-cutting symptoms and monitoring of diagnostic severity in practice. 

In most cases, the tools provided by the APA are clear, direct and ready to use; however, these online assessments vary widely in format, quality and rigor of psychometric validation (Jones, 2012b). For example, the severity measure for depression is the Patient Health Questionnaire–9 (APA, 2014b; Kroenke, Spitzer, & Williams, 2001). This well-developed instrument is in the public domain, and psychometric data are easy to access and indicate a strong degree of psychometric integrity. On the other hand, the Severity Measure for Panic Disorder–Adult (Shear et al., 2001) has limited validation and few publicly available references regarding development procedures and psychometric considerations (Keough et al., 2012). From an ethical perspective, counselors who use these measures are responsible for ensuring that they do so in a manner that is within their scope of practice and includes appropriate attention to instrument validity and administration procedures. Professional counselors must adhere to ethical standards (American Counseling Association [ACA], 2014; National Board for Certified Counselors [NBCC], 2012) and best practice guidelines (Association for Assessment in Counseling, 2003) when administering and interpreting diagnostic assessments. 

A potentially useful tool to enhance clinical understanding of a client’s cultural worldview, the cultural formulation interview (CFI) is the APA’s attempt to address critics’ claims that the DSM has not historically included culture as part of diagnostic assessment (Dailey et al., 2014). Whereas the DSM-IV-TR (2000) included some cultural characteristics within its diagnostic classifications, it was clear that consumers needed more attention to psychosocial and envi­ronmental factors (Smart & Smart, 1997). The DSM-5 has continued this trend by updating diagnostic classification to include culture-related diagnostic issues for most disorders, supplemental information about cultural concepts and inclusion of the CFI. 

The CFI is a 15–20 minute semi-structured interview consisting of 16 key questions (APA, 2013). With its coverage of numerous topics related to cultural perceptions of the presenting problem, the CFI helps counselors facilitate conversations about domains such as etiological origin, specific circumstances, interpersonal support systems, and coping and help-seeking behavior. Twelve additional modules, to be used as supplements to the CFI or independent of the CFI, are provided by the APA. These modules address topics or specific populations, such as immigrants and refugees; coping and help seeking; and spiritual, religious, or moral traditions. These modules can provide a firm foundation for culturally sensitive counselors to build competence and better understand a client’s worldview from a diagnostic perspective. Even if counselors simply find the CFI a helpful tool for facilitating conversations about culture, the inclusion of the CFI in the DSM-5 is an important step forward in help­ing professionals improve their understanding of cultural competence as essential to diagnostic assessment. 

Perhaps most importantly, counselors do not have to use assessment measures or interview tools associated with the DSM-5 unless those assessment measures are integrated into standard operating procedures with insurance panels or agency policies. We encourage counselors to be selective and discerning as they incorporate emerging tools into practice. Because we expect the APA to continue to release new dimensional assessment and supplemental practice tools on a rolling basis, counselors may wish to visit the DSM-5 website and continue to assess the degree to which the recommended tools may enhance their practice.


Professional counselors comprise one of the largest bodies of DSM consumers (Frances, 2011). Regardless of background, training or theoretical orientation, counselors are responsible for understanding diagnostic practices and using them responsibly (ACA, 2014; NBCC, 2012). Counselors who are aware of recent modifications to the DSM position themselves for continued advancement of care systems that support “diverse individuals, families, and groups to accomplish mental health, wellness, education, and career goals” (Kaplan et al., in press). In this article, we attended to higher-level philosophical and structural changes within the DSM so that counselors may deepen their understanding regarding underlying foundations and motivations for DSM-5 revisions, even as they adopt more concrete diagnostic practices. We hope this historical and philosophical context helps counselors better advocate for a seat at the table in future DSM revision processes. In the meantime, counselors may use this information to make informed decisions about whether and how they will use the DSM-5.


Conflict of Interest and Funding Disclosure

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



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DSM-5 Conceptual Changes: Innovations, Limitations and Clinical Implications

Gary G. Gintner

The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) includes numerous alterations to specific disorders, as well as fundamental conceptual and organizational changes. The purpose of this article is to review three fundamental conceptual changes in DSM-5: the harmonization of the manual with the International Statistical Classification of Diseases and Related Health Problems, the introduction of spectrum disorders and dimensional ratings, and the new organization of the manual. For each change, potential benefits and shortcomings are discussed in terms of innovation, limitations and clinical implications.

Keywords:  DSM-5, ICD-10, classification, diagnosis, spectrum disorders 

The DSM is probably one of the most widely referenced texts in the mental health field. Considering this scope of influence, the release of its latest edition, DSM-5 (American Psychiatric Association [APA], 2013), has garnered considerable interest among professionals, patient advocacy groups and the public alike (Paris, 2013). Reactions have ranged from enthusiastic support (McCarron, 2013) to concern (Welch, Klassen, Borisova, & Clothier, 2013) and even calls to reject the manual’s use outright (Frances, 2013; Frances & Widiger; 2012). The strength of this reaction—both positive and negative—reflects the scope of change. DSM-5 attempts to integrate almost 20 years of burgeoning research in psychopathology, classification and treatment outcomes that have emerged since the publication of DSM-IV (APA, 1994), the last major revision of the manual’s criteria sets. While DSM-5 has made numerous alterations to specific disorders, fundamental conceptual and organizational changes have had the most substantial impact on reshaping the manual (APA, 2013; Regier, Kuhl, & Kupfer, 2013).

The purpose of this article is to review three of these fundamental conceptual changes: the harmonization of the manual with the ICD, the introduction of spectrum disorders and dimensional ratings, and the new organization of the manual. For each of these innovations, three questions will be addressed. First, what was the basis for introducing the change as an innovation to the manual? Here the rationale and potential contribution of the change will be discussed. Special attention will be paid to issues such as enhanced diagnostic accuracy, coverage and clinical utility. Second, does the innovation have any potential drawbacks or limitations? For example, to what extent could the innovation contribute to over or underdiagnosis, limit access to treatment, or pose some harm like increased stigmatization? Third, what are the practical consequences of the innovation relative to how clinical mental health counselors provide care for their clients? This section considers the impact on day-to-day practice and how the diagnostic process itself may be transformed. The conclusion section ties these three threads of innovations together and discusses implications for mental health practice in the 21st century.

DSM and ICD Harmony 

There are two major classification systems for mental disorders: the DSM, used primarily in North America, and the ICD, used worldwide under the auspices of the World Health Organization (WHO). The ICD is a much broader classification encompassing causes of death, illness, injury and related health issues with one chapter dedicated to mental and behavioral disorders (Stein, Lund, & Nesse, 2013). As part of the United Nations Charter, countries around the world have agreed to use the ICD codes to report mortality, morbidity and other health information so that uniform statistics can be compiled. In the United States, the ICD codes are the official codes approved by the Health Insurance Portability and Accountability Act (HIPAA), which are used by insurance companies, Medicare, Medicaid and other health-related agencies (Goodheart, 2014). The code numbers that the DSM has always used are derived from whatever the official version of ICD is at that time. Currently, the ninth revision of the ICD (ICD-9; WHO, 1979) is the official coding system in the United States. The 10th revision of the ICD (ICD-10; WHO, 1992/2010) is scheduled to go into effect on October 1, 2015. 

The DSM and ICD classifications of mental disorders have a number of similarities, but also have important differences. Both are descriptive classifications that categorize mental disorders based upon a constellation or syndrome of symptoms and signs. Symptoms are the client’s reports of personal experiences such as feeling sad, anxious or worried. Signs, on the other hand, are observable client behaviors such as crying, rapid speech, and flat affect. Structurally, both manuals group related mental disorders into either chapters (DSM) or diagnostic blocks (ICD). The names and diagnostic descriptions for many of the mental disorders in the ICD are similar to those in the DSM, a consequence of collaboration over the years and a shared empirical pool from which both have drawn. 

Despite these similarities, there are significant disparities. First, DSM criteria are very specific and detailed, while the ICD relies more on prototype descriptions with less detailed criteria and minimal background information to guide the diagnostic process (First, 2009; Paris, 2013; Stein et al., 2013; WHO, 1992). Second, since DSM-III (APA, 1980), the DSM has used a multiaxial system that notes not only relevant mental and medical disorders, but also other diagnostic information such as environmental factors (Axis IV) and level of functioning (Axis V). The ICD, on the other hand, has always employed a nonaxial system that simply lists medical disorders, mental disorders, and other health conditions. These differences in complexity reflect the constituencies that each manual is designed to serve: The DSM is primarily used by licensed mental health professionals with advanced degrees, while the ICD needs to be accessible to a range of health care professionals worldwide with a broad range of educational backgrounds (Kupfer, Kuhl, & Wulsin, 2013; WHO, 1992).

A third discrepancy is that the names and descriptions for many disorders differ, which at times reflects marked conceptual differences (First, 2009). For example, in ICD-10 (WHO, 1992) bulimia nervosa has to be characterized by a “morbid dread of fatness” (p. 179), a concept akin to anorexia, while DSM-IV-TR (Text Revision; APA, 2000) requires that self-evaluation be “influenced” (p. 549) by only body shape or weight. As another example, the definition of the type of trauma that qualifies for post-traumatic stress disorder (PTSD) is much broader in ICD-10 (allowing for events that are exceptionally threatening or catastrophic) than in DSM-IV-TR (requiring that the event must be associated with actual or threatened death, serious injury, or threat to the physical integrity). These ICD-DSM disparities have led to difficulties comparing research results, collecting health statistics, communicating diagnostic information and reaching similar diagnostic decisions (APA, 2013; First, 2009; Widiger, 2005). Like conversing in two different languages, the diagnosis has often been lost in translation. 


From the outset of the DSM-5 development process there was a concerted effort to address these disparities. Joint meetings of representatives from APA and WHO met regularly throughout the process in an effort to make the manuals more compatible (APA, 2013; Regier et al., 2013). The goal was to find ways of harmonizing structural, conceptual and disorder-specific differences. The results of this process have had immediate effects on the look of DSM-5 and will have long-term effects on the harmonization of DSM-5 with the upcoming ICD-11, expected to be released in 2017 (APA, 2013; Goodheart, 2014). 

The most significant impact of the harmonizing effort is the discontinuation of the multiaxial system in DSM-5. Axes I–III, the diagnostic axes (APA, 2000), are now collapsed into a nonaxial system, consistent with the ICD format. Psychosocial and environmental problems (formerly Axis IV) can be noted using ICD-10’s codes for problems and situations that influence health status or reasons for seeking care. These are usually referred to as Z codes and were formerly termed V codes in DSM-IV-TR. Axis V’s Global Assessment of Functioning (GAF) has been removed and replaced by an ICD measure for disability, the World Health Organization Disability Assessment Schedule (WHODAS) 2.0 (APA, 2013). Unlike the GAF, however, this rating is not required and serves only as an ancillary tool.

The following is an example of how a DSM-5 diagnosis might be listed using ICD-9’s nonaxial system in ICD-9:

296.42 Bipolar I disorder, current episode manic, moderate severity, with mixed features

307.83 Borderline personality disorder

V62.29 Other problem related to employment

The order of diagnoses would indicate that the bipolar disorder was the principal diagnosis and either the focus of treatment or reason for visit. In this example, borderline personality disorder is a secondary diagnosis. The V code is noted because it is an important area to target in the treatment plan.

There were three major reasons for abandoning the multiaxial system. First, health professionals in general medicine found it difficult to use because it was so different from the ICD format (Kupfer et al., 2013). Second, the multiaxial system contributed to the idea that mental disorders were qualitatively different from medical disorders, a dated dualistic distinction between mind and body (APA, 2013; Kupfer et al., 2013; Lilienfeld, Smith, & Watts, 2013). Third, research had shown that distinctions between Axes I and II were artificial and did not reflect that these axes actually overlapped considerably (Lilienfeld et al., 2013). Thus, the multiaxial system seemed to create artificial distinctions that did not seem valid (Lilienfeld et al., 2013). The ICD, on the other hand, offered a more simplified system that allowed a diverse group of health professionals to code disorders using a similar format.

Substantial harmonization of the manuals, however, will happen in the future. Not much could be done with harmonizing ICD-10 (WHO, 1992), a manual of the DSM-IV (APA, 1994) era, the organization and conceptual framework of which were well established (APA, 2013; Goodheart, 2014). The forthcoming ICD-11 will adopt much of DSM-5’s organizational restructuring (discussed below) and include a number of the new DSM-5 disorders (APA, 2013; Goodheart, 2014). 


Despite the potential contribution of this harmonization, there are three major drawbacks to consider. First, the loss of the multiaxial system may compromise the richness of the diagnostic assessment. In a sense, the multiaxial system was holistic in that it provided a way of noting prominent psychiatric conditions, maladaptive personality functioning, medical conditions, relevant stressors and environmental problems, and overall functioning. What will prompt clinicians to consider these important domains remains unclear. Noting V codes and assessing disability using the WHODAS 2.0 may be an alternative. However, these tasks are not required in the diagnostic workup and, if history is any guide, will probably be underutilized.

A second consideration is that consilience with the ICD clearly makes the DSM-5 a “medical classification” (APA, 2013, p. 10) and as David Kupfer, the Task Force Chair of DSM-5, has put it, “psychiatric disorders are medical disorders” (Kupfer et al., 2013, p. 388). The DSM espouses that it is atheoretical (APA, 2013; Lilienfeld et al., 2013), but the momentum is clearly swinging toward the central role of biological factors. This risks a reductionistic conceptualization of mind as simply brain. Alternative perspectives that recognize the importance of contextual, psychological, developmental and cultural factors, fundamental to the mental health counseling tradition (Gintner & Mears, 2009), may suffer as a result. The picture is more ominous considering the National Institute of Mental Health’s initiative, Research Domain Criteria (RDoC), designed to develop the next generation of psychiatric classification based upon underlying etiology of “brain disorders” (p. 749) and the identification of biomarkers (e.g., laboratory tests) to direct treatment selection (Insel et al., 2010). The direction in which the diagnostic train is heading is clear. The question is whether the track can be altered to one that is more balanced and biopsychosocial.

A third concern is that efforts to harmonize the manuals do not address many of the disparities between DSM-5 and ICD-9 or ICD-10. This is particularly true of the new disorders that DSM-5 has added, which lack clear ICD-9 or ICD-10 counterparts. The ICD codes that have been selected often do not map well onto these disorders. For example, the code for DSM-5’s hoarding disorder translates to ICD-9’s and ICD-10’s obsessive-compulsive disorder (OCD). Ironically, hoarding disorder was added because research showed that 80% of the time individuals with this condition did not meet criteria for OCD. As another example, binge eating disorder was added to DSM-5 to recognize individuals who had a pattern of maladaptive bingeing episodes, but did not have the compensatory behaviors (e.g., purging) characteristic of bulimia nervosa. The ICD code selected for this disorder was, nevertheless, bulimia nervosa. Because ICD is updated annually, it may be that more appropriate codes will be made available in future years. Thus, while ICD-DSM consilience has occurred, at least to this point, it has been superficial and restricted to the nonaxial formatting of the diagnosis. Clearly, it may enhance the curb appeal of DSM-5 to the medical community, but the real interior renovation is yet to occur, awaiting ICD-11. 

Clinical Implications

The demise of the multiaxial system means that mental health counselors must be more intentionally biopsychosocial in their diagnostic assessments. More meat can be put on the bare-bones nonaxial system by systematically assessing these biological, psychological and sociocultural factors. This can be accomplished by always assessing whether any important contextual factors can be noted using the V codes, which will be termed Z codes when ICD-10 goes into effect. The WHODAS 2.0, the retired GAF, and other functioning measures can be recruited to assess impairment. While these measures are not part of the formal diagnosis, they can be noted in the chart and inform treatment planning. 

Many insurance companies require a multiaxial diagnosis. The GAF score was often used to justify level of care. At the time of this writing, it is not clear what insurance companies will do with these modifications. The decision here will be important. What insurance companies require, for better or worse, often has profound impact on what clinicians do and the kind of clinical care they deliver.

Spectrum Disorders and Dimensionality 

Both the DSM and ICD classify mental disorders into discrete categories. Clinicians make a yes-no decision about whether or not an individual has a disorder, based upon the particular criteria. But it has long been known that this categorical approach is fraught with problems (First & Westen, 2007; Widiger, 2005). First, comorbidity is common and there is some question as to whether comorbid conditions such as depression and anxiety are distinct or are really different expressions of some shared underlying dysfunction (Lilienfeld et al., 2013). Second, clinicians have used the not otherwise specified (NOS) category 30–50% of the time, indicating that a sizable proportion of phenomena have a varied presentation that existing categories do not capture (Widiger, 2005). This is problematic because NOS is not particularly informative in terms of describing the condition or making decisions about treatments. Finally, a categorical system assumes that each disorder is homogenous and that disorder occurs at the particular cut point. There is no recognition of subthreshold symptoms, and there is the assumption that those who do fulfill the criteria are qualitatively similar. This view is at odds with data showing that symptoms vary considerably in terms of severity and accompanying features (First & Tasman, 2004). In this sense, categorical assignment loses potentially useful clinical information about the condition and about what treatment strategies might be indicated. 


DSM-5 attempts to address this issue by introducing dimensionality to supplement the categorical approach (APA, 2013). While categories indicate differences in kind, dimensions describe variations in degree (Lilienfeld et al., 2013). From this perspective, mental disorders are considered to lie on a continuum, like blood pressure. Theoretically, the spectrum can run from optimal functioning to significant impairment. Markers of morbidity or adverse outcome determine where on the spectrum the cut point for disorder is drawn. In the case of blood pressure, for example, it is 140/90. This dimensionality allows for more fine-grained determination of not only severity or impairment, but also improvement or deterioration. Over the past 30 years, research has shown that many mental disorders appear to be more dimensional and heterogeneous than suggested by ICD’s or DSM’s purely categorical system (First & Westen, 2007; Helzer, 2011; Paris, 2013). 

Dimensionality is incorporated into DSM-5 in three general ways. First, DSM-5 has added several formal spectrum disorders, which combine highly related disorders. Autism spectrum disorder merges together DSM-IV-TR’s autism disorder, Asperger’s disorder, childhood disintegrative disorder and pervasive developmental disorder NOS. Research has shown that these four conditions share many common symptoms, and the differences are more a matter of degree (APA, 2013; Tsai & Ghaziuddin, 2014). Another spectrum disorder is substance use disorder, which blends the former categories of abuse and dependence. The somatic spectrum is captured by somatic symptoms disorder, which merges what was formerly somatization disorder, pain disorder and undifferentiated somatoform disorder. For each of these spectrum disorders, DSM-5 provides a severity rating as well as other specifiers to note degree of impairment and complicating features. 

A second way that dimensionality is infused into DSM-5 is that severity ratings and an expanded list of specifiers have been placed within the existing categories. In a sense, DSM-5 tries to dimensionalize the category. While this was done to some extent in previous editions, DSM-5 broadens this effort throughout the manual. For example, a number of new specifiers were added to describe mood episodes such as anxious distress (presence of comorbid anxiety), mixed features (presence of symptoms from the opposite mood pole), and peripartum onset (onset of symptoms sometime during pregnancy through one month post-delivery). The addition of these notations can be helpful in making treatment-planning decisions (First & Tasman, 2004). For example, severity ratings are an important consideration in deciding whether to use psychotherapy or medication for the treatment of major depressive disorder (APA, 2010). Feature specifiers like anxious distress and mixed features have been shown to increase suicide risk and portend a more complicated treatment regime (APA, 2013; Vieta & Valentí, 2013).

A third way that dimensionality is being promoted in DSM-5 is through the availability of a variety of online assessment measures (APA, 2014). These are rating scales that fall into three general categories. First, there are disorder-specific measures that correspond closely to the diagnostic criteria. These measures could be used to buttress the more clinical assessment that relies on the diagnostic criteria. They could also provide a means of assessing the client’s baseline and response to treatment over time. Measures are available for a range of disorders including depression, many of the anxiety disorders, PTSD, acute stress disorder and dissociative symptoms. Versions are available for adults as well as children aged 11–17. Most of these are self-completed but some are clinician-rated. A second type of measure is the WHODAS 2.0, discussed earlier, which assesses domains of disability in adults 18 and older. A third type of measure is referred to as cross-cutting symptom measures (CCSM). Similar to a broadband assessment of bodily systems in medicine, these measures assess common psychiatric symptoms that may present across diagnostic boundaries and may be clinically significant to note in the overall treatment plan. Level 1 CCSM is a brief survey of 13 domains of symptoms (e.g., depression, anxiety, psychosis, obsessions, mania). A more in-depth Level 2 assessment measure is available for a domain that indicates a significantly high rating. These measures can be reproduced and used freely by researchers and clinicians and can be downloaded at Use of these types of measure is hoped to add surplus information that can aid diagnosis, case monitoring and treatment planning. 


Dimensions are not only intuitively appealing, but also seem to be a better reflection of nature (Lilienfeld et al., 2013). Notwithstanding, serious concerns have been raised. First, determining the appropriate cut point on these dimensions is critical in terms of determining true psychopathology. If the bar is set too low, there is a danger of pathologizing normal behavior. If set too high, those who need treatment may be excluded and denied services. At this point, data suggest that at least for autism spectrum disorder and substance use disorder, the bar might be set too high. For both, DSM-5 criteria tend to miss people on the more benign end of the spectrum. For example, those who formerly might have been diagnosed with mild to moderate Asperger’s, pervasive developmental disorder NOS, or substance abuse may no longer qualify for a diagnosis (Beighley et al., 2013; Mayes, Black, & Tierney, 2013; Peer et al., 2013; Proctor, Kopak, & Hoffmann, 2013). On the other hand, Frances (2013) has suggested that the threshold for somatic symptoms disorder is set too low, pathologizing many with normal worry about their medical illnesses. 

A second concern is that lumping mild and more severe disorders into a unitary spectrum disorder can have unintended social effects, especially for people on the more benign end of the spectrum. For example, those who formerly were diagnosed with Asperger’s disorder will now be labeled with autism spectrum disorder. A college student who was diagnosed with alcohol abuse using DSM-IV-TR criteria will now carry the same diagnosis as someone who is considered an alcoholic and dependent (Frances, 2013). One unanswered question is the impact of these types of name changes on perceived stigma and consequent help seeking. 

A final concern is that the dimensional measures were released prematurely without adequate testing and without sufficient guidelines for their use (Jones, 2012; Paris, 2013). While some of the measures are well established (e.g., Patient Health Questionnaire [PHQ]-9; APA, 2014), others have little to no psychometric support (e.g., Clinician-Rated Severity of Autism Spectrum and Social Communication Disorders). Scoring guidelines are made available, but information about the measure’s psychometric properties and norming are lacking. There also is no information on who is qualified to use these measures and what type of training they should have. Thus, while dimensionality may be an important innovation in the development of the DSM classification system, there are significant challenges ahead in calibrating these dimensions, refining the measures and considering social consequences. 

Clinical Implications

Will dimensionality help or hinder the diagnostic process? On one level, the additional information about the condition may shift counselors’ fundamental way of thinking about treatment from “curing” clients (dichotomous) to helping them move toward more optimal points on the spectrum (dimensional). The availability of dimensional measures has the potential of improving diagnostic accuracy and providing a measure of treatment outcome (Segal & Coolidge, 2007). It may open the door to more measurement-based care, in which these ratings can be used to assess more precisely the need for care and the extent to which clients are profiting from treatment. This process may be more feasible to administer, score and record if these measures can be stored on tablets or mobile applications. 

In terms of using these dimensional measures, however, the unanswered question is—at what cost? Clinicians are already busy, and anything that encumbers that process even more will be resisted (Paris, 2013). Criteria sets are now a bit more complex to navigate because of the added severity rating and feature specifiers. It will take considerable time to learn and master the range of measures that have been posted online, much less research their psychometric appropriateness for the situations in which they will be used. The wild card is whether managed care will require these types of measures as a way of documenting need for treatment and response to provided services. At this point, clinicians would be best served to proceed cautiously, ensuring that the measures they use are reliable and valid for the client population intended.

The New Organization of DSM-5 

How was it decided in previous editions of the DSM which chapters to include and which disorders to place in each of them? While some research guided this process, tradition and clinical consensus were the primary sources that informed the organization of these earlier manuals (First & Tasman, 2004; Regier et al., 2013; Widiger, 2005). DSM-5 took a radically different approach, drawing upon research that examined how disorders actually cluster together. In this section, the new framework is examined and potential benefits and costs discussed. 


The DSM-5 manual is divided into three major sections. Section I provides an introduction, a discussion of key concepts such as the definition of a mental disorder, and guidelines for recording a diagnosis. Section II is the meat of the manual and contains all the mental disorders and other conditions that can be coded with their diagnostic criteria and background information. Section III includes tools for enhancing the diagnostic process, such as some of the dimensional measures discussed earlier, the WHODAS 2.0, and a Cultural Formulation Interview designed to assess the impact of culture on the clinical presentation. This section also includes a list of proposed mental disorders that require further study (e.g., Internet gaming disorder) and an alternative system for diagnosing personality disorders. 

Table 1 lists DSM-5’s major categories (chapters) of mental disorders. Two general principles determined the sequence of chapters and the placement of disorders within chapters. First, disorders were grouped into similar clusters based upon shared underlying vulnerabilities, risk factors, symptoms presentation, course and response to treatment (APA, 2013). Groups that are positioned next to each other share more commonalities than those placed further apart. For example, bipolar disorder follows schizophrenia spectrum because they share a number of vulnerability factors (APA, 2013). Next to bipolar disorder is the chapter on depressive disorders. However, the sequence of chapters indicates that depressive disorders are more distantly related to schizophrenia spectrum. Next, internalizing disorders characterized by depression, anxiety and somatic symptoms are listed in adjacent chapters because of common risk factors, treatment response and comorbidity (APA, 2013). Externalizing disorders, noted by their impulsivity, acting out and substance use, are placed in the latter part of the manual.

Table 1

DSM-5 Classification

Sequence of Chapters in Section II

Neurodevelopmental DisordersSchizophrenia Spectrum and Other Psychotic DisordersBipolar and Related DisordersDepressive DisordersAnxiety Disorders

Obsessive-Compulsive and Related Disorders

Trauma- and Stressor-Related Disorders

Dissociative Disorders

Somatic Symptom and Related Disorders

Feeding and Eating Disorders

Elimination Disorders

Sleep-Wake Disorders

Sexual Dysfunctions

Gender Dysphoria

Disruptive, Impulse Control, and Conduct Disorders

Substance-Related and Addictive Disorders

Neurocognitive Disorders

Personality Disorders

Paraphilic Disorders

Other Mental Disorders

Medication-Induced Movement Disorders and Other Adverse Effects of Medication

Other Conditions That May Be a Focus of Clinical Attention

This shared commonality principle is also evident in the placement of disorders within chapters. As a result, a number of disorders have been transferred to different chapters. For example, DSM-IV-TR’s chapter on sexual and gender identity disorders contained sexual dysfunctions (e.g., premature ejaculation), paraphilias (e.g., exhibitionism) and gender identity disorder. Research showed that these three were not highly related, so they have been moved into different chapters, each of which is more proximally located to related disorders (APA, 2013). As another example, DSM-IV-TR’s anxiety disorders chapter has been divided into three separate chapters: anxiety disorders that are more fear-based (e.g. phobias); obsessive-compulsive and related disorders, which are characterized by preoccupations and repetitive behaviors (e.g., body dysmorphic disorder); and trauma- and stressor-related disorders. The latter is akin to a stress-response spectrum that ranges from severe reactions like PTSD to milder reactions characteristic of an adjustment disorder. It is hoped that these organizational changes will help clinicians locate disorders as well as identify related comorbidities (APA, 2013). 

A second organizational principle is that the DSM-5 framework reflects a life-span perspective, both across and within chapters. Neurodevelopmental disorders (e.g., autism spectrum disorder, attention-deficit/ hyperactivity disorder [ADHD]) are listed first because they typically emerge early in life. Schizophrenia spectrum disorders also frequently have antecedents that manifest themselves in childhood (APA, 2013). Next are disorders that usually appear in adolescence and early adulthood, such as bipolar disorders, depressive disorders and anxiety disorders. In the middle and back of the manual are disorders that emerge in adulthood or late adulthood, such as personality disorders and neurocognitive disorders (e.g., dementia related to Alzheimer’s disease). 

A developmental perspective also is infused into the organization of each chapter. DSM-IV-TR’s chapter on disorders of infancy, childhood and adolescence has been eliminated, and these disorders have been redistributed throughout the manual into relevant chapters. Each chapter is developmentally organized with disorders that emerge in childhood listed first, followed by those that appear in adolescence and adulthood. For example, oppositional defiant disorder and conduct disorder have been moved to the beginning of the chapter on disruptive, impulse control and conduct disorders. In addition, the criteria sets now include developmental manifestations of symptoms. For example, the ADHD criteria set includes both child and adult examples of the various symptoms. There also is an expanded section on development and course for each of the disorders, which explains how symptoms typically unfold over the life span. It is hoped that these types of changes will help clinicians recognize age-related manifestations of symptomatology (Kupfer et al., 2013; Pine et al., 2011). 

The intent of the DSM-5 initiative was to develop a more valid organizational structure grounded in research. In the end it also may help to uncover common etiological factors—the holy grail of classification efforts (Insel et al., 2010; Stein et al., 2013). Certainly, these changes will help with differential diagnosis. The organization provides a better map of the relationship between disorders and how the diagnostic landscape may change over the life span. 


The new organization of the DSM-5 has been generally well received (Stein et al., 2013). One major concern that has been raised, however, is the decision to dismantle the chapter on child and adolescent disorders (Pine et al., 2011). Now there is not one place where the range of childhood disorders is listed. The neurodevelopment disorders—the remnant of the former child and adolescent chapter—is largely limited to disorders that manifest with early developmental delays and problems with language, learning, motor behavior, thinking or attention. Missing, however, are a broader range of behavior problems and anxiety disorders that the former chapter included. The problem is that many of these disorders can co-occur. For example, about 30–50% of children with conduct disorder have a specific learning disorder (Gintner, 2000). The wide separation of conditions such as these in the manual may interfere with accurate detection, especially among those who are not familiar with child and adolescent disorders. 

Clinical Implications

Mental health counselors have a new organization to master. Anecdotally, probably one of the most common comments I hear about the new manual is, “Where do I find X now?” Understanding the new organization of the manual will require more than simply looking over the new structure. It will be critical to read the manual to understand why disorders were grouped in a particular chapter. Chapters that are either newly introduced in the manual or that were significantly altered will certainly need to be carefully reviewed. These include the chapters on neurodevelopmental disorders, obsessive-compulsive and related disorders, trauma- and stressor-related disorders, substance-related and addictive disorders, and neurocognitive disorders.

Importantly, the new DSM-5 message is that the structure is designed to indicate relationships within chapters and between chapters. This is a different way of thinking diagnostically. For example, in considering possible diagnostic alternatives, the clinician can first ask this broad question: Is this on the internalizing or externalizing spectrum? If the condition seems more internalizing, then the possible chapters have been winnowed down, and progressively more specific questions can be asked to locate the disorder in the particular chapter. The organization also alerts the diagnostician that adjacent chapters may hold comorbid conditions or even unexplained subthreshold symptoms. To take advantage of this diagnostic aid, however, it will be critical for mental health counselors to learn their way around this new framework.


These conceptual changes define the new look of DSM-5. ICD’s consilience, dimensionality and the organizational restructuring have fundamentally transformed DSM-5 into a 21st-century document that reflects the current state of knowledge in the mental health profession. The good news is that these changes may make the manual a better reflection of nature (i.e., research has shown it to be more valid) compared to previous editions. As a result, the way counselors diagnose and how they think about mental disorders is changing. Hopefully, such change will not only result in better care, but will also help researchers identify the deeper etiological substrates of mental disorders.

In science, progress also can have a dark side. While the DSM-5 incorporates the latest research, the entire development process and critical review highlight the primitive state of knowledge in the profession. While the spectrums and dimensions will no doubt transform the way mental health professionals diagnose, at this point they are crude and may help certain client populations, but hurt others. Harmonization with the ICD will probably take the DSM-5 to a broader audience of health providers. But it also further medicalizes the DSM-5 and will steer it perilously close to a biologically-based classification system. It will be up to mental health counselors and allied mental health professionals to help correct the course and find the middle way exemplified in the biopsychosocial model. Until then, DSM-5’s advances will be tempered by these potential limitations.

Conflict of Interest and Funding Disclosure

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




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

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 ( 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.


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,

Clinical Application of the DSM-5 in Private Counseling Practice

Jason H. King

The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5; APA, 2013) continues its 60-year legacy as a standard reference for clinical practice in the mental health field. Six mental health disorders are reviewed with a focus on changes between the DSM-IV-TR and the DSM-5 that represent the new landscape for each of these disorders, respectively. Following the summary of changes, a clinical scenario is presented so that counselors can capture the vision of using the DSM-5 in their counseling practice. Clinical formulation (sample diagnosis) using the DSM-5 is also presented for each disorder classification.

Keywords: DSM-5, DSM-IV-TR, private practice, clinical formulation, mental disorders 

The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5; APA, 2013) continues its 60-year legacy as a standard reference for clinical practice in the mental health field. This practical, functional and flexible guide is intended for use by trained counselors in a wide diversity of contexts and facilitates a common language to communicate the necessary characteristics of mental disorders present in their clients (APA, 2013). As counselors use the DSM-5, they will notice an expanded discussion of developmental and life span considerations, cultural issues, gender differences, integration of scientific findings from the latest research in genetics and neuroimaging, and enhanced use of course, descriptive and severity specifiers for diagnostic precision (APA, 2013). They will also notice a dimensional approach to diagnosis, consolidation and restructuring of most mental disorders; a new definition of a mental disorder; and emerging assessments and monitoring tools so as to promote enhanced clinical case formulation.

The intent of this article is to assist all counseling specialists by presenting six clinical scenarios from the author’s counseling practice. The article begins by summarizing the clinical utility of the DSM-5 and provides recommendations for counselors on how to sequence their study of the new manual. Discussed next are use of the new emerging assessment measures, autism spectrum disorder, schizophrenia spectrum and other psychotic disorders, sleep-wake disorders, neurocognitive disorders, and comorbid conditions such as excoriation (skin-picking) disorder and post-traumatic stress disorder—with a focus on prominent changes between the DSM-IV-TR and the DSM-5. Clinical formulation and its associated rationale using the DSM-5 are presented for each disorder classification.

Counselors are encouraged to read the full manual and to especially read the Preface; Section I (i.e., Introduction, Use of the Manual, and Cautionary Statement for Forensic Use of DSM-5); Section III: Emerging Measures and Models (i.e., Assessment Measures); and Appendix (i.e., Highlights of Changes From DSM-IV to DSM-5) before they attempt applied clinical use of the manual. To appreciate the rationale for the DSM-5 changes, counselors are encouraged to read the DSM-IV-TR discussion on limitations to the categorical approach (APA, 2000, pp. xxxi–xxxii) and on the nonaxial format (p. 37). This sequencing of study will help counselors use the manual as intended and avoid diagnostic errors, as well as maintain cultural sensitivity and avoid historical and social prejudices in the diagnosis of pathology (ACA, 2014).

Cross-Cutting Symptom Measures and Disorder-Specific Severity Measures

Clinicians are to administer emerging assessment measures at the initial interview and to monitor treatment progress, thus serving to promote the use of initial symptomatic status and reported outcome information (APA, 2013). The DSM-5 cross-cutting symptom measures support comprehensive assessment by drawing attention to clinical symptoms that manifest across diagnoses. Cross-cutting symptom measures have two levels. Level 1 measures offer a brief screening of 13 domains for adults (i.e., depression, anger, mania, anxiety, somatic symptoms, suicidal ideation, psychosis, sleep problems, memory, repetitive thoughts and behaviors, dissociation, personality functioning, and substance use) and 12 domains for children and adolescents (i.e., depression, anger, irritability, mania, anxiety, somatic symptoms, inattention, suicidal ideation/attempt, psychosis, sleep disturbance, repetitive thoughts and behaviors, and substance use). Level 2 measures provide a more in-depth assessment of elevated Level 1 domains to facilitate differential diagnosis and determine severity of symptom manifestation. The DSM-5 disorder-specific severity measures correspond closely to the criteria that constitute the disorder definition and are intended to illuminate additional areas of inquiry that may guide treatment and prognosis (APA, 2013; Jones, 2012). Counselors can access these no-cost assessment measures at The DSM-5 provides counselors with further information on the background and reasoning for use of these emerging measures in clinical practice (see pp. 733–748).

Autism Spectrum Disorder 

The New Landscape

From as early as 1993, authors and researchers have referred to the various pervasive developmental disorders as autism spectrum disorder (Rutter & Schopler, 1992; Shuster, 2012; Tanguay, Robertson, & Derrick, 1998). They have also called for use of a dimensional rather than a categorical classification as used in DSM-IV and DSM-IV-TR (Kamp-Becker et al., 2010). Unlike the dichotomous approach of the DSM-IV-TR categorical model, the dimensional approach uses three or more rating scales to measure severity, intensity, frequency, duration or other characteristics of given diagnoses (Jones, 2012). Consensus in the research community for a spectrum classification is clearly demonstrated in that 95% of publications in the past 5 years have used the term “autism spectrum disorder.” Hence, the DSM-5 uses the term spectrum and further informs counselors that “autism spectrum disorder encompasses disorders previously referred to as early infantile autism, childhood autism, Kanner’s autism, high-functioning autism, atypical autism, pervasive developmental disorder not otherwise specified, childhood disintegrative disorder, and Asperger’s disorder” (APA, 2013, p. 53). Consolidating use of these dichotomous autism-based titles into a spectrum designation helps to avoid diagnostic confusion and to minimize fragmented treatment planning.

Based on factor structure models, the DSM-5 presents a major reconceptualization and reorganization of the DSM-IV-TR autistic disorder symptomatology (Guthrie, Swineford, Wetherby, & Lord, 2013). This new spectrum, or dimensional classification, helps counselors to properly assess deficits in social-emotional reciprocity (i.e., the inability to engage with others and share thoughts and feelings); nonverbal communicative behaviors used for social interaction (i.e., absent, reduced or atypical use of eye contact [relative to cultural norms], gestures, facial expressions, body orientation or speech intonation); ability to develop, maintain and understand relationships (i.e., absent, reduced or atypical social interest, manifested by rejection of others, passivity or inappropriate approaches that seem aggressive or disruptive); and marked presentations of restricted, repetitive patterns of behavior, interests or activities. This reconceptualization of autism in the DSM-5 provides counselors with a denser diagnostic cluster to reduce excessive application of the DSM-IV-TR pervasive developmental disorder not otherwise specified classification that resulted in overdiagnosis and concerning prevalence rates (Maenner et al., 2014). 

The DSM-5 further recognizes autism due to Rett syndrome, Fragile X syndrome, Down syndrome, epilepsy, valproate, fetal alcohol syndrome or very low birth weight through use of the specifier associated with a known medical or genetic condition or environmental factor. Counselors also may use the specifiers with or without accompanying intellectual impairment and with or without accompanying language impairment. Examples of descriptive specifier usage include with accompanying language impairment—no intelligible speech or with accompanying language impairment—phrase speech. If catatonia is present, counselors record that separately as catatonia associated with autism spectrum disorder. Severity, or intensity of symptoms, for autism spectrum disorder are now communicated on three levels: Level 1 mild requiring support, level 2 moderate requiring substantial support, and level 3 severe requiring very substantial support (APA, 2013). 

The level of interference in functioning and support required is communicated by using the DSM-5 Clinician-Rated Severity of Autism Spectrum and Social Communication Disorders scale (APA, 2013, p. 52). Examples of mild rating in the social communication psychopathological domain may include the following: without supports in place, deficits in social communication cause noticeable impairments; has difficulty initiating social interactions and demonstrates clear examples of atypical or unsuccessful responses to social overtures of others; and may appear to have decreased interest in social interactions. Examples of mild rating in the restricted interests and repetitive behaviors psychopathological domain may include rituals and repetitive behaviors (RRBs) that cause significant interference with functioning in one or more contexts, or resists attempts by others to interrupt RRBs or to be redirected from fixated interest (APA, 2013).

Examples of moderate rating in the social communication psychopathological domain may include marked deficits in verbal and nonverbal social communication skills, social impairments apparent even with supports in place, limited initiation of social interactions, and reduced or abnormal response to social overtures from others. Examples of moderate rating in the restricted interests and repetitive behaviors psychopathological domain may include RRBs and/or preoccupations and/or fixated interests that appear frequently enough to be obvious to the casual observer and inhibit functioning in a variety of contexts. Frustration or distress is apparent when RRBs are interrupted; it is difficult to redirect attention from fixated interest (APA, 2013).

Examples of severe rating in the social communication psychopathological domain may include severe deficits in verbal and nonverbal social communication skills that cause significant impairments in functioning, very limited initiation of social interactions, and minimal response to social advances from others. Examples of severe rating in the restricted interests and repetitive behaviors psychopathological domain may include preoccupations, fixed rituals and/or repetitive behaviors that significantly interfere with functioning in all domains; distinct distress when rituals or routines are interrupted; difficulty redirecting from fixated interest or returns to it quickly. Counselors are advised to review Table 2 Severity Levels for Autism Spectrum Disorder displayed in the DSM-5 (APA, 2013, p. 52).

Clinical Scenario

Walter, a 22-year-old male, was referred to counseling by the State Office of Rehabilitation for career and vocational assistance, with a special focus on his mental health needs and confirming the presence of his previous diagnosis of Asperger’s disorder given in 2004. Counselors working with adults presenting with autism spectrum symptoms will appreciate the DSM-5’s new adult textual narrative. Some of these additions help to understand adults like Walter, who:

  • Must show persistent symptoms from early childhood across multiple contexts.
  • Display difficulties processing and responding to complex social cues;
  • Suffer from anxiety because of purposefully calculating what is socially intuitive for other adults;
  • Express difficulty in coordinating nonverbal communication with speech;
  • Struggle to comprehend what behavior is considered appropriate in one situation but not another; and
  • Learn to suppress repetitive behavior in public.

Following assessment procedures outlined in the DSM-5 to use “standardized behavioral diagnostic instruments with good psychometric properties, including caregiver interview, questionnaires and clinician observation measures” (APA, 2013, p. 55) and by Jones (2010), clinical assessment of Walter included the following:

  • Biopsychosocial clinical interview of Walter with his mother as an additional informant
  • Level 1 Cross-Cutting Symptom Measure (see APA, 2013, pp. 733–744 or
  • The Clinician-Rated Severity of Autism Spectrum and Social Communication Disorders (see APA, 2013, p. 52 or
  • Historical evaluations (prior psychological testing results)
  • Collateral reports from the referring vocational rehabilitation counselor
  • Simon Baron-Cohen’s Autism Spectrum Quotient (Baron-Cohen, Wheelwright, Skinner, Martin, & Clubley, 2001; Ketelaars et al., 2008)

Adhering to DSM-5 dimensional rather than DSM-IV-TR multiaxial classification (Jones 2012), Walter was diagnosed using this format:

299.00 Autism spectrum disorder; requiring substantial support for social communication and social interaction (level 2 moderate); requiring support for restricted repetitive behaviors, interests and activities (level 1 mild); without accompanying intellectual impairment; without accompanying language impairment; without catatonia.

Notice the diagnostic precision offered by the DSM-5 in comparison with Walter’s non-descriptive diagnosis using the DSM-IV-TR formulation: Asperger’s Disorder (APA, 2000). In contrast, the severity ratings for autism spectrum disorder are listed independently for social communication and restricted repetitive behaviors, rather than providing a global rating for both psychopathological domains (per the DSM-5 they are listed from most severe to least severe). For Walter, his moderate severity rating of requiring substantial support for social communication means: “Marked deficits in verbal and nonverbal social communication skills; social impairments apparent even with supports in place; limited initiation of social interactions; and reduced or abnormal responses to social overtures from others” (APA, 2013, p. 52). His mild severity rating of requiring support for restricted repetitive behaviors (RRBs) means: “Inflexibility of behavior causes significant interference with functioning in one or more contexts. Difficulty switching between activities. Problems of organization and planning hamper independence” (APA, 2013, p. 52). The diagnostic formulation offered to counselors in the DSM-5 provides a richer contextual description of the client to support more personalized treatment planning. This attention to dimensional ratings and individualized treatment strategies is also captured in the newly conceptualized schizophrenia spectrum disorders.

Schizophrenia Spectrum and Other Psychotic Disorders 

The New Landscape

Counseling clients presenting with psychotic and schizophrenia spectrum disorders is challenging and diagnostically complex. To assist with these difficulties, the DSM-5 presents a new conceptualization to facilitate clinical utility and to streamline diagnostic formulations (Bruijnzeel & Tandon, 2011). Similar to autism, schizophrenia has been referenced as a spectrum disorder since 1995 (Kendler, Neale, & Walsh, 1995) and the DSM-5 marks the official recognition of this spectrum conceptualization by embedding the word in the diagnostic title. Essential to competent practice in this area is reading the section on key features that define the psychotic disorders on pages 87–88 of the DSM-5 (APA, 2013; e.g., delusions, hallucinations, disorganized thinking, grossly disorganized or abnormal motor behavior, and negative symptoms). Further critical reading is the new Clinician-Rated Assessment of Symptoms and Related Clinical Phenomena in Psychosis on the DSM-5 pages 89–90 (APA, 2013). These pages describe the heterogeneity of psychotic disorders and the dimensional framework for the assessment of primary symptom severity within the psychotic disorders. This spectrum conceptualization differs from the DSM-IV-TR categorical and mutually exclusive diagnostic system that assumed “mental disorders are discrete entities, with relatively homogeneous populations that display similar symptoms and attributes of a disorder” (Jones, 2012, p. 481). 

The new Clinician-Rated Dimensions of Psychosis Symptom Severity (CRDPSS) is used to understand the personal experience of the client, to promote individualized treatment planning, and to facilitate prognostic decision making (Flanagan et al., 2012; Heckers et al. 2013). Counselors can obtain the CRDPSS in the DSM-5 pages 742–744 (APA, 2013) or The CRDPSS is an eight-item measure used to assess the severity of mental health symptoms that are important across psychotic disorders. These symptoms include delusions, hallucinations, disorganized speech, abnormal psychomotor behavior, negative symptoms (i.e., restricted emotional expression or avolition), impaired cognition, depression and mania. Psychosis symptoms are rated on a five-point scale: not present, equivocal (severity or duration not sufficient to be considered psychosis), mild (little pressure to act, not very bothered by symptoms), moderate (some pressure to respond or somewhat bothered by symptoms) and severe (severe pressure to respond to voices or very bothered by voices). 

According to the DSM-5, proper use of the CRDPSS may include clinical neuropsychological assessment (especially of client cognitive functioning) to help guide diagnosis and treatment. Counselor “assessment of [client] cognition, depression, and mania symptom domains is vital for making critically important distinctions between the various schizophrenia spectrum and other psychotic disorders” (APA, 2013, p. 98). Depending on the stability of client symptoms and treatment status, the CRDPSS may be completed at regular intervals as clinically indicated to track changes in client symptom severity over time. Consistently high scores on a specific domain may indicate significant and problematic areas for the client that may warrant further assessment (mental status examination), treatment (counseling and pharmacological), and follow-up (case management). 

In the DSM-5, delusional disorder is retained as listed in DSM-IV-TR, including its classic subtypes of erotomanic, grandiose, jealous, persecutory and somatic. Some textual updates occur in the DSM-5 for brief psychotic disorder that place emphasis on disorganized or catatonic behavior. Schizophreniform disorder in the DSM-5 parallels the description in the DSM-IV-TR. Diagnostic precision for schizophrenia in the DSM-5 is communicated with new course specifiers that can “be used after a 1-year duration of the disorder and if they are not in contradiction to the diagnostic course criteria” (APA, 2013, p. 99). These new course specifiers communicate a time period in which the symptom criteria are fulfilled (acute), a period of time during which improvement after a previous episode is maintained and in which the defining criteria of the disorder are only somewhat fulfilled (partial remission), or a period of time after a prior episode during which no disorder-specific symptoms are present (full remission). Counselors also can communicate these specifiers based on first episode, multiple episodes, continuous episodes or unspecified. Use of these specifiers assists counselors in determining the intensity, frequency and duration of clinical intervention services that are more person-centered.

To align with a dimensional, or spectrum paradigm, the categorical DSM-IV-TR schizophrenia subtypes (i.e., paranoid type, disorganized type, catatonic type, undifferentiated type and residual type) are not used in the DSM-5 because they are included in the previously described CRDPSS. Research also does not support the use of the subtypes and does not indicate any qualitative differences between the subtypes that impact treatment planning or symptom presentation (Tandon et. al., 2013). Catatonia, a syndrome of disturbed motor, mood and systemic signs, becomes a specifier in the DSM-5, applicable for neurodevelopmental, depressive, bipolar and all psychotic disorders (APA, 2013). Unlike the DSM-IV-TR, the DSM-5 does not contain the following exception clause to diagnose schizophrenia: “Only one Criterion A symptom is required if delusions are bizarre or hallucinations consist of a voice keeping up a running commentary on the persons’ behavior or thoughts, or two or more voices conversing with each other” (APA, 2000, p. 312). Removal of this language restricts classification to avoid excessive classification in nonclinical profiles, thus promoting ethical practice (ACA, 2014).

Although the DSM-5 acknowledges that “there is growing evidence that schizoaffective disorder is not a distinct nosological category” (APA, 2013, pp. 89–90; see also Malaspina et al., 2013), this disorder is retained, with some textual refinements to more stringently define the clinical syndrome. These changes include the following: criterion B: “lifetime duration of the illness” (APA, 2013, p. 105); and criterion C: major mood episode must be “present for the majority of the total duration for the active and residual portion of the illness” (APA, 2013, p. 105) instead of the DSM-IV-TR’s focus on substantial portion for the active and residual portion of the illness.

Clinical Scenario

Ryan, a 22-year-old Caucasian male, presented with an extensive history of auditory hallucinations and erotomanic and paranoid delusions. In the spirit of the DSM-5, he was administered the CRDPSS six times, beginning with the onset of counseling and then at various counseling sessions during his treatment. Use of the CRDPSS promotes clinical utility. For example, Ryan is able to identity trends and patterns related to life stressors and symptom elevations and reductions. This level of clinical assessment provides a framework for targeted treatment planning and clinical intervention. Ryan also feels empowered over his mental illness and obtains a more positive perspective regarding his self-efficacy with coping skills to manage his psychotic symptoms. Most importantly, the CRDPSS encourages measurement-based care in the burgeoning era of practice-based evidence requirements (Tandon et al., 2013). Adhering to the DSM-5 dimensional classification, I diagnosed Ryan using this format:

295.70 Schizoaffective disorder, bipolar type, severe hallucinations, moderate delusions (erotomanic and persecutory), moderate abnormal psychomotor behavior, moderate negative symptoms, equivocal disorganized speech, continuous episode, currently in partial remission, without catatonia.

Compare the DSM-5 clinical formulation to the DSM-IV-TR diagnostic formulation:

295.70 Schizoaffective disorder, bipolar type.

The DSM-5 diagnostic conceptualization offers a contextualized framework in “developing a comprehensive treatment plan that is informed by the individual’s cultural and social context” (APA, 2013, p. 19) by rating primary symptoms of psychosis in order of severity so as to promote prognostic decision-making. This level of diagnostic specificity also is found in the DSM-5 sleep-wake disorders.

Sleep-Wake Disorders 

The New Landscape

Sleep-wake disorders in the DSM-5 represent a radical revamping of diagnostic syndromes, clinical conceptualization and specifier annotations. This is because the “DSM-IV was prepared for use by mental health and general medical clinicians who are not experts in sleep medicine” (APA, 2013, p. 362). Grounded in the current International Classification of Sleep Disorders, 2nd edition (ICSD-2), the DSM-5 sleep-wake disorders work group used this classification system as a benchmark for diagnostic revision. When counselors read each sleep-wake disorder in the DSM-5, they will discover that a note about relationship to the ICSD is presented. Because of the new sleep-wake disorder conceptualization and the dimensional (instead of categorical) formulation of mental disorders in the DSM-5, counselors are to use the emerging measures for sleep-wake disorders for children and adults located at 

As counselors read the sleep-wake disorders chapter in the DSM-5, they will notice an increased emphasis on a multidimensional approach to assessment that includes medical examination, such as the use of polysomnography, quantitative electroencephalographic analysis and testing for hypocretin (orexin) deficiency (APA, 2013). They will also notice a greater emphasis on the dynamic relationship between sleep-wake disorders and certain mental or medical conditions, and that pediatric and developmental criteria and the general text are integrated based on existing neurobiological and genetic evidence and biological validators (Kaplan, 2013). The DSM-5 sleep-wake disorders textual descriptors use the terminology “coexisting with” or “comorbidity” instead of the DSM-IV-TR “related to” or “due to.” Sleep-wake disorders in the DSM-5 further provide diagnostic precision by offering use of course specifiers (i.e., episodic, persistent, recurrent, acute, subacute), descriptive specifiers (i.e., with mental disorder, with medical condition, with another sleep disorder), and severity specifiers (i.e., mild, moderate, severe). 

The insomnia-based sleep-wake disorders focus on problems with initiating or maintaining quality sleep. Some of these disorders preclude assessment by a counselor, as they require examination by a sleep medicine expert. The DSM-IV-TR primary insomnia and insomnia related to another mental disorder are merged in the DSM-5 to become insomnia disorder. The DSM-IV-TR primary hypersomnia and hypersomnia related to another mental disorder are merged to become the DSM-5 hypersomnolence disorder. Narcolepsy is retained in the DSM-5 with substantial symptom description changes, five new specifiers and requirements for sleep medicine examination to confirm a diagnosis. Narcolepsy now requires either the presence of cataplexy (sudden loss of muscle tone), hypocretin deficiency as measured using cerebrospinal fluid, or REM sleep latency deficiency as measured using polysomnography (APA, 2013). Breathing-related sleep disorders in the DSM-5 include obstructive sleep apnea hypopnea, central sleep apnea (new for the manual) and sleep-related hypoventilation (new for the manual). Circadian rhythm sleep-wake disorders in the DSM-5 no longer recognize jet lag, resulting in five types (i.e., delayed sleep phase, advanced sleep phase, irregular sleep-wake, non-24-hour sleep-wake and shift work) for counselors to select when diagnosing this syndrome. Parasomnias, defined as abnormal behavior or physiological events during sleep, also are reconceptualized in the DSM-5. The DSM-IV-TR sleepwalking disorder and sleep terror disorder are merged to become the DSM-5 non–rapid eye movement sleep arousal disorder, with sleepwalking type, sleep-related eating, sleep-related sexual behavior, and sleep terror type specifiers (APA, 2013). Nightmare disorder is retained with no substantial changes from the DSM-IV-TR. The DSM-IV-TR parasomnia not otherwise specified is renamed in the DSM-5 to rapid eye movement sleep behavior disorder for disruptive dream enacting behaviors, and DSM-IV-TR dyssomnia not otherwise specified is renamed in the DSM-5 to restless legs syndrome.

Clinical Scenario

Jasmine, a 36-year-old Caucasian female, is married and has four children. She reported a history of major depression (with two to three episodes of intense suicidal ideation) and generalized anxiety disorder. Results from the World Health Organization’s Adult ADHD Self-Report Scales (Kessler et al., 2004) indicated possible attention-deficit/hyperactivity disorder combined presentation. Results from the psychometric Conners’ Continuous Performance Test II confirmed the presence of a mild to moderate ADHD combined presentation profile. Despite pharmacological (both prescription and over the counter) and psychological (sleep hygiene and behavioral-focused) interventions, Jasmine continued to report daytime sleepiness, fatigue and unrefreshing sleep throughout the week, lasting for many months. This produced functional impairment with employment obligations and interpersonal relationships.

In the spirit of the DSM-5 and in collaboration with her general practitioner, Jasmine was referred to a local sleep medicine clinic to receive formal sleep-wake disorder testing (polysomnography). This was done to confirm the presence of an independent sleep-wake disorder not better accounted for by her depression and anxiety disorders. The resulting sleep-wake study report included the following excerpts:

This is 36-year-old female patient with a past medical history that is remarkable for gastric reflux, allergies and asthma. Patient is overweight with a BMI (body mass index) of 26.31. There is a longstanding history of: frequent awakenings, use of sleeping pills, frequent difficulty waking up, nonrestorative sleep, excessive daytime sleepiness, nasal congestion, frequent loud snoring, palpitations, night sweats and waking up with muscle paralysis. Patient complains of excessive daytime sleepiness with an Epworth Sleepiness score that is abnormal at 14 out of 24. Total sleep time is adequate at 8 hours per night. Patient denies smoking and drinking alcohol. Current medications include: Pantoprazole, Simvastatin, Amitriptyline, Loratadine and Fluticasone. As such, an overnight sleep study was ordered for evaluation of an underlying sleep-related breathing disorder.


  • Obstructive apneas (suspension of external breathing) of 17.1/hour associated with oxygen desaturation to as low as 72%. This is consistent with the diagnosis of moderate Obstructive Sleep Apnea.
  • Sleep-related hypoventilation/hypoxemia due to sleep apnea is present.
  • Severe initial insomnia.


  • Continuous positive airway pressure (CPAP) therapy should be offered to this patient given the risk of stroke and the significant daytime sleepiness. As such, a second overnight sleep study for CPAP titration is strongly recommended. If daytime sleepiness persists despite adequate CPAP therapy, then further evaluation for hypersomnolence should be considered.

Recall that hypersomnolence, excessive sleepiness, is a new disorder for the DSM-5. Addition of this diagnosis conforms to the sleep medicine expert’s recommendation for potential comorbid existence.

Adhering to the DSM-5 dimensional rather than the DSM-IV-TR multiaxial classification (Jones, 2012), Jasmine received the following diagnostic formulation:

  • 327.23 Moderate obstructive sleep apnea hypopnea (see APA, 2013, pp. 378–383);
  • V61.10 Relationship distress with spouse (see APA, 2013, p. 716);
  • 296.32 Moderate major depressive disorder, recurrent (the Level 2 — Depression—Adult [PROMIS Emotional Distress—Depression—Short Form] and the Severity Measure for Depression—Adult [Patient Health Questionnaire–9] were administered to determine severity rating (see also Jones, 2012; APA, 2014);
  • 327.24 Mild idiopathic sleep-related hypoventilation (see APA, 2013, pp. 387–390);
  • 314.01 Mild attention-deficit/hyperactivity disorder, combined presentation, in partial remission (see APA, 2013, pp. 60–61 for discussion on new severity and remission specifier options); and
  • 300.02 Mild generalized anxiety disorder (the Severity Measure for Generalized Anxiety Disorder—Adult [APA, 2014] was administered to determine severity rating).

Counselors are reminded that depression, anxiety and cognitive changes often accompany sleep-wake disorders and must be addressed in treatment planning and management (APA, 2013). To assist with targeted treatment interventions for sleep-wake disorders, counselors are encouraged to use Milner and Belicki’s (2010) sleep hygiene recommendations.

Neurocognitive Disorders 

The DSM-IV-TR chapter “Dementia, Delirium, Amnestic, and Other Cognitive Disorders” is renamed to “Neurocognitive Disorders” (NCDs) in the DSM-5. Cognitive impairments occur in most mental disorders, including schizophrenia, bipolar disorder, depression, attention-deficit/hyperactivity disorder and autism (APA, 2013). However, the DSM-5 NCDs work group focused on those disorders for which the cognitive deficit is the primary one and is attributable to known physical or metabolic brain disease­­—hence the designation neurocognitive (Campbell, 2013).

To delineate between normative aging declines and lifelong patterns, the DSM-5 requires neuropsychological testing as part of the clinical evaluation process (except for delirium). Compared to the DSM-IV-TR, the NCDs in the DSM-5 represent a significant reorganization and reconceptualization (Ganguli, 2011) reflected in two new diagnostic categories: major and mild NCDs (Geda & Nedelska, 2012). Major NCD is characterized by significant cognitive decline, interference with activities of daily living, and symptom manifestation two or more standard deviations from the mean on neurocognitive domains (see Table 1, APA, 2013, pp. 593–595). Specifiers for the major NCD designation include mild (difficulties with instrumental activities of daily living, such as housework or managing money), moderate (difficulties with basic activities of daily living, such as feeding and dressing), and severe (fully dependent).

In contrast to major NCD, mild NCD is characterized in the DSM-5 as modest cognitive decline, intact activities of daily living, and symptom manifestation one standard deviation from the mean on neurocognitive domains. Mild NCD is a former diagnostic consideration from the DSM-IV-TR (2000) Appendix B: Criteria Sets and Axes Provided for Further Study (p. 764). Mild NCD is considered an up-streaming diagnostic conceptualization to assist with early diagnostic detection because the neuropathology underlying mild NCD emerges well before the onset of clinical symptoms (APA, 2013).

The DSM-5 offers two new NCD designations: probable and possible. Probable is added to the diagnostic title if there is evidence of a causative disease genetic mutation from either genetic testing, evidence of family history, evidence from laboratory blood testing, or evidence from neuroimaging. Possible is used if there is no evidence resulting from the previously mentioned probable objective factors (APA, 2013). Counselors also may use the retained DSM-IV-TR descriptive specifier, without or with behavioral disturbance to indicate the presence of psychotic symptoms, mood disturbance, agitation, apathy or other behavioral symptoms.

The DSM-5 contains 10 etiological specifiers (formally referred to as subtypes in the DSM-IV-TR). The DSM-5 changed the title of the DSM-IV-TR Pick’s disease to frontotemporal lobar degeneration and changed the DSM-IV-TR’s Creutzfeldt–Jakob disease to Prion disease so as to more objectively communicate the active pathophysiological mechanisms responsible for the neuronal degeneration and resulting cognitive disturbances (APA, 2013). The DSM-5 added Lewy body disease and multiple etiologies as etiological specifiers and merged the DSM-IV-TR dementia due to head trauma and postconcussional disorder (found in Appendix B: Criteria Sets and Axes Provided for Further Study) to become traumatic brain injury (TBI). Counselors will appreciate the table listed on page 626 (APA, 2013) that presents severity ratings for TBI, and will find that Jones, Young, and Leppma’s (2010) article complements the DSM-5 conceptualization of TBI and offers additional assessment and diagnostic assistance.

Clinical Scenario

Jaxson, a male client in his mid-40s who suffered three TBIs, each resulting from independent automobile accidents, presented for counseling. He presented with post-concussion syndromes reflected in physical symptoms (headaches, dizziness, fatigue, noise/light intolerance, insomnia, nausea, physical weakness), cognitive symptoms (memory complaints, poor concentration), and emotional symptoms (depression, anxiety, irritability, increased aggression, mood lability). Textual additions to the DSM-5 further explained the causal relationship between TBIs and major depressive episodes, facilitating a more accurate clinical formulation. The most salient DSM-5 (APA, 2013) diagnostic guidelines included the following:

  • With moderate and severe TBI, in addition to persistence of neurocognitive deficits, there may be associated neurophysiological, emotional, and behavioral complications. These may include . . . depression, sleep disturbance, fatigue, apathy, inability to resume occupational and social functioning at pre-injury level, and deterioration in interpersonal relationships.
  • Moderate and severe TBI have been associated with increased risk of depression. (p. 626)
  • Individuals with TBI histories report more depressive symptoms, and these can amplify cognitive complaints and worsen functional outcome. (p. 627)
  • There are clear associations, as well as some neuroanatomical correlates, of depression with . . . traumatic brain injury. (p. 181)

Using the DSM-5’s Severity Ratings for TBI, three previously administered clinical neuropsychological tests and the DSM-5’s Table 1 Neurocognitive Domains, Jaxson received the following dimensional diagnostic formulation per the DSM-5 (APA, 2013):

  • 293.83 Moderate-severe depressive disorder due to TBI, with major depressive-like episode (p. 181; coding rules require that a mental disorder due to another medical condition be listed first; pp. 22–23);
  • Moderate-mild disability (87 per self-administered World Health Organization Disability Assessment Schedule [WHODAS] 2.0; pp. 745–748);
  • 331.83 Probable mild neurocognitive disorder (NCD) due to TBI (pp. 624–627);
  • V62.29 Other problem related to employment (recent change of job, underemployment and psychosocial stressors related to work due to TBI; p. 723); and
  • V61.29 Relationship distress with spouse (due to TBI; p. 716).

This approach to clinical case formulation also is demonstrated in the assessment and diagnosis of post-traumatic stress disorder and excoriation (skin-picking) disorder.

Comorbid Diagnostic Formulation 

Comorbidity refers to the presence of multiple diagnoses or pathologies within the same individual (Jones, 2012). This final section presents a discussion on the DSM-5’s new obsessive-compulsive and related disorder, excoriation (skin-picking) disorder and the revised conceptualization of post-traumatic stress disorder.

Excoriation (Skin-Picking) Disorder

Excoriation, also referred to as dermatillomania (Grant et al., 2012), is characterized by the repetitive and compulsive picking of skin, leading to tissue damage, and is a new diagnosis to the DSM-5. This addition reflects the growing prevalence of this psychiatric condition (Grant et. al., 2012). Excoriation is characterized by compulsive picking, rubbing, squeezing, lancing or biting of the skin. Not included in this disorder are individual behaviors that involve nail biting, lip biting or cheek biting. If individuals manifest these conditions they are coded as other specified obsessive-compulsive related disorder (APA, 2013, p. 263). Cutting, or nonsuicidal self-injury, is not a codable mental disorder in the DSM-5 (see APA, 2013, pp. 803–806) and is not conceptualized in the symptomology of excoriation. Counselors are encouraged to consider cutting behavior in their clients as manifestations of symptoms related to depressive disorders, bipolar disorders, anxiety disorders, trauma disorders—and most particularly dissociative identity disorder and borderline personality disorder, in which self-injurious behavior is frequent. Individuals engaged in excoriation may target their face, arms, hand, skin irregularities, pimples, calluses or scabs. They may use objects such as tweezers, pins, scissors and fingernails and be triggered by anxiety, boredom, distress or tension (Grant et al., 2012). Some individuals with excoriation display rituals (e.g., biting off, chewing and swallowing skin), permanent skin damage, scarring, lesions, infection or disfigurement. Individuals with excoriation spend several hours per day for months and years picking at their skin, thinking about picking, and resisting urges to pick. Because the skin-picking is so frequent, pain is not routinely reported. Marked functional impairment from excoriation may include work interference, missed school, difficulty managing school tasks and studying, and avoidance of social or entertainment events. Excoriation cannot be due to physiological effects of a substance (e.g., methamphetamine or cocaine), to another medical condition (e.g., scabies), or better explained by symptoms of another disorder (APA, 2013).

Post-Traumatic Stress Disorder

Some important modifications to post-traumatic stress disorder occur in the DSM-5. First, the DSM-IV-TR language has shifted from “threat to the physical integrity of self or others” (APA, 2000, p. 467) to “sexual violence” (APA, 2013, p. 271). Second, the DSM-5 removed the DSM-IV-TR criterion A2 “subjective fear-based distress” because not all traumatized individuals experience fear, terror or horror when exposed to a trauma stressor. Some traumatized individuals may become anhedonic, dysphoric, aggressive or phobic; experience arousal and reactive-externalizing behaviors; or experience dissociation. Third, a new trauma exposure source is added to the traditional DSM-IV-TR trauma sources (i.e., directly experiencing, witnessing, and learning that a traumatic event occurred to a close family member or friend): “experiencing repeated or extreme exposure to aversive details of the traumatic event(s)” (APA, 2013, p. 271). An important note regarding this new exposure source in the DSM-5 indicates that “criterion A4 does not apply to exposure through electronic media, television, movies, or pictures, unless exposure is work related” (APA, 2013, p. 271). Examples of work-related electronic media exposure may include an individual who edits graphic news video or pictures, an individual who performs frequent digital-based forensic science investigations of graphic crime scenes, or an individual who views military-oriented electronic images displaying graphic human remains captured from unmanned aerial vehicles. Fourth, the DSM-5 requires that an individual manifest at least one symptom from each of the following pathological clusters:

  • Intrusion symptoms;
  • Persistent avoidance of stimuli;
  • Negative alterations in cognitions and mood (new to the DSM-5); and
  • Marked alterations in arousal and reactivity.

Fifth, the DSM-IV-TR specifier “delayed onset” is renamed to “delayed expression” in the DSM-5 so as to communicate whether the full diagnostic criteria are not met until at least 6 months after the trauma-causing event (APA, 2013, p. 272). Sixth, “with dissociative symptoms” (Dalenberg & Carlson, 2012) is a new descriptive specifier that can include either depersonalization (e.g., feeling as though one were in a dream; feeling a sense of unreality of self or body or of time moving slowly) or derealization (e.g., the world around the individual is experienced as unreal, dreamlike, distant or distorted; APA, 2013). Seventh, separate diagnostic criterion exist for children ages 6 years and younger. Counselors are encouraged to read van den Heuvel and Seedat (2013) for a detailed review of screening measures and diagnostic instruments for post-traumatic stress disorder in preschool populations.

Clinical Scenario

Mary, a female in her mid-50s, presented with an extensive history of sexual trauma resulting in post-traumatic stress disorder and excoriation. To verify the presence and severity of her trauma and excoriation, Mary was administered the DSM-5 Level 1 cross-cutting symptom measure. Elevated responses (i.e., feeling nervous, anxious, frightened, worried, or on edge and feeling driven to perform certain behaviors or mental acts over and over again) triggered administration of the DSM-5 Level 2 cross-cutting symptom measures (i.e., the Repetitive Thoughts and Behaviors Scale, the National Stressful Events Survey PTSD Short Scale, and the Modified Brief Dissociative Experiences Scale). Adhering to the DSM-5 dimensional classification, Mary’s diagnostic formulation was conceptualized in the following format: 

  • 309.81 Moderate post-traumatic stress disorder, with mild depersonalization
  • 698.4 Excoriation (skin-picking) disorder.

This diagnostic formulation contains a layered intensity description as both the disorder and the descriptive specifier have a severity rating; hence promoting clinical utility by informing Mary’s treatment plan and assisting with prognostic and outcome factors (APA, 2013). For example, this level of diagnostic precision targeted Mary’s cognitive, affective and behavioral post-traumatic and depersonalization symptoms individually, rather than globally.


The DSM-5 represents 12 years of culminating work among hundreds of medical and mental health professionals. The manual was revised in a manner so as to stimulate new clinical perspectives, to promote a new generation of research into the biological markers of mental health disorders and to facilitate more reliable diagnoses of the disorders (APA, 2013). This article presented clinical scenarios from actual clients the author worked with in an outpatient counseling private practice. The intent is that counselors feel more comfortable and confident in their use of the DSM-5 to develop a counseling professional identity that stimulates client growth and development (Erikson & Kress, 2006; King, 2012).


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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Jason H. King is Student Development Coordinator in the School of Counseling at Walden University. Correspondence can be addressed to Jason H. King, 100 Washington Avenue South, Suite 900, Minneapolis, MN 55401-2511,


Evaluating Emerging Measures in the DSM-5 for Counseling Practice

Erika L. Schmit, Richard S. Balkin

The American Psychiatric Association introduced emerging measures to the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) classification system. The authors present a primer on dimensional assessment and a review of the emerging measures endorsed by the American Psychiatric Association. The development of the emerging measures is discussed in light of the 1999 Standards for Educational and Psychological Testing and the DSM-5 criteria, showing that the measures lack conformity to various evidences of validity and lack alignment with the DSM-5 criteria. Hence, counselors should be cautious in the adoption of such measures because the measures may not augment comprehensively the categorical system of diagnosis currently endorsed by the American Psychiatric Association.

Keywords: diagnosis, dimensional assessment, DSM-5, measures, American Psychiatric Association 


Historically, counselors relied on the categorical system of diagnosis employed by the American Psychiatric Association (APA) and included in the variations of the Diagnostic and Statistical Manual of Mental Disorders (DSM). Jones (2012) highlighted the introduction of dimensional measures for diagnosis in the fifth edition of the DSM (DSM-5). Whereas a categorical approach to diagnosis classifies a diagnosis as either present or absent, a dimensional approach to diagnosis entails using measures to evaluate the extent to which symptoms exist (Jones, 2012). Hence, the dimensional approach provides a continuum to evaluate symptoms, whereas a categorical system does not. The APA (2013g) affirmed that the measures in the DSM-5 are to be used in conjunction with other diagnostic materials and that they are designed to provide a dimensional approach to diagnosis, as opposed to a categorical approach. The purpose of this article is to review the dimensional measures in conjunction with diagnostic criteria and standards for psychological measures.

The dimensional approach to diagnosis does have certain advantages, such as the ability to address comorbid symptoms and an increased utility in research (Bjelland et al., 2009; Jones, 2012; Kraemer, Noda, & O’Hara, 2004). However, categorical approaches to diagnosis are more easily operationalized (Bjelland et al., 2009) and dimensional diagnoses can be converted easily to cut-points to provide a categorical system (Kraemer et al., 2004). Clinical utility is a primary concern with implementing dimensional classifications for diagnoses (Livesley, 2007). With respect to the medical model, physicians diagnose and treat an illness; hence, an illness is present (and therefore treated) or is not present. Dimensional diagnoses present a different paradigm in which a disorder exists on a continuum. If a disorder is only somewhat present, the justification for treatment often becomes ambiguous, and consequently, the processes of charting the course of the diagnosis and conducting research become ambiguous as well. However, given the propensity of researchers to utilize instruments that measure constructs on a continuum, dimensional classifications may offer a method of demonstrating variability within a diagnosis (Helzer, van den Brink, & Guth, 2006). Dimensional classifications may be more helpful in measuring symptoms related to personality disorders (Livesley, 2007), anxiety and depression (Bjelland et al., 2009), and substance use (Helzer et al., 2006), due to the employment of different treatment modalities based on  symptom severity. For example, medication management may not be considered with mild depression even though it may be effective; however, it may become a stronger consideration with moderate or severe depression (Stewart, Deliyannides, Hellerstein, McGrath, & Stewart, 2012).

Livesley (2007) advocated for integrating categorical and dimensional classifications for diagnoses. However, Helzer et al. (2006) indicated that a dimensional diagnosis must be associated with the operational definition of the said diagnosis, which implies that dimensional assessments must address the appropriate content to obtain a valid measure of the intended classification (i.e., diagnosis). What follows is an overview of evidences of validity for measures and an evaluation of dimensional measures advocated by the APA (2013g).

Cross-Cutting Symptom Measures 

The APA (2013g) provided a section in the DSM-5 titled “Emerging Measures and Models” (p. 729) that contained “tools and techniques to enhance the clinical decision-making process, understand the cultural context of mental disorders, and recognize emerging diagnoses for further study” (p. 731). At the forefront of this section the APA introduced cross-cutting symptom measures (CCSMs), which are utilized for consideration across diagnostic symptoms. The DSM-5 only includes a few CCSMs, but the APA’s website (2014) offers access to a comprehensive list of CCSMs. CCSMs include two levels; Level 1 is concise, including 1–4 items on each domain, while Level 2 is more comprehensive, including a measure for each domain. The Level 1 CCSMs are more general measures that include symptoms across domains consistent with common diagnostic categories (e.g., depression, anxiety; APA, 2013g) and assess a wider scope of time (i.e., two weeks). The Level 1 CCSMs are designed for adults (23 items across 13 domains) or children (25 items across 12 domains). Adults and children/adolescents between the ages of 11 and 17 may complete self-report versions. A parent/guardian version is available for children between the ages of 6 and 17.

The Level 2 CCSMs are utilized after finding threshold scores from Level 1 measures. Level 2 measures contain more detailed symptom investigation that can help with diagnosis and treatment, including assessment of a shorter time period (i.e., 7 days). Level 2 measures include such symptoms as depression, anger, mania, anxiety, somatic symptoms, sleep disturbance, repetitive thoughts and behaviors, substance abuse, inattention, and irritability. Certain measures address how often the individual has been bothered by a symptom within a time period of 7 days, and others ask the individual to pick a statement in a cluster that best represents the way he or she has been feeling within the past 7 days. Similar to the Level 1 measures, adults and children/adolescents between the ages of 11 and 17 may complete a self-report version; a parent/guardian version is available for children between the ages of 6 and 17. These measures are to be used at the early stages of treatment and throughout the treatment process.

When comparing the Level 2 measures advocated by the APA (2013g) to the emotional and behavioral symptoms included in the DSM-5 diagnoses, many crucial criteria are absent, thereby inadequately addressing validity evidence based on test content. This dearth of missing criteria may indicate a lack of consistency between the measures and the DSM-5 diagnostic criteria. Furthermore, the Level 2 measures focus more on specific symptoms than on actual diagnoses. For example, the CCSMs include assessments of anger, which is a symptom of many disorders in the DSM-5, but not a disorder itself. In addition, common psychometric properties, such as the reporting of reliability estimates of the scores, are not readily apparent, if published at all. Therefore, standards related to the alignment of the instruments with DSM symptoms (i.e., evidence based on test content) are circumspect. As Helzer et al. (2006) reported, the dimensional approach to diagnosis must align with the definition of the diagnosis in the DSM-5 

Connecting Validity Standards to CCSMs

Pertinent to the utilization of the emerging measures for the purposes of diagnosis and clinical decision making is the extent to which the measures align with diagnostic criteria and are useful. The American Educational Research Association (AERA), the American Psychological Association, and the National Council on Measurement in Education (NCME) jointly publish the Standards for Educational and Psychological Testing. AERA et al. (1999) outlined issues related to instrument development, fairness and bias, and application of results to various settings (e.g., educational, vocational, psychological). With respect to evaluating research, issues of test construction, specifically evaluating validity and reliability, need to be addressed. According to AERA et al., “validity refers to the degree to which evidence and theory support the interpretations of test scores entailed by proposed uses of test” (1999, p. 9). Validity, therefore, is not simply about the alignment of an instrument with theory and research, but also about how the scores are used. The most recent edition of the standards was published in 1999, which represented the fourth edition of the joint publication and the sixth publication by at least one of the representative bodies. As of August 2013, AERA et al. approved a revision to the 1999 Standards; however, a publication date is pending the development of a new agreement regarding how the revised Standards will be managed and published (AERA et al., 2009). Thus, the 1999 Standards represent the most current edition for measurement guidelines.

AERA et al. (1999) identified five evidences for evaluating the validity of a measure: (a) evidence based on test content, (b) evidence based on response processes, (c) evidence based on internal structure, (d) evidence based on relationships to other variables and (e) evidence based on consequences of testing. Evidence based on test content is specifically related to the extent to which the items are aligned with existing theory and the operational definition of the construct. Evidence of test content often is established through documentation of a review of extant literature and expert review. Evidence based on response processes includes an analysis of how respondents answer or perform on given items. In counseling research, some documentation about how respondents interpret the items may be noted. Evidence based on internal structure refers to the psychometric properties of the instrument. For example, items on a scale should be correlated as they measure the same construct, but they should not be overly correlated, as that could indicate that the items are not measuring anything unique. Generally, factor analysis and reliability estimates are used to indicate adequate factor structure and accurate and consistent responses for scores. Evidence based on relationships to other variables is usually demonstrated through some type of correlational research in which the scores on an instrument are correlated with scores on another instrument. Hence, how an instrument correlates to another instrument provides evidence that the same construct is being measured. Evidence based on consequences of testing refers to the need to document the “intended and unintended consequences” of test scores (AERA et al., 1999, p. 16). The choice of using scores on an instrument should be aligned with theory and practice. 

Evidence of Validity for the Emerging Measures

To address the psychometric properties of each of the measures is outside the scope of this article. The APA promoted various measures with common psychometric properties reported extensively in research, while other measures’ psychometric properties were not as evident (Aldea, Rahman, & Storch, 2009; Allgaier, Pietsch, Frühe, Sigl-Glöckner, & Schulte-Körne, 2012; Altman, Hedeker, Peterson, & Davis, 1997; Feldman, Joormann, & Johnson, 2008; Han et al., 2009; Livianos-Aldana & Rojo-Moreno, 2001; Storch et al., 2007; Storch et al., 2009; Stringaris et al., 2012; Titov et al., 2011). From the reported measures, fairly strong psychometric properties were apparent. However, not all of the measures promoted have extensive reports (e.g., PROMIS measures). In addition, some measures do not adequately parallel the DSM-5 diagnoses that one might expect. The following sections include detailed comparisons of emerging measures and their corresponding DSM-5 diagnoses. The overall purpose of this manuscript is to identify the measures’ level of congruency with DSM-5 criteria. Thus, counselors need to be aware that certain measures may provide different information about a disorder, and therefore, counselors should make informed choices regarding whether to follow the DSM-5’s criteria. The DSM-5 criteria are a major source for providing diagnoses; and counselors should be cautious when interpreting measures, particularly when the measures are inconsistent with DSM-5 criteria.

Emotional Measures. When comparing the symptoms on the PROMIS Emotional Distress—Depression—Short Form (PROMIS Health Organization [PHO] and PROMIS Cooperative Group, 2012g) for adults to symptoms in the DSM-5 on depressive disorders, the former seems to lack many crucial symptoms for depression (APA, 2013g). Containing eight statements—each asking how often the individual has been bothered by the symptom with a time period of 7 days—the measure lacks clarity as to what depression actually looks like. Common symptoms of depression such as lack of pleasure in activities, lack of appetite, weight loss, sleep loss, fatigue and thoughts of death are not addressed. The APA (2013g) noted that irritability can be a mood shown in children with the diagnoses. The parent and pediatric measures (PHO and PROMIS Cooperative Group, 2012h; 2012i) fail to include the aforementioned mood symptom, nor do they mention thoughts of death. Therefore, the DSM-5 criteria for depression appear to be more inclusive than the PROMIS Short Form criteria. 

The PROMIS Emotional Distress—Anger—Short Form, the PROMIS Emotional Distress—Calibrated Anger Measure—Pediatric, and  the PROMIS Emotional Distress—Calibrated Anger Measure—Parent (PHO and PROMIS Cooperative Group, 2012a, 2012b, 2012c) are comprised of five to six short statements (e.g. “I felt angry”) completed on a 1 (never) to 5 (always) scale. Anger is included in many diagnoses, but the closest example in the DSM-5 is the chapter titled “Disruptive, Impulse-Control, and Conduct Disorders,” whose disorders can include angry moods (APA, 2013g, p. 461). Although this chapter of the DSM-5 is most likely intended for children and adolescents, all the criteria listed in the DSM-5 for angry/irritable mood from the diagnosis of oppositional defiant disorder (ODD) are included in the PROMIS measures for anger. Furthermore, because anger is present in many diagnoses in DSM-5, all measures can be helpful in providing information on anger depiction with individuals.

The PROMIS Emotional Distress—Anxiety—Short Form (PHO and PROMIS Cooperative Group, 2012d) for adults includes seven items that measure symptoms observed in an individual experiencing anxiety (e.g., “I felt anxious,” “I felt fearful”). The adult measure examines both the feelings of anxiety and fear but, unlike the child measure, omits specific places or situations where fear or anxiety is experienced. The pediatric and parent measures (PHO and PROMIS Cooperative Group, 2012e, 2012f) are more detailed, examining a few situations and places (e.g., home and school) while the adult measure (PHO and PROMIS Cooperative Group, 2012d) examines only feelings associated with anxiety (e.g., fearful, anxious, worried). When comparing anxiety measures to DSM-5 criteria, the measures lack many important criteria, particularly the adult measure which focuses on specific feelings only.

Mania is a symptom most often seen in bipolar and related disorders in the DSM-5 (APA, 2013g). The Altman Self-Rating Mania Scale (ASRM; Altman et al., 1997) is utilized for mania depiction. The five clusters focus on happiness, self-confidence, sleep, talk and activeness. When compared to the DSM-5 criteria for mania, the ASRM is lacking in certain areas such as distractibility, racing thoughts and high-risk activity involvement (APA, 2013g). Also, the ASRM does not address the importance of an irregular mood disturbance (i.e. elevated, expansive or irritable). The measure does not encompass all symptoms needed for mania, whereas the DSM-5 criteria are more expansive.

Behavioral Measures. The somatic symptom measures, which were modified from the Patient Health Questionnaire Physical Symptoms (PHQ-15; Spitzer, Williams, & Kroenke, n.d.-a, n.d.-b, n.d.-c), examine different somatic symptoms and the frequency of each symptom in a given week. The modified somatic symptom measures inform the individual and his or her clinician of the severity of symptoms such as headaches, shortness of breath and stomach pain. The main difference between the symptoms measured by the scales and those discussed in the “Somatic Symptom and Related Disorders” chapter of the DSM-5 is that the scales do not include any analysis of the excessive thoughts and feelings associated with the somatic symptoms (APA, 2013g, p. 309). The modified somatic symptom measures tell the client or clinician if and how much a symptom is present, but unlike the DSM-5 criteria, they do not focus on the individual’s actual concern over the symptom. The DSM-5 is not focused on the child population for most somatic disorders, but it does describe the most common symptoms of somatic symptom disorder as abdominal pain, headaches, fatigue and persistent nausea. Children can exhibit somatic symptoms, but they rarely worry about these symptoms before adolescence (APA, 2013g). The adult, child and parent/guardian versions of the somatic symptom measure are similar, but with two exclusions on the child and parent/guardian version (“menstrual cramps or other problems with your periods WOMEN ONLY” and “pain or problems during sexual intercourse”; Spitzer et al., n.d.-a, n.d.-b, n.d.-c).

The PROMIS—Sleep Disturbance—Short Forms (PHO and PROMIS Cooperative Group, 2012j, 2012k, 2012l) are utilized to determine sleep issues in the past week. The measures contain such questions as “my sleep was refreshing” and “I had trouble sleeping” (PHO and PROMIS Cooperative Group, 2012j, 2012k). The sleep-wake disorders in the DSM-5 include individual discontent with sleep, which can result in distress and impairment (APA, 2013g). Therefore, the PROMIS measures lack in that they do not have statements regarding whether the sleep disturbance is affecting the individual’s life negatively. The DSM-5 (APA, 2013g) does include different manifestations of certain symptoms for children (e.g., a child may struggle to fall asleep without a caregiver). Symptoms in children can occur because of particular situations such as inconsistent sleep schedule and conditioning issues. The onset of some sleep disorders happens in late adolescence or adulthood, with the exception of narcolepsy, which has an average onset in childhood and adolescence/young adulthood. Also, nightmare disorder happens most often in children and adolescence (APA, 2013g).

The repetitive thoughts and behaviors measures, which were adapted from the Florida Obsessive-Compulsive Inventory (FOCI) Severity Scale (Part B) and the Children’s Florida Obsessive-Compulsive Inventory (C-FOCI) Severity Scale, each include five items directing the individual to rate each question. The questions are focused on time, distress, control, avoidance and interference of the thoughts or behaviors (Goodman & Storch, 1994a, 1994b). The “Obsessive-Compulsive and Related Disorders” chapter in the DSM-5 examines main symptoms such as obsessions and compulsions (APA, 2013g, p. 235). Although the DSM-5 specifically identifies the symptoms as obsessions and compulsions, the adaptations of the FOCI and C-FOCI identify the symptoms as simply thoughts and behaviors. The FOCI and C-FOCI include fairly similar symptoms of obsessive-compulsive disorder with simpler terms and language. The FOCI does not include the anxiety portion, but does ask about distress. Also, the FOCI and C-FOCI do not include a specific repetitive behaviors component (Goodman & Storch, 1994a, 1994b). For the most part these two measures are very similar. Each of the five questions is focused on the same topic; the minor difference is language. For example, the adult scale asks how much distress the thoughts/behaviors cause, while the child version asks how much they bother the child. The adult measure utilizes the word work while the child measure uses the word job (Goodman & Storch, 1994a, 1994b). The measures have components similar to DSM-5 criteria, but there are inconsistencies between the two.

The Level 2—Substance Use—Adult measure, adapted from the National Institute on Drug Abuse (NIDA)-Modified ASSIST (NIDA, n.d.-a), includes 10 items that measure how often an individual used a substance in the past two weeks. The substances included are painkillers, stimulants, sedatives or tranquilizers, marijuana, cocaine or crack, club drugs, hallucinogens, heroin, inhalants or solvents, and methamphetamine. The interviewee answers from 0–4 based on how many days the substance is used. The measure does not include alcohol, tobacco or caffeine as substances (NIDA, n.d.-a). In DSM-5, the chapter “Substance-Related and Addictive Disorders” focuses on substance addictions as well as process or behavioral addictions (APA, 2013g, p. 481). The Level 2—Substance Use—Adult measure and the criteria for substance use disorders in the DSM-5 have very little in common besides the use of a substance. The DSM-5 contains topics such as intoxication, withdrawal, social impairment, risky use, behavioral issues, psychological issues and all of their related symptoms (APA, 2013g). The possible symptoms of substance use are important to examine when treating an individual who has used a substance, and therefore the expanded criteria of the DSM-5 are necessary. The parent and child versions (NIDA, n.d.-b, n.d.-c) of the substance use measures (15 items each) are longer than the adult version (10 items). The parent and child versions include tobacco, alcohol, steroids and other medicines, while the adult version does not. None of the above measures examine caffeine use (NIDA, n.d.-a, n.d.-b, n.d.-c).

The Swanson, Nolan, and Pelham, version IV (SNAP-IV; Swanson, 2011) for inattention in children aged 6–17 is an eight-item measure answered by a parent or guardian of the child. The items can be answered on a scale of 0 (not at all) to 3 (very much). The items center on the lack of attention to certain people, items and behaviors, such as organizing tasks, paying attention to details, and being distracted (Swanson, 2011). Inattention in children is included in the attention-deficit/hyperactivity disorder in the DSM-5 (APA, 2013g, p. 59). Items 1–8 on the SNAP-IV (Swanson, 2011) are worded very similarly to the inattention items in the DSM-5 (APA, 2013g), with only minor changes. The only DSM-5 item not included in SNAP-IV regards forgetfulness of daily activities (APA, 2013g). The SNAP-IV measure and the DSM-5 criteria appear to be relatively equal in diagnostic usefulness.

The irritability measures, identified as Affective Reactivity Index (ARI; Stringaris et al., 2012), for parent/guardian of child age 6–17 and child age 11–17, contain the same items and are rated either 0 (not true), 1 (somewhat true), or 2 (certainly true). Anger is a topic used in three of the seven items. Other main topics include annoyance, temper and irritability (Stringaris et. al., 2012). The irritability measures can be compared to the “Angry/Irritable Mood” section of the ODD diagnosis in DSM-5 (APA, 2013g, p. 462). The three criteria here are included in each measure, making both resources useful. 

Disorder-Specific Severity Measures. The disorder-specific severity measures are similarly complementary to diagnostic criteria in the DSM-5 and are made for those who have met or are close to meeting a diagnosis. The two types of measures included are self-administered (adult and child age 11–17) and clinician-administered. Disorders included in the self-administered measures are depression, separation anxiety disorder, specific phobia, social anxiety disorder (social phobia), panic disorder, agoraphobia, generalized anxiety disorder, post-traumatic stress symptoms, acute stress symptoms, and dissociative symptoms (APA, 2014). Disorders and symptoms included in the clinician-administered measures are autism spectrum and social communication disorders, psychosis symptoms, somatic symptom disorder, ODD, conduct disorder, and nonsuicidal self-injury (APA, 2013b, 2013a, 2013f, 2013e, 2013c, 2013d).

Generally, the disorder-specific severity measures have a different time frame for meeting criteria for symptoms than the DSM-5 does and do not discuss significant distress or proportion to danger. Few, if any, differences exist between the adult and child measures. The clinician-rated measures are short and lack clarity on definitions. For example, the measures on ODD as well as nonsuicidal self-injury do not include the construct definitions (APA, 2013e, 2013d).

Self-Administered Measures. The Severity Measure for Depression—Adult and Severity Measure for Depression—Child Age 11–17 (Spitzer et al., n.d.-d, 2002), which were adapted from the Patient Health Questionnaire-9 (PHQ-9), include nine items rated from 0 (not at all) to 3 (nearly every day) with a time period of the past 7 days. The first two items on these measures are similar to the first two symptoms needed for major depressive disorder in the DSM-5, both referring to depressed mood and decreased interest or pleasure (APA, 2013g). These measures include somewhat of a weight component similar to that of the DSM-5, although the weight items on the measures examine appetite/overeating, while symptoms in the DSM-5 examine an extra component of weight loss/gain or appetite changes. The components regarding sleeping and psychomotor symptoms, fatigue, worthlessness, concentration and thoughts of death on the measures are all similar to criteria in the DSM-5, although worded differently. Irritability is added to an item on the child measure (Spitzer et al., 2002), but was not included in the adult measure (Spitzer et al., n.d.-d). The child measure’s item on eating refers to “poor appetite, weight loss, or overeating,” (Spitzer et al., 2002) whereas the adult measure does not mention weight loss (Spitzer et al., n.d.-d); similarly, one DSM-5 criterion for major depressive disorder states, “in children, consider failure to make expected weight gain” (APA, 2013g, p. 161). In spite of a few differences, the Severity Measures for Depression are mostly consistent with DSM-5 criteria for major depressive disorder.

The Severity Measure for Separation Anxiety Disorder—Adult and Severity Measure for Separation Anxiety Disorder—Child Age 11–17 (Craske et al., 2013g, 2013h) include 10 items examining the past 7 days based on a scale of 0 (never) to 4 (all of the time). The statements focus on separation and thoughts, behaviors and feelings behind the separation (Craske et al., 2013g, 2013h). The 10 items from the measure are mostly similar to criteria for separation anxiety disorder in the DSM-5 (APA, 2013g). Items 1 and 2 on the measures (which refer to terror, fear, fright, anxiety, worry and nervousness) appear similar to the distress from separation criteria in the DSM-5 with different wording. Thoughts of bad things happening, avoidance of places, physical symptoms of anxiety and difficulty sleeping are similar criteria to those in the DSM-5. The four items included in the measures but not in the DSM-5 criteria are as follows: “when separated, left places early to go home,” “spent a lot of time preparing for how to deal with separation,” “distracted myself to avoid thinking about being separated,” and “needed help to cope with separation” (Craske et al., 2013g, 2013h). Although these measures and the DSM-5 contain similar criteria for separation anxiety disorder, the measure includes items that may not be congruent to DSM-5 criteria. 

The Severity Measure for Specific Phobia—Adult and Severity Measure for Specific Phobia—Child Age 11–17 (Craske et al., 2013k, 2013l) have 10 items that include five different groups of phobias, including (a) driving, flying, tunnels, bridges or enclosed spaces; (b) animals or insects; (c) heights, storms or water; (d) blood, needles or injections; and (e) choking or vomiting. The individual completing the form chooses one phobia and answers items according to that phobia on a scale of 0 (never) to 4 (all of the time; Craske et al., 2013k, 20131). The measures include more items than the criteria in the DSM-5. Items 1 and 2 (terror, fear, fright; anxiety, worry, nervousness) on the measures resemble criterion A (fear or anxiety) in the DSM-5 for specific phobia (APA, 2013g, p. 197). Physical symptoms (e.g., racing heart, tense muscles) are not included in the DSM-5 criteria. Avoidance of a situation is included both in the measures and in the DSM-5. The items in the measures which are not included in the DSM-5 are “spent a lot of time preparing for, or procrastinating about (i.e., putting off), these situations,” “distracted myself to avoid thinking about these situations” and “needed help to cope with these situations” (Craske et al., 2013k, 2013l). The specifiers in the DSM-5 (animal, natural environment, blood-injection-injury, situational and other) are similar to phobias included in the measures (APA, 2013g, p. 198). The DSM-5 states that “in children, the fear or anxiety may be expressed by crying, tantrums, freezing, or clinging” (APA, 2013g, p. 197), and this information is not included in the child version of this measure.

The Severity Measure for Social Anxiety Disorder (Social Phobia)—Adult and Severity Measure for Social Anxiety Disorder (Social Phobia)—Child Age 11–17 (Craske et al., 2013i, 2013j) are 10-item measures completed on a scale of 0 (never) to 4 (all of the time). The social situations described in the measures are the same as those described in the DSM-5 for social anxiety disorder (social phobia; APA, 2013g). Items 1, 2 and 3 on the measures are similar to criteria A and B in the DSM-5. Physical symptoms such as racing heart and tense muscles are included in the measures but are not included in the DSM-5 criteria. Avoidance of social situations is included in both the measures and the DSM-5 criteria. There are items included in the measures that are not included in the DSM-5 criteria, such as “spent a lot of time preparing what to say or how to act in social situations” and “distracted myself to avoid thinking about social situations” (Craske et al., 2013i, 2013j). One DSM-5 criterion states that “the social situations almost always provoke fear or anxiety” (APA, 2013g, p. 202), an item which is not present in the measures. In the DSM-5 there are a few differences for children with social anxiety disorder. Anxiety has to take place with peers and not only with adults. Furthermore, fear/anxiety can be expressed through crying, tantrums, freezing, clinging, shrinking or not speaking. These differences are not included in the child version of the measure (Craske et al., 2013j).

The Severity Measure for Panic Disorder—Adult and Severity Measure for Panic Disorder—Child Age 11–17 (Craske et al., 2013e, 2013f) are 10-item measures completed on a scale of 0 (never) to 4 (all of the time). The measures provide a definition and the symptoms of a panic attack in an individual (Craske et al., 2013e, 2013f). This information is similar to the definition of panic disorder in the DSM-5 (APA, 2013g). The measures include six of the 13 symptoms included in the DSM-5. Items on the measures that are not included in the DSM-5 criteria include “left situations early, or participated only minimally, because of panic attacks,” “spent a lot of time preparing for, or procrastinating about (putting off), situations in which panic attacks might occur,” “distracted myself to avoid thinking about panic attacks” and “needed help to cope with panic attacks” (Craske et al., 2013e, 2013f). The DSM-5 includes certain symptoms that the measures do not, including choking feelings, pain in chest, nausea, sensations of chills or heat, sensations of numbness or tingling, and derealization or depersonalization (APA, 2013g, p. 208). The measures have an item on sleeping issues, which was not included in the DSM-5.

The Severity Measure for Agoraphobia—Adult and Severity Measure for Agoraphobia—Child Age 11–17 (Craske et al., 2013a, 2013b) are 10-item measures to be completed on a scale of 0 (never) to 4 (all of the time). The instructions for the measures include situations on which to base the items (e.g., being in crowds or public spaces, traveling). The criteria for agoraphobia in the DSM-5 include significant distress caused by at least two of the following five situations: “being outside of the home alone,” “using public transportation,” “standing in line or being in a crowd” and being in “open spaces” and/or “enclosed spaces” (APA, 2013g, p. 217). The fear and anxiety experienced and the avoidance of situations are included in both the measures and the DSM-5 criteria. Although avoidance is included in the measures, the reason for the avoidance is not. Items included in the measures but not in the DSM-5 criteria include “had thoughts about panic attacks, uncomfortable physical sensations, getting lost, or being overcome with fear in these situations”; “spent a lot of time preparing for, or procrastinating about (putting off), these situations”; “distracted myself to avoid thinking about these situations”; and “needed help to cope with these situations” (Craske et al., 2013a, 2013b). Also, two items on physical sensations from the measures are not present in the DSM-5 criteria (APA, 2013g; Craske et al., 2013a, 2013b).

The Severity Measure for Generalized Anxiety Disorder—Adult and Severity Measure for Generalized Anxiety Disorder—Child Age 11–17 (Craske et al., 2013c, 2013d) are 10-item scales completed on a scale from 0 (never) to 4 (all of the time). Differences are found when comparing the measures to generalized anxiety disorder in the DSM-5 (APA, 2013g). The measures do not include the following DSM-5 criteria: anxiety and worry occurring for 6 months or more, difficulty controlling worry, the anxiety and worry perhaps being associated with difficulty concentrating and irritability, and the anxiety and worry causing distress (APA, 2013g, p. 222). The measures include the following items that the DSM-5 does not: “avoided, or did not approach or enter, situations about which I worry”; “left situations early or participated only minimally due to worries”; “spent lots of time making decisions, putting off making decisions, or preparing for situations, due to worries”; “sought reassurance from others due to worries”; and “needed help to cope with anxiety” (Craske et al., 2013c, 2013d). Also, item 3 on the measures (“had thoughts of bad things happening”) is similar to criterion A in the DSM-5 (“anxiety and worry . . . about a number of events or activities”) with different wording (APA, 2013g, p. 222; Craske et al., 2013c, 2013d).

The National Stressful Events Survey PTSD Short Scale (NSESSS; Kilpatrick, Resnick, & Friedman, 2013c) contains nine items and is to be completed on a scale of 0 (not at all) to 4 (extremely). The criteria for post-traumatic stress disorder (PTSD) in the DSM-5 include a list of possible stressful events and situations (APA, 2013g). The NSESSS does not include a list of stressful events and situations for the individual. Criteria and items that are the same or similar on the NSESSS and in DSM-5 PTSD criteria include flashbacks, emotional (NSESSS) or psychological distress (DSM-5), avoidance, negative feelings about self, distorted cognitions and blame, negative emotional states, loss of interest in activities, anger and irritability, self-destructive behavior, hypervigilance and startle response (APA, 2013g; Kilpatrick et al., 2013c). The items/criteria may be worded and/or organized differently but they have the same meaning. Although all items on the NSESSS are included in the DSM-5’s criteria for PTSD, the DSM-5 includes additional criteria beyond what the NSESSS measures, which suggests the DSM-5 as being more thorough of the two, and indicates the inconsistencies of the NSESSS when compared to the DSM-5 criteria. The following criteria from the DSM-5 are not included in the NSESSS: dreams, physiological reactions, dissociative amnesia, detachment/estrangement from others, inability to experience positive emotions, concentration issues and sleep issues. There are notes in the DSM-5 for application to children. Children may partake in recurring play/reenactment having to do with the traumatic event. Dreams with unrecognizable content may occur (APA, 2013g). The criteria above were not included in the child version of the NSESSS (Kilpatrick, Resnick, & Friedman, 2013d). Also, the DSM-5 has a different section for children 6 and under, but the NSESSS is to be completed by children 11–17 (APA, 2013g; Kilpatrick et al., 2013d).

The National Stressful Events Survey Acute Stress Disorder Short Scale (NSESSS; Kilpatrick et al., 2013a) for severity of acute stress symptoms includes seven items and is to be completed on a scale of 0 (not at all) to 4 (extremely). Six out of the seven items on this measure are the same as those on the measure for PTSD above. Items that are also included in acute stress disorder in the DSM-5 are flashbacks, emotional (NSESSS) or psychological distress (DSM-5), detachment, avoidance, hypervigilance, startle response and irritability/anger (APA, 2013g). Similar to the NSESSS for PTSD, all seven items on the NSESSS for acute stress disorder are included in the DSM-5 criteria, but certain DSM-5 criteria are not included in the NSESSS. The criteria not included are as follows: dreams, inability to experience positive emotions, dissociative amnesia, sleep disturbance and concentration issues. There are notes in the DSM-5 for application to children. Children may partake in recurring play/reenactment having to do with the traumatic event. Dreams with unrecognizable content may occur. The criteria above were not included in the child version of the NSESSS (Kilpatrick et al., 2013b). Neither of the NSESSS measures fully assess an individual for the DSM-5 criteria for PTSD or acute stress disorder.

The Brief Dissociative Experiences Scale (DES-B)—Modified (Dalenberg & Carlson, 2010a) has eight items and is completed on a scale of 0 (not at all) to 4 (more than once a day) in the past 7 days. When comparing this measure to dissociative disorders in the DSM-5, it is hard to find a specific criterion that matches closely to items on the scale (APA, 2013g, p. 291). The closest criterion is found under dissociative identity disorder (DID; APA, 2013g). Although the wording is different, disruption of identity and gaps in recollections are both present in the DES-B and DSM-5 criteria for DID. Some items on the DES-B are also included in depersonalization/derealization disorder (APA, 2013g, p. 302). Both depersonalization and derealization symptoms are included in DES-B. There is one note under DID in the DSM-5 applicable to children: symptoms in children are not better justified by imaginary or fantasy play. This is not included in the child version of the DES-B (Dalenberg & Carlson, 2010b). Although items included in the measures are present in DSM-5 criteria, overall, the measures are inconsistent with DSM-5 criteria.

Clinician-Rated. The Clinician-Rated Severity of Autism Spectrum and Social Communication Disorders is a measure that assesses “the level of interference in functioning and support required as a result of: a) any social communication problems AND b) any restricted interests and repetitive behaviors” (APA, 2013b). The two disorders included are autism spectrum disorder (APA, 2013g, p. 50) and social (pragmatic) communication disorder (APA, 2013g, p. 47). The clinician must choose one of these disorders. The clinician rates the two items above (social communication and restricted interests /repetitive behaviors) based on levels 0 (none), 1 (mild; requiring support), 2 (moderate; requiring substantial support), and 3 (severe; requiring very substantial support). The measure does not go into detail about these disorders’ diagnostic criteria, but the DSM-5 offers a detailed account (APA, 2013b, 2013g). Besides simply stating the two issues above, the measure fails to include specific criteria from the DSM-5. 

The Clinician-Rated Dimensions of Psychosis Symptom Severity (APA, 2013a) is a measure that rates symptoms of psychosis based on presence and severity in the last 7 days. The eight domains included in the measure are hallucinations, delusions, disorganized speech, abnormal psychomotor behavior, negative symptoms (restricted emotional expression or avolition), impaired cognition, depression and mania. The clinician rates the symptoms either 0 (not present), 1 (equivocal), 2 (present, but mild), 3 (present and moderate) or 4 (present and severe; APA, 2013a). According to the DSM-5, the five main features of psychotic disorders include delusions, hallucinations, disorganized speech, grossly disorganized or catatonic behavior, and negative symptoms (APA, 2013g, pp. 96, 99). These main features are included in the measure as well as three others. Schizophreniform disorder (APA, 2013g, p. 96) and schizophrenia (APA, 2013g, p. 99) include the five main features for criteria in the DSM-5 but not the last three included in the measure, which are impaired cognition, depression and mania (APA, 2013a). Other disorders, such as depressive or bipolar disorders with psychotic features, would include either a depressive or manic symptom (APA, 2013g, 2013a). Because the measure assesses psychosis symptoms that are consistent with DSM-5, this measure could be useful in determining severity but not consistent with any specific diagnosis. 

The Clinician-Rated Severity of Somatic Symptom Disorder (APA, 2013f) includes three items in which the clinician rates somatic symptoms based on presence and severity in the last 7 days. The scale is to be completed from 0 (not at all) to 4 (very much). The main themes of the three questions are concerns, anxiety, and time and energy (APA, 2013f). The somatic symptom disorder in the DSM-5 includes the three themes above in criterion B with similar wording, but also includes criteria not present in the measure (APA, 2013g, p. 311), so the measure is again inconsistent with DSM-5 criteria.  

The Clinician-Rated Severity of ODD (APA, 2013e) and the Clinician-Rated Severity of Conduct Disorder (APA, 2013c) both include only one item to assess based on the presence and severity of any ODD or conduct disorder symptoms (APA, 2013g). The scales are to be completed from level 0 (none) to level 3 (severe). The items simply state, “Rate the level or severity of the OPPOSITIONAL DEFIANT problems that are present for this individual” (APA, 2013e) and “Rate the level or severity of the conduct problems that are present for this individual” (APA, 2013c). The criteria for diagnosis are not listed in the measures but can be found under ODD and conduct disorder in the DSM-5 (APA, 2013g). Although the criteria for both are absent in the measures, APA refers clinicians to the DSM-5, which suggests that the measures completely parallel the diagnostic criteria.

The Clinician-Rated Severity of Nonsuicidal Self-Injury (APA, 2013d) is a one-item measure that examines the presence and severity of any nonsuicidal self-injury problems that have happened in the past year. The scale is to be completed based on five levels, including 0 (none), 1 (subthreshold), 2 (mild), 3 (moderate), and 4 (severe). The item simply states, “Rate the level or severity of the NONSUICIDAL SELF-INJURY problems that are present for this individual” (APA, 2013d). The symptoms are not listed but can be found under nonsuicidal self-injury in the DSM-5 (APA, 2013g, p. 803). Similarly to the previous measures stated, the APA directs clinicians to the DSM-5, which again indicates an alignment to diagnostic criteria.

Implications for Counseling Practice 

The APA (2013g) endorsed dimensional assessment to be used in conjunction with categorical diagnoses. An effort to establish measurement protocols in a process often deemed rather subjective is laudable. The APA indicated that the assessment system was an “emerging” (2013g, p. 729) system, which indicates a rather circumspect decision by the APA. The DSM system represents a system of classifying diagnoses, whose current framework is 20–30 years old and widely established (Jones, 2012). Given the influence of the DSM system of diagnosis (e.g., reimbursement, research studies, treatment planning), the publication of the emerging measures that fail to meet basic standards of testing and measurement could be confusing to counselors expecting that scores of the emerging measures would provide consistent and accurate information about severity and be consistent with diagnostic classifications in the DSM-5.

The presence of validity evidence across the emerging measures is inconsistent, based on erratic reporting of psychometric information and lack of alignment with diagnostic criteria, such as what was documented regarding the disorder-specific severity measures. Although many of the measures were validated for clinical use, other measures lack this information. Perhaps the most basic critique of the system is that the publication of these measures lack alignment with the very diagnostic categories they are supposed to evaluate.

Evidence based on test content (AERA et al., 1999) is perhaps the most basic type of evidence for providing validity evidence of measures. The process entails that instruments that are developed be aligned with published research and expert review. Hence, the presence of dimensional measures that are supposed to align with the DSM-5 classification system but fail to be comprehensive in the breadth of symptoms covered could be a serious limitation of these emerging measures.

Professional counselors should be cautious in the adoption of the dimensional measures. Many quality measures already exist that adequately align with the categorical diagnostic system of the APA. For example, in the development of the Beck Depression Inventory (BDI)-II, Beck, Steer, and Brown (1996) updated the initial BDI to align with the diagnostic symptoms of depression used in the DSM-IV. The APA should follow similar processes in terms of content alignment and the collection and analysis of data to provide evidence of psychometric properties; counselors must be aware that adherence to this process was not systematically implemented. Both the CCSMs and severity measures were designed to review general symptoms commonly apparent across a broad range of clients and to “be administered both at initial interview and over time to track the patient’s symptom status and response to treatment” (APA, 2013g, p. 733). However, the variability with respect to the diagnostic classifications and absence of psychometric properties limits the potential for these measures to provide accurate and valid assessments.

The measures may be helpful in confirming clinical impressions or identifying potential problem areas that warrant further exploration. To some degree, however, counselors should be aware of potential ethical dilemmas that could arise from using the emerging measures endorsed by the APA. According to the American Counseling Association (ACA), “counselors have a responsibility to the public to engage in counseling practices that are based on rigorous research methodologies” (2014, p. 8). Clearly, the extent to which the published emerging measures represent rigorous research is at issue. APA does identify the measures as “emerging” (2013g, p. 729), thereby acknowledging the preliminary nature of the dimensional assessments. From a public health standpoint, the consequences of basing diagnoses or justifying clinical care or improvement solely on the emerging measures could be egregious. As third-party payers and managed care companies scramble to adopt the new classification system, the presence of the emerging measures could be mistaken as an endorsement for their adoption by organizations (e.g., managed care companies) that lack the understanding of the measurement and evaluation principles. The presence of the emerging measures in the DSM-5 presents an incomplete system that may not augment comprehensively the categorical system of diagnosis currently endorsed by the APA (2013g). Counselors using the emerging measures should employ other well-established measures and protocols to corroborate their clinical impressions and findings.

Counselors should be careful when interpreting the results of instruments that lack adequate empirical data to support respondent results; they should also qualify any conclusions, diagnoses, or recommendations that are based on assessments or instruments (ACA, 2014, p. 12). When emerging measures are used for diagnostic classification or to denote changes in symptoms or distress, counselors should identify the extent to which the findings from the dimensional assessment match the clinical impressions or findings from other assessment tools. Assessment tools, in general, provide information that should not stand alone (Balkin & Juhnke, 2014), and the use of the dimensional measures is not an exception to this rule.


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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Erika L. Schmit is a doctoral student at Texas A&M University – Corpus Christi. Richard S. Balkin, NCC, is an Associate Professor and Assistant Dean at Texas A&M University – Corpus Christi. Correspondence can be addressed to Erika L. Schmit, Texas A&M University – Corpus Christi, Counseling and Educational Psychology Department, College of Education, ECDC 232, 6300 Ocean Drive, Unit 5834, Corpus Christi, TX 78412-5834,