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

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

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

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

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

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

Prevalence of Eating Disorders

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

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

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

Overview of Changes in DSM-5 

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

Table 1

Past and Current Feeding and Eating Disorder Diagnoses

Specific Changes to Eating Disorder Diagnoses 

Pica and Rumination Disorder

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

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

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

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

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

Avoidant Restrictive Food Intake Disorder

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

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

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

Anorexia Nervosa

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

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

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

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

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

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

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

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

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

Bulimia Nervosa

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

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

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

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

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

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

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

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

Obesity

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

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

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

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

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

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

Implications for Counselors 

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

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

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

Conflict of Interest and Funding Disclosure

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

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

Trauma Redefined in the DSM-5: Rationale and Implications for Counseling Practice

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

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.

DSM, Psychotherapy, Counseling and the Medicalization of Mental Illness: A Commentary from Allen Frances

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.

References

American Psychiatric Association. (1980). Diagnostic and statistical manual of mental disorders (3rd ed.). Washington, DC: Author.

American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: Author.

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.