Jul 5, 2014 | Article, Volume 4 - Issue 3
Laura E. Welfare, Ryan M. Cook
Major depressive disorder, bipolar I disorder and schizophrenia are chronic conditions, and adults who have these diagnoses often benefit from mental health treatment throughout their lives. The recent fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) included changes to many diagnoses. Consequently, counselors need to understand the changes and revise their diagnostic practices accordingly. Changes affect new clients being diagnosed for the first time as well as long-term clients who were initially diagnosed many years ago. This manuscript provides an explanation of changes to major depressive disorder, bipolar I disorder and schizophrenia. Case examples illustrate implications for counselors who work with clients who have these three serious and chronic mental illnesses. Counselors, following best practice guidelines and the American Counseling Association’s ethical mandate, can take advantage of this opportunity to ensure that clients understand their mental health conditions and that documented diagnoses are accurate and thorough.
Keywords: major depressive disorder, bipolar I disorder, schizophrenia, DSM-5, diagnoses, chronic mental illness
Major depressive disorder, bipolar I disorder and schizophrenia are chronic mental health conditions. Adults who have these diagnoses often benefit from mental health treatment from counselors, psychiatrists and other clinicians throughout their lives. A new edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5; American Psychiatric Association [APA], 2013) has been released. The changes therein impact both new clients who present for initial assessment and also clients who have been in treatment for chronic conditions. A thorough understanding of the implications for revising existing diagnoses will help counselors provide quality services to clients who need ongoing support. Counselors also are responsible for helping clients understand their diagnoses, so the release of the DSM-5 is an opportunity to ensure that both new clients and clients in long-term treatment have an opportunity to ask questions about their conditions (American Counseling Association [ACA], 2014). Using the full terminology available in the DSM-5 (e.g., defined diagnoses instead of other specified umbrella diagnoses and including specifiers to highlight key features of the disorder) will help establish the new common language so that clinicians and clients can all communicate effectively about treatment. To illustrate how counselors can use the DSM-5 to best serve clients who have major depressive disorder, bipolar I disorder and schizophrenia, this article provides information about each disorder, a description of the changes from the DSM-IV-TR to the DSM-5, case examples and conclusions.
Major Depressive Disorder
Nearly 16 million adults in the United States experience a major depressive episode each year (Substance Abuse and Mental Health Services Administration [SAMHSA], 2013), as defined by the DSM-IV-TR (APA, 2000). Individuals who experience major depressive disorder suffer from impairment in every part of their lives, including relationships, functioning at work and self-care. When symptoms of depression increase, individuals may not feel motivated to spend time with others. They may feel no pleasure in previously enjoyable activities and experience interactions with others as draining. Similarly, a previously motivated and engaged employee may seem distracted or disconnected at work and absenteeism may become a problem. In addition to problems in relationships and at work, self-care also is impacted by major depression. Time and energy for healthy habits such as exercise and meal preparation may be lost. In severe cases, a lack of attention to basic hygiene may be observable.
The severity and length of symptoms can vary tremendously for individuals with major depressive disorder. Some people never experience remission while others may enjoy years without symptoms (National Institute of Mental Health [NIMH], n.d.-a). The longer the period of remission, the lower the likelihood of a recurrence (APA, 2013). For those individuals who have more severe episodes, a history of multiple previous episodes, or were first diagnosed at a younger age, lifelong mental health treatment may be necessary to increase quality of life (APA, 2013).
Treatment. Almost 11 million people diagnosed with major depressive disorder sought treatment in 2012, which was approximately 68% of those diagnosed with the disorder (SAMHSA, 2013; based on DSM-IV-TR criteria). The most common forms of treatment are medications (e.g., antidepressants), psychotherapy/counseling or a combination of the two. In 2012, 45% of all individuals who had a major depressive episode used a combination of psychotherapy/counseling and medications, while 14.1% used psychotherapy/counseling only, and 6.6% used medication only (SAMHSA, 2013). More than half of the individuals who received medication for their major depressive episode did so from their general practitioner (SAMHSA, 2013). For those who sought psychotherapy/counseling, many accessed outpatient counseling at a mental health clinic or private practice in the community. About .8% reported they were hospitalized at some point in the year (SAMHSA, 2013). Others may have received treatment that included more intensive interventions such as case management to help with access to services and subsistence or day treatment to provide all-day support and supervision when needed. Because such a small percentage of clients seek psychotherapy/counseling alone (SAMHSA, 2013), it is likely that counselors who work with clients who have major depressive disorder do so as part of a treatment team. Counseling is an essential part of treatment, as there is ample empirical evidence for its effectiveness, particularly cognitive-behavioral and interpersonal techniques (e.g., Paradise & Kirby, 2005).
Bipolar I Disorder
Bipolar I disorder affects roughly .6% of the population (APA, 2013). It is a lifelong disorder, as nearly all of the individuals who have one manic episode will have multiple episodes in their lifetime (APA, 2013). Symptoms of bipolar I disorder can be detrimental to relationships, daily functioning and financial stability of the individual who is diagnosed with the disorder. The cyclical nature of bipolar I disorder leads to instability, as the episodes of depression, mania and remission each have a different impact on the individual’s life. During episodes of depression, the impact is similar to that caused by major depressive disorder, as described above. In contrast, some individuals with bipolar I disorder report enjoying manic episodes as they escalate because of improved mood, energy and productivity. However, elevated mood often comes with dangerous grandiosity, distractibility and impulsivity. During periods of remission when symptoms are mild or absent, the person may attempt to repair the consequences of their manic episodes (e.g., excessive shopping) and depressive episodes (e.g., neglected chores).
Few people seek treatment on their own during manic episodes. Initiating or expanding treatment during a manic episode is important to prevent irreparable damage and to ensure safety. Grandiosity combined with risky behaviors can lead to physical injuries and property damage, and the euphoria of elevated mood can quickly shift to anger and irritability. For more than half of individuals with bipolar I disorder, depressive episodes follow manic episodes (APA, 2013), which is especially dangerous to the individual if he or she is not in a secure treatment setting.
Treatment. Roughly two-thirds of those diagnosed with bipolar I disorder receive treatment each year (Merikangas et al., 2007). The most common form of treatment is medication, including mood stabilizers, atypical antipsychotics and antidepressants (NIMH, n.d.-b). While many of these medications are effective in managing symptoms, some can have serious side effects resulting in additional medical risks such as liver or kidney issues. These risks, in addition to lack of insight into illness, preference for manic episodes, and comorbid personality or addictive disorders can lead to noncompliance (Colom et al., 2000).
In treating bipolar I disorder, individual therapy and family counseling may be helpful in developing client interpersonal skills and increasing quality of life (NIMH, n.d.-b; Steinkuller & Rheineck, 2009). There is clear empirical evidence suggesting that individuals who participated in psychotherapy more frequently and for a longer duration in addition to using medication had a better prognosis than those who participated in fewer sessions over a shorter period of time (NIMH, n.d.-b.; Steinkuller & Rheineck, 2009). These individuals appeared to recover more quickly, have fewer relapses and require fewer hospitalizations.
Schizophrenia
About 1% of Americans have schizophrenia (NIMH, n.d.-c). Only one in five people diagnosed with the disorder return to the level of functioning they had before onset. Therefore, schizophrenia is often a pervasive and lifelong disorder that can severely impair daily functioning. Individuals with schizophrenia may have difficulty completing tasks, focusing on assignments and processing information. Because onset of schizophrenia is typically in early adulthood, a person’s ability to make educational progress and develop necessary skills to obtain a job or receive a degree may be limited (NIMH, n.d.-c). The lack of income threatens stable housing and basic needs. Therefore, individuals diagnosed with schizophrenia are likely to require financial assistance from family or public funding sources.
Treatment. The most common form of treatment for schizophrenia is medication. Antipsychotic medications focus on managing symptoms by reducing the severity and frequency of hallucinations and delusions. However, not all medications work for all individuals, and many can have significant side effects such as blurred vision, tremors, drowsiness, sensitivity to sunlight and tardive dyskinesia (NIMH, n.d.-c). Because of these side effects and the cognitive impairments inherent in the disorder, medication compliance is a problem, as individuals will sometimes skip doses or discontinue medications altogether.
Other forms of treatment are recommended in conjunction with medication, such as counseling and psychoeducation to teach individuals skills for daily functioning, interacting with others, self-care and employment (NIMH, n.d.-c). Person-centered approaches may be effective, as a lack of insight into the illness may cause clients to become skeptical about treatment (Kreyenbuhl, Nossel, & Dixon, 2009; NIMH, n.d.-c).
In summary, roughly one in 10 Americans will experience major depressive disorder, bipolar I disorder or schizophrenia each year, and two-thirds of those will seek treatment for their conditions (Merikangas et al., 2007; SAMSHA, 2013). Counselors who provide essential services to clients may have first made the diagnosis long ago and likely are part of a treatment team. With the release of the new version of the DSM, best practice is to review and revise diagnoses for all clients to ensure accuracy. Each change to major depressive disorder, bipolar I disorder and schizophrenia is described below.
Changes from DSM-IV-TR to DSM-5
Major Depressive Disorder
The mood disorders section in the DSM-IV-TR began with criteria for mood episodes (e.g., depressive, manic, hypomanic; APA, 2000). The mood episodes were later included in the diagnostic criteria for mood disorders. The DSM-5 has a different format. The mood disorders are separated into two sections: depressive disorders, and bipolar and related disorders. In addition, the DSM-5 lists complete criteria for each disorder in one place, rather than separating the mood episodes from the rest of the criteria for each disorder (e.g., major depressive disorder).
Major depressive disorder now includes a streamlined list of symptoms and examples of each so that clinicians may better understand the intended criteria. Part A of the diagnostic criteria did not change: “Five (or more) of the following symptoms have been present during the same 2-week period and represent a change from previous functioning; at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure” (APA, 2013, p. 160). The nine symptoms that follow are very similar to the symptoms listed in the DSM-IV-TR. The first symptom focuses on depressed mood and is the hallmark of the disorder. The example “hopeless” was added to increase clarity about the way clients may describe how they feel. The requirement of clinically significant distress did not change, nor did the verbiage about symptoms being caused by a medical condition or better explained by other disorders.
A significant change was made to criterion E of DSM-IV-TR, often called the bereavement exclusion. The previous rule was that major depressive disorder could not be diagnosed following the death of a loved one or other loss unless the symptoms persisted for 2 months (as opposed to the typical 2-week required duration). The DSM-5 states that responses to loss may include feelings and behaviors that match those listed in the criteria for major depressive disorder. Although the reaction may be considered understandable given the recent loss, if criteria for the disorder are met, the diagnosis may be given regardless of the circumstances. Representatives from the depressive disorders work group explained their rationale for this change at the 2013 American Psychiatric Conference (Zisook, 2013). They noted that the criteria for diagnosis should be defined without regard to the cause of the symptoms. Many things can cause or exacerbate depressive symptoms. Most individuals who suffer losses (e.g., death of a loved one, divorce, unemployment) will not experience symptoms severe enough to merit diagnosis (Zisook, 2013). Severe depressive symptoms, such as those required for diagnosis of major depressive disorder, merit clinical attention regardless of external causes in the individual’s life. The DSM-5 gives the counselor the discretion to diagnose major depressive disorder in grieving clients if the symptoms have been met for 2 weeks, rather than requiring 2 months of suffering as noted in the DSM-IV-TR.
Perhaps more relevant to those clients who have long been diagnosed with major depressive disorder, the DSM-5 included changes to the specifiers. Single episode, recurrent, mild, moderate and severe are again included with different numerical codes for each. One change is that psychotic features can now be added to mild, moderate or severe levels. Specifiers about seasonal pattern, catatonia, melancholia, and atypical features remain with expanded descriptors in some cases. Postpartum was changed to peripartum because symptoms often emerge during pregnancy, which would not fit the DSM-IV-TR specifier of postpartum, but is important nonetheless. The term peripartum means during the pregnancy or in the 4 weeks following delivery, so this specifier can be used in both cases. In addition, new specifiers were added: with anxious distress and with mixed features. Both are described below.
The specifier with anxious distress is to be used when the client experiences two or more of the following symptoms most days: feels tense, feels unusually restless, worry disrupts concentration, fears something bad will happen, or worries about losing control of oneself. The severity of the anxious distress specifier also is noted, using mild, moderate, moderate-severe and severe. This specifier was added because clinicians frequently described the presence of some symptoms of anxiety in their clients who have major depressive disorder. Often, the threshold is not met for a comorbid anxiety disorder diagnosis but the symptoms are significant nonetheless. Clients with anxious distress are more likely to attempt suicide and may require more intensive treatment than those with depression alone; therefore, it is essential that counselors note these symptoms in the diagnosis (APA, 2013; Goldberg, 2013).
The specifier with mixed features applies when clients have subthreshold hypomania most days in addition to symptoms of depression. For example, the criteria require three of the following symptoms to be present nearly every day during most of the days in the depressive episode: elevated mood, grandiosity, pressured speech, racing thoughts, increased energy, involvement in risky activities or decreased need for sleep. This specifier is important to note because clients who have major depressive disorder with mixed features are more likely to develop bipolar I or bipolar II disorder (Coryell, 2013). Because treatment for the bipolar disorders is often different from treatment for major depressive disorder, noting the mixed features is important to help clinicians track changes in the client’s symptoms closely.
A final change in DSM-5 that affects multiple diagnoses, including major depressive disorder, is the inclusion of cross-cutting symptom measures (APA, 2013). The goals of these instruments are to help clinicians understand client symptoms more effectively, to identify co-morbidity of symptoms and to track changes in symptoms over time (Clarke, 2013). The Level 1 Cross-Cutting Symptom Measure–Adult is a self-report measure for adults to provide clinicians with information about the presence of symptoms. This measure also can be completed by an informant if the individual lacks the capacity to do so (APA, 2013). The measure consists of 23 questions related to 13 domains such as depression, anger and anxiety. To complete the measure, an individual rates the presence of symptoms over the past 2 weeks using a 5-point Likert scale (0 = none or not at all to 4 = severe or nearly every day). For most of the domains, a rating of mild or greater on any item is an indicator for a clinician to conduct a more detailed assessment (APA, 2013). However, for suicidality, psychosis and substance use, endorsement of any symptoms necessitates further investigation. Further assessment may include the use of the level 2 cross-cutting symptom measures. These domain-specific instruments are not included in DSM-5, but are available online at http://psychiatry.org/practice/dsm/dsm5/online-assessment-measures (APA, 2014). The cross-cutting measures can be administered numerous times for initial and ongoing assessment. Clinical trials revealed that the measures are easy to use and incorporate into daily practice and provide meaningful information (Clarke, 2013). Clients who participated in the clinical trials felt better understood by their clinicians when they used these measures (Clarke, 2013). Therefore, cross-cutting measures in the DSM-5 can be excellent information-gathering tools that counselors can use to make informed diagnostic and treatment decisions.
Bipolar I Disorder
As described above, bipolar I disorder is now included in a separate section for bipolar and related disorders, and the complete diagnostic criteria list is found in one place (i.e., APA, 2013, p. 123). The core prerequisite for bipolar I disorder continues to be the presence of at least one manic episode, and several of the criteria for the manic episode were revised to increase clarity.
For example, criterion A for a manic episode in the DSM-IV-TR describes “a distinct period of abnormally and persistently elevated, expansive, or irritable mood, lasting at least 1 week (or any duration if hospitalization is necessary)” (APA, 2000, p. 362). In the DSM-5, the phrase “and present most of the day, nearly every day” was added to clarify how frequently the mood state must be present (APA, 2013, p. 124). Similarly, in criterion B, the DSM-5 specifies that the elevated, expansive or irritable mood must “represent a noticeable change from usual behavior” (APA, 2013). In the list of seven symptoms under criterion B, two were revised for greater clarity. The DSM-5 notes that distractibility can be either reported or observed. Psychomotor agitation is defined as “purposeless non-goal-directed activity” (APA, 2013, p. 124).
Criterion C from the DSM-IV-TR states that the episode in question must truly be a manic episode, not a mixed one. Mixed episodes were removed entirely from the DSM-5 as they were exceedingly rare, and instead a specifier denoting mixed features was added (Coryell, 2013). Additionally, the exclusion for manic-like episodes caused by antidepressant treatment was also removed. That is, in the DSM-IV-TR, if the manic symptoms follow antidepressant treatment such as medication, light therapy or electroconvulsive treatment, they are not considered symptoms of a true manic episode. In the DSM-5, that exclusion is removed. If a client displays symptoms that meet the criteria for a manic episode, the diagnosis can be given regardless of previous antidepressant treatment.
Additional descriptors also were added to the criteria for a hypomanic episode, although the diagnosis continues to describe individuals who display manic symptoms, but do not show clinically significant impairment. The elevated, expansive or irritable mood must be present for 4 consecutive days and for most of the day. The antidepressant exclusion also is removed from the hypomanic episode criteria, but clinicians are cautioned not to interpret irritability or agitation as sufficient for diagnosis. Bipolar I specifiers for severity and course remain the same, except that the psychotic features specifier is now coded separately from severity, as described above in major depressive disorder. Similarly, the specifiers with anxious distress and with mixed features were added to the bipolar disorders.
Schizophrenia
How schizophrenia is conceptualized did not change from the DSM-IV-TR to the DSM-5, but the criteria for the diagnosis did change significantly. In the DSM-IV-TR, criterion A stated that two or more of the following symptoms must be present for at least 1 month unless successfully treated: delusions, hallucinations, disorganized speech, grossly disorganized or catatonic behavior, or negative symptoms. An additional note permitted diagnosis with only one symptom of delusions or hallucinations if bizarre or persistent. The DSM-5 increases the diagnostic threshold by requiring the presence of delusions, hallucinations or disorganized speech (as opposed to the diagnosis being possible based on disorganized behavior and negative symptoms alone) and removing the single symptom option for meeting criterion A. The duration requirement remains the same as in DSM-IV-TR: at least 1 month of active symptoms in a time period of at least 6 months of impairment. Criterion D remains the schizoaffective disorder and mood disorder exclusion, but the text was revised to define how frequently manic or depressive symptoms must be present in order to meet full criteria. The DSM-5 specifies that mood symptoms must be present for at least half of the total duration of active and residual psychotic phases in order to be considered (APA, 2013).
The specifiers about the episodic or continuous symptoms and remission were changed in the DSM-5 and the subtypes were removed entirely. Course specifiers were revised for clarity and now include descriptors for first episode, multiple episodes, continuous or unspecified. These specifiers are not used until the disorder has been present for 1 year. In the DSM-5, the subtypes are not included as part of the diagnosis. For example, DSM-IV-TR language such as 295.30 schizophrenia, paranoid type is no longer used. The types are still described under the delusional disorder criteria, but the differentiated types of schizophrenia are no longer endorsed. Almost all schizophrenia diagnoses are now coded 295.90 schizophrenia, except for those individuals who have catatonia, and their diagnoses are coded 293.89. In the DSM-5, the Clinician-Rated Severity of Psychosis Symptoms Severity scale was added (APA, 2013). The rating scale and other instruments are available online at http://psychiatry.org/practice/dsm/dsm5/online-assessment-measures. Clinicians are instructed to rate the presence of symptoms over the previous 7 days across eight dimensions. The dimensions, rated from 0 (no presence) to 4 (severe and present), are hallucinations, delusions, disorganized speech, abnormal psychomotor behavior, negative symptoms, impaired cognition, depression and mania. During a presentation on the DSM-5 (Malaspina, 2013), representatives from the schizophrenia spectrum and other psychotic disorders work group explained that symptoms for individuals with schizophrenia can change over time. Therefore, the scale was designed to help clinicians note their detailed observations of the client and track changes in symptoms across time.
Case Examples
Some of the changes previously described are minor and do not result in revisions to the core diagnoses of clients with these disorders. However, some changes might impact diagnoses, and others might alter the way we describe the disorder or the name of the disorder itself. As with the conversion from the DSM-III-R (APA, 1987) to the DSM-IV (APA, 1994), the process will be ongoing. The cases below illustrate possible changes that counselors, supervisors and counselor educators can make immediately in their practices.
Martha: Major Depressive Disorder
Martha is a 47-year-old married mother of two. She works part-time as a real estate agent and is active in her Episcopal church. Her husband spends long hours at work and is often required to travel out of town. Her two adult children live nearby. Her father is deceased and her mother’s health is unstable, although she lives at a local assisted living facility.
Martha’s depression was first recognized by her family doctor when she was 23. He was not familiar with the DSM (DSM-III-R at that time), but recognized symptoms of sadness, hopelessness, emptiness and fatigue. He began prescribing her a relatively new drug called Prozac. Martha experienced improvement immediately. For the next 6 years Martha’s family doctor managed her depression with occasional dosage increases and biannual checkups. Just before her 30th birthday, Martha experienced her first severe depressive episode and attempted suicide. She had delivered her second child three weeks prior, and her husband found her after she cut her wrists.
Martha was hospitalized and received her first full mental health evaluation. Using the DSM-IV criteria, she was diagnosed with 296.33 major depressive disorder, recurrent, severe without psychotic features, with postpartum onset. Recurrent was given because of her self-reported symptom and treatment history. Her present symptoms far exceeded the minimum required for diagnosis, so the episode was considered severe. Martha was coherent, denied hearing voices or seeing images, and showed no evidence of delusions, so no psychotic features were noted. The suicide attempt occurred 3 weeks after delivery and depressive symptoms had been present for at least a week at that point; therefore, Martha met criteria for the postpartum onset specifier. Martha also experienced anxiety about caring for her children and managing her life but did not meet criteria for an anxiety disorder. Following discharge from the hospital, Martha continued to see the psychiatrist she met while hospitalized and began seeing a licensed professional counselor. Martha worked well in counseling and experienced long periods of remission and several more moderate depressive episodes in the 17 years that followed. She maintained regular appointments with her psychiatrist for medication management and sought counseling at times of increased depression or stress.
Presently, Martha has just resumed seeing a licensed professional counselor. She describes sadness, low energy, hopelessness, limited pleasure, insomnia, and stressors related to aging, her family relationships and her mother’s failing health. Her psychiatrist adjusted her medication and suggested that she resume counseling for additional support. Although the counselor has worked with Martha previously, the resumption of services is a great opportunity to revisit her diagnosis.
At this time, Martha’s core diagnosis of major depressive disorder, recurrent remains appropriate. Upon further exploration of Martha’s symptoms, the counselor finds that seven symptoms are present; therefore, Martha’s depressive episode is considered moderate. The new specifier with moderate anxious distress is also appropriate for inclusion because of Martha’s reported stressors. Martha feels tense and restless nearly every day. She worries about her children, her health, and her mother, and has difficulty focusing on her work and household tasks. She describes the feelings of depression as present all day, every day, and the stress, worry, and tension as present nearly every day, particularly when she attempts to “face reality” and engage with others or accomplish tasks around the house. A review of Martha’s history shows that anxious distress may have always been present during her depressive episodes. It was noted during her hospitalization and during previous counseling services, but had not reached the severity level necessary for an anxiety disorder diagnosis. Noting these important symptoms using the specifier may help Martha get the treatment she needs. Using the cross-cutting symptom measures to track her symptoms of depression and anxiety may be helpful as the counselor works to find the most effective ways to facilitate progress on Martha’s goals.
During Martha’s 24 years of treatment, she has had several slightly different diagnoses. Her first unspecific depression diagnosis from the family physician was further identified by the evaluation she had while an inpatient using the DSM-IV criteria for 296.33 major depressive disorder, recurrent, severe without psychotic features, with post-partum onset. Martha’s current diagnosis of 296.32 major depressive disorder, recurrent, moderate, with moderate anxious distress is reflective of both her history and current presentation.
Bo: Bipolar I Disorder
Bo is a 32-year-old single male. He lives alone with the support of his mother and brother. He has held numerous entry-level jobs for short time periods. Presently, he is unemployed and receiving Social Security Disability benefits. He receives treatment through a local mental health center. His current treatment program is called Program of Assertive Community Treatment (PACT; National Alliance on Mental Illness, 2014) and includes psychiatry, counseling, case management and vocational rehabilitation services. Some services occur at the local mental health center and some occur in his home or in the community.
Bo was first diagnosed (per the DSM-IV-TR) with 296.90 mood disorder, not otherwise specified when he was 24. During adolescence, Bo had a history of drug and alcohol use, academic and behavioral problems at school, and minor legal infractions. At age 22, Bo had a stable job, one year of sobriety, and lived alone for the first time. After 3 days of no returned phone calls, Bo’s brother began a search and finally found him in an apparent manic state. He was rambling enthusiastically about a new business in media promotions. He had drawings and notes scattered across his apartment with what appeared to be logos for the business. Bo told his brother that he would make millions of dollars with his connections in the music industry. Bo’s brother was concerned given that Bo had no such relationships. With just a little prodding, Bo revealed he had already spent his life savings and sold his motorcycle to get the business started and needed to borrow more money to “make it happen.” He became furious and destructive when his brother challenged his ideas. Bo’s brother was alarmed and took him to the local emergency room for an evaluation.
The emergency clinician met with Bo and determined that although some of his symptoms matched those for a manic episode, his vague symptom history and relatively short duration of illness precluded diagnosis of bipolar I disorder at that time. Bo was diagnosed with 296.90 mood disorder, not otherwise specified and referred to a crisis stabilization program for treatment and further evaluation. Bo was resistant to treatment because he did not believe his behavior to be inappropriate. After 4 days in crisis stabilization, Bo’s mood changed dramatically and he entered a major depressive episode. He expressed suicidal intent and was hospitalized. His diagnosis was revised to 296.53 bipolar I disorder, most recent episode depressed, severe without psychotic features (per DSM-IV-TR at the time).
Over the next 10 years Bo received ongoing psychiatric and mental health services from the community mental health center. His engagement in treatment waxed and waned, as did his symptoms. He had several six- to eight-month periods of remission and was hospitalized five additional times for severe manic or depressive episodes. Presently, Bo has been unemployed for 5 years and receiving Social Security Disability benefits for 3 years. After his most recent hospitalization, Bo was referred to the PACT team. His mother and brother continue to be supportive and are delighted to have the more intensive program to help Bo achieve stability again. In the PACT program, client services are reviewed every 120 days. Bo’s review is due, which is an opportunity to check his diagnosis for compliance with the new DSM-5 criteria.
Bo has stabilized somewhat since discharge from the hospital but continues to have attenuated manic symptoms. At the time of hospitalization, Bo’s symptoms were present most of the day, every day, so he exceeded the clarified requirement for diagnosis in the DSM-5. Among other symptoms, Bo demonstrated distractibility, but his grandiosity precluded him from acknowledging that. However, clinicians observed the distractibility in session; therefore, the criterion was met. Bo did not demonstrate mixed features or experience psychosis so those revisions in the DSM-5 are not pertinent here. He has received antidepressant treatment in the past but not in recent months; therefore, no extra consideration is necessary to ensure that criterion F is met. Given this presentation, Bo’s diagnosis remained bipolar I disorder, most recent episode manic.
Because of the improvement Bo has achieved since hospital discharge, in partial remission can be added to the diagnosis at his 120-day review. Therefore, his complete diagnosis is 296.45 bipolar I disorder, most recent episode manic, in partial remission. Bo’s improvement is tenuous, however, and requires ongoing medication compliance and supportive counseling. The PACT team is designed to provide this long-term support and counselors are an essential part of that program (Salyers & Tsemberis, 2007). Given the complexity and variability of Bo’s symptoms, a counselor may find it helpful to administer regularly the Level 1 Cross-Cutting Symptom Measure to track changes over time. The counselor also could use the more specific Level 2 assessment to track symptoms in a particular domain such as mania.
Saul: Schizophrenia
Saul is a 20-year-old unemployed male. He currently lives in the home he grew up in with his mother, father and 14-year-old brother. Since graduating from high school, Saul has worked a part-time job while taking classes at a local community college.
Saul was first hospitalized at age 18 after he began to tell his family that he was a messenger from God. Saul’s family had a difficult time understanding what Saul was telling them, as it was uncharacteristic of him, but initially they were not concerned. However, Saul’s parents became more alarmed as they noticed he was increasingly more preoccupied with the belief. They also observed that his grades began to suffer and he was spending more time reading religious material online rather than socializing with his friends. After a couple of months of this and no signs of improvement, Saul’s parents contacted the local community mental health center for help.
Saul was voluntarily hospitalized because of uncharacteristic behavior. While in the hospital, he received a mental health evaluation from a psychiatrist. The psychiatrist noted that there was no evidence of disorganized speech, catatonia or negative symptoms. Additionally, Saul denied auditory and visual hallucinations and the psychiatrist did not observe Saul responding to internal stimuli. Saul reported that his mood was good and the psychiatrist noted no evidence of mania or depression. However, Saul routinely told the psychiatrist he was a messenger from God and often perseverated on the topic. He also reported the detrimental impact that his work as God’s messenger was having on his life. Saul and his family both denied any history of substance use, and a toxicology screen was negative for common street drugs, which could have led to the sudden change in behavior. In sum, there was no medical explanation for the change in behavior.
Using the DSM-IV-TR, the psychiatrist diagnosed Saul with 295.30 schizophrenia, paranoid type. He cited evidence of a bizarre delusion, thus requiring only one symptom to meet criterion A. The psychiatrist noted paranoid type, which was appropriate given Saul’s preoccupation with the religious themes and the grandiose nature of the delusions. The psychiatrist prescribed an antipsychotic medication for Saul and encouraged him to follow up with a counselor and psychiatrist in the community for outpatient care.
After discharge from the hospital, Saul received outpatient treatment from a licensed professional counselor and a psychiatrist. Saul took his medication each day with the assistance of his parents, who monitored his compliance. Saul was able to complete high school and started courses at a community college and worked part-time. However, when Saul was 20 years old, his psychiatrist noted a concern in his blood work, which was likely a side effect of the medication he was taking. Saul’s psychiatrist changed his medication because of this concern.
Quickly, Saul’s preoccupation with his role as a messenger from God returned. Saul again began to have difficulty with course work and dropped out of school. He was fired from his job because his boss became frustrated that Saul was frequently late, took too long to complete tasks at work and appeared disengaged. There also were reports that he was scaring customers by asking about their religious faith and commitment to God. When Saul stopped showering, his parents requested that he be evaluated again and he was hospitalized for a second time.
During his second hospitalization, Saul received another mental health evaluation from a psychiatrist. Saul continued to insist that he was a messenger from God and he perseverated on religious themes. Saul said he felt compelled to act on God’s commands, which he now heard as a deep male voice. The psychiatrist noted that Saul’s responses in session were delayed, he frequently asked for questions to be repeated and he seemed to be responding to his hallucinations. Using the DSM-5, the psychiatrist diagnosed Saul with 295.90 schizophrenia, multiple episodes, currently in acute episode. There was evidence of at least two symptoms for criterion A: evidence of delusions, auditory hallucinations and diminished emotional expression. Saul reported feeling sad or down at times, but through Saul’s report and the treatment team’s observations, it appeared that this occurred less than half the time during an active psychotic phase, which ruled out schizoaffective disorder.
Saul’s psychiatrist also completed a quantitative severity assessment using the Clinician-Rated Dimensions of Psychosis Symptom Severity from the DSM-5 (APA, 2013). Saul’s psychiatrist rated the impairment in the past seven days for the eight areas of functioning using a scale ranging from 0 (no presence) to 4 (present and severe). The psychiatrist rated hallucinations as 4 because Saul was frequently responding to voices, which limited his ability to track their conversation and impaired his functioning. Delusions were rated 3 because of pressure to follow God’s commands. This pressure caused Saul to isolate from others, research religious themes, neglect his personal hygiene and pester customers about their beliefs, which cost him his job. Disorganized speech was rated 0 as the psychiatrist noted Saul’s speech was normal. The psychiatrist did not observe any abnormal psychomotor behavior; therefore, it was scored 0 as well. Negative symptoms were rated 3 as Saul displayed moderate decrease in facial expressiveness. Impaired cognition was rated 3 as Saul was unable to take classes and concentrate at work. Thus his functioning was significantly below what would be expected from an individual of Saul’s age and socioeconomic status. Depression was rated as 1 because Saul reported feeling sad or down some of the time, but did not appear preoccupied with sadness. Mania was rated as 0 because there was no evidence of elevated or expansive mood.
The Clinician-Rated Dimensions of Psychosis Symptom Severity scale may be repeated at hospital discharge or during subsequent treatment in order to track Saul’s progress. Additionally, Saul’s counselor may find it useful to track his symptoms using the Level 1 Cross-Cutting Symptom Measure. While in the hospital, Saul endorsed sadness on some of the past seven days. If Saul were to respond to an item on the depression domain as mild or greater, the counselor could also use the Level 2 Cross-Cutting Symptom Measure for depression to gather additional information.
Saul’s case is unique in that his initial presentation 2 years ago would not have met full criteria for schizophrenia had it occurred after the DSM-5 was released. At the time of his second hospitalization, when the DSM-5 was in use, the additional symptoms made it clear that schizophrenia was the appropriate diagnosis for Saul. Ongoing treatment may help Saul achieve stability and improve his quality of life, and the repeated use of the severity scale may help track his progress.
Conclusion
These scenarios illustrate which changes from DSM-IV-TR to DSM-5 had an impact on preexisting client diagnoses. Note the core diagnoses did not change, only some of the terminology and specifiers. Why then is it important for counselors to learn about the changes and review existing client diagnoses? Consider the following reasons for careful diagnostic practice.
Section E.5 of the ACA Code of Ethics (ACA, 2014) mandates that counselors maintain careful, culturally sensitive diagnostic practices. Section A.2.b further requires counselors to take steps to explain the diagnosis and its implications to their clients. Some clients, particularly those who were previously diagnosed, may not have had the opportunity to discuss the meaning of their diagnosis or its implications with a mental health professional. They may have little knowledge at all or longstanding misconceptions. Some clients, like Martha, may have been first diagnosed by a primary care physician who was not familiar with the DSM and the specific features of depression that it details. The release of the DSM-5 is an opportunity to check in and use counseling and advocacy skills to help clients develop an accurate and healthy understanding of their diagnoses. The cross-cutting symptom measures provide a stimulus to engage in a dialogue about the client’s symptoms and treatment needs. Use of these instruments gathers valuable information and helps clients feel better understood (Clarke, 2013). Counselors can have a tremendous influence on how clients conceptualize their mental health, so taking advantage of this opportunity to shape it in a positive way is a great service to the client.
Additionally, converting to DSM-5 criteria and terminology is essential to meet the common language goal that inspired the initial creation of the DSM. Each edition of the DSM has included revisions that changed the criteria or titles used to describe disorders, but instant conversion to the new terms does not happen in practice. For example, manic-depressive disorder became bipolar I disorder in the third revision of the DSM almost 35 years ago (APA, 1980) and yet some people still use the antiquated term today. Attending to the changes and discussing them with colleagues and clients will speed adoption of the new common language. Modeling ethical, careful, current diagnostic practices may have a positive ripple effect on colleagues as well. If counselors, supervisors and counselor educators all use the terms and criteria set forth by DSM-5, we can more easily communicate within our profession and across treatment teams.
In fact, the DSM-5 authors made a special call for all clinicians to use the DSM-5 language as carefully and specifically as possible. For example, authors asked clinicians to avoid using the catchall diagnoses at the end of each section (i.e., not otherwise specified in the DSM-IV-TR, other specified and unspecified in the DSM-5; Phillips, 2013). These diagnoses are sometimes necessary in the short term (as in the case of Bo above), but with additional information a more defined diagnosis is often possible. The DSM-5 authors also called on clinicians to attend carefully to the use of specifiers (e.g., Coryell, 2013; Goldberg, 2013). Many of the revisions to specifiers were made because of the potential impact on client treatment. For example, the presence of anxious distress (as in Martha above) complicates the treatment of depression. Noting the anxious distress in the diagnosis itself brings attention to those symptoms and reduces the likelihood that they will be overlooked. For Martha, it seems that when she is able to rise up out of her depression enough to engage in life, her anxiety surges and discourages her from attempting engagement again. It may be that her anxiety needs to be addressed before she can effectively work on her depression.
The DSM-5 authors also cautioned clinicians that one of the limitations of the DSM-IV-TR was that too many diagnostic criteria overlapped, leading to what is called “artificial co-morbidity” (Tandon, 2013). Individuals may be diagnosed with multiple disorders because of shared criteria. For example, a client’s irritability, social withdrawal and anger outbursts may have underlying depression, mania, delusional thinking or anxiety. These are features of bipolar disorder, major depressive disorder, schizoaffective disorder and post-traumatic stress disorder, and the convolution can lead to overdiagnosis and, ultimately, improper treatment. Arriving at more accurate diagnoses quickly will lead to better care for clients, and DSM-5 includes a new tool to help counselors do just that. The Cross-Cutting Symptoms Measures allow a counselor to assess for the presence of symptoms that are related to multiple diagnoses and consider whether a specifier or comorbid diagnosis is appropriate (APA, 2013).
Accurate diagnoses also are essential to ongoing research on these and other mental health conditions. Medical record research is increasingly common, particularly with the adoption of electronic medical records and the conglomeration of large managed care companies. That means that the diagnoses counselors record on billing documentation or enter into client medical records are likely to become part of a behind-the-scenes research project. Often these projects use data points such as diagnosis, number of hospitalizations, frequency of outpatient sessions and medication dosages to conduct large-scale analyses of trends or outcomes in treatment. Research like this does not require client or clinician consent because the existing data is anonymized and permission is granted en masse by the organization. Important evidence-based practice recommendations come from this type of study; therefore, using the most accurate documentation, whether the counselor intends to participate in research or not, is important for valid studies.
In sum, the DSM-5 has set forth changes in criteria and terminology used to describe major depressive disorder, bipolar I disorder and schizophrenia. Counselors can take advantage of this opportunity to help clients develop a healthy, accurate understanding of their diagnoses. The release of the DSM-5 also is an opportunity to revise diagnoses, paying careful attention to specifiers, in order to adhere to the common language it establishes. Thorough, accurate diagnoses support the selection of effective treatments and ongoing research on the treatment of these conditions. All counselors, supervisors and counselor educators can work together as we address these important goals.
Conflict of Interest and Funding Disclosure
The author reported no conflict of interest or funding contributions for the development of this manuscript.
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Laura E. Welfare, NCC, is an Associate Professor at Virginia Polytechnic Institute and State University. Ryan M. Cook is a doctoral student at Virginia Polytechnic Institute and State University. Correspondence can be addressed to Laura E. Welfare, 309 E. Eggleston Hall (0302), Blacksburg, VA 24061, welfare@vt.edu.
Jul 4, 2014 | Article, Volume 4 - Issue 3
Maureen C. Kenny, Mérode Ward-Lichterman, Mona H. Abdelmonem
The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) introduced a chapter titled “Feeding and Eating Disorders,” which takes a life-span approach to diagnosing eating disorders and contains all related diagnoses. Rather than appearing throughout the text, all eating disorders are now contained within their own chapter for ease of review and comparison. Changes to the feeding and eating disorders include diagnostic revisions and the addition of several new disorders, including avoidant/restrictive food intake disorder and binge-eating disorder. While pica and rumination disorder remain unchanged, anorexia nervosa and bulimia nervosa experience some criteria changes. There is now a system for classifying the severity of several eating disorders (mild, moderate and severe) and an emphasis on body mass index for the diagnosis of anorexia nervosa. The DSM-5 also attempted to address the number of cases of eating disorders that did not meet criteria in any one category (e.g., eating disorder not otherwise specified), and the authors discuss the result of this attempt in examining two new disorders. This paper examines these changes and addresses clinical implications, while alerting counselors to important diagnostic information.
Keywords: eating disorders, DSM-5, pica, anorexia nervosa, bulimia nervosa, binge eating
With the publication of the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5; American Psychiatric Association [APA], 2013a) in May 2013 came structural changes to the categorization of disorders as well as criteria changes to a variety of disorders. One diagnostic category that experienced multiple changes is eating disorders. As stated in the DSM-5, “feeding and eating disorders are characterized by a persistent disturbance of eating or eating-related behavior that results in the altered consumption or absorption of food and that significantly impairs physical health or psychosocial functioning” (APA, 2013a, p. 329). Previously spread throughout several chapters in the DSM, these disorders are now self-contained in a single, more comprehensive chapter titled “Feeding and Eating Disorders.” This revised diagnostic category includes several new disorders and reflects changes to the criteria and wording of some existing diagnoses. While some of the changes are minor, all are noteworthy (Hartmann, Becker, Hampton, & Bryant-Waugh, 2012) and warrant examination. This article seeks to highlight the changes to this category and assist counselors in a greater understanding of these updated diagnoses.
Prevalence of Eating Disorders
One study by Hudson, Hiripi, Pope, and Kessler (2007) used data from the National Comorbidity Survey Replication to generate estimates of the prevalence of anorexia nervosa (AN), bulimia nervosa (BN) and binge-eating disorder (BED) among adults in the United States. The researchers based these estimates on the criteria found in the DSM-IV (Hudson et al., 2007). The authors report the following lifetime prevalence rates for AN, BN and BED, respectively: 0.9% among females and 0.3% among males, 1.5% among females and 0.5% among males, and 3.5% among females and 2.0% among males (Hudson et al., 2007). Of note is that BED, a new diagnosis in the DSM-5 (but one for which criteria appeared in the appendices of DSM-IV-TR), is by far the most prevalent of these three eating disorders. Also worth noting is the fact that the statistics for women, specifically for women under age 20, indicate that eating disorders are common among this subset of the population; young women appear to be afflicted at dramatically higher rates than the population at large. Using the DSM-5 criteria, Stice, Marti, and Rohde (2013) found a lifetime prevalence of 13.1% among this population, concluding that “one in eight young women” (p. 455) will have some form of diagnosable eating disorder.
Not represented in the figures above is the fact that in the past, the most common eating disorder diagnosis has been the DSM-IV and the DSM-IV-TR category eating disorder not otherwise specified (EDNOS; Fairburn & Cooper, 2011; Machado, Gonҫalves, & Hoek, 2013). EDNOS cases may represent as many as 60% of eating disorder diagnoses (Fairburn et al., 2007). As Smink, van Hoeken, and Hoek (2012) pointed out, a “major goal” (p. 407) of the revisions reflected among eating disorders in DSM-5 was to decrease significantly the number of EDNOS or unspecified diagnoses. The addition of BED and the changes to AN and BN (which resulted in generally less stringent criteria) reflect this aim (Smink et al., 2012). Studies concluded that the DSM-5 criteria will, in fact, reduce the number of EDNOS diagnoses considerably (Allen, Byrne, Oddy, & Crosby, 2013; Fairburn & Cooper, 2011; Machado et al., 2013). The authors in all three studies determined, however, that the number of cases that will not meet the revised DSM-5 criteria for AN, BN or BED is still sizable (Allen et al., 2013; Fairburn & Cooper, 2011; Machado et al., 2013).
While the prevalence of AN and BN are reasonably well established, the DSM-5 cites the prevalence of pica as unclear (APA, 2013a). It is predominantly recognized among children, most notably those with intellectual disabilities (Mash & Wolfe, 2013); pregnant women (Geissler, Mwaniki, Thiong’o, & Friis, 1998; Khan et al., 2009); adults with iron deficiency (Moore & Sears, 1994); and institutionalized persons (McAlpine & Singh, 1986). The prevalence of rumination disorder is also inconclusive, but believed to be higher in individuals with intellectual disabilities than the general population (APA, 2013a). Similarly, there are no reported prevalence rates for avoidant/restrictive food intake disorder (APA, 2013a).
Overview of Changes in DSM-5
Before the current edition of the DSM, feeding and eating disorders were in two main sections of the manual: (1) Disorders Usually First Diagnosed in Infancy, Childhood or Adolescence and (2) Eating Disorders (APA, 2013a). The former no longer appears in the DSM-5. With the removal of a separate section describing disorders that were most likely to occur in childhood or adolescence, the DSM-5 now contains chapters for each diagnostic category, which include both disorders that may first manifest during youth and others that may not surface until adulthood. In line with one objective of the DSM-5, the placement of eating and feeding disorders in their own chapter ensures that diagnoses are applicable across the life span (Bryant-Waugh & Kreipe, 2012), and helps bring attention to the development and presentation of symptoms at various points in the life span; this reflects what some refer to as the age and stage approach (Bryant-Waugh, 2013). The childhood section that was removed had previously contained several eating disorders (e.g., pica and rumination). The new chapter in the DSM-5 now contains eight eating disorders (APA, 2013a), including several new disorders, among which are avoidant/restrictive food intake disorder (which replaces, but significantly expands on, feeding disorder of infancy or early childhood) and BED. The diagnoses of other specified feeding or eating disorders and unspecified feeding or eating disorders are new and replace the diagnosis of EDNOS. The already existing disorders of pica, rumination disorder, AN and BN reflect some minor changes as well. While many feeding and eating disorders share symptoms or behaviors, it is important to note that an individual can receive only one diagnosis (Dailey et al., 2014). The feeding and eating disorders diagnostic criteria are mutually exclusive, meaning that if a client is diagnosed with one disorder in this chapter, the client cannot be diagnosed with another (with pica as the only exception). The DSM-5 wants to ensure differentiation of each disorder and help counselors plan treatment that targets the unique features of a disorder (APA, 2013a). See Table 1 for a review of DSM-IV-TR and DSM-5 classification of eating disorders.
Table 1
Past and Current Feeding and Eating Disorder Diagnoses
|
DSM- IV-TR
|
DSM-5
|
| Pica |
Pica |
| Rumination Disorder |
Rumination Disorder |
| Feeding Disorder of Infancy or Early Childhood |
Avoidant/Restrictive Food Intake Disorder |
| Anorexia Nervosa |
Anorexia Nervosa |
| Bulimia Nervosa |
Bulimia Nervosa |
|
Binge-Eating Disorder |
| Eating Disorder Not Otherwise Specified (EDNOS) |
Other Specified Feeding or Eating Disorder |
|
Unspecified Feeding or Eating Disorder |
Specific Changes to Eating Disorder Diagnoses
Pica and Rumination Disorder
Pica and rumination disorder are two eating disorders that often receive less clinical attention from counselors than other eating disorders. This is probably due to the fact that these disorders are likely to be observed in institutionalized settings, and that treatment may necessitate the expertise of behavioral analysts or therapists highly trained in working with developmental disabilities (Williams & McAdam, 2012). Only the locations of pica and rumination have changed in the DSM-5: These disorders now appear in the chapter on feeding and eating disorders. With this change, these diagnoses are now applicable to individuals across the life span. The criteria for these disorders did not change.
Pica is the ingestion of non-nutritive substances (e.g., hair, chalk, paint chips) over at least a one-month period. Availability and the age of the affected individual often determine what substances a person will consume (Hartmann et al., 2012). Some reports have included individuals eating paper, tissues, wood, metal, small rocks, carpet and soap (Matson, Belva, Hattier, & Matson, 2011). The eating of these non-food substances is deemed to be inappropriate to the developmental level of the individual and is not part of a cultural or socially accepted practice (APA, 2013a). Generally, clinicians see this disorder in children with intellectual disabilities (Mash & Wolfe, 2013). However, the fourth criterion of the diagnosis notes that if this condition does occur within the context of a developmental or intellectual disability, it should be sufficiently severe to warrant clinical attention.
Children with pica eat normal foods as well as non-nutritive foods. In most cases, the disorder remits on its own, or will cease with improved environmental conditions or added infant stimulation (Mash & Wolfe, 2013). One common thought is that this disorder presents in children who do not have sufficiently stimulating environments. Hartmann et al. (2012) reported that some clinicians regard pica as a form of self-soothing behavior, employed when one’s arousal reaches a certain level. However, for children with intellectual disabilities, it may be life-threatening (Matson et al., 2011). Ingestion of metal or other items with high toxicity pose a threat to the developing child (Hartmann et al., 2012). There are multiple treatments available for such individuals including punishment, overcorrection, restraint, positive reinforcement, psychopharmacology and time out (Matson et al., 2013). There is some literature that discusses the presence of pica in pregnant women, which may cause lead poisoning or other health issues for the developing fetus (Thihalolipavan, Candalla, & Ehrlich, 2013).
There were no major changes to the diagnosis of rumination disorder in the DSM-5. Rumination disorder is repeated regurgitation (e.g., spewing up or spitting up of food) for a period of at least one month (APA, 2013a). This regurgitation of food is not attributable to any related medical or gastrointestinal condition. Thus, the regurgitation is voluntary and distinguished from vomiting or gastroesophageal reflux. Similar to pica, the fourth criterion of this diagnosis notes that if this condition does occur within the context of a developmental or intellectual disability, it is sufficiently severe to warrant clinical attention. Some individuals with rumination disorder appear to engage in the behavior for self-soothing effects, while for others it is habitual and a difficult behavior to reduce (Hartmann et al., 2012). Certainly, this disorder reduces the social functioning of an individual, as it is a socially undesirable behavior.
The DSM-5 reports that both pica and rumination disorder are generally first observable in infancy, but onset can occur in childhood, adolescence or adulthood. Another commonality of these diagnoses in DSM-5 is that they both now have a specifier of in remission. This is reserved for individuals who may have previously met the criteria of the disorder, but have not “for a sustained period of time” (APA, 2013a, p. 330). Additionally, pica and rumination disorder are concurrently diagnosable. Another commonality of these disorders is that they often occur in secret and are difficult to detect (Hartmann et al., 2012). Individuals are not likely to disclose their engagement in these behaviors. For young children, parental report is critical in assessment.
Avoidant Restrictive Food Intake Disorder
An interesting addition to the DSM-5 is the diagnosis of avoidant restrictive food intake disorder (ARFID). The essence of this disorder is a disturbance in eating or feeding characterized by inadequate food intake (Bryant-Waugh & Kreipe, 2012). This inadequacy may mean that the individual does not meet necessary energy intake needs for the day (i.e., by consuming too few calories from food), or has an insufficient nutritional diet, or both. This disorder replaces feeding disorder of infancy or early childhood, but also adds significant new criteria. As Kreipe and Palomaki (2012) stated, “Although it has somewhat awkward phrasing, the name captures the key clinical features of non-eating disorder eating disturbances: avoiding (not necessarily ‘refusing’) foods for a variety of reasons, and restricting intake in the amount and/or range of foods eaten” (p. 428). In the DSM-IV-TR (APA, 2000), feeding disorder of infancy or early childhood primarily emphasized the child’s persistent failure to eat adequately, with significant failure to gain weight or significant loss of weight over at least one month. The primary symptom was a disturbance in eating or feeding not attributable to an associated medical or gastrointestinal condition, and the disorder was required to have an onset before six years of age. With the addition of ARFID, those criteria remain the same, but there is the additive criterion of significant nutritional deficiency, and dependence on enteral feeding (i.e., tube feeding) or oral nutritional supplements. The diagnosis is more specific in stating that the eating or feeding disturbance may be related to the sensory characteristics of food or a concern about aversive consequences of eating (e.g., nausea). The second criterion (a new addition) also mentions that a lack of available food or an associated, culturally sanctioned practice cannot account for the disturbance. The other criteria remain the same (e.g., ARFID cannot occur during the course of AN or BN; the condition cannot be related to a medical condition). It is, however, likely to co-occur with autism spectrum disorder or other neurodevelopmental disorders. Similar to other disorders in the DSM-5, one can apply in remission here if the individual previously met the full criteria for the disorder, but now has not met these criteria for a sustained period.
Sometimes the individual with ARFID restricts certain foods, and at other times, there is an inadequate intake of vitamins and minerals. The inadequacy of energy intake may result in a child’s poor growth, weight loss or low weight. In their study on picky eating among children, Jacobi, Schmitz, and Agras (2008) pointed out that the longer the duration of the pickiness, the more avoidant the child becomes to trying new foods. However, children with ARFID are more than just picky eaters, as they suffer from failure to meet nutritional and/or energy needs that may result in weight loss. As the criteria imply, some of these individuals must rely on enteral feeding.
The clinical presentation of ARFID is quite variable (Bryant-Waugh & Kreipe, 2012). Over time, there may be evidence that subgroups of the disorder are present, requiring further classification. Bryant-Waugh and Kreipe (2012) describe several presentations that include some of the ARFID symptoms. For example, some children (and some adults) eat only certain-colored foods or foods with a particular texture, thus ingesting only a narrow range of foods. Others may avoid certain foods based on past negative experiences with them, usually gastrointestinal problems. While there is no specific assessment for ARFID, careful clinical interviewing, including parental observations and a medical evaluation, are necessary for diagnosis. Because ARFID and AN share many common symptoms in childhood and young adulthood (e.g., low weight, food avoidance), differential diagnosis may be difficult (APA, 2013a). The DSM-5 reminds counselors that in AN, the individual has a persistent fear of becoming fat and/or gaining weight, which is not present in ARFID. We refer readers to Bryant-Waugh (2013) for a case study of a child with ARFID, including assessment questions and treatment.
Anorexia Nervosa
The DSM-5 diagnostic criteria for AN reflect several significant changes from the criteria outlined in DSM-IV-TR. There are two particularly noteworthy changes to the first criterion for an AN diagnosis in DSM-5. The first of these is that what was described as “refusal to maintain body weight” in the DSM-IV-TR (APA, 2000, p. 589) has been reframed as “restriction of energy intake relative to requirements” in the DSM-5 (APA, 2013a, p. 338). The removal of the word refusal, which has negative connotations, results in a more neutrally worded criterion. Moreover, the new phrasing of this criterion in DSM-5 focuses specifically on the central behavioral component of AN (i.e., restriction of intake), rather than upon the results of this behavior (i.e., body weight).
The second key change to this first criterion is that the specific guideline provided in DSM-IV-TR as a definition of a less than “minimally normal” body weight (i.e., below “85% of that expected”; APA, 2000, p. 589) no longer appears in the DSM-5. The new criterion instead highlights the essential role of context (e.g., age, sex, developmental status) in determining whether a particular individual is at a “significantly low weight” for his or her own body (APA, 2013a, p. 338). This change is particularly important because, while the DSM-IV-TR clarifies that 85% is intended as a guideline, once incorporated into the criteria, it became in many cases a requirement for insurance reimbursement (Hebebrand & Bulik, 2011).
The second criterion for AN previously included only the cognitive symptom of “intense fear of gaining weight or becoming fat” (APA, 2000, p. 589). That same language appears in the DSM-5, but the new criterion includes a behavioral component as well. Moreover, because the word or is used rather than and, the behavioral manifestation of this criterion can actually stand in for other, more overt expressions of the cognitive component. In other words, according to the DSM-5, an individual engaging in “persistent behavior that interferes with weight gain” (APA, 2013a, p. 338) can now meet this second criterion even if he or she does not explicitly communicate anxiety around weight gain. This change may have particular relevance in pediatric cases, because some children with AN have not yet developed the cognitive abilities required either to have or to express this intense fear (Bravender et al., 2010; Reierson & Houlihan, 2008; Workgroup for Classification of Eating Disorders in Children and Adolescents, 2007).
The third criterion in the DSM-5 is very similar to that of the previous edition, aside from one notable distinction. In the new DSM, the phrase “persistent lack of recognition” (APA, 2013a, p. 339) replaces “denial” (APA, 2000, p. 589) in describing the anorexic individual’s perspective on the risks posed by his or her underweight status. As with the change to criterion one, the result of this rewording is more value-neutral (like refusal, the word denial has negative connotations). The resulting criterion may also be more accurate, in that the focus is on an inability of the anorexic individual to recognize the inherent dangers of his or her condition, rather than a conscious repudiation of the truth.
Although these small linguistic changes may not seem especially significant, the outcome is a set of criteria that is, on the whole, less stigmatizing. This is important because research indicates that many clinicians have negative biases toward individuals with eating disorders. This may be especially true in the case of those with AN, and the stigma appears to impact the availability of quality treatment for the disorder (Thompson-Brenner, Satir, Franko, & Herzog, 2012).
The fourth criterion for AN, which appears in the previous edition, was removed altogether from the DSM-5, so that there are now only three criteria for a diagnosis of AN. This previous criterion, amenorrhea (the cessation of menstruation), applied only to females who had achieved menarche (APA, 2000). By definition, then, this criterion inherently excluded all males, as well as pre-pubertal and post-menopausal females. Also excluded were females taking hormonal contraceptives (APA, 2013b). The removal of amenorrhea therefore results in a more inclusive set of criteria, reflective of the APA’s (2013a) stated goal of avoiding “overly narrow” diagnostic categories (p. 12), which in the past have contributed to an excess of EDNOS diagnoses (Fairburn & Cooper, 2011; Machado et al., 2013).
As in the DSM-IV-TR, the criteria for AN in the DSM-5 include specifiers of restricting or binge-eating/purging types (APA, 2000, 2013a). The language in the new edition is similar to that of the previous edition, but clarifies that the specifier applies to the last 3 months (APA, 2013a), rather than the DSM-IV-TR’s more vaguely stated “current episode” (APA, 2000, p. 589). This change is relevant because the empirical evidence indicates that crossover between subtypes is frequent (Eddy et al., 2008). The DSM-5 reflects this research, and the text in the manual cautions that because such crossover occurs, “subtype description should be used to describe current symptoms rather than longitudinal course” (APA, 2013a, p. 339). It may be worth noting that some in the field have concluded that these diagnostic subtypes of AN are not actually clinically relevant (e.g., Eddy et al., 2008), although clearly the DSM-5 does not reflect this thinking.
Like other disorders in the DSM-5, the diagnostic criteria for AN now include additional specifiers regarding remission status (partial or full) and severity (APA, 2013a). The remission specifier may be especially useful for clinicians working with individuals with eating disorders, AN in particular. For example, with regard to the weight criterion, an individual who reaches “normal” weight will no longer meet the full criteria for an AN diagnosis, but may still be struggling with other key components of the disorder (e.g., intense fear of weight gain). Such a scenario may be particularly likely with this disorder, especially because a change in weight status can be the result of outside intervention rather than internal motivation (Nicholls, Lynn, & Viner, 2011).
Finally, the DSM-5 includes a severity specifier that uses the individual’s body mass index (BMI). There are three levels of severity: extreme (BMI < 15 kg/m2), severe (BMI 15–15.99 kg/m2), moderate (BMI 16–16.99 kg/m2) and mild (BMI > 17 kg/m2). As the manual states, the ranges are from the World Health Organization categories for thinness in adults. For children and adolescents, clinicians are encouraged to use the BMI percentiles. These levels of severity help indicate the clinical symptoms, the potential need for supervision and the degree of functional disability (APA, 2013a).
Bulimia Nervosa
The diagnosis of BN remains largely the same in the DSM-5, although there are some modifications to the criteria. BN is characterized by repeated, uncontrollable binge-eating episodes (criterion A) accompanied by ongoing compensatory behaviors to avoid weight gain (criterion B). These behaviors to avoid weight gain include “self-induced vomiting; misuse of laxatives, diuretics, or other medications; fasting; or excessive exercise” (APA, 2013a, p. 345). The DSM-5 brings no changes to these first two criteria from the DSM-IV-TR. Also unchanged in the new edition is the fourth criterion, the following key cognitive symptom: “self-evaluation is unduly influenced by body shape and weight” (APA, 2013a, p. 345).
The major change to BN in the DSM-5 is in criterion C, the frequency of the compensatory behaviors required for diagnosis. In the DSM-5, this frequency has been reduced from an average of twice weekly to an average of only once per week. The required duration of these behaviors, however, remains the same in DSM-5: three months. Research indicates that individuals who display these behaviors at this new, lower threshold of once per week experience similar levels of pathology and distress (Wilson & Sysko, 2009). This decrease in frequency is likely to result in more diagnoses of BN; as stated, “increased prevalence rates are the result of a general lowering of diagnostic thresholds for eating disorders” (Dailey et al., 2014, p. 180).
A secondary change to the BN criteria is the removal of the specifier regarding purging and nonpurging types of BN (APA, 2000). In the past, these specifiers described the type of compensatory behavior used by the individual. In the DSM-5, the criterion for compensatory behavior includes both types, so no further specifier is necessary. This change reflects the research indicating that many individuals with BN regularly engage in both purging and nonpurging compensatory behaviors, making this specifier insignificant (Ekeroth, Clinton, Norring, & Birgegård, 2013; Vaz, Peñas, Ramos, López-Ibor, & Guisado, 2001).
BN, like the other disorders in the DSM-5, now has severity specifiers. For this diagnosis, the assessment of severity depends upon the frequency of inappropriate compensatory behaviors (e.g., the average number of times an individual purges in a given week). Depending on the frequency of compensatory behaviors per week, a case may be categorized as one the following: mild (1–3 episodes), moderate (4–7 episodes), severe (8–13 episodes) or extreme (14 or more episodes) (APA, 2013a). Finally, as with other disorders in the DSM-5, clinicians can apply the specifiers of partial or full remission to BN.
Binge-Eating Disorder
The diagnosis of BED is new to the DSM-5. First mentioned in the DSM-IV (Striegel-Moore & Franko, 2008), the disorder appeared in that edition and the subsequent text revision under EDNOS, with research criteria outlined in the appendices (APA, 2000). With the publication of the DSM-5, BED was promoted from “criteria sets . . . for further study” (APA, 2000, p. 759) to being a full-fledged diagnosis. This addition is highly significant because BED is likely to be the most prevalent eating disorder (Striegel-Moore & Franko, 2008).
BED shares the binge-eating criterion of BN (i.e., consuming an objectively large quantity of food in a relatively short time while experiencing a loss of control). The disorder differs from BN, however, in that individuals with BED do not engage in compensatory behaviors (e.g., vomiting or laxative use) after binge eating. An additional distinction is that BED does not include a key cognitive criterion necessary for a diagnosis of BN—the undue influence of weight and shape on self-concept (APA, 2013a).
The second criterion for BED describes behaviors, emotions and cognitions associated with binge eating. The criterion includes five items and specifies that individuals must display a minimum of three to qualify for diagnosis. Examples are eating in the absence of physical hunger, eating unusually quickly and experiencing feelings of guilt and disgust around eating. Although a diagnosis of BN does require the presence of binge eating, that diagnosis does not include these additional criteria.
As is the case with other eating disorders, the diagnostic criteria for BED in the DSM-5 reflect reduced requirements for duration and frequency. Whereas the research criteria in the DSM-IV-TR specified that bingeing must take place at least two days a week for six months (APA, 2000), the DSM-5 diagnostic criterion is that binge eating must occur an average of once per week, for a minimum of three months (APA, 2013a). In the DSM-5, frequency is measured in times—rather than days—per week (for discussion, see DSM-IV-TR Appendix B, APA, 2000). In keeping with the other eating disorders, DSM-5 includes a severity specifier for BED, with, for example, between one and three episodes per week constituting mild BED, and 14 or more episodes per week qualifying as extreme (APA, 2013a). The addition of this severity rating is very helpful, as it will allow clinicians to determine the seriousness of the individual’s disorder in order to assist in treatment planning. Clinicians should also now specify whether an individual is in partial or full remission from BED.
Obesity
The introduction to the chapter on feeding and eating disorders explicitly addresses the decision not to include obesity as a diagnosis in the DSM-5. This statement outlines the reasons that obesity itself does not constitute a mental disorder: “Obesity (excess body fat) results from the long-term excess of energy intake relative to energy expenditure. A range of genetic, physiological, behavioral, and environmental factors that vary across individuals contributes to the development of obesity” (APA, 2013a, p. 329). In other words, obesity is a physical condition caused by a number of contributing factors and is not, therefore, simply the embodiment of a psychological state. The introduction goes on to clarify, however, that there exist complex relationships between obesity and several psychiatric conditions. This section also refers to the connection between obesity and medications used to treat mental disorders (APA, 2013a).
One of the disorders described by the DSM-5 as having a “robust association” with obesity is BED (APA, 2013a, p. 329). The relationship between obesity and BED is complicated. The manual specifies, on the one hand, that while some obese individuals suffer from BED, the majority do not. Moreover, individuals with BED are not necessarily obese; they may be overweight, or their weight may fall in the normal range (Striegel-Moore & Franko, 2008). On the other hand, obesity is a risk factor for BED (Decaluwé & Braet, 2003), and “the risk of presenting with BED increases with increasing obesity” (Hill, 2007, p. 151). One might assume that binge eating would precede obesity, but the relationship appears to move in the opposite direction (Decaluwé & Braet, 2003). Obesity also is a risk factor for the development of BN (Decaluwé & Braet, 2003; Hill, 2007).
Other Specified Feeding or Eating Disorder and Unspecified Feeding or Eating Disorder
Whereas the DSM-IV-TR contained the catchall diagnostic category of EDNOS, this category no longer appears in the DSM-5. The EDNOS category previously was reserved for individuals who did not meet the full criteria for an eating disorder (e.g., a woman who meets all criteria for AN except that she has regular menses). It has been reported that this diagnosis was overly used by practitioners (Bryant-Waugh & Kreipe, 2012), so the changes in the DSM-5 attempt to address this problem. The literature indicates that many individuals who were being treated for an eating disorder received this diagnosis because they did not meet the stringent criteria for AN or BN (e.g., Sysko & Walsh, 2011). As mentioned previously, researchers have reported that EDNOS represented as many as 60% of all eating disorder diagnoses (Fairburn et al., 2007).
In the DSM-5, two new diagnostic categories replace EDNOS: other specified feeding or eating disorder and unspecified feeding or eating disorder. Other specified feeding or eating disorder refers to individuals who present symptoms characteristic of a feeding or eating disorder that causes clinically significant impairment, but does not meet the full criteria for any of the disorders in this section. However, when applying this diagnosis, the clinician is able to specify or state the specific reason that the presentation does not meet the full criteria. Thus, the specific reason should follow the diagnosis. An example of this diagnosis would be BN (of low frequency and/or limited duration). In this example, the individual meets all of the criteria of BN except that the inappropriate compensatory behavior and binge eating occur at a frequency less than once a week and/or for less than 3 months.
This diagnosis presents a contrast with another new diagnosis, unspecified feeding or eating disorder. In using this designation, the clinician is unable to provide the specific reason why the clinical presentation does not meet full criteria. This may be because of insufficient information from the client, such as may occur when a client obtains treatment in an emergency setting or a clinician fails to gather enough information during intake. In these cases, the client displays symptoms of an eating or feeding disorder that is causing clinically significant impairment, but does not meet the full criteria for any disorder.
Implications for Counselors
Given the prevalence of some eating disorders, as well as their presence across the life span, counselors will likely encounter individuals suffering from a diagnosable eating disorder at some point in their career. In fact, research suggests that DSM-5 criteria will result in a rise in the prevalence of diagnosable eating disorders (Allen et al., 2013). This prediction underscores the importance of those in the counseling profession becoming well-informed regarding these revised criteria. New, broader criteria, when implemented by well-informed professionals, will likely increase the chances that a greater portion of the individuals suffering from these disorders will receive the help they need.
Feeding and eating disorders appear to exist on a continuum, with some related behaviors frequently occurring in the population at large. The skilled counselor will be able to differentiate between behaviors that would not be considered pathological (e.g., overeating or typical “dieting”), or are developmentally appropriate (e.g., picky eating), and those that are indicative of greater dysfunction (e.g., binge eating, dramatically restricting calories). Counselors should be aware, however, that clients with eating disorders may not be forthcoming about their symptoms, hide their behaviors and display resistance to seeking help (Abbate-Daga, Amianto, Delsedime, De-Bacco, & Fassino, 2013). Also, many individuals who are at risk for developing eating disorders or who have them may never seek help (Dailey et al., 2014). In addition, full recovery from eating disorders is the outcome in only about 50% of cases, while 20% of individuals make no improvement (Schlozman, 2002). Thus, many individuals have a lifelong battle with eating disorders and relapse is common. It is critical, therefore, that counselors screen all clients for potential eating disorders. Careful assessment of the client’s underlying thoughts, symptom presentation and impairment will help counselors make a correct diagnosis.
Eating disorders can be damaging to one’s physical well-being, emotional health and interpersonal relationships (Dailey et al., 2014). These factors, coupled with the possible medical consequences and potential fatality of some eating disorders, highlight the need for counselors who work with these clients to have specialized training. If a counselor does not have the appropriate background in eating disorders, it is vital that he or she refer the client to an eating disorders specialist. Moreover, individuals with eating disorders must consult a physician for a comprehensive physical assessment and intervention (Piran, 2013). Given the complexity of the symptom presentation, treatment is likely to involve a multidisciplinary team approach for treatment of eating disorders (Dailey et al., 2014) and counselors would be wise to familiarize themselves with treatment resources in their community.
Conflict of Interest and Funding Disclosure
The author reported no conflict of interest or funding contributions for the development of this manuscript.
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Maureen C. Kenny, NCC, is a Professor at Florida International University. Mérode Ward-Lichterman is a graduate student at Florida International University. Mona H. Abdelmonem is an alumna of Florida International University. Correspondence can be addressed to Maureen C. Kenny, 11200 SW 8th Street, ZEB 247A, Miami, Florida 33199, kennym@fiu.edu.
Jul 3, 2014 | Article, Volume 4 - Issue 3
Laura K. Jones, Jenny L. Cureton
Trauma survivors are a unique population of clients that represent nearly 80% of clients at mental health clinics and require specialized knowledge on behalf of counselors. Researchers and trauma theorists agree that, with the exception of dissociative identity disorder, no other diagnostic condition in the history of the Diagnostic and Statistical Manual of Mental Disorders (DSM) has created more controversy with respect to the boundaries of the condition, diagnostic criteria, central assumptions and clinical utility than post-traumatic stress disorder. However, this mutable conceptualization of trauma and its aftermath have considerable implications for counseling practice. With the recently released fifth edition of the DSM (DSM-5), the definition of trauma and the diagnostic criteria for post-traumatic stress disorder have changed considerably. This article highlights the changing conceptualization of trauma and how the DSM-5 definition impacts effective practices for assessing, conceptualizing and treating traumatized clients.
Keywords: trauma, post-traumatic stress disorder, PTSD, DSM-5, diagnostic, clinical utility
Nearly 80% of clients seen in community mental health clinics have experienced at least one incident of trauma during their lifetime, representing roughly five out of every six clients (Breslau & Kessler, 2001). Over the past 15 years, between increases in school and community violence in the United States and unrelenting wars overseas, overt exposure to traumatic events has become an epidemic. Such events affect individuals across the life span and precipitate numerous diagnoses within the Diagnostic and Statistical Manual of Mental Disorders (DSM), most notably post-traumatic stress disorder (PTSD; Breslau & Kessler, 2001).
Survivors of trauma are a unique population of clients who require specialized knowledge and multifaceted considerations on behalf of counselors (Briere & Scott, 2006). The Council for Accreditation of Counseling and Related Educational Programs (CACREP) reiterates across both master’s and doctoral training levels the importance of understanding the implications of trauma theory, research and practice in counselor preparation and ultimately practice. CACREP (2009) standards incorporate trauma training within all eight core curricular areas of demonstrated knowledge and within each core counseling track. Section II, Professional Identity, says that counselors should understand the “effects of … trauma-causing events on persons of all ages” (CACREP, 2009, p. 10). However, even with the notable rates of trauma exposure, the deleterious outcomes faced by survivors and the call for counselor training in this area, counselors report feeling unprepared to work with survivors (Parker & Henfield, 2012). Over 60% of practicing therapists reported wanting additional support and education in their trauma work (Cook, Dinnen, Rehman, Bufka, & Courtois, 2011).
Trauma theorists agree that, with the exception of dissociative identity disorder, no other diagnostic condition in the history of the DSM has created more controversy about boundaries of the condition, symptomatological profile, central assumptions, clinical utility and prevalence than PTSD (Brewin, Lanius, Novac, Schnyder, & Galea, 2009). Changing definitions and the rationale for such shifts have significant implications for counselors. The fifth edition of the DSM (DSM-5), released in May 2013 (American Psychiatric Association [APA], 2013a), contains substantial changes, including the reorganization of “Trauma- and Stressor-Related Disorders” (TSRDs) into a new category and chapter distinct from “Anxiety Disorders,” the restructuring of factors, the modification of symptoms and specifiers, and the addition of a new subtype of PTSD in children.
The highly debated and variable definition of trauma and the diagnostic criteria for psychological responses to traumatic events may contribute to low counselor efficacy in trauma practice. Without a clear understanding of the latest views and requirements for trauma diagnosis using DSM-5, counselors may feel tentative about assessing for trauma and selecting efficacious interventions. This manuscript explores the changing definitions of trauma over time, implications of such changes on counseling practice and areas of needed growth and research. While this article’s core focus is on PTSD, we also briefly describe other TSRDs. By outlining DSM-5 changes, reviewing recent research substantiating such modifications and providing practical suggestions for practitioners, we hope to mitigate confusion and enhance efficacy in counselors working with trauma clients during this crucial diagnostic transition.
History of Trauma
Derived from the Greek word for “wound,” tales of trauma and the its profound consequences thereof date back to writings in antiquity. Only in the late 19th century did Pierre Janet and Sigmund Freud provide the first writings on the characterizations and clinical implications of traumatic events. In the mid-1890s, both practitioners developed similar theories of the etiology of hysteria, namely experiences of psychological trauma, particularly sexual trauma (Herman, 1992a). The theories presented in Freud’s The Aetiology of Hysteria (1962), however, were met with vehement contention, and such censuring stifled potential ramifications of his discoveries. Consequently, contemporary theories and definitions of trauma became largely fashioned from studies of male soldiers’ reactions to the horrors of war. Investigations of traumatic stress and apposite interventions for survivors emerged following World War I, purportedly as a means of rehabilitating soldiers for redeployment (van der Kolk, 2007). This attention waned during times of peace, but took command of the mental health research and literature during the Vietnam War. Concurrently, marked attention again became drawn to the consequences of sexual and domestic violence against women and children owing to the Women’s Movement (Herman, 1992a).
The examination of traumatic responses on both fronts (i.e., combat and interpersonal violence) led to the inclusion of a distinct PTSD diagnosis in the third edition of the DSM (DSM-III; APA, 1980). Previous iterations of the DSM recognized reactions to stressful experiences as a “transient situational disturbance,” suggesting that without an underlying psychological condition, the individual’s psychological experiences would wane as the stressor subsided (Yehuda & Bierer, 2009). However, the DSM-III classified trauma as an event existing “outside the range of usual human experience” (APA, 1980, p. 236) and provided legitimization for the potential pervasive and deleterious effects of exposure. As research continues, however, both the definitions of what constitutes a traumatic experience and what characterizes the symptoms of PTSD have rapidly transformed.
The publications of the DSM-IV and DSM-IV-TR brought a considerably more inclusive definition of trauma (APA, 1994, 2000).Varied events as a car accident, a natural disaster, learning about a death of a loved one, and even a particularly difficult divorce were considered variations of traumatic experience. This expanded definition engendered a 59% increase in trauma diagnoses (Breslau & Kessler, 2001). Modern trauma theory conceptualizes trauma and traumatic responses as occurring along a continuum (Breslau & Kessler, 2001), with researchers elucidating the importance of differentiating between traumatic experiences when investigating the etiology, physiological responses, course and efficacious therapeutic interventions for the range of potential traumatic responses (Breslau & Kessler, 2001; Kelley, Weathers, McDevitt-Murphy, Eakin, & Flood, 2009). The unique consequences of these diverse populations may be obscured if survivors of disparate populations are combined in research or excluded from trauma definitions altogether.
Primary Challenges to the DSM-IV-TR
The 13 years between the DSM-IV-TR (2000) and the DSM-5 (2013a) engendered considerable debate regarding how trauma was defined and the core criteria of PTSD. In the DSM-IV-TR, the presence of at least six symptoms (out of 17) distributed among three core symptom clusters served as a basis for diagnosing PTSD. This three-factor model stipulated that following a traumatic event, which induced fear, helplessness or horror, a survivor must experience at least one symptom of persistent re-experiencing (criterion B), three symptoms of avoidance or emotional numbing (criterion C), and two indicators of increased arousal (criterion D), all of which must persist for at least 1 month. Further, a clinician could specify whether the condition was acute, chronic and/or with delayed onset. An examination of the challenges surrounding this diagnosis follows.
Is Trauma an Anxiety Disorder?
PTSD was historically characterized as an anxiety disorder within the DSM. Authors supporting this view reference the pronounced fear and classical conditioning believed central among survivor experiences and treatment approaches that aim to extinguish such fear-based responses (i.e., exposure therapies; Zoellner, Rothbaum, & Feeny, 2011). Zoellner et al. (2011) branded PTSD a “quintessential anxiety disorder” (p. 853), arguing that the co-occurrence of PTSD with other anxiety disorders suggests common core constructs. These authors warned that reclassifying PTSD would suggest incorrectly to clinicians and researchers that “fear and anxiety are not critical in understanding PTSD” (p. 855). However, other researchers promoted making trauma-related disorders a new diagnostic category, suggesting that the traumatic event and not the symptoms demarcate such disorders (Nemeroff et al., 2013). Nemeroff et al. (2013) suggested that using the traumatic event as the foundation for the diagnosis respects the intensely heterogeneous nature and symptomatic presentation of the disorder.
Precipitating Events and Subjective Response
Also termed the stressor criterion, PTSD criterion A stipulated two requirements. An individual must first experience a traumatic episode (A1), defined as:
A direct personal experience of an event that involves actual or threatened death or serious injury, or other threat to one’s physical integrity; or witnessing an event that involves death, injury, or a threat to the physical integrity of another person; or learning about an unexpected or violent death, serious harm, or threat of death or injury experienced by a family member or other close associate (APA, 2000, p. 463).
The second prerequisite (A2) required that the survivor must have experienced “intense fear, helplessness, or horror” (p. 467) following the event. Clinicians and researchers have criticized both requirements (Breslau & Kessler, 2001; Friedman, Resick, Bryant, & Brewin, 2011).
The debate over what constitutes a traumatic event emerged with the first inclusion of the diagnosis into the DSM-III, and has persisted. Some researchers argued that the DSM-IV’s broad definition of trauma led to “bracket creep” (McNally, 2009, p. 598) and overdiagnosis of PTSD resulting from less threatening events. McNally (2009) questioned the ramifications of having equivalent diagnoses for a traumatized individual who watched the World Trade Center collapse from thousands of miles away and a survivor who escaped the building directly. Some postulated that weakening the A1 criteria had detrimental outcomes in client care and in forensic and disability settings and supported a narrower definition of trauma (Rosen & Lilienfeld, 2008). Others starkly disagreed, suggesting that what may be traumatic for one individual may not be for another, and that an attempt to include all possible traumatic events within the context of a diagnosis was futile (Brewin et al., 2009). Numerous researchers and clinicians have remarked that for no other diagnosis in the DSM is a specific precursory event stipulated, and they have argued for the removal of the A1 event altogether (Brewin et al., 2009), questioning the compulsory relationship between a traumatic event and PTSD (i.e., other disorders may result from such an event) and asserting that minor events, repeated over time, can likewise lead to PTSD.
More prominent was dispute over the latter stressor requirement (A2). Friedman et al. (2011) emphasized that the presence of a subjective response did not predict that an individual who would go on to develop PTSD. Although these subjective responses are characteristic trauma reactions, limiting the range of psychological responses may discount subpopulations, most notably survivors of sexual and partner violence, military and first responders (Friedman et al., 2011). The predominant post-traumatic reactions of interpersonal violence survivors include anger, guilt and shame; the military and first responders often report not having an immediate emotional reaction to traumatic exposure as a result of their training. In a sample of adult sexual assault survivors, over 75% endorsed shame as a leading psychological response (Vidal & Petrak, 2007). Over 20% of survivors were misdiagnosed due to not meeting the A2 criteria (Creamer, McFarlane, & Burgess, 2005).
Three-factor Model: The Avoidance and Numbing Debate
The third criterion for a PTSD diagnosis in DSM-IV-TR included experiencing at least three symptoms related to either behavioral avoidance or affective numbing (APA, 2000). Having a double-barreled criterion engendered considerable disagreement in trauma research and clinical practice. Although these two constructs were initially considered synonymous, with emotional numbing serving as a volitional form of emotional avoidance, research has elucidated differences in their bases, functions and neurophysiological underpinnings (Asmundson, Stapleton, & Taylor, 2004). Foa, Riggs, and Gershuny (1995) further determined that emotional numbing, over and above avoidance or another symptomatic feature of PTSD, best distinguishes PTSD from other diagnostic categories. Conceptually, authors (Foa, Zinbarg, & Rothbaum, 1992; Ullman & Long, 2008) frequently distinguished avoidance and numbing by examining the intentionality behind the event: whereas avoidance represents conscious attempts to escape trauma-related stimuli or responses, numbing is an unconscious and automatic physiological response to trauma exposure. Confirmatory factor analyses substantiated such claims and repeatedly demarcated a four-factor rather than a three-factor model of PTSD that differentiates avoidance and numbing (Friedman et al., 2011).
The integrated conceptualization of numbing and avoidance had marked significance on clinical practice. It was often difficult to confirm three of the seven conditions (Schützwohl & Maercker, 1999), leading to subthreshold diagnoses or underdiagnosis. Further, the severity of numbing precipitated a category of trauma survivors marked by the most chronic and pervasive disturbances following trauma and most pronounced disruptions in daily life (Breslau, Reboussin, Anthony, & Storr, 2005). In addition, Asmundson et al. (2004) determined that symptoms of avoidance and numbing are differentially influenced by treatment approaches, reinforcing the notion that avoidance and numbing should be considered and clinically addressed as distinct symptomatic concerns. Further, using the DSM-IV, a clinician treating an unconscious response (i.e., numbing) as an intentional action (i.e., avoidance) could unintentionally lead to treatment that was ineffective, blaming, disempowering or even re-traumatizing to clients.
Subthreshold Diagnoses
Several of the aforementioned considerations denote concern around subthreshold or subsyndromal survivors, namely individuals whose trauma did not match the A1 or A2 events or whose symptoms did not fulfill the restrictive criterion C. These survivors, potentially facing grossly impaired functioning, did not fulfill PTSD criteria and thus may have been prohibited from receiving any services, appropriate services or related validation of their experiences (Cukor, Wyka, Jayasinghe, & Difede, 2010; Schützwohl & Maercker, 1999). Problems with subthreshold diagnoses and misdiagnoses under the DSM-IV guidelines were particularly notable among children (Pynoos et al., 2009; Scheeringa, Zeanah, & Cohen, 2011). Using DSM-IV criteria, over 30% of children with pervasive symptoms and severe functional impairment did not meet criteria (Scheeringa, Myers, Putnam, & Zeanah, 2012). Although notes regarding symptom presentation in children were presented, the DSM-IV did not identify a separate diagnosis for preschool post-traumatic reactions. Researchers argued that the DSM-IV criteria were not attentive to developmental considerations, owing largely to the linguistic and introspective differences of young children, and provided unrepresentative criteria for this population (Pynoos et al., 2009; Scheeringa et al., 2011). Consequently, researchers highlighted the need for child-specific PTSD criteria. Underdiagnosis in children and adults is particularly troubling given that these populations of survivors have long been misdiagnosed and stigmatized by the DSM (Fish, 2004; Rojas & Lee, 2004). Drawing on both behavioral and neurological research, these challenges to the DSM-IV PTSD diagnosis touched at the core of trauma theory and resulted in many shifting perspectives in the fifth edition. Given the historical complications in trauma theory and recent reformulations of trauma, it is important that counselors receive guidance on trauma-informed practice using the DSM-5 (APA, 2013a).
Shifting Perspectives and New DSM-5 Diagnostic Criteria
In the DSM-5, PTSD now serves as the cornerstone of a new category of diagnoses, TSRD. Within the new category, the definition of trauma is more explicit, and the symptomatic profile was expanded from a three- to four-factor structure. Subjective responses following a traumatic event are no longer required, and a separate preschool diagnosis for children 6 years old and younger is now available. The modifications to the PTSD diagnosis in the DSM-5 are delineated in Table 1.
Exemption from Anxiety Disorders
The foremost change in the DSM-5 diagnosis of PTSD is its assignment to an innovative diagnostic category, TSRDs. Throughout the review period, members of the Trauma and Stressor-Related and Dissociative Disorders (TSRDD) Sub-Work Group of the DSM-5 (Friedman, 2013) determined that PTSD did not “fit neatly into the anxiety disorder niche to which it had been assigned since DSM-III” (p. 549). This redefining of PTSD marks a significant shift from its former conceptualization and highlights the central importance of the predisposing stressor. Exposure to a traumatic or aversive event is now recognized as a vital cause of an entire class of conditions affecting mental well-being. Before the DSM-5, trauma exposure was an accepted catalyst of Acute Stress Disorder and PTSD, yet the explicit influence of such aversive events on numerous other disorders went largely unacknowledged.
Restructuring the Stressor Criterion
Emphasis on the precipitating traumatic event called for reconsideration of the definition of trauma. Despite the argument by Brewin et al. (2009) that what is or is not considered a traumatic event should be defined by the individual rather than a committee, the DSM-5 retained criterion A1, with modifications to the breadth of the definition. Trauma is now defined as exposure to actual or threatened death, serious injury or sexual violence in one or more of four ways: (a) directly experiencing the event; (b) witnessing, in person, the event occurring to others; (c) learning that such an event happened to a close family member or friend; and (d) experiencing repeated or extreme exposure to aversive details of such events, such as with first responders. Actual or threatened death must have occurred in a violent or accidental manner; and experiencing cannot include exposure through electronic media, television, movies or pictures, unless it is work-related.
Table 1
Key Modifications to PTSD in DSM-5
|
PTSD Modifications
|
| Location |
New category: “Trauma- and Stressor-Related Disorders”No longer a subcategory of “Anxiety Disorders” |
| Criteria |
|
| A. Exposure |
Included sexual violence as a traumatic event
Exposure refined to include:
- Learning the event(s) occurred to close family or frienda,
- Repeated or extreme exposure to details of the event(s)b, i.e., vicarious trauma.
Removed A2, subjective response (i.e., fear, helplessness, horror) |
| B. Intrusion(1 of 5) |
No major changes |
C. Avoidance
(1 of 2) |
New separate criterion (factor) for avoidance symptoms
No major changes to symptoms |
D. Negative Alterations in Mood/cognition
(2 of 7) |
New criterion (factor) for numbing symptoms
Two new symptoms:
- Persistent negative emotional states
- Persistent blame
|
E. Arousal and Reactivity
(2 of 6) |
One new symptom:
- Reckless or self-destructive behavior
|
| F. Duration |
No change: Still 1 month since stressor |
| G. Significance |
No change |
| H. Not substance or medical |
Added criterion |
| Specifiers |
Two types available:
- With dissociative sx, i.e., depersonalization or derealization
- With delayed expression of 6 or more months
|
| Subtype |
For children 6 years or younger (Preschool subtype)
Separate criteria |
Note. sx = symptoms. Adapted from DSM-5 (APA, 2013a, p. 272).
aActual or threatened death must have been violent or accidental.
bSuch exposure through media, television, movies or pictures does not qualify unless for work.
Several changes in the DSM-5 definition stand out immediately, such as the inclusion of sexual violence within the core premise of trauma. Experiencing sexual violence may precipitate PTSD, as can witnessing it, learning about it and experiencing repeated exposure to stories of such acts. Furthermore, loss of a loved one to natural causes is no longer considered a causal factor. For example, now a client whose partner unexpectedly died of a heart attack no longer fits PTSD criteria. Lastly, a new subset of possible exposure has been established, namely vicarious trauma. This is the first time that DSM criteria have included deleterious effects of repeatedly witnessing or hearing stories regarding the aftermath of trauma. This inclusion may not be surprising to trauma counselors, as nearly 15–20 % develop PTSD symptoms from hearing and sharing in the stories of survivors; this inclusion may help to legitimize the gravity of counselors’ reactions (Arvay & Uhlemann, 1996; Meldrum, King, & Spooner, 2002). The inclusion also may serve to de-stigmatize the reactions of first responders and reinforce the need for wellness training and post-exposure care (Royle, Keenan, & Farrell, 2009). However, the DSM-5 clearly states that vicarious trauma cannot be the result of repeated exposure via electronic or print media. This precludes, for example, McNally’s (2009) case example of an individual with trauma symptoms who repeatedly witnessed the attacks on the World Trade Center by way of television monitors.
Removal of Subjective Response
Along with changes to the definition of trauma, the DSM-5 now excludes the A2 subjective response. The PTSD diagnosis now represents survivors who experience reactions other than fear, helplessness or horror, or who exhibit no pronounced emotional response. For example, a client who witnessed a fatal car accident and predominantly feels pervasive guilt for not offering support could be diagnosable. This change has great significance for numerous populations and may lead to more survivors gaining access to efficacious mental health care.
A Four-Factor Approach
In accordance with evidence supporting a four-factor model of PTSD, the APA (2013a) split the previous criterion C into two distinct categories within the DSM-5: (a) avoidance and (b) negative reactivity and related numbing. The new criterion C (i.e., persistent avoidance) requires only one of the two original avoidance symptoms. The new criterion D in DSM-5, “negative alterations in cognitions and mood” (p. 271, APA, 2013a), underscores the notion that trauma leads to unconscious numbing of positive emotions and increased negative affect overall (Frewen et al., 2010). Persistent negative emotionality and persistent blame are additions to the original symptom profile, the latter of which predicts PTSD severity and chronicity (Moser, Hajcak, Simons, & Foa, 2007). Two of seven symptoms must be endorsed in the new criterion D.
Criterion B (i.e., presence of intrusive symptoms) remains unchanged from the DSM-IV, and requires only one of five symptoms. The new criterion E, persistent alterations in arousal, reflects the previous criterion D and includes one additional symptom, reckless or self-destructive behaviors. Self-destructive behaviors comprise anything from hazardous driving to suicidal behavior (Friedman, 2013). Two of the now six symptoms of altered arousal are required. Despite refinements to criteria, considerable overlap remains across and within PTSD symptoms, such as between intrusion and the dissociative-depersonalization specifier.
Dissociative Specifier
In addition to delayed expression, the DSM-5 includes specifiers for dissociative symptoms in PTSD, with either depersonalization or derealization constituting the primary presentation. Dissociation often predicts significantly greater severity, chronicity and impairment in survivors, as well as decreased responsiveness to common treatment approaches (Lanius, Brand, Vermetten, Frewen, & Spiegel, 2012). The inclusion of this subtype acknowledges differences in neurological and physiological functioning among this population (Felmingham et al., 2008) and relevant needs and clinical considerations (Lanius et al., 2012).
Post-traumatic Stress Disorder in Children
In recognizing the gross oversights in previous iterations of the DSM regarding developmental considerations in PTSD, the DSM-5 explicitly provides a preschool subtype for children 6 years and younger. This new diagnosis honors the unique trauma experiences and responses of children, with symptoms that are behaviorally based and thus not reliant upon the cognitive or linguistic complexity absent in young survivors. For example, symptoms include restless sleep, temper tantrums or decreased participation in play. Children may express symptoms through behavior or play reenactment, which may or may not appear related to the traumatic event. The preschool subtype retains the three-factor model that combines avoidance and negative alterations of mood and cognition. To circumvent concerns related to children not meeting criterion C requirements, only one of six symptoms is necessary. These changes have pronounced implications for counseling adult and child survivors of trauma.
Implications for Counseling Practice
Understanding these changes and the rationale behind them is essential to thorough client conceptualization and efficacious counseling. Otherwise, counselors may feel tentative about key areas of care, such as assessing for trauma exposure, making accurate diagnoses, selecting efficacious interventions and filing reimbursement claims. A consideration of specific ways the new that the DSM-5 PTSD diagnosis impacts counselors, clients and clinical practice follows.
Multifarious Symptom Structure and Trauma Prevalence
The expanded PTSD symptom set in the DSM-5 set leads to extensive variations in possible trauma responses. The increase in symptoms from 17 in the DSM-IV-TR to 20 in the DSM-5 now yields over 600,000 possible symptom combinations (Galatzer-Levy & Bryant, 2013). Consider this number in comparison to the potential 70,000 combinations possible in the DSM-IV-TR (2000), a number already criticized for its expansiveness, and the meager 256 possible for depression (Zoellner et al., 2011). This marked increase in symptom patterns calls into question prevalence rates for trauma under the new DSM. A recent study established similar prevalence rates using DSM-5 and DSM-IV-TR criteria, 39.8% and 37.5%, respectively, and an overall 87% consistency between the two versions (Carmassi et al., 2013). Carmassi et al. (2013) determined that the discrepancy was due primarily to individuals not fulfilling criterion C within the DSM-IV-TR. This finding illustrates the impact of modifications related to the bifurcation of avoidance and numbing. Kilpatrick et al. (2013), however, found marginally decreased prevalence with the DSM-5, citing constraints on the A1 definition of trauma. However, both studies found significantly increased prevalence among females than males using DSM-5 (Carmassi et al., 2013; Kilpatrick et al., 2013).
Although heterogeneity may provide a more thorough scope and representation of traumatic responses, the considerable variation in behavioral presentation may lead to confusion among both counselors and clients (Friedman, 2013). Two clients may present in drastically different manners, but receive the same diagnosis. One client with PTSD may be distrustful, experience violent nightmares and behave aggressively, while another with a PTSD diagnosis is more withdrawn and self-blaming, with internally directed negative emotionality. Conversely, a counselor could have two clients who present analogously; and yet, due to the nature of the traumatic event, one could be diagnosable and the other not. This may cause complications for counselors in providing psychoeducation or in determining appropriate clinical interventions.
Counselors will encounter many questions with the changing and heterogeneous face of PTSD. For instance, would a counselor work differently with the client with a PTSD diagnosis than with a client having an analogous presentation, but no PTSD diagnosis? Do neurological ramifications differ dramatically now given the shifting labels, and thus call for varied interventions? How does a counselor explain to a client who had PTSD under the DSM-IV that she or he no longer meets criteria nor qualifies for reimbursement with the new diagnosis of adjustment disorder? Or will adjustment disorder, re-categorized as a TSRD in DSM-5, now be recognized by third-party payment systems as a reimbursable disorder? Although some answers are beginning to unfold, an increased awareness and adaption of trauma assessment, treatment and administration can help counselors navigate such questions and effectively work with clients.
Client Assessment
Changes precipitated by the DSM-5 require counselors be acutely aware of the modified PTSD diagnostic criteria for careful assessment of survivors. Thorough assessment includes applying both informal and formal approaches, using multiple sources of information, and conducting initial and ongoing screenings. During the present transition, informal assessment becomes especially important as efforts to revise and validate formal assessment tools continue.
Informal assessment. Given the central importance of trauma exposure in client care, counselors may continue to struggle to sensitively solicit needed information early in the counseling process. Honed skills for developing and continually fostering the therapeutic alliance are essential to client disclosure and in conscientiously deciphering such information. Some clients may be more reticent to share information, while others may reveal very detailed accounts of their story. In either case, counselors need to remain cognizant of the risk for re-traumatization during this process and pace sessions accordingly. Friedman (2013) also recognized that the current conceptualization of trauma in the DSM-5 insinuates the trauma has already happened, and that the individual is now “in a context of relative safety” (p. 763). This assumption may complicate assessment of individuals in enduring traumatic environments (e.g., partner violence).
During informal assessment with adults, counselors should practice acute observation skills for nonverbal clues that may signal present intrusive, numbing, arousal and dissociative symptomatology. Reported experiences of feeling detached from body or mind and reports of the world seeming dreamlike or unreal are primary indicators of dissociative experiences. Objective cues of dissociative responses also may be present, such as the client appearing to space out (Briere & Scott, 2013). Further, behavioral responses such as reckless and self-destructive behavior must also be recognized as potential trauma responses. The two new criterion D symptoms related to client cognitions, however, require counselors to determine a survivor’s cognitive perception of the event, self and world, and how perceptions of the latter two may have shifted post-trauma. Moreover, given the current distinction between numbing and avoidance symptoms, counselors may need to discern conscious from unconscious motivations behind client behaviors.
In children, informal assessment of traumatic responses, although now facilitated by developmentally appropriate criteria, may be particularly challenging. This requires keen observation of behavior, interpersonal interactions, sleep patterns and play. Cohen et al. (2010) suggested that child assessments must account for the onset of symptoms and changing patterns therein to avoid potential misdiagnoses. Recognizing how trauma responses manifest in children will help counselors correctly identify child survivors and help children get the mental health care needed to avert potentially protracted concerns across the life span.
Formal assessment. Formal assessment methods consistent with the revised diagnostic criteria are an essential adjunct to a counselor’s informal assessment. A notable addition to the DSM-5 is the provision of diagnostic assessments. Many are still considered “emerging,” as the APA continues to gather feedback from clinicians (APA, 2014). Counselors can familiarize themselves with these measures and stay updated on their availability and validation through the DSM-5 website (www.psych.org/practice/dsm/dsm5).
Relevant formal measures of PTSD for the DSM-5 include the following: Level 1 Cross-Cutting Symptom Measures for brief assessment, Level 2 measures for in-depth domain-specific assessment, disorder-specific Severity Measures, and potentially Early Development and Home Background Forms (APA, 2014). Level 1 surveys include questions related to avoidance, sleep quality, repetitive unpleasant thoughts and other symptoms found in DSM-5 PTSD criteria. This level provides a measure for adults, a self-rated measure for children ages 11 to 17, and a guardian-rated measure for children ages 6 to 17. Level 2 Cross-Cutting Symptom Measures allow for more in-depth explorations of symptoms. Disorder-Specific Severity Measures contain the National Stressful Events Survey PTSD Short Scales for adults and for children ages 11-17. Although guardian measures are available, the applicable age range is limited from 6 to 17 years. Thus these measures are not appropriate for assessing symptoms in preschool children, despite the addition of distinct diagnostic criteria for this population.
In addition to the DSM-5 measures provided by the APA, the National Center for PTSD updated three measures to include DSM-5 criteria: the Clinician-Administered PTSD Scale for DSM-5 (CAPS-5), the PTSD Checklist for DSM-5 (PCL-5), and the Life Events Checklist for DSM-5 (LEC-5). Counselors wanting to access these measures can submit requests on the National Center for PTSD’s website (www.ptsd.va.gov/).
Differential diagnosis: A resource with limitations. Another component of assessment is differential diagnosis. The use of updated measures for formal assessment may not always resolve confusion engendered by facets of DSM-5 diagnosis such as overlapping criteria. Selecting among the Level 2 cross-cutting measures may be challenging, as many currently focus on anxiety, anger and inattention, which may not be applicable or adequate in assessing PTSD. Differential diagnosis may help counselors gain needed clarity and is often considered integral to every initial clinical encounter and the basis for treatment planning (First, 2014).
Decision trees allow for diagnostic determination based on the entirety of a client’s presenting symptoms and assist in identifying diagnostic options by using lists of symptoms relevant to PTSD, including distractibility, mood concerns, suicidal behavior, anxiety, avoidance and insomnia. Out of the 29 available decision trees in the DSM-5 Handbook of Differential Diagnosis (First, 2014), nine include decisions that may result in an accurate diagnosis of PTSD or another TSRD, not including lists with adjustment disorder as the sole TSRD.
However, some decision trees, which include symptoms reflective of PTSD criteria, do not include the disorder as a possible conclusion. For instance, criterion D covers “negative alterations in cognitions and mood,” though none of the three decision trees associated with mood include PTSD. The new symptom in criterion E is “self-destructive or reckless behavior,” yet the Decision Tree for Suicidal Ideation or Behavior does not include PTSD as a possible diagnosis, nor does its counterpart for self-injury or self-mutilation. Thus, in the initial absence of information about a precipitating event, well-developed informal assessment skills for PTSD may be the best tool a counselor can use to form initial hypotheses for client conceptualization and associated treatment planning.
Treatment
New changes to the DSM also engender implications for PTSD treatment. As noted, the four-factor model of PTSD discriminates between avoidance and negative emotionality/numbing. This transition emphasizes the need to address these two constructs as unique symptom sets in survivors and highlights the influence of neuroscience research on best practices in trauma care. For instance, positive emotional numbing is considered a neurologically based symptom outside the conscious control of survivors, as opposed to the conscious or conditioned behavioral-based responses of effortful avoidance used to decrease arousal (Asmundson et al., 2004). The degree of emotional numbing versus avoidance in clients (or vice versa) suggests differential subpopulations of survivors and thus treatment approaches. For example, exposure therapy has proven particularly beneficial for avoidance symptoms (Asmundson et al., 2004). However, given the longstanding conceptual overlap in avoidance and numbing symptoms, optimal measures to assess treatment responses to emotional numbing have been limited (Orsillo, Theodore-Oklota, Luterek, & Plumb, 2007). Such findings suggest that effective treatment for trauma clients may become increasingly multidimensional and multidisciplinary.
The addition of new symptoms within criterion E and subtypes of PTSD calls for modified treatment approaches and goals for survivors who fulfill such criteria. For example, the inclusion of reckless or self-destructive behaviors as a feature of hyperarousal in criterion E now encompasses suicidal behavior (Friedman, 2013). Researchers have long denoted strong correlations between PTSD and suicide risk (Krysinka & Lester, 2010). The inclusion of self-destructive behavior as a symptom finally gives credence to this relationship. Counselors should practice vigilance and responsiveness to warning signs of suicidality. Regarding treatment, distress tolerance was shown to moderate PTSD and suicidal behavior (Anestis, Tull, Bagge, & Gratz, 2012), although perceived social support may buffer the impact of trauma symptoms on such behavior (Panagioti, Gooding, Taylor, & Tarrier, 2014). Similarly, the addition of dissociative subtypes highlights the severity and uniqueness of this subpopulation and the need for appropriate treatment considerations. Cloitre et al. (2012) endorsed a staged treatment emphasizing affective and interpersonal regulation as one option for treating dissociation in PTSD.
The addition of a preschool PTSD diagnosis increases the discernible importance of trauma-informed counseling with children and families. Research on best practices with children 6 years old and younger supports the use of cognitive-behavioral therapy (CBT), individually or in groups, most notably Trauma-Focused CBT; as well as child-parent relational psychotherapy; EMDR; and play therapy (Scheeringa, 2014). Scheeringa stressed that the key to working with this age group is engaging the child in developmentally appropriate methods that respect linguistic and introspective abilites (2014). Although some treatment implications stemming from the DSM-5 are presently discernible, additional research on best practices for addressing novel symptoms and symptom patterns of PTSD in children and adults will further inform practice.
Reimbursement and Legal Ramifications
Additional implications of DSM-5 modifications, such as healthcare consequences, remain largely unknown. General healthcare implications are explored in a file provided on the DSM-5 website (APA, 2013b), with the major foci including International Classification of Diseases (ICD) coding and assessment of disability and functioning. The APA (2013b) assured “periodic updates of agreements with federal agencies, private insurance companies, and medical examination boards as they become available” (p. 4). It can be expected that insurance companies will continue to reimburse for PTSD. However, a parallel expectation or hope is for companies to begin reimbursing more consistently for subthreshold PTSD, adjustment disorder and related diagnoses.
Conclusion
Although the changes to PTSD in the DSM-5 were empirically based and arose after considerable analysis and debate, several areas of concern and oversight still stand. Research remains mixed about overall prevalence rates of vicarious trauma (VT) in mental health practitioners (Kadambi & Ennis, 2004). Given the inclusion of VT in trauma definitions, the expected increase of PTSD diagnoses in clients, and the related potential for reimbursement and access to care for a broader range of traumatized clients, the prevalence of VT in clinicians may increase as well. Further research is needed on prevalence, risk and protective factors, and effective help for counselors experiencing VT. The addition of VT in the DSM-5 provides a diagnostic construct, yet future research will yield notable contributions to conceptualization and inform counseling practices for individuals experiencing VT.
Furthermore, a growing body of evidence suggests that a traditional diagnosis of PTSD is not sufficient to describe the range and intensity of symptomatology experienced in survivors of unremitting and recurrent abuse, notably abuse during early stages of development. Research has determined that such iterative and early trauma engenders symptomatic sequelae divergent from adult onset or isolated acts of violence (Herman, 1992b; van der Kolk, Roth, Pelcovitz, Sunday, & Spinazzola, 2005). Herman (1992b) and van der Kolk et al. (2005) proposed a diagnostic formulation distinct from PTSD: complex PTSD or disorders of extreme stress not otherwise specified (DESNOS). The profoundly disruptive nature of DESNOS led researchers to characterize complex PTSD as an experience of “mental death” (p. 617; Ebert & Dyck, 2004). In field trials on the addition of complex PTSD in forthcoming editions of DSM, 68% of children who experienced sexual abuse were found to have complex PTSD over and above an expression of PTSD alone (Roth, Newman, Pelcovitz, van der Kolk, & Mandel, 1997). In a follow-up to earlier field trial studies, van der Kolk et al. (2005) found early interpersonal trauma gives rise to more complex pathology than later interpersonal victimization, and that the younger the age of onset of the trauma, the more likely the individual is to suffer from C-PTSD. However, at the time of the DSM-5’s publication, the TSRDD Sub-Work Group of the DSM-5 determined that there was not currently enough information on the distinctiveness and pervasiveness of the disorder to warrant a formal diagnosis (Friedman, 2013). However, the group incorporated certain proposed DESNOS symptoms (e.g., self-destructive behavior, dissociative subtype) into the reformulated diagnosis (Friedman et al., 2011). Given evidence of uniquely deleterious consequences of early and repeated trauma, ongoing conceptualization and validation of DESNOS will be essential.
Although the DSM-5 provides improvements to PTSD diagnoses, it also presents notable challenges and engenders numerous unanswered questions for counselors and other mental health professionals. Counselor experiences in the field will inform practice, and continued research will provide more coherent understanding of criteria such as negative emotionality and numbing, accurate assessment of TSRDs, and ramifications in legal, health care and forensic settings. To continue to work ethically within their scope of practice (American Counseling Association, 2014), counselors must ensure that they are trained in the area of trauma and continue to seek professional education and guidance on the ongoing developments in this topic.
Conflict of Interest and Funding Disclosure
The author reported no conflict of interest or funding contributions for the development of this manuscript.
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Laura K. Jones, NCC, is an Assistant Professor at the University of Northern Colorado. Jenny L. Cureton, NCC, is a doctoral student at the University of Northern Colorado. Correspondence can be addressed to Laura K. Jones, University of Northern Colorado, Department of Applied Psychology and Counselor Education, Box 131, Greeley, CO 80639, laura.jones@unco.edu.
Jul 2, 2014 | Article, Volume 4 - Issue 3
Saundra M. Tomlinson-Clarke, Colleen M. Georges
The 2013 publication of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5) marked the reemergence of issues related to the appropriateness of diagnosis and the uses of the DSM-5 within the counseling profession. Concerns focus on the implications of the DSM-5 for counseling professionals whose professional identity is grounded in a prevention and wellness model, and the impact of the diagnostic process on counseling ethical practice. In this article, the authors explore the use of the DSM-5 in counseling training and practice. The authors also discuss integrating DSM-5 diagnosis into a counselor training framework while maintaining a wellness orientation. Multicultural and strength-based considerations are recommended when using the DSM-5 in counseling training and practice, while maintaining consistency with a philosophical orientation focused on development and wellness and delivering services that are indicative of a unified counseling professional identity.
Keywords: diagnosis, DSM-5, strengths, wellness, counselor training, multicultural
The history of the counseling profession dates back to the vocational guidance movement of the early 1900s. As society became increasingly industrialized, a need arose to improve individuals’ vocational choices (Whiteley, 1984). With a focus on helping people to resolve problems in living, the counseling profession has maintained an emphasis on growth, prevention and early intervention across the life span (Gladding, 2013). Counseling is defined as “a professional relationship that empowers diverse individuals, families, and groups to accomplish mental health, wellness, education, and career goals” (Kaplan, Tarvydas, & Gladding, 2013). According to Remley and Herlihy (2014), many problems and issues that people face are developmental in nature. A wellness orientation toward helping and help seeking and the use of holistic approaches to treatment distinguish professional counselors from other mental health professionals (Mellin, Hunt, & Nichols, 2011). A focus on normal development and positive lifestyles promotes counselor professional identity and unifies the counseling profession (Gale & Austin, 2003). Given its common historical roots of assisting individuals with educational, occupational and emotional well-being (Whiteley, 1984), the field of counseling psychology also “maintains a focus on facilitating personal and interpersonal functioning across the life span. . . [with] particular attention to emotional, social, vocational, educational, health-related, developmental, and organizational concerns” (Society of Counseling Psychology, American Psychological Association, Division 17, 2014). Therefore, counselors, counseling psychologists and counselor educators benefit from understanding the dynamics of human growth and development in developing responsive interventions for clients with mental health concerns (Ibrahim, 1991). Furthermore, in creating a shared vision for supporting counselors, services to clients and the counseling profession, “advocat[ing] for optimal human development by promoting prevention and wellness” was among the six critical themes identified at the Counselor Advocacy Leadership Conference (Kaplan & Gladding, 2011, p. 368).
With the publication of the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5; American Psychiatric Association [APA], 2013), issues related to counselor professional identity, diagnosis and the use of the DSM-5 within the counseling profession have reemerged. Concerns focus on the implications of the DSM-5 for counseling professionals who advocate prevention and wellness, and the impact of the diagnostic process on counseling ethical practice (Kress, Hoffman, Adamson, & Eriksen, 2013). Also, multicultural and contextual considerations may be ignored when adhering to a medical model implied by the DSM system. Despite these criticisms, few models exist for integrating diagnosis using the DSM-5 into a wellness and prevention orientation, which is central to professional counseling training and practice. Our goal is to explore the use of the DSM-5 in counseling training and practice, and to suggest ways that DSM-5 diagnosis might be integrated into a counselor training framework while maintaining a wellness orientation.
DSM and Counseling Training
Distinguishing counseling from other mental health professions by a focus on human development, prevention and wellness does not exclude counseling professionals and trainees from acquiring an understanding of behavior across the adaptive-maladaptive continuum. In promoting a counselor professional identity, and reinforcing the consensus definition of professional counseling as empowering individuals, families and groups, teaching diagnosis using the DSM-5 to counseling trainees requires a cultural and contextual understanding of individuals and their concerns. Providing counseling trainees with learning experiences designed to foster knowledge and skills extends beyond exposure to the DSM-5 classification systems for categorizing behavior identified as disordered. Successfully integrating knowledge, skills and practices of diagnosis and the DSM-5 into counselor education involves a review of counselor common core curricular and professional practice (Council for Accreditation of Counseling and Related Educational Programs [CACREP], 2009).
In the requirements for common core curricular experiences and demonstrated knowledge, CACREP (2009) requires that all counseling trainees learn about “the nature and needs of persons at all developmental levels and in multicultural contexts” (II.G.3, p. 10), including “theories for facilitating optimal development and wellness over the life span” (II.G.3.h, p. 10) and about “human behavior, including an understanding of developmental crises, disability, psychopathology, and situational and environmental factors that affect both normal and abnormal behavior” (II.G.3.f, p. 10). Furthermore, the standards for Addiction Counseling and Clinical Mental Health Counseling specifically require demonstrated “professional knowledge, skills, and practices” (CACREP, 2009, III, p. 17; p. 29), use of the current DSM and use of other diagnostic tools. Therefore, in addition to common core curricular experiences that develop knowledge and skills needed for “facilitating optimal development and wellness over the life span” (CACREP, 2009, II.G.3.h, p. 10), professional counselors must have diagnostic knowledge, skills and practices. This includes understanding “etiology, the diagnostic process and nomenclature, treatment, referral, and prevention of mental and emotional disorders” (CACREP, 2009, III.C.2, p. 30) and “the range of mental health service delivery” (III.C.5, p. 30). Specifically, CACREP (2009) standards require that counseling trainees must evidence knowledge, relevant skills and practices that include the following: knowledge of the use of the current edition of the DSM (i.e., DSM-5), an understanding of possible biases that might occur when using diagnostic tools with culturally diverse clients, knowledge of the correct use of diagnosis during a traumatic event, and the ability to differentiate “between diagnosis and developmentally appropriate reactions” to traumatic events (CACREP, 2009, III.L.3, p. 34). Moreover, in demonstrating knowledge, skills and practices of the diagnostic process, counseling trainees must understand the implications of diagnosis and treatment interventions. To this end, Kress et al. (2013) stressed the importance of weighing both the benefits and risks of diagnosis when working with clients.
DSM-5 and Counseling Practice
Despite goals of revising the diagnostic classification scheme to make it “more clinically valuable and more biologically valid” (Nemeroff et al., 2013, p. 2), and of acknowledging cultural variations in clients’ expressions of their concerns (Brown & Lewis-Fernández, 2011), the DSM-5 has been criticized from within and beyond the psychiatric community. Released in May 2013, the DSM-5 was met with controversy from mental health professionals and organizations representing their interest in providing effective clinical mental health services to clients (Washburn, 2013). Many viewed the DSM-5 as an extension of the traditional medical model of diagnosis. For example, Ladd (2013) criticized DSM diagnosis for (1) ignoring the therapeutic alliance as a critical aspect of treatment; (2) depending on “statistically acquired symptoms” and “specific rules and timelines” created by Task Force/Work Group professional experts (p. 2); and (3) gearing its usefulness toward “insurance companies, managed care agencies and other professionals in the health care system” (p. 3). The American Mental Health Counselors Association (AMHCA) DSM-5 Task Force (2012), among other groups, submitted feedback to improve the DSM-5 draft. Although the DSM provides a common language for presenting client problems (Hinkle, 1999), the language and assumptions associated with the criteria for diagnosis became the focus of criticism. Stressing the important distinction of “separating the art of mental health diagnosis and complying with the mental health diagnosis business,” Ladd (2013, p. 3) described the DSM as “the diagnostic instrument for the ‘mental health diagnosis business’ with categories and labels used as the language for insurance reimbursement, pharmaceutical treatment, and collaboration between experts” (p. 3).
Due to a growing need for quality mental health services, counseling professionals are providing services to clients presenting with a diverse range of concerns. Counselors are often required to diagnose clients’ problems using the DSM-5 (Miller & Prosek, 2013). DSM diagnosis is necessary for counselors to access managed care and insurance company reimbursements (Hinkle, 1999). However, a traditional use of the DSM may pathologize behavior and separate diagnosis from treatment interventions (Ivey & Ivey, 1999). Counselors faced with these ethical dilemmas may question their professional identity, the usefulness of a wellness orientation and the effectiveness of counseling-related tasks (McAuliffe & Eriksen, 1999; Mellin et al., 2011). Counselors’ challenge to adhere to a wellness orientation as the foundation of their professional identity may be further tested by other mental health professionals’ tendency to conceptualize health and illness using models of pathology and remediation (McAuliffe & Eriksen, 1999). These dilemmas in counseling practice are more likely to become problematic when counselors are not grounded in a strong professional identity. Gale and Austin (2003) encouraged counselors to embrace a wellness model rather than an illness or deficit model of help seeking and treatment planning. Counselor clinical judgment is critical to the diagnostic process. Notwithstanding criticisms of the DSM, Johnson (2013) asserted that diagnosis is directly related to the philosophical and theoretical orientations of the clinician. The medical model used in diagnosis negatively impacts clients’ willingness to seek help for their concerns, and also influences mental health professionals’ orientations toward deficit models (McAuliffe & Eriksen, 1999).
Important considerations for teaching the DSM are directly related to understanding the diagnostic process and implications for models of helping used to conceptualize counseling goals and interventions with clients. Given the focus on prevention, wellness and health across the life span, key questions arise when teaching the DSM-5 to counseling trainees from a traditional medical model that is “focused disproportionately on the physical aspects of illness” (Ingersoll, 2002, p. 115). A traditional disease model views the helper as the expert responsible for healing the client (McAuliffe & Eriksen, 1999). Brickman et al. (1982) viewed this model of helping as deficient in that the helper fosters dependency, which is antithetical to an empowering therapeutic relationship. Teaching the DSM-5 to counseling students requires an understanding of a developmental and wellness orientation. Models of helping must be philosophically and theoretically congruent with a professional counseling identity. To this end, counseling trainees must be challenged to examine their beliefs about seeking help and their view of a helper in the counseling relationship. Diagnosis and treatment should not be separate; rather, diagnosis should occur in conjunction with treatment (Ivey & Ivey, 1999). Viewing clients from a holistic perspective assumes that the greatest source of information lies within the client, not a manual or system of classifying disorders. Focusing on clients’ strengths rather than deficiencies helps to empower clients as part of their learning and development. Integrating multicultural and strength-based considerations as part of the diagnostic process helps to ensure that clients receive culturally responsive counseling interventions.
Integrating Multicultural and Strength-Based Considerations
Counselors, counseling psychologists and counselor educators have been instrumental in recognizing the role of culture and integrating multicultural perspectives in an attempt to understand behavior more fully (Pedersen, 1991; Sue, Sue, Sue, & Sue, 2014). Although racial-ethnic minority groups remained underrepresented in research examining psychopathology, African-American and Hispanic or Latino clients are more likely to be diagnosed, to receive diagnoses of greater severity and to experience less effective treatment outcomes than are White clients (Johnson, 2013; Sue & Sue, 2013). Consequently, multicultural counselor competencies are necessary to address counselors’ culturally biased assumptions and to increase counseling effectiveness in a society changing in culture and diversity (Arredondo et al., 1996; Pedersen, 1987, 2003; Sue, Arredondo, & McDavis, 1992; Sue et al., 1982; Sue & Sue, 2013). Multiculturalism integrates culturally specific and universal perspectives in explaining the dynamics of behavior and developing culturally responsive approaches to treatment. However, counselors may ignore multicultural considerations when adhering to a medical model implied by the DSM. Ivey and Ivey (1999) called on counseling professionals to apply multicultural perspectives when using the DSM. In advancing a contextual understanding of behavior and disorders, Sue et al. (2014) developed a multipath model using four dimensions (i.e., biological, psychological, social and sociocultural) to describe etiological explanations of abnormal behavior.
Social, cultural and economic considerations must be acknowledged when attempting to identify and classify behavior diagnosed as maladaptive. Sue et al. (2014) distinguished cultural universality from cultural relativity in describing behavior within a sociocultural context. Important cultural nuances may be misunderstood when viewed by others who are culturally dissimilar. The result is the labeling of culturally normal behavior as maladaptive. To this end, myths associated with abnormal behavior have led to the social construction of diagnostic categories, which have been cited as major criticisms of using the DSM. Among these faulty assumptions is the belief that abnormal behavior can be readily recognized, distinguished from normal behavior and therefore categorized according to a diagnostic classification scheme (Maddux, 2002; Sue et al., 2014). Maddux (2002) further stated that diagnostic categories used in making biased clinical judgments lead to culturally unresponsive treatment interventions. Inherent in this approach is the basis of the medical model, in which clients are more often treated for pathological behavior (McAuliffe & Eriksen, 1999).
A step toward more holistic diagnostic practices appeared in the DSM-5 in the form of dimensional rather than categorical assessments. These dimensional assessments of every categorical diagnosis were designed to assist counselors with diagnosis and treatment planning (Jones, 2012). Unlike previous versions of the DSM that used a categorical system, dimensional assessments view disorders on a continuum, representing varying degrees of a behavior (Sue et al., 2014). The dimensional assessment also allows counselors to consider individual differences and the influences of race and culture (Johnson, 2013). With the dimensional model, counselors are able to determine whether a diagnostic criterion is present and rate its severity (Brown & Lewis-Fernández, 2011). Viewing disorders on a continuum of behavior may decrease comorbidity; however, it also may affect clients’ accessibility to services by eliminating clients who might have formerly met the criteria for diagnosis or diagnosing clients with a disorder that would have been excluded based on the former criteria. Examples include autism spectrum disorder and depression resulting from bereavement, respectively. Given these changes, the effect of the DSM-5 on diagnosis may impact clients’ access to mental health services and create ethical dilemmas for counselors related to over- and undertreatment.
In addition to the dimensional assessments, the DSM-5 also contains disorders associated with cultural issues. Psychosocial factors are included by using V codes from the World Health Organization’s (WHO) International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM; WHO, 1979) and Z codes from the International Classification of Diseases, Tenth Revision (ICD-10; WHO,1992), as well as three new terms: cultural syndrome, cultural idiom of distress and cultural explanation or perceived cause (Pomeroy & Anderson, 2013). Counselors must become familiar with the ICD-10-CM diagnostic codes, which will become the standard medical coding system in the United States beginning October 1, 2015. Inclusion of psychosocial factors evidences the relationship between psychosocial factors and mental health. Multicultural considerations in diagnosis allow mental health practitioners to understand cultural and individual characteristics that define identity and experience. These characteristics of a client’s identity are multiple and interlocking. The uniqueness that defines a client may be lost if group generalizations as represented by the DSM-5 are used as the only means of understanding a client’s experiences. Critical to understanding clients and their stories is the ability to conceptualize clients as individuals interacting within the sociocultural context in which they live. This also involves hearing clients’ stories from their perspective, using their own words.
The importance of cultural influences on mental health diagnosis also is demonstrated by the inclusion of the Cultural Formulation Interview (CFI; Pomeroy & Anderson, 2013). The CFI was developed to improve cross-cultural diagnostic assessment and was created from the Outline for Cultural Formulation (OCF) of the DSM-IV (Aggarwal, Nicasio, DeSilva, Boiler, & Lewis-Fernández, 2013). In keeping with multicultural competency models, the CFI provides a way for counselors to explore and understand clients’ experiences and worldviews, as well as clients’ cultural explanations and interpretations of their concerns. However, Aggarwal et al. (2013) cautioned that the overstandardization of the CFI may result in counselor and client barriers such as the following: a counselor misunderstanding the problem and the problem severity, a lack of conceptual relevance between the client’s concern and counseling interventions, and a counselor and client’s lack of acceptance and unwillingness to engage in the process. Counselors’ ability to develop authentic and caring relationships is essential to accurate diagnosis and relevant counseling interventions. When clients are viewed as unique and counselors understand their experiences, accurate diagnosis and ethical practice are ensured (Swartz-Kulstad & Martin, 1999).
Moving beyond an illness model toward a counselor-client collaborative wellness model begins with a process of engaging with the client, gathering the information needed for assessing the client and trusting in the therapeutic alliance to accomplish the goals of treatment (Ivey & Ivey, 1999). Contrary to the medical or illness model, in which the client’s weaknesses or deficiencies precipitate the diagnosis, treatment and policy decisions, the integration of a strength-based framework and counselor preparation ensures a holistic approach to assessment and treatment (Wright & Lopez, 2002). Working with clients from a holistic perspective requires knowledge and skills that preserve the integrity of the counseling profession by embracing multicultural and strength-based considerations. A framework adapted from positive psychology, defined as “the study of . . . what is ‘right’ about people––their positive attributes, psychological assets, and strengths” (Kobau et al., 2011, p. e1), assists in bolstering resilience and promoting mental health.
Strength-Based Approaches to Diagnosis
Character Strengths and Virtues
Character Strengths and Virtues: A Handbook and Classification (CSV; Peterson & Seligman, 2004), which its authors dub a “Manual of the Sanities” (p. 3) in the introductory chapter, was developed in part as a companion to the DSM that focuses on classifying what is right about people. It includes explicit criteria for character strengths and launched the development of several assessment tools that aid in diagnosing one’s strengths in the way that the DSM diagnoses one’s limitations. Character strengths are the foundation of strength-based approaches and provide a way to assess client functioning from a wellness orientation (O’Hanlon & Bertolino, 2012). The CSV distinguishes three conceptual levels: (1) virtues: core characteristics that moral and religious philosophers esteem; (2) character strengths: processes that define virtues; and (3) situational themes: practices that lead people to establish specific character strengths in certain situations.
Parallel to the DSM, the CSV outlines 10 specific criteria that must be satisfied to warrant inclusion as a character strength. Using these criteria, 24 character strengths were identified under the respective umbrellas of six core virtues: (1) wisdom and knowledge (creativity, curiosity, open-mindedness, love of learning, and perspective); (2) courage (bravery, persistence, integrity, and vitality); (3) humanity (love, kindness, and social intelligence); (4) justice (citizenship, fairness, and leadership); (5) temperance (forgiveness and mercy, humility and modesty, prudence, and self-regulation); and (6) transcendence (appreciation of beauty and excellence, gratitude, hope, humor, and spirituality). The CSV also broadly outlines strength assessment strategies, as well as interventions that further cultivate strengths. For example, counselors might assist clients in realizing or reaffirming their virtue of strength of courage by exploring the will to achieve goals while facing external or internal opposition (O’Hanlon & Bertolino, 2012). This exercise empowers clients and provides counselors with a positive rather than a negative assessment of client behavior. Similarly, the use of positive talk moves clients away from a perspective of deficiency and illness toward encouragement and motivation for change.
Using the CSV in conjunction with the DSM enables counselors to help their clients identify, take pride in and use their character strengths and virtues to enhance well-being in all areas of their lives. Gander, Proyer, Ruch and Wyss (2013) found that using one’s signature strengths in a different way lowered depression and boosted happiness for six months. Wood, Linley, Matlby, Kashdan and Hurling’s (2011) longitudinal study determined that using one’s strengths was correlated with well-being; decreased stress; and greater self-esteem, positive affect and vitality, with the effects still present at three-month and six-month follow-ups. Furthermore, the majority of positive counseling interventions focus on character strength interventions, which have been found to benefit both adults and children dealing with depression and anxiety (Rashid & Anjum, 2008; Seligman, Rashid, & Parks, 2006).
Client diagnosis and conceptualization using the DSM-5 may be incomplete if clinicians do not consider clients’ environmental resources, well-being and strengths (Snyder et al., 2003). Minor alterations to this diagnostic system could promote emphasis on positive functioning and provide information that could contribute to a more complete client picture and conceptualization. Recommendations for rescaling the Axis V Global Assessment of Functioning (GAF) Scale of the DSM-IV-TR included creating a functioning baseline, with the current GAF level of 100 (absence of symptomatology) rescaled to a midpoint of 50. This would have encouraged practitioners to identify and use client strengths, with a GAF of 1 representing severely impaired functioning, 50 representing good health and 100 representing optimal functioning. Snyder et al. (2003) also suggested adding personal strengths and growth facilitators through three brief questions and four positive psychology assessments that measure hope, optimism, personal growth initiative and subjective well-being. Similarly, Magyar-Moe (2009) suggested using a seven-axis system of positive psychological assessment that included documenting positive and negative aspects of clients’ cultural identities, as well as clients’ personal strengths as facilitators of growth.
These exercises, based in positive well-being, are consistent with a wellness orientation of helping and should not be solely limited to clients’ growth and development. Counseling trainees and professional counselors benefit personally and professionally when functioning from a strength-based orientation. For example, based on findings from attribution theory, negative labels affect motivation for change (O’Hanlon & Bertolino, 2012). Therefore, O’Hanlon and Bertolino cautioned against using negative diagnostic labels that may communicate a belief that clients are unable to change. From this perspective, counselors must continually examine their own behavior and the subtle messages that clients might receive during counseling. Through strength-based exercises, counselors are encouraged to promote strengths and resilience as part of an ongoing reflective practice.
Conclusion
Teaching the process of diagnosis using the DSM-5 to counseling trainees is not an easy undertaking. Developed as a tool that promotes a language for use in the larger mental health system (Hinkle, 1999), the DSM is required learning for counseling trainees, and demonstrating professional knowledge, skills and practices is required for professional counselors. Teaching the basic vocabulary and criteria associated with disorders is only the first level of discussion. Effectively teaching diagnosis informed by multicultural and strength-based perspectives includes acknowledging the purpose and limitations of the DSM-5, and examining beliefs about helping, and the role and behavior of helpers. Counselors must explore the concept of normal behavior and their ability to identify abnormal behavior, as well as factors influencing growth and change.
Peterson (2013) stated, “we have developed a wonderful vocabulary that explains what goes wrong with folks and we have almost nothing to say about what can go right with folks” (p. 7). Teaching diagnosis and the DSM-5 integrated with multicultural and strength-based considerations helps counselors to understand what goes right with clients. Through this understanding, clients’ strengths, character and virtues become the support for growth and change within the counseling relationship. Rather than focusing on illness and deficiencies, counselors and clients acknowledge strengths and use them to assist clients in resolving problems in life. Informing the diagnostic process with multicultural and strength-based considerations fosters a holistic view of clients and reinforces counselor advocacy of optimal human functioning. Counselors must consider culture, context and strengths for the diagnostic process to be useful in working with clients from a wellness orientation (Adams & Quartiroli, 2010).
Furthermore, multicultural and strength-based practice considerations encourage reflection and counselor reflective practice, which challenge culturally biased assumptions that negatively affect counselor judgments about clients and the diagnostic process. As a result, counseling professionals do not view clients as confined and limited to a diagnosis; rather, they conceptualize clients as resilient and evolving (Adams & Quartiroli, 2010). Recognizing limitations and possibilities of the DSM-5, embracing a wellness and holistic orientation, and understanding clients from their cultural and situational contexts with a focus on strengths are critical factors that reduce ethical dilemmas and support the use of the DSM-5 in counseling training and practice (Adams & Quartiroli, 2010; Gale & Austin, 2003; McAuliffe & Eriksen, 1999). Integrating multicultural and strength-based considerations into counseling training and practice increases the likelihood that counselors will embrace a professional identity congruent with a wellness orientation when using the DSM-5 as a tool in the diagnostic process (Mannarino, Loughran, & Hamilton, 2007).
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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Saundra M. Tomlinson-Clarke is an Associate Professor at Rutgers University. Colleen M. Georges is an Adjunct Professor at Rutgers University. Correspondence can be addressed to Saundra Tomlinson-Clarke, 10 Seminary Place, New Brunswick, NJ 08901-1183, saundra.tomlinson-clarke@gse.rutgers.edu.
Jul 1, 2014 | Article, Volume 4 - Issue 3
Let us start with two important disclaimers. First, I will be identifying the many ways that the Diagnostic and Statistical Manual of Mental Disorders (DSM) system has been detrimental to psychotherapy and how the fifth edition (DSM-5; American Psychiatric Association [APA], 2013) will make the current situation even worse. However, this does not mean that I consider DSM diagnosis irrelevant to psychotherapy and counseling, nor do I believe that psychotherapists and counselors should neglect learning about diagnosis. I do not trust therapists who focus their contact with the client exclusively around the DSM diagnosis. Hippocrates believed that it is more important to know the person who has the disease than the disease the person has. Nevertheless, I also do not trust therapists who are completely free-form, impressionistic and idiosyncratic in their approach to clients. DSM diagnosis is only a small part of what goes into therapy, but it is often a crucial part. We need to know what makes each person different and unique; on the other hand, we also need to group clients with similar problems as a way of choosing interventions and predicting the treatment course.
The second disclaimer relates to the proper roles of medication, psychotherapy and counseling. The DSM has promoted a reductionistic medicalization of mental illness that, in combination with misleading drug company marketing strategies, has created a strong bias toward treatment with medication and against treatment with psychotherapy and counseling. I am greatly disturbed by the resulting enormous overuse of psychotropic drugs among both adults and children, many of whom do not need psychotropic drugs and would do much better without them. However, we must be equally alert to the fact that many people who need medication do not receive it. Psychotherapists and counselors are important gatekeepers who should recognize when medication is needed and when it is not. It makes no sense to be for or against medicating clients. It is crucial that medication not be used carelessly, but also essential to realize that it is sometimes absolutely necessary.
I will offer a brief history. Before the publication of the DSM-III (APA) in 1980, psychiatric diagnosis was a subject of little interest or importance because it was unreliable and not particularly useful for treatment planning. The DSM-III marked a sudden and dramatic change—it made diagnosis a major focus of clinical attention and the starting point of all treatment guidelines. Its provision of clearly defined criteria allowed for reasonably reliable diagnosis and for targeting specific symptoms that became the focus of treatment. The DSM-III’s influence exceeded all expectations, in some ways useful, but also with a significant defect. The prevailing mental health approach before the DSM-III was the well-rounded biopsychosocial model. At that time, clinicians conceptualized symptoms as arising from the complex interplay of brain functioning, psychological factors, and familial and social contexts. Perhaps without intention, the DSM-III downgraded the psychological and social factors and promoted undue emphasis on the biological factors. The DSM-III was advertised as “atheoretical” and neutral, usable by practitioners of all professional orientations. To some small degree, this was true; yet the DSM-III’s emphasis on purely descriptive psychiatry strongly favored biological treatments over cognitive-behavioral treatments. This bias proved to be irrelevant and eventually destructive to family and psychodynamic therapies. The descriptive DSM-III method focused attention on surface symptoms in the individual and ignored both deeper psychological understanding and the social and familial contexts. Clinicians often adopted a symptom checklist approach to evaluation and forgot that a complete evaluation must account for psychological factors, social supports and stressors.
In addition to its considerable impact on the mental health profession, the DSM-III also significantly affected the pharmaceutical industry. Drug companies benefited greatly from the DSM-III approach, particularly since 1987 when Prozac established the template for promoting blockbuster psychiatric drugs. Pharma realized that the best way to sell pills is to promote disease-mongering. Their marketing campaign offers the misleading idea that mental disorders are underdiagnosed, easy to diagnose due to chemical imbalances in the brain and best treated with a pill. The marketing targeted psychiatrists first, then primary care physicians and, since 1997, the general public. In the United States and New Zealand, drug companies have successfully bullied the government into allowing direct advertising to consumers on television, in print and on the Internet. Use of medication has skyrocketed as a result of these billion-dollar marketing budgets, turning us into a pill-popping society. This increase in drug use is great for Pharma shareholders and executives, but often inappropriate for clients and terribly costly to the economy. More than $40 billion a year are spent on psychiatric drugs. Most of these (80%) are prescribed by primary care doctors with little training or interest in psychiatric diagnosis or treatment, while under strong pressure from patients and drug company representatives, and after only seven minutes of evaluation on average. During the last decade, many drug companies have received enormous fines (e.g., one fine was $3.3 billion) for illegal marketing practices, but they continue because the rewards are so great.
For mild to moderate psychiatric problems, psychotherapy and counseling are just as effective as medication, and their effects are much more enduring. Most people taking medication would probably have been better off had they received psychotherapy or counseling. Unfortunately, psychotherapy and counseling suffer from two great disadvantages in their competition with drug treatment. Drug companies are enormously profitable industrial giants with billion-dollar budgets to push their products. In contrast, the mental health field is more of a nickel-and-dime, mom-and-pop operation with absolutely no marketing punch. Insurance companies further tilt the playing field by consistently favoring medication management over psychotherapy and counseling based on the mistaken assumption that it will be cheaper. In fact, brief treatments are often much more cost-effective because their effects are lasting, whereas medication may be necessary for years or a lifetime.
The medicalization of mental illness has had a dire impact on our clients and our society. Twenty percent of the population regularly takes a psychiatric drug, many for problems of everyday life more amenable to watchful waiting or psychotherapy and counseling than to drug treatment. It is astounding that there are now more overdoses and deaths from prescription drugs than street drugs. The tremendous societal investment in psychiatric drugs also misallocates resources much better spent on terribly underfunded social investments. Would it not be better for children to have smaller classes and more gym periods than for so many of them to be on pills for ADHD?
In preparing the DSM-IV (APA, 1994), we attempted to hold the line against diagnostic inflation and the medicalization of normality; however, we failed. During the past 20 years, the United States has experienced fad epidemics of ADHD, autism and bipolar disorder. We were conservative in writing the DSM-IV, but failed to anticipate or prevent its careless misuse under external pressure, particularly drug company marketing and the requirement of a psychiatric diagnosis for clients to qualify for school services and disability benefits. The quick fix is to give a diagnosis, but often this does more harm than good in the long run. Inaccurate diagnoses are easy to give but hard to remove. Often they haunt the client for life with stigma, unnecessary treatments and reduced expectations. Making an accurate diagnosis requires really knowing one’s client, which may take weeks or even months. In uncertain situations, it is better to underdiagnose than overdiagnose a symptom pattern, and better to be safe than sorry.
The DSM-5 will considerably increase medicalization and may turn our current diagnostic inflation into hyperinflation. Overdiagnosis transforms normal grief into major depressive disorder, normal temper tantrums into disruptive mood dysregulation disorder, normal forgetfulness of old age into minor neurocognitive disorder, poor eating habits into binge eating disorder, and expectable worry about physical symptoms into somatic symptom disorder. It also further loosens the already far too slack criteria for attention deficit disorder and contains a completely confusing definition of autism. Experience teaches that whenever the diagnostic spigot is unrestricted, drug company revenues increase, and less funding is available to support psychotherapy and counseling visits.
The DSM is only one guide to diagnosis—it is not a bible or official manual of diagnosis. The DSM codes that clinicians routinely use for reimbursement are in fact all International Classification of Diseases, Clinical Modification (ICD-CM) codes that are available for free on the Internet. DSM-5 is one suggested way to arrive at an ICD-CM diagnosis, but it is not the only or best way. Other more reliable guides to psychiatric diagnosis are available. Therapists do not have to buy or use the DSM-5 unless they work for an institution that requires it.
Receiving a psychiatric diagnosis can be a turning point in a client’s life. An accurate diagnosis can lead to an effective treatment plan; an inaccurate diagnosis can lead to side effects, stigma, high costs, reduced opportunities and needless suffering. Severe and classic presentations require quick diagnosis and immediate intervention, usually including medication. Milder, equivocal presentations allow for and require a more cautious approach. Therefore, watchful waiting or brief counseling is usually best.
Conflict of Interest and Funding Disclosure
The author published two books that critically
review the DSM-5, titled Saving Normal and
Essentials of Psychiatric Diagnosis.
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