Marc A. Grimmett, Adria S. Dunbar, Teshanee Williams, Cory Clark, Brittany Prioleau, Jen S. Miller
Research studies indicate that the number of African Americans diagnosed with oppositional defiant disorder (ODD) is disproportionately higher than other demographic groups (Feisthamel & Schwartz, 2009; Schwartz & Feisthamel, 2009). One contributing factor for this disproportionality is that White American clients presenting with the same disruptive behavioral symptoms as African American clients tend to be diagnosed with adjustment disorder. Feisthamel and Schwartz (2009) concluded, “counselors perceive attention deficit, oppositional, and conduct-related problems as significantly more common among clients of color” (p. 51), and racial diagnostic bias may influence the assessment process. Racial biases in clinical decision making are explained in a conceptual pathway developed by Feisthamel and Schwartz (2007).
In the pathway, counselors who hold stereotypical beliefs about clients selectively attend to client information. The counselor’s judgment is influenced by personal bias, resulting in misdiagnosing the client. African American masculinity stereotypes of criminal mindedness, violent behavior, aggression and hostility (Spencer, 2013) held by counselors with low multicultural social justice counseling competence (Ratts, Singh, Nassar-McMillan, Butler, & McCullough, 2015; Sue, Arredondo, & McDavis, 1992) potentially foster misdiagnosis and overdiagnosis of African American males with ODD.
Studies on how African American males are diagnosed with ODD and specific implications for African American males are relatively nonexistent. McNeil, Capage, and Bennett (2002) indicated the majority of information on children diagnosed with ODD has been obtained from primarily White children and families. They recommended that counselors working with African American families consider the African American family’s unique stressors, worldviews and burdens; possible inclusion of the extended family; possible therapist biases that conflict with client’s worldview; and positive factors that lead to competency, self-reliance and health in African American culture (Lindsey & Cuellar, 2000). Thus, an appropriate ODD diagnosis in African American males requires assessment and treatment plan considerations that include other related factors.
Diagnosing Oppositional Defiant Disorder in African American Males
According to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5; American Psychiatric Association [APA], 2013), ODD is characterized by a pattern of behavior that includes angry and irritable mood, argumentative and defiant behavior, and/or vindictiveness. Symptoms must cause significant problems at home, school or work; must occur with at least one individual who is not a sibling; and must persist for 6 months or more (APA, 2013). The diagnostic assessment also determines that (a) these behaviors are displayed more often than is typical for peers, and (b) symptoms are not associated with other mental health disorders such as anxiety, depression, antisocial behavior and substance abuse disorders.
High rates of ODD diagnosis among African American males may occur because of low cultural competency in diagnosis and counselor bias (Guindon & Sobhany, 2001; Hays, Prosek, & McLeod, 2010; Snowden, 2003). Spencer and Oatts (1999) and Clark (2007), for example, found that health professionals misinterpreted symptoms of disruptive behavior disorders like ODD at greater rates for African American children. Misdiagnosis was common among children assessed as having symptoms of (a) obsessive compulsive disorder and response to rigid classroom rules, (b) bipolar disorder or attention-deficit/hyperactivity disorder and engagement in destructive behavior, and (c) anxiety disorder (e.g., social anxiety) and dislike for school, and defiance toward teachers. These symptoms also may result from unfair treatment and discrimination (Smith & Harper, 2015). Misdiagnosis of ODD can reasonably be expected to have potentially adverse implications for healthy psychological, emotional and social development in family and education systems.
Primary caregivers of children diagnosed with ODD report mild to moderate levels of depression and anxiety and severe levels of stress (Oruche et al., 2015). Caregivers report having overwhelming difficulty managing the aggressive and defiant nature of their children’s behaviors and constantly watching over their children to prevent them from hurting themselves or others (Oruche et al., 2015). The well-being of family members who are not primary caregivers (i.e., in some cases fathers, siblings, grandparents) is rarely considered in disruptive behavior research, although these family members experience many of the same stressors outlined by primary caregivers (Kilmer, Cook, Taylor, Kane, & Clark, 2008). Siblings of diagnosed adolescents have demonstrated high rates of anxiety, poor school performance and adjustment problems (Kilmer et al., 2008; Oruche et al., 2015). Children with disruptive behavior disorders whose family members participated in their treatment showed improved grade point averages and attendance and reduced drop-out rates relative to students whose family members considered themselves uninvolved (Reinke, Herman, Petras, & Ialongo, 2008). While family interventions appear helpful, an accurate diagnosis remains the first step in creating an effective treatment plan and not causing further harm to clients (e.g., school suspension, expulsion, incarceration; Smith & Harper, 2015).
Students with aggressive disruptive behaviors also have higher rates of mental health risk factors, including school maladjustment, antisocial activity, substance use and early sexual activity (Schofield, Bierman, Heinrichs, & Nix, 2008). Children diagnosed with ODD experience a range of academic problems, including in-school suspensions (Reinke et al., 2008), high school drop-out (Vitaro, Brendgen, Larose, & Trembaly, 2005), and lower academic grades and achievement scores (Bub, McCartney, & Willett, 2007). ODD was not cited as a contributing factor; however, a recent report by Smith and Harper (2015) revealed that in Southern states African American males comprised 47% of student suspensions and 44% of expulsions from K–12 public schools in the United States, which was highest among all racial and ethnic groups. School administrators also were more likely to rate African American children higher on symptoms related to behavioral disorders than White American children (Epstein et al., 2005).
Finally, 50–70% of juveniles detained in the United States have a diagnosable behavioral health disorder (e.g., ODD; Schubert & Mulvey, 2014). While African American youth make up only 16% of the total youth population in the United States, they account for 37% of the detained population (National Council on Crime and Delinquency, 2007). Given the potential negative trajectory of an ODD diagnosis for some African American males, the diagnostic process warrants further consideration.
The purpose of this qualitative research study was to (a) help understand and explain the contextual factors, diagnostic processes and counseling outcomes associated with the diagnosis of ODD in African American males, and (b) identify, describe, and make meaning of patterns and trends in mental health care systems that may be associated with the apparent overdiagnosis of African American boys with ODD. A consensual qualitative research (CQR) design was employed in this study to identify, describe and make meaning of the diagnostic processes and outcomes related to ODD. The following components of CQR identified by Hill et al. (2005) were used in this study: (a) open-ended questions in semistructured interviews “to allow for the collection of consistent data across individuals, as well as more in-depth examination of individual experiences,” (b) research team collaboration (i.e., two judges and one auditor) throughout the data analysis process for multiple perspectives, (c) “consensus to arrive at the meaning of the data,” (d) an auditor to check the work of the two judges; and (e) “domains, core ideas, and cross-analyses in the data analysis” (p. 196).
The research team included a counselor educator and licensed psychologist (African American male, age 42), counselor educator and licensed professional counselor (White American female, age 36), three clinical mental health graduate students (African American female, age 23; White American female, age 28; White American male, age 29) and one public administration graduate student (African American female, 34). All research team members had clinical experience (i.e., as mental health counselors, research and counseling interns, or parents of clients receiving counseling) with African American males who have been diagnosed with ODD. Training to conduct the study involved reading and discussing [Hill, Knox, Thompson, Williams, Hess, & Ladany, 2005; Hill, Thompson, & Williams, 1997]; attending in-person research team meetings to discuss, design, plan and implement the research study; and electronic communication throughout the process. Feelings and reactions (i.e., biases) related to the study were openly discussed among the research team throughout the process to minimize influences on data analysis. Research team biases included: (a) awareness of apparent disproportionality of ODD diagnosis in African American males compared to other populations, based on clinical experience, (b) potential low multicultural competence of counselors making diagnoses, and (c) difficulties for African American males with an ODD diagnosis.
Six mental health professionals met the following criteria for participation in this study: (a) the ability to verbally describe and explain the diagnostic criteria for ODD (during the interview for data collection), (b) a minimum of 2 years’ clinical experience working with clients who have ODD as demonstrated by professional resume or curriculum vitae and explanation at the interview, and (c) a professional mental health license.
The sample consisted of diverse practitioners in identity, years of experience, professional position and places of employment. Racial/ethnic and gender identities of participants were: African American female, African American male, multiracial Arab American female, White American female (n = 2), and White American male. Participant ages ranged from: (a) 30–35 years (n = 2), (b) 35–40 years (n = 2) and (c) over 40 years (n = 2). Reported mental health licenses included: licensed professional counselor associate (n = 1), licensed professional counselor (n = 2), licensed professional counselor supervisor (n = 1), licensed clinical social worker (n = 1) and licensed psychological associate (n = 1). Years holding licensure ranged from less than one to greater than 15. The majority of participants described their professional position as a clinical supervisor and mental health counselor (n = 3), with others identifying as mental health counselors (n = 2) and multisystemic therapy program supervisor (n = 1). All participants reported working within a private organization, with two participants employed by a for-profit community mental health agency, three participants by a non-profit community mental health agency and one participant in private practice.
The Institutional Review Board for the Use of Human Subjects in Research evaluated and approved the study. Participant recruitment involved purposeful sampling of mental health providers from local Critical Access Behavioral Health Agencies likely to meet participant criteria. Research team members contacted 10 potential participants by e-mail and follow-up phone calls to explain the study and ask for their participation. Once eligibility had been determined based on selection criteria, six mental health professionals were selected to create an intentionally diverse sample. Participants scheduled an in-person appointment to complete the informed consent process with a team member, signed the form indicating understanding and agreement to participate in the study, and engaged in an in-depth interview lasting 1 to 1.5 hours, at the office of the participants or the first author. Codes and pseudonyms protected confidential participant information and data was audio-recorded and transcribed for each interview.
Semi-structured interviews. Interview questions for the study were based on a literature review, an evaluation of the DSM-5 (APA, 2013) criteria for ODD, and pilot field interviews with mental health professionals, clients, and clinical directors experienced in providing or receiving services related to ODD. Participants were asked 12 initial questions about the process of making an ODD diagnosis for African American male clients that focused on: life circumstances that contributed to an ODD diagnosis; structural and cultural factors related to diagnosis (e.g., What are the social systems involved in the diagnosis?); post-diagnosis outcomes and implications (e.g., What happens after a client receives the diagnosis?); and treatment plan considerations (e.g., What are the benefits and/or problems of the treatment plan?).
Data were analyzed using CQR beginning with a start domain list created from the initial interview questions and transcript of the first interview, where all research team members coded first interview data into domains, “topics used to group or cluster data” (Hill et al., 2005, p. 200). Next, core ideas, “summaries of the data that capture the essence of what was said in fewer words with greater clarity,” from each domain were recorded using direct quotes from participants (Hill et al., 2005, p. 200). Cross-analysis was then completed to characterize the frequency of the data: “general applies to all or all but one case; typical applies to more than half up to cutoff for general; and variant applies to two cases up to the cutoff for typical” (Hill et al., 2005, p. 203). Finally, one team member acted as the auditor and provided feedback throughout the analysis process, and most importantly, ensured “that all important material has been faithfully represented in the core ideas, that the wording of the core ideas succinctly captures the essence of the raw data, and that the cross-analysis elegantly and faithfully represents the data” (Hill et al., p. 201).
The consensus process commenced in the collaborative team design and implementation of the study and proceeded with the independent analysis of the data by the coders and auditor. Domains, core ideas and cross-analyses were then presented, discussed, debated and confirmed during in-person research team meetings, by e-mail and video conferencing. A multilayered consensus process over time contributed to the stability of the data for trustworthiness, along with: (a) consistency and documentation of data collection procedures, (b) research team description and positionality statement, (c) providing quotes that capture core ideas, and (d) using a research team of coders and an auditor to analyze data. No cases were withheld from the initial cross-analysis for the stability check of the data, as Hill et al. (2005) found it is not necessary. Rather, Hill et al. (2005) suggested presenting “evidence of trustworthiness in conducting data analysis,” as described (p. 202).
Four domains were identified related to diagnosing ODD. Categories further define each domain, supported by core ideas using direct quotes from the participants. Table 1 shows the frequency of categories within each of the domains. Hill et al. (1997) outlined the following categories: general if it applies to all (6), typical if it applies to half or more (3–5), and variant if it applies to less than half of the participants (2 up to typical; all categories applied to at least half of the participants; therefore, none were variant).
Most insurance companies require counselors to diagnose clients with a mental disorder in order to obtain payment for mental health services (Kautz, Mauch, & Smith, 2008). Many insurance companies require that a diagnosis be made during the first few counseling sessions, sometimes within the very first counseling session. All participants described the role and influence of insurance companies and managed care in the diagnostic process. One participant expressed, “the diagnosis is necessary to get paid, so you have to find something. You are not looking objectively. You are just giving them a diagnosis.” The participant continued:
We see this proportion of diagnoses [with African American males] because the insurance in managed care world drives agencies like this one and drives providers to say that an [African American] child is diagnosed a particular way . . . There is this incentive to diagnose and to diagnose in a short period of time.
|Table 1Summary of Domains From the Cross-Analysis of the Participants (N = 6)
Domain and Category
|Diagnosis required for payment of services
|Reimbursement likelihood drives the type of diagnosis given
|Insufficient assessment time allotted for proper diagnosis
|Oppositional defiant disorder diagnostic criteria
|Criteria are too general
|Criteria provide a convenient catch-all for providers
|Oppositional defiant disorder is stigmatized
|African American males
|Long-term negative implications
|Assessment, diagnosis and treatment
|Family, community and other contextual considerations
|Mental health counselor bias
|Cultural and contextual integration
Findings suggested that the assessment time allotted by insurance companies to diagnose a mental disorder undermines the diagnostic process and invalidates the diagnosis. One participant emphasized, “the client is not going to open up to you within that time frame; this is the first time the child is ever seeing you. Those types of things progress over time.” Further structural and systemic assessment problems also were identified by another participant:
You’re allowed to do one assessment per year for the client . . . The assessor would take the previous assessment, use a majority of that information, and then just ask what has changed between then and now . . . there [are] a lot of questions that the previous assessment didn’t answer or didn’t really look into. So that piece gets missed.
Oppositional Defiant Disorder Diagnostic Criteria
The DSM-5 criteria for ODD are too general, providing a convenient catch-all for providers. Symptoms of ODD align with typical child and adolescent behavior as well as other childhood disorders (e.g., ADHD), adjustment disorder, depression and anxiety, depending on developmental context (APA, 2013). Every participant expressed the relative malleability of the ODD criteria. “It’s an easy diagnosis for most people to fit into that category, if they’re having trouble with the legal system and there’s nothing else going on,” noted one participant. Another added that ODD “serves as a holding cell for behaviors that are not understood.” Finally, one mental health counselor stated:
There are no differentials for ODD. It’s all under this blurry category of disruptive behaviors. On one hand it looks easy to diagnose, but on the other hand it’s very complicated when you are not ethically doing the right thing.
Oppositional Defiant Disorder Is Stigmatized
An ODD diagnosis carries negative social weight and judgment within and beyond the mental health fields. African American males are particularly vulnerable to diagnostic stigmatization due to multiple marginalizations that can occur when intersecting with other forms of oppression, such as racism (Arrendondo, 1999; Ratts et al., 2015). Most participants referenced long-term negative implications for these clients, including, “I think it leaves a permanent scar, with elementary kids all the way up.” One participant expressed further that:
I have had kids that have been diagnosed with [ODD] and they drop out. I have had young African American boys in my office and they say ‘You know this has been going on with me since I was a kid?’ And you know that they are telling the truth. They ask themselves, ‘Why am I still in school?’ So they drop out.
Another mental health counselor added:
I see it when we go to court even [with] an African American judge. African American boys would typically get a harsher sentence. It’s a systemic issue. We just start viewing through a lens and we automatically have an assumption to what the problem is. We have a negative interpretation of one kid’s actions versus another.
Assessment, Diagnosis and Treatment
Assessment, diagnosis and treatment do not account for family, community and other contextual problems affecting the client’s mood and behavior. One mental health counselor explained, “if the parent has been incarcerated, they are going to act out. If they are dealing with a domestic violence situation in their home, this is a way of relieving stress for them.” Another participant added:
We leave the whole family out of this process . . . That may be where the problems exist. It is person centered to a fault. To the neglect of it being family centered versus person centered or being both, because you would dare not want to intervene with a child and not involve family. Despite [that] the parents will come and say, 95% of the time, ‘I am okay—you need to fix my son or daughter.’ When treatment plans get tailored based on that premise, then everybody is in trouble.
Trauma also was identified as a contextual issue that warrants consideration in the diagnostic process.
Past trauma, living in very difficult situations, near or below poverty are not taken into account. What might be very adaptive behaviors for a kid, or might be situational dependent, are then just translated into the diagnosis.
Participants acknowledged mental health counselor bias plays a role in diagnosis as well. A mental health counselor may have a tendency to diagnose certain clients with ODD because it is a familiar and commonly used diagnosis. One mental health counselor stated, “a lot of times, particularly with new clinicians, [ODD] is a buzz word . . . like ADD was a buzz word years ago.” A different participant shared the diagnostic rationale, “it helps them, too, because it’s a relatively non-offensive diagnosis. It’s not as personal a diagnosis, so they don’t feel as bad being diagnosed oppositional defiant disorder as they would something else.”
The relative cultural competency of practitioners also was referenced by participants as potentially compromising the diagnostic process, with one indicating that:
When I think about oversight and training, it’s limited in terms of how much exposure they’ve had to diversity training or multiculturalism. What might present as disrespect or non-compliance might be very culturally appropriate . . . The assumption is made that these things are all dysfunctional for the individual as opposed to other contextual factors that are going on.
The purpose of this study was to understand the diagnostic processes and implications associated with ODD. Findings suggest that a diagnosis of ODD can result from more factors than client symptoms fitting the diagnostic criteria. While none of the research or interview questions asked specifically about the role of insurance or managed care, every participant indicated that third party billing influenced the diagnostic process.
Specifically, the mental health counselors interviewed were keenly aware of the necessity of making a diagnosis for insurance reimbursement. It appeared that ODD is considered a reliable diagnosis for billing purposes; however, diagnostic necessity may also create an ethical dilemma for mental health counselors who want to provide quality care and need to earn a living. The possibility of racial diagnostic bias remains, even with insurance requirements, when African Americans are more likely to receive a diagnosis of ODD, while White Americans presenting with similar symptoms receive a diagnosis of adjustment disorder (Feisthamel & Schwartz, 2009; Schwartz & Feisthamel, 2009).
Professional ethical standards and best practices warrant full consideration of a diagnosis, including the purpose served and implications, as related to the health and well-being of clients (American Counseling Association [ACA], 2014). Even when a diagnosis is not warranted or conflicts with theoretical, philosophical or therapeutic approaches, mental health providers serving clients who do not pay cash for services are forced to accommodate diagnostic requirements. The use of a diagnosis as a therapeutic tool, designed to act in concert with others, has also come to serve as the gateway to mental health care services.
In the case of African American male clients, an ODD diagnosis can be particularly stigmatizing with immediate and long-term implications for marginalization and tracking (Cossu et al., 2015). Educational, judicial and incarceration data clearly demonstrate that African American males are disproportionately suspended and expelled from school compared to their peers (U.S. Department of Education Office for Civil Rights, 2014); receive harsher sentences in judicial systems for the same offenses as other defendants (Ghandnoosh, 2014; Rehavi & Starr, 2012); and are more likely to be stopped, searched, assaulted and killed by police officers than other community members (Gabrielson, Jones, & Sagara, 2014; Weatherspoon, 2004). Since ODD is categorized as a disruptive behavior disorder, it may be considered, intentionally or unintentionally, a justification, rationale or explanation for these disparate outcomes. When the diagnosis of a mental disorder is used for purposes other than helping the client, it opens the door to unintended and problematic consequences.
The assessment process is critical to making an accurate diagnosis and should not be limited to the most readily available, convenient or confirmatory information. With ODD, alternative, viable explanations for client symptoms have to be considered that may include family history and dynamics, personal trauma and social–cultural context. Guindon and Sobhany (2001) noted, “often there are discrepancies between the counselor’s perception of their clients’ mental health problems and those of the clients themselves” (p. 277). Again, there may be a tendency to diagnose African American males with perceived behavioral problems with ODD without full consideration of historical and contextual variables that may better explain mood and behavior and warrant a different diagnosis altogether (Hays et al., 2010).
Mental health counselors also have certain biases, within and beyond personal awareness, that create diagnostic tendencies, which may undermine the diagnostic process and invalidate the results of the assessment. Assessment practices and structures appear to accommodate intrinsic and individual information, more so than extrinsic and systemic variables (Hays et al., 2010). For these reasons, the gathering of client information for diagnostic purposes must be as comprehensive and inclusive as possible, notwithstanding measures to limit mental health counselor bias, such as supervision and consultation.
The ACA Code of Ethics outlines the need for even the most experienced counselors to seek supervision and consultation when necessary (ACA, 2014). One potential blind spot for many counselors experiencing bias toward African American male clients is not realizing the need for supervision and consultation when it arises. Understanding that ODD diagnoses within the African American male community have been shown to be inflated is a first step toward decreasing counselor bias. Second, recognizing the subjective nature of making an ODD diagnosis, especially since many of the behaviors and emotions listed as diagnostic criteria also “occur commonly in normally developing children and adolescents” (APA, 2013, p. 15) is another critical aspect of ensuring accurate diagnoses are made.
Counselors are trained from a multimodal approach to diagnosis based on Western medicine; therefore, diagnosing clients is a culturally-based practice (Sue & Sue, 2015). Furthermore, most research in the area of mental and behavioral health has, in large part, not included people of color (U.S. Department of Health and Human Services, 2001). Cultural discrepancies also are evident in the demographic characteristics represented within the counseling profession. Approximately 71% of counselors in the United States are women, and only 18.4% of counselors identify as Black or African American (U.S. Department of Labor, 2015); therefore, most African American male clients will likely have different cultural backgrounds from their counselors. These factors create a need for consultation and supervision to ensure that the personal and professional worldviews of counselors are not inhibiting accurate diagnosis and treatment planning for African American male clients.
In addition to supervision, another measure to limit counselor bias would be to practice reflective cultural auditing, a 13-step process for walking counselors through how culture may impact their work with clients from initial meeting through termination and follow-up. This process allows counselors to reflect on what may seem like client resistance, but may instead be a “disruption in the working alliance” (Collins, Arthur, & Wong-Wylie, 2010, p. 345) based on cultural differences. In addition to utilizing reflective audits of individual cases, it also can be helpful for counselors to review case files regularly, taking into account race and ethnic background, along with symptoms and reported diagnosis. Finding diagnostic patterns within one’s own practice can help counselors reflect on their clinical work and identify areas of bias that may exist.
Implications for Professional Counselors
Thinking through the diagnostic process and beyond the diagnosis requires the mental health counselor to consider and balance the needs of the client, provision of ethical and effective mental health services, expectations and requirements of employers, and earning a living. The following recommendations are offered to help mental health professionals balance these diagnostic considerations in light of current findings, particularly in the assessment and diagnosis of ODD.
In order to make an accurate diagnosis, billing considerations should not be a determining factor in the assessment process. We acknowledge that payment for services is a necessary component for earning a living as a mental health counselor; at the same time, there is an inherent conflict of interest between ethical diagnostic practices and billing when they are not considered as separate processes. Counselors can reference the ACA Code of Ethics (2014) regarding cultural sensitivity (Section E.5.b) as well as historical and social prejudices in the diagnosis of pathology (Section E.5.c). Additionally, counselors may reference the guidelines for informed consent in the counseling relationship (Section A.2.b), ensuring that clients are aware of how information in their client records will be used and how it may impact clients in the future. When appropriate, counselors may choose a less stigmatizing diagnosis initially (e.g., adjustment disorder), while continuing to learn more about a client’s context and cultural background before making a final diagnosis.
Consider extrinsic and external factors that may contribute to emotional and behavioral symptoms presented. It is important to keep in mind that a pattern of ODD behavior includes anger and irritability, argumentative and defiant behavior, and/or vindictiveness, which causes significant problems at work, school or home, and lasts at least 6 months. In order to qualify as ODD symptoms, these behaviors must occur with at least one person who is not a sibling, and must occur on their own (i.e., not as part of another mental health problem, such as depression, anxiety, antisocial behavior and substance abuse disorders). If family history and dynamics, personal trauma and community/contextual factors contribute to any of the above systems, a diagnosis of ODD may not be the most accurate, thereby leading to ineffective, if not harmful treatment plans and outcomes. A diagnosis of adjustment disorder may be more beneficial to ensure that the client receives adequate treatment, which would hopefully increase the client’s chances of having a positive counseling outcome.
African American males are diagnosed with ODD at a disproportionately higher rate than other social demographic groups (Feisthamel & Schwartz, 2009). Ethical and best practice standards require mental health professionals to understand personal biases that might inform their work as well as to develop strategies to reduce or eliminate negative impact (ACA, 2014; Ratts et al., 2015; Sue et al., 1992). In addition, mental health counselors need to use continuing education to remain aware of current trends in the field relevant to the populations they serve (ACA, 2014; Ratts et al., 2015). Health professionals should adhere to diagnostic criteria and integrate multicultural counseling competencies in order to avoid making decisions based on pre-defined misconceptions.
Implications for Counselor Educators and Supervisors
Included in the Council for Accreditation of Counseling and Related Educational Programs (CACREP) accreditation standards is the responsibility of counselor education programs to train students on “the effects of power and privilege for counselors and clients” (CACREP, 2016, p. 9). It is imperative that counselor educators provide specific training on racial bias among counselors, which often is automatic and hidden from conscious awareness (Abreu, 2001).
Creating a safe, comfortable, respectful classroom environment in which students are able to honestly self-reflect and ask questions is necessary to integrate and infuse multicultural and social justice counseling competence training within counselor education programs (Ratts et al., 2015). Counselors-in-training need the opportunity to think critically and experience cognitive dissonance in the classroom regarding ways African American males are portrayed and the erroneous assumptions often made by authority figures and institutions of power. In turn, counselors need to be aware of how these portrayals and assumptions potentially impact the mental health services African American males receive.
In addition to didactic teaching, experiential exercises also are critical for meaningful learning to take place (Sue & Sue, 2015). Assignments that illustrate personal and systemic prejudice can help students reflect on their own potential biases as well as build awareness of systemic influences that may impact clients of color in ways counselors-in-training previously had not considered. Reading assignments that illustrate common biases among counselors can normalize the phenomenon in ways that facilitate student openness to learning and self-reflection. In addition, using diverse theories when discussing diagnosis and treatment planning can ensure multiple perspectives are acknowledged, including the perspective that diagnoses can be both helpful and harmful to clients. Counselor educators have a responsibility to ensure students graduate with an awareness of the need to constantly monitor their own biases and prejudices toward African American males, as well as knowing when to seek supervision and consultation.
Finally, counselor educators can implement a multicultural competence approach to teaching clinical assessment and diagnosis. Guindon and Sobhany (2001) offered a conceptual framework that can be utilized in the classroom in order to achieve this goal: (a) obtain a specific and complete understanding of the client’s chief complaint, (b) be aware of discrepancies in counselor and client perceptions of clinical reality, (c) elicit clients’ clinical realities and explain counselor clinical models, (d) engage in active negotiation with the client as a therapeutic ally, (e) recognize the importance of renegotiation (of perception of presenting problem), and (f) use assessment instruments advisedly and with caution. The authors intended for this framework to be used by “counselors from any cultural background [to] assist those who are not like themselves” (Guindon & Sobhany, 2001, p. 279).
Limitations of the Study
The CQR model allowed the research team to independently and collaboratively analyze the data through a deliberate, thorough and comprehensive process over time to understand the meanings. Multiple perspectives and the relational dynamic within our team helped to check our own biases and to clearly grasp the view of our participants. The findings of this study represent an in-depth analysis of the perspectives of six licensed mental health professionals with experience diagnosing and working with clients who are diagnosed with ODD that may apply to some degree to working with similar populations and contexts. Life and professional experiences of the researchers and participants, however, naturally interact and influence our understandings of the meanings of the data. As such, different combinations of research team members, participants, or contexts could reveal similar, additional or different findings in a similar study. Finally, two graduate student members of the initial research team graduated before data analysis commenced; therefore, we had fewer coders than originally planned. Additional coders would have provided other perspectives on the data and may have further enhanced the meaning-making process.
Conclusion and Future Research
A mental health diagnosis such as ODD has destructive potential when not used properly. Professional counselors, then, have social power in their capacity to diagnose a client with a mental disorder (APA, 2013; Prilleltensky, 2008). Such power requires that counselors cultivate awareness of personal and professional biases that may influence the diagnostic process. Factors driving the diagnostic process extend beyond the mental health needs of the client and can play a critical role in assessment. Contextual explanations, including historic and systemic contexts, must be considered before a diagnosis is given. Attending to the role of counselor bias to prevent overdiagnosis is an ethical responsibility for which counselor educators and practicing counselors must hold themselves accountable.
Additional research is needed to consider whether the diagnosis–billing model is the most optimal and ethical for mental health care, particularly for preventive mental health and for African American male clients and other marginalized populations. Further study also is warranted to capture the long-term implications of an ODD diagnosis, including identifying ways in which a client‘s family can advocate for school and community resources (e.g., outpatient counseling, mentoring programs, support groups). Finally, possible relationships between an ODD diagnosis, school discipline practices and crime adjudication with marginalized groups (e.g., African American males) should be explored, given the drop-out-of-school-to-prison pipeline that is now widely recognized as a reality for many African American males (Barbarin, 2010).
Conflict of Interest and Funding Disclosure
The authors reported no conflict of interest
or funding contributions for the development
of this manuscript.
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Marc A. Grimmett is an Associate Professor at North Carolina State University. Adria S. Dunbar is an Assistant Professor at North Carolina State University. Teshanee Williams and Cory Clark are doctoral students at North Carolina State University. Brittany Prioleau and Jen S. Miller are licensed professional counselors. Correspondence can be addressed to Marc. A. Grimmett, Campus Box 7801, Raleigh, NC 27695-7801, email@example.com.
Nicole A. Stargell, Victoria E. Kress, Matthew J. Paylo, Alison Zins
Excoriation disorder, sometimes colloquially referred to as skin picking disorder, is a newly added disorder in the Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5; American Psychiatric Association [APA], 2013). Despite being a newly-classified DSM disorder, excoriation disorder is relatively common and affects between 1.4 and 5.4% of the general population (Grant et al., 2012). The purpose of this article is to provide professional counselors with a general understanding of how to assess, diagnose and treat excoriation disorder.
The prevalence of excoriation disorder may be underestimated, as it is sometimes overlooked, particularly because of comorbidity with other mental disorders (e.g., depression, anxiety, obsessive-compulsive disorder; Hayes, Storch, & Berlanga, 2009). Previously underestimated numbers of its prevalence also may be due to the covertness often associated with this disorder (Grant & Odlaug, 2009). Many people with excoriation disorder go to great lengths to hide their behavior from others (e.g., significant others, family members, health professionals) due to fear or embarassment.
Historically, excoriation disorder has been associated with obsessive-compulsive disorder (OCD), and it is now listed as a unique diagnosis in the obsessive-compulsive and related disorders section in the DSM-5 (Ravindran, da Silva, Ravindran, Richter, & Rector, 2009). According to the APA (2013), excoriation disorder involves the recurrent, excessive and often impulsive scratching, rubbing and picking of skin which leads to tissue damage and lesions. Those who have excoriation disorder frequently initiate attempts to eradicate these destructive behaviors, yet have difficulty doing so. In order for the diagnosis of excoriation disorder to be applied, individuals must experience clinically-significant distress or impairment in social, occupational or other important areas of functioning due to the routine nature of the skin picking behaviors (APA, 2013). Because of its physical manifestation, this phenomenon has frequently been discussed in medical research, but it is now receiving attention in mental health circles.
Etiology of Excoriation Disorder
Little is known about the etiology of excoriation disorder. Much of the current excoriation disorder research has been based on previous research conducted on trichotillomania. Excoriation disorder and trichotillomania are body-focused repetitive behaviors (BFRB) under the same DSM-5 classification, and the etiologies behind both disorders might be similar (Flessner, Berman, Garcia, Freeman, & Leonard, 2009). Most theorists suggest that excoriation disorder is rooted in both biological and psychological factors (Grant et al., 2012).
Biological factors related to excoriation disorder include genetic predispositions and neurological sensitivity to emotional stimuli, which result in emotional impulsivity and a need to self-soothe (Snorrason, Smári, & Ólafsson, 2011). In one study of 40 individuals who had excoriation disorder, 43% had a first-degree relative with the disorder (Neziroglu, Rabinowitz, Breytman, & Jacofsky, 2008). Specific genes (e.g., Hoxb8 and SAPAP3) have been identified as potential predictors of this disorder (Grant et al., 2012). In animal studies, mice with these genes engaged in excessive grooming to the point of skin lesions, behaviors similar to those of people who have excoriation disorder (Grant et al., 2012). Conversely, in another study, humans with the SAPAP3 gene only met criteria for excoriation disorder 20% of the time (Dufour et al., 2010). It is important to note that genetics appear to play a role in the development of excoriation disorder, but other factors contribute to the disorder’s etiology and maintenance as well (Grant et al., 2012; Lang et al., 2010).
In terms of psychological factors, skin picking behaviors help regulate uncomfortable emotions and can become a behaviorally-reinforced coping mechanism used to manage negative feelings (Lang et al., 2010). Some researchers suggest that excoriation disorder is rooted in higher levels of emotional impulsivity and that this characteristic supports and encourages the development of the disorder (Grant et al., 2012). Those with excoriation disorder experience obsessive thoughts about skin picking and engage in more impulsive, sensation-seeking behaviors (e.g., picking, rubbing) than those without the disorder (Snorrason et al., 2011). Those with excoriation disorder often have a greater difficulty with response inhibition and an increased difficulty suppressing an already initiated response as compared to control participants (Grant, Odlaug, & Chamberlain, 2011; Odlaug & Grant, 2010). For example, it might be more difficult for those with excoriation disorder to retract their hand if they already started reaching for an object to use to excoriate. This elevated level of impulsivity may be rooted in brain abnormalities; however, further research is necessary to clearly establish this connection (Grant et al., 2012).
Another common theory regarding the onset and maintenance of excoriation disorder is that skin picking behaviors can help regulate emotions and can become a behaviorally-reinforced coping mechanism used to manage elevated levels of anxiety, stress and arousal. Individuals who skin pick often display elevated stress responses to normal stimuli (Lang et al., 2010), and skin picking appears to temporarily sooth such stress. Additionally, obsessive thoughts about skin imperfections and anxiety over not picking can be temporarily relieved by completing the behaviors (Capriotti, Ely, Snorrason, & Woods, 2015). As such, there is a behavioral component—in addition to the genetic and biological components of the disorder—that must be considered when understanding the etiology, assessment, diagnosis and treatment of excoriation disorder.
Assessment and Diagnosis of Excoriation Disorder
The proposed etiologies (e.g., genetic predispositions, biological markers) and functions (e.g., soothing emotional reactivity, reducing obsessive thoughts) of excoriation disorder inform the diagnostic and assessment process. It is important that counselors have a thorough understanding of the DSM-5 criteria for excoriation disorder and understand that many clients with this disorder might hide physical markers and omit skin picking information unless asked directly (Grant & Odlaug, 2009). As such, counselors might use formal assessments, in addition to clinical judgment, in order to make an accurate diagnosis and best understand the client’s behaviors.
A number of assessment tools can be used to assist in assessing, diagnosing and treating those who have excoriation disorder. Each measure can be utilized by counselors in developing a holistic conceptualization of the client and for engaging in differential diagnosis. Upon accurate diagnosis of excoriation disorder, assessment measures also can aid counselors in selecting appropriate treatment goals, interventions and modalities for each client, and they can be used to assess client behavior change.
Keuthen et al. (2001b) constructed three skin picking scales that can be used to assess excoriation disorder and aid in the assessment and treatment process. The first measure, the Skin Picking Scale (SPS), can be used to measure the client’s self-reported severity of skin picking behaviors. This measure consists of six items that relate to the frequency of picking urges, intensity of picking urges, time spent engaging in skin picking behaviors, interference of the behaviors in functioning, avoidance behaviors and the overall distress associated with the excoriation-related behaviors. Each item is assessed on a 5-point scale of 0 (none) to 4 (extreme), resulting in a range of total scores between 0 and 24. The SPS demonstrated high internal consistency with adequate convergent validity (Keuthen et al., 2001a). Pragmatically, this measure can be used to distinguish self-injurious skin picking from non-self-injurious skin picking. As treatment gains are made, corresponding scores should decrease.
The second measure is the Skin Picking Impact Scale (SPIS). The SPIS is a self-report questionnaire designed to assess the impacts or consequences of repetitive skin picking (e.g., negative self-evaluation, social interference; Keuthen et al., 2001a). Each of the scale’s 10 items are rated on a 6-point scale from 0 (none) to 5 (severe), resulting in a total score ranging from 0 to 50. The SPIS has high internal consistency (Keuthen et al., 2001a; Snorrason et al., 2013), and scores appear to correlate with duration of picking, satisfaction of picking and shame associated with picking.
The third measure is the Skin Picking Impact Scale-Shorter Version (SPIS-S). The SPIS-S is the shorter version of the SPIS consisting of only a 4-question scale (Snorrason et al., 2013). The SPIS and the SPIS-S have a similar factor structure and both have high internal consistency. These measures assess the impacts of picking behaviors on social life, perceived embarrassment associated with picking behaviors, consequences of picking behaviors and perception of attractiveness (Snorrason et al., 2013). The ultimate difference between the two scales is the brevity of the shorter version measure as compared to 10 items on the other measure. Snorrason and associates (2013) found acceptable discriminant and convergent validity for the SPIS and the SPIS-S; both measures may be considered for clinical use.
The Milwaukee Inventory for the Dimensions of Adult Skin Picking (MIDAS) is another skin picking assessment measure (Walther, Flessner, Conelea, & Woods, 2009). The MIDAS consists of 21 items and highlights the degree of focused picking (e.g., body sensations, reaction to negative emotions) and automatic picking behaviors (e.g., unaware of skin picking behaviors, concentrating on another activity, unintentional picking; Walther et al., 2009). Within the measure, each item is rated on a 5-point scale (i.e., 1–5; not true of my skin picking to always true for my skin picking), and a specific score is provided for focused and automatic picking. The MIDAS demonstrates adequate internal consistency and good validity (i.e., construct and discriminant), making it a reliable and valid measure for distinguishing types of skin picking behaviors (Walther et al., 2009). This assessment is especially useful in facilitating an understanding of the client’s motivations for skin picking, as well as potential ways to reduce the problematic behaviors.
The Skin Picking Impact Survey (SKIS; Tucker, Woods, Flessner, Franklin, & Franklin, 2011) is a self-report survey measure. The SKIS, which consists of 92 items, is used to explore multiple dimensions of skin picking behaviors. This survey consists of individual items that assess skin picking symptoms (e.g., presentation), levels of severity (e.g., urges, intensity, time spent, distress, avoidance), consequences (i.e., physical and psychosocial), treatment-seeking history, and demographic information. The SKIS demonstrated acceptable internal consistency (Tucker et al., 2011). Additional items are used to assess for comorbid disorders and other associated symptoms (e.g., depression, anxiety, stress).
Finally, a unique approach to assessing excoriation disorder is to utilize a functional analysis assessment (LaBrot, Dufrene, Ness, & Mitchell, 2014). Although not created primarily to assess skin picking behaviors, a functional analysis assessment is a behavioral technique used to explore the relationship between any stimuli and response (e.g., being cold and shivering; LaBrot et al., 2014). With regards to excoriation disorder, the functional analysis assessment consists of behavior scales and individual interviews with anyone close to the client (e.g., spouse, family member, classroom teacher). The interviews include a discussion of the client’s behaviors and antecedents to such behaviors (LaBrot et al., 2014). This interview also involves a direct observation of the client in the most problematic setting (e.g., home, work, school), and counselors should take note of the time of day or events that often lead up to skin picking behaviors.
A functional analysis assessment also might involve the use of a thought log to help explore thoughts that lead to skin picking behaviors (LaBrot et al., 2014). This connection between thoughts (i.e., obsessions) and behaviors (i.e., compulsions) is characteristic of the obsessive-compulsive DSM-5 classification under which excoriation disorder is housed. Counselors may suggest that clients self-monitor their skin picking behaviors in order to better understand the frequency, triggers, cues, and increases or reductions in thoughts and behaviors. For example, clients may be asked to place a journal or worksheet in places where picking often occurs (e.g., bathroom, bedroom) and then to report and rate the intensity of urges, precipitating events, alternative behaviors, and if picking behaviors actually occurred. When assessing skin picking, clients also should be invited to note any attempts to stop picking, consequences of the skin picking behaviors, and other behaviors that could potentially serve as incompatible replacements (LaBrot et al., 2014). The use of a functional analysis assessment allows the counselor to gain a more complete, contextual picture of the behaviors.
To gain a richer understanding of the client’s behaviors, counselors might (if approved by the client) gather assessment and baseline information from the client’s friends and family members (Grant & Stein, 2014). During the assessment process, counselors should explore all aspects of the client’s life, including recent life experiences, past traumas and current life stressors (LaBrot et al., 2014). An accurate diagnosis and collaborative treatment plan can be developed when this information is integrated to form a contextual understanding of the client’s skin picking experiences.
A thorough assessment helps counselors to identify an accurate diagnosis. Armed with assessment data, counselors can determine the presence of excoriation disorder and any comorbid disorders. In order to accurately diagnose the disorder, counselors must be familiar with the DSM-5 diagnostic criteria and understand diagnostic considerations related to the disorder.
The onset of excoriation disorder varies significantly, but it most often begins in early adolescence or between the ages of 30 to 45 years old (Grant et al., 2012). Skin picking causes physical harm, and clients often make repeated attempts to reduce the behavior because of the distress and physical impairment it invites. By definition, excoriation disorder is not caused by a substance or medical condition and not accounted for by another disorder (APA, 2013). The diagnostic features of excoriation disorder remain the same regardless of age or other multicultural factors (Grant et al., 2012). The general features that a counselor should look for when diagnosing excoriation disorder include a preoccupation with picking behaviors, difficulty in controlling the behaviors and distress resulting from the behaviors.
Because this is a newer diagnosis, it is often overlooked, misdiagnosed (Grant et al., 2012), or overshadowed by comorbid diagnoses (APA, 2013; Grant & Stein, 2014; Hayes et al., 2009). It is important to distinguish between excoriation disorder and nonsuicidal self-injury, both of which involve self-inflicted damage to the body that provides relief from unwanted thoughts or feelings (APA, 2013). Nonsuicidal self-injury is typically motivated by negative thoughts or feelings about the self in relation to others, and bodily harm provides a feeling of relief or euphoria (APA, 2013; Shapiro, 2008). Conversely, excoriation disorder is an obsessive-compulsive and related disorder and is more ritualistic; unwanted thoughts and feelings are directly related to bumps or certain types of scabs on the body, and clients have a routine related to removal (e.g., examining, picking) and disposal (e.g., playing with or eating) of such bumps or scabs (APA, 2013; Capriotti et al., 2015; Walther et al., 2009).
Individuals with excoriation disorder generally have difficulty resisting the urge to pick and often believe their behavior cannot be altered or changed (Kress & Paylo, 2015). Typically, there are two types of picking behaviors: behaviors that are automatic and behaviors that are focused (Christenson & Mackenzie, 1994). Individuals who engage in picking behavior outside of their awareness, such as while watching television or while reading a book, are engaging in what is known as automatic picking. Those who are fully aware of their behavior and pick to regulate or to manage negative emotions due to specific thoughts or stressors are engaging in focused picking. Both types of picking typically cause client embarrassment, impair functioning and are difficult to manage and control (Odlaug, Chamberlain, & Grant, 2010).
Although focused skin picking might seem to be more directly tied to conscious obsessions than the automatic type, both types were reclassified under obsessive-compulsive and related disorders in the DSM-5 due to the universal obsessive and compulsive features of the disorder; these obsessions and compulsions also are shared with individuals who have trichotillomania (Snorrason, Belleau, & Woods, 2012) and body dysmorphic disorder (Tucker et al., 2011). In each of these disorders, obsessions lead to an overwhelming urge to act upon unhelpful thoughts, which is often followed by a brief sense of relief once the compulsion has been engaged and completed. However, the urge inevitably arises again (despite bodily damage and some potential shame), and the cycle continues.
Ultimately, excoriation disorder is characterized by recurrent and excessive tissue damage that is not better accounted for by nonsuicidal self-injury. Those who have excoriation disorder have difficulty controlling their picking behaviors and experience clinically significant distress or impairment as a result of these behaviors (APA, 2013). Assessment measures can be used in conjunction with the DSM-5 in order to make an accurate diagnosis that can inform clients’ treatment.
Treatment of Excoriation Disorder
Several evidence-based treatment options are available for use in treating those who have excoriation disorder (Kress & Paylo, 2015). Unfortunately, many providers fail to use evidence-based treatment approaches in their work with this population (Tucker et al., 2011). A relatively small number of randomized controlled treatment studies have been conducted on this population; however, the most evidence-based approaches include cognitive behavioral therapy, habit reversal training and pharmacotherapy (Capriotti et al., 2015; Kress & Paylo, 2015).
Cognitive Behavioral Therapy
Cognitive behavioral therapy (CBT) is an effective strategy for working with clients who have excoriation disorder (Grant et al., 2012; Schuck, Keijsers, & Rinck, 2011). Schuck et al. (2011) conducted a randomized study of college-age students who reported pathological skin picking; participants were provided four sessions of CBT and compared to those on a waitlist. These researchers observed a significant decrease in psychosocial impact of skin picking, severity of skin picking and perceived strength of skin picking cognitions in the group randomly assigned to the four sessions of CBT. These treatment effects were maintained at a two-month follow-up, thus suggesting that CBT is effective in reducing the severity of symptoms, effect of symptoms and dysfunctional cognitions associated with excoriation disorder.
Practically, CBT for clients with excoriation disorder is focused on using cognitive restructuring to counter dysfunctional thoughts (Schuck et al., 2011). Before engaging in CBT techniques, a counselor should ascertain the nature and location of the picking and provide clients with psychoeducation regarding the etiological and maintenance factors related to their disorder. Socratic questioning is one CBT technique used to help clients recognize their fundamental beliefs and automatic thoughts surrounding skin picking (Kress & Paylo, 2015). When applying this technique, the counselor generates a hypothesis about the client’s thoughts (that lead to skin picking), but leads the client to the information rather than suggesting it. The client is led to insight through a series of questions regarding the topic of interest. For example, the counselor might believe that a client’s skin picking obsessions become stronger when personal and professional obligations become overwhelming. The counselor might ask, “What feelings do you have when picking? What time of day do you typically pick? Are there ever days when you do not pick?” The counselor would use reflections to organize and expand upon the client’s responses until they gain new insight about their thoughts, patterns and beliefs regarding this behavior.
When using CBT, irrational thoughts are examined for validity and replaced with more rational thoughts and behaviors (Kress & Paylo, 2015). For example, an individual tempted to engage in skin picking after an argument with a spouse would challenge the need to pick with more rational thoughts, such as, “Even if I become anxious, I can tolerate the anxiety. Instead of picking, I can clean the house or exercise.” This type of change occurs over a period of time, and counselors and clients should celebrate small victories, such as delayed or reduced skin picking, as the more rational thoughts begin to become more salient.
CBT not only involves cognitive interventions, but also includes behavioral interventions such as homework, preventative measures, activity replacement and relapse prevention (Capriotti et al., 2015; Kress & Paylo, 2015; Schuck et al., 2011). Counselors may assign homework such as CBT thought logs to help clients track picking behaviors. While reviewing the logs in session, counselors can assist clients in developing preventative measures, such as wearing gloves or bandages to hinder skin picking, and activity replacement such as reading a book, cleaning or watching television instead of skin picking. CBT also places a heavy emphasis on relapse prevention, or the preparation to prevent future urges to pick.
Habit Reversal Training
Habit reversal training (HRT) is an effective strategy for working with clients who have excoriation disorder (Capriotti et al., 2015; Grant et al., 2012; Teng, Woods, & Twohig, 2006). HRT is a behavioral approach that involves helping clients gain awareness of their skin picking and then replace the picking with more adaptive behaviors (Grant et al., 2012; Ravindran et al., 2009; Snorrason & Bjorgvinsson, 2012; Teng et al., 2006). The first step of treatment is awareness training, which helps clients who are often unaware of their skin picking to associate factors, such as time of day and specific situations, to skin picking behavior (Teng et al., 2006). To facilitate this awareness, a counselor may point out in-session skin picking behavior. After developing an awareness of antecedent situations (i.e., the situations that precede picking incidents), the counselor and client collaboratively develop a competing response, or another behavior that is inconsistent with skin picking, to substitute for the skin picking behaviors (Teng et al. 2006). An example of an alternative behavior would be clenching one’s fist each time a client notices that he or she is picking. This competing response, which should be one that is easily applicable in a number of situations, diminishes the urge or reduces its intensity.
The next step in HRT is the establishment of a contingency management system or token economy involving rewards and punishments. This type of treatment approach allows the clients’ behaviors to be rewarded as they make successive approximations toward the goal. Rewards and punishments must be meaningful to clients, and they also must be specific and timely. At first, rewards are extrinsic, such as verbal praise or toys with children. As target behaviors are reached (e.g., reduced skin picking), clients begin to access more intrinsic reinforcers (e.g., an increased sense of self-esteem, feelings of belonging within the community/society). Finally, clients are coached to consistently implement these operant conditioning strategies outside of session and to eventually apply them to new behaviors (Capriotti et al., 2015; Teng et al., 2006). The client gradually realizes that skin picking is not a necessary coping skill, as other, more adaptive behaviors can be used to effectively reduce stress.
Teng et al. (2006) conducted a controlled study in which they compared HRT treatment to a waitlist control group. These researchers demonstrated a significant reduction in skin picking behaviors at the termination of treatment and upon follow-up assessment, as compared to the control group. The research on HRT suggests that it is a promising approach for use with those who have excoriation disorder.
Acceptance and Commitment Therapy
Acceptance and commitment therapy (ACT), when used in conjunction with HRT, demonstrates clinical promise in treating those who have excoriation disorder (Capriotti et al., 2015; Flessner, Busch, Heideman, & Woods, 2008). Capriotti et al. (2015), through the use of multiple clinical case studies, demonstrated that Acceptance-Enhanced Behavioral Therapy (i.e., ACT plus HRT) decreased excoriation symptomology in three of four participants in their case study research. These results support the findings of a similar case study done by Flessner et al. (2008), which demonstrated decreased symptomatology of excoriation disorder when ACT was incorporated with HRT.
ACT uses mindfulness techniques to teach acceptance of negative thoughts and emotions and then combines behavior-change techniques to address unhealthy behaviors (Flessner et al., 2008). Initially, the counselor helps the client investigate previous attempts to curb skin picking behaviors (such as avoidance or relaxation while picking). Then, the client and counselor work to distinguish between urges to pick (i.e., thoughts, feelings, sensations) and actual skin picking, emphasizing that even if urges are acted upon, they will soon return. As such, the focus is on increased distress tolerance and acceptance of urges (Kress & Paylo, 2015). The difficulty of controlling urges can be illustrated through metaphors in which the client gains control and a position of power over an undesirable, yet steadfast external circumstance (e.g., working is unavoidable, but you can find a job you enjoy).
Next, using ACT treatment, the client’s ability to control his or her own thoughts and behaviors is highlighted. This emphasis on controlling behavior stands in contrast to most clients’ natural inclination to focus on controlling or avoiding external situations. Next, the counselor and client work to modify and change the thoughts and feelings associated with urges to pick (Flessner et al., 2008). The client and counselor address six processes that contribute to healthy, flexible living: present-moment awareness; acceptance (as opposed to avoidance); nonjudgmental awareness of one’s thoughts; values clarification; changing, rather than reducing, unhelpful thoughts; and short- and long-term behavioral goals. Lastly, treatment progress is reviewed, and the client and counselor engage in relapse management (Flessner et al., 2008; Twohig, Hayes, & Masuda, 2006). Counselors also can integrate medication management when therapeutically indicated.
If pharmacotherapy is used to treat excoriation disorder, it should be used in conjunction with counseling; medication can control physical symptoms, but contributing mental health factors must be addressed in order to holistically help the client make enduring behavior changes (Grant et al., 2012). Selective serotonin reuptake inhibitors, specifically Fluoxetine (Prozac), have been shown to be effective in treating excoriation disorder and other BFRB (Grant et al., 2012; Simeon et al., 1997). However, this effect has not been consistent across clients (Grant & Odlaug, 2009). Therefore, additional research on the effectiveness of medication is needed. Counselors should provide intentional treatments for clients while taking into account unique client considerations.
Although those with excoriation disorder might go to great efforts to conceal their wounds from others (Grant & Odlaug, 2009), they are likely to admit to skin picking behaviors when effectively questioned by a mental health professional (APA, 2013). It is important to ensure the clients with excoriation disorder are physically well (i.e., free from medical complications associated with picking), and a referral to medical professionals to ensure physical safety and appropriate medical care may be necessary (Grant et al., 2012).
Excoriation disorder occurs more often in those who also have OCD (APA, 2013). Several additional disorders are often found to be comorbid with excoriation disorder, including trichotillomania, major depressive disorder, anxiety, psychotic disorders, neurodevelopmental disorders and factitious disorder (APA, 2013; Hayes et al., 2009). Picking behaviors also could be due to a general medical condition or substance use (e.g., such as with methamphetamine addictions), and these should be ruled out (APA, 2013).
Those with first-degree family members who have excoriation disorder are more likely to also develop skin picking behaviors (APA, 2013). However, skin picking often begins during puberty, and the onset is often associated with the development of skin irregularities (e.g., acne; APA, 2013, Tucker et al., 2011). It was found that approximately 87% of college-aged students in Turkey who had acne or other skin blemishes displayed some skin picking behaviors, but only about 2% reported clinically-significant symptoms of excoriation disorder (Calikusu, Kucukgoncu, Tecer, & Bestepe, 2012). The aforementioned finding suggests that dermatological factors, such as acne, might explain the onset of excoriation disorder, but not necessarily the maintenance of such behaviors. As such, family history of such behaviors should be considered by counselors when assessing and treating this disorder.
Collaborative relationships with other professionals can be helpful when working with a client who has excoriation disorder. If clients are provided with psychopharmaceutical interventions, counselors should take care to communicate with the prescribing physician in order to help the client maintain proper medication schedules and to potentially provide psychoeducational support to the client (Grant et al., 2012). Although consultation with a dermatologist is not always necessary, this valuable resource should be integrated into treatment when possible, and open communication can ensure that clients are receiving the support that they need (Calikusu et al., 2012; Grant et al., 2012).
Finally, although excoriation disorder is now an official DSM diagnosis, the research literature on effective treatments is still in its infancy stage (Capriotti et al., 2015). Additional research also is needed to determine the prognosis of excoriation disorder. As previously indicated, researchers have found psychopharmaceutical and cognitive behavioral interventions to be promising (Flessner et al., 2008; Grant et al., 2012; Schuck, et al., 2011; Simeon et al., 1997), but additional outcome research still needs to be conducted on this disorder (Capriotti et al., 2015). Further research on this new DSM-5 disorder will provide more concrete information regarding assessment and treatment options for this population.
The etiology of excoriation disorder is still being explored, and several theories are currently supported as viable options. Both biological and psychological factors appear to contribute to the development and maintenance of this disorder (Grant et al., 2012). Skin picking behaviors are often found in those who have higher levels of emotional impulsivity, and these behaviors might serve as a way for individuals to regulate their emotions.
There are several formal measures that can be used to aid in the assessment and diagnosis of excoriation disorder. In addition to formal quantitative measures, the functional analysis assessment is a helpful method that can be used to increase both the client’s and the counselor’s understanding of the behaviors (LaBrot et al., 2014). Regardless of the assessment procedures employed, counselors should explore all aspects of the client’s life in order to create a comprehensive treatment approach.
Since excoriation disorder is a new diagnosis in the DSM-5, it is often overlooked or misdiagnosed. Counselors should fully assess a client’s presenting concerns in order to determine an accurate and helpful diagnosis. Counselors also should note that this disorder is often comorbid with other mental disorders (APA, 2013; Grant et al., 2011; Hayes et al., 2009).
In terms of the treatment of excoriation disorder, CBT is one of the more evidence-based approaches (Grant et al., 2012; Schuck et al., 2011), as is HRT (Grant et al., 2012; Teng et al., 2006). ACT has been used with success with HRT (Capriotti et al., 2015; Flessner et al., 2008). Psychopharmacotherapy also holds promise as an effective adjunct to psychosocial treatments (Grant et al., 2012; Simeon et al., 1997).
Conflict of Interest and Funding Disclosure
The authors reported no conflict of interest
or funding contributions for the development
of this manuscript.
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Nicole A. Stargell, NCC, is an Assistant Professor at the University of North Carolina at Pembroke. Victoria E. Kress, NCC, is a Professor at Youngstown State University. Matthew J. Paylo is an Associate Professor at Youngstown State University. Alison Zins is a graduate student at Youngstown State University. Correspondence can be addressed to Nicole Stargell, UNC Pembroke, P.O. Box 1510, Department of Educational Leadership and Counseling, 341 Education Building, Pembroke, NC 28372, firstname.lastname@example.org.
Matthew R. Buckley
It is a pleasure to introduce this special DSM-5 edition of The Professional Counselor, which provides a solid primer regarding changes in the DSM-5 diagnosis process and how these changes will likely impact mental health professionals. Changes within the DSM-5 have prompted counselors to revisit the basics of diagnosis and consider the cessation of certain conventions (e.g., the multiaxial system) and what these changes mean to counselors as they perform their vital work for the benefit of clients. The unprecedented inclusion of various mental health professionals in the development of the DSM-5 is an inherent recognition of how this tool is being used across a wide range of professional disciplines that focus on psychopathology. I hope these articles not only inform, but encourage further research into the practical use of the DSM-5, “stimulate new clinical perspectives” in mental illness (American Psychiatric Association [APA], 2013, p. 10), and inspire continued professional dialogue around DSM nosology and the diagnostic processes.
Keywords: DSM-5, diagnosis, psychopathology, mental illness, multiaxial system
The fifth edition of the Diagnostic and Statistical Manual for Mental Disorders (DSM-5) is an update of a major diagnostic tool (APA, 2013). The manual was originally designed to help mental health professionals within a wide variety of disciplines assess and conceptualize cases in which people were suffering from mental distress. This conceptualization is important in that it facilitates an understanding in a common language toward the development of treatment planning to address complex and entrenched symptomology. The DSM has undergone numerous iterations and represents the current knowledge of mental health professionals about mental illness (APA, 2013). One of the primary aims of the DSM-5 workgroups was to align the manual with the current version of the International Classification of Diseases (ICD-9). In addition, political, social, legal and cultural dynamics influenced the development of the DSM-5—and not without controversy (Greenberg, 2013; Locke, 2011; Linde, 2010; Pomeroy & Anderson, 2013). As with any tool, concerns have emerged about the potential of misuse. It is the professional responsibility of skilled and ethical mental health counselors and other professionals to prevent misapplication of the manual (American Counseling Association [ACA], 2014, E.1.b, E.5.a–d). Walsh (2007) succinctly noted that “the primary goal of the DSM is to enhance the care of individuals with psychiatric disorders” (p. S3).
The introduction of the DSM-IV-TR states that the DSM has been used by numerous mental health practitioners (APA, 2000), with no mention of their investment as legitimate stakeholders in the process of DSM development. Well before the final revision of the DSM-5, various mental health professionals, organizations and other relevant collaborators helped formulate the manual in unprecedented capacities. In the introduction to the DSM-5 (APA, 2013) the authors intentionally state that numerous stakeholders were involved in DSM-5 development including counselors and “patients, families, lawyers, consumer organizations, and advocacy groups” (p. 6). Of particular note was the inclusion of national organizations such as the ACA in the form of a DSM-5 task force, which submitted position statements and recommendations to the APA. Various mental health professionals participated directly in the formulation of the DSM-5, primarily in field trials which “supplied valuable information about how proposed revisions performed in everyday clinical settings” (p. 8). Much of the data supports the use of more than 60 cross-cutting and severity symptom measures (see http://www.psychiatry.org/practice/dsm/dsm5/online-assessment-measures).
First (2010) reported that utilizing broad and diverse populations of mental health professionals provides rigor for clinical utility. Achieving clinical utility within the DSM diagnostic processes meets the following four objectives:
to help clinicians communicate clinical information to other practitioners, to patients and their families, and to health care systems administrators;
to help clinicians implement effective interventions in order to improve clinical outcomes;
to help clinicians predict the future in terms of clinical management needs and likely outcomes; and
to help clinicians differentiate disorder from non-disorder for the purpose of determining who might benefit from disorder-based treatments. (First, 2010, p. 466)
Any changes to the DSM were framed within the context of how they might be utilized by all mental health professionals, including revisions to definitions of diagnoses and symptoms, proposed diagnostic categories, dimensional assessment (including cross-cutting), and a renewed emphasis on severity specifiers. Ultimately, the consideration was whether the revised manual would be accepted and utilized by the practitioners it proposed to serve (APA, 2013; First, 2010). First (2010) noted that no mandate exists requiring the use of the DSM by any professional, and that other tools used to arrive at an ICD diagnosis exist or are in development (e.g., the NIMH Research Domain Criteria initiative; APA, 2013; Nussbaum, 2013). The DSM-5 workgroups were challenged to revise the manual in order to make it user-friendly and maintain its relevance among mental health professionals. Even though the manual is an imperfect resource, the goal was to enhance clinical utility.
Determining a Differential Diagnosis
In his primer on diagnostic assessment focused on the DSM-5, Nussbaum (2013) offers six considerations in determining a differential diagnosis that serve as an important basis for practice. These considerations or steps include the following:
to what extent signs and symptoms may be intentionally produced;
to what extent signs and symptoms are related to substances;
to what extent signs and symptoms are related to another medical condition;
to what extent signs and symptoms are related to a developmental conflict or stage;
to what extent signs and symptoms are related to a mental disorder; and
whether no mental disorder is present.
Each of these process steps serves as important reminders for getting back to the basics of rendering diagnoses that help inform treatment. When working with clients, these steps function as points of reference to rule out potential factors influencing misdiagnosis. Additionally, client cultural factors are essential at capturing comprehensive context for assessment and diagnosis.
Consider to what extent signs and symptoms may be intentionally produced. Signs and symptoms may be purposely feigned on the part of a client for secondary gain (e.g., financial benefits, drug seeking, disability status, attention from others, reinforcement of an identity of pathology, avoiding incarceration). Counselors must recognize the context in which signs and symptoms occur and pay attention when something does not “fit” with how a client presents for treatment. Assessing prior mental health treatment (including outcomes), cultural factors and potential motives to fake an illness can assist counselors in making an accurate differential diagnosis.
Consider to what extent signs and symptoms are related to substances. A wise and influential professor and mentor during my graduate training said, “Always assess for substance use!” Clients can present with a variety of conditions that are induced by prescription or over-the-counter drugs, illicit substance, or herbal supplements (Nussbaum, 2013). An important emphasis within the DSM-5 is substance-use and substance-induced disorders, which are included in many relevant diagnostic criteria (APA, 2013). Counselors are well-advised to make this determination in the initial assessment and continue to assess throughout the course of treatment.
Consider to what extent signs and symptoms are related to another medical condition. Clients present with signs and symptoms that may be caused by or coincident with another medical condition in a variety of ways. Nussbaum (2013) defined possible manifestations including (a) medical conditions that directly or indirectly alter signs and symptoms, (b) treatments for medical conditions that alter signs or symptoms, (c) mental disorders and/or treatments that may cause or exacerbate medical conditions, or (d) both a mental disorder and a medical condition that are not causally related. Counselors should gather medical information from the client and appropriately follow up with medical personnel as needed to ensure proper and accurate diagnosis, which will lead to more targeted and effective treatment.
Consider to what extent signs and symptoms are related to a developmental conflict or stage. A primary strength of counseling professional identity is the focus on human development as a key factor in client distress and resiliency. The counseling practice of “meeting clients where they are” includes where they are developmentally. Counselors must recognize where incongruence exists between what clients present and the expected behaviors or characteristics of their particular developmental stage. Nussbaum (2013) stresses the importance of gathering a comprehensive psychosocial history to determine expected developmental milestones. Being on the lookout for developmental delays, regressive behaviors of an earlier developmental period, primal defense mechanisms, or signs of “a developmental conflict in a particular relationship” (p. 201) will help ensure that all essential contextual factors are addressed when making a diagnosis.
Consider to what extent signs and symptoms are related to a mental disorder. The definition of mental disorder has not changed significantly from previous versions of the DSM: a mental disorder is “a syndrome characterized by clinically significant disturbance in…cognition, emotion regulation, or behavior that reflects a dysfunction in the psychological, biological, or developmental processes…[and] usually associated with significant distress or disability in social, occupational, or other important activities” (APA, 2013, p. 20). Identifying mental disorders, or the process of diagnosis, involves more than clear-cut observations and often includes the consideration of complex factors involving comorbidity, symptom clusters “that may be part of a more complex and unified syndrome that has been artificially split in the diagnostic system” (Nussbaum, 2013, p. 202), overlap between diagnostic criteria, genetic predisposition, and the mutual influence of two or more conditions. Counselors must be careful to consider the presence of these factors, consult when necessary, and take into account differential diagnosis to determine the most appropriate diagnosis given the verbal and observable data available.
Consider whether no mental disorder is present. Sometimes a client may present with symptoms that do not meet the full diagnostic criteria for a mental disorder, despite significant distress in social, occupational or other areas of functioning. In these cases, utilizing the not otherwise specified or unspecified diagnoses may be warranted in order to provide opportunities for deeper inquiry. For example, the symptoms of a disorder may be a secondary reaction to an identifiable social stressor that may justify a diagnosis of an adjustment disorder. The possibility exists that there may not be a diagnosis present (Nussbaum, 2013), and in these cases, counselors and other mental health professionals are challenged to make that decision in the face of pressures to diagnose.
It is imperative that counselors take their clients’ social and cultural influences into account when assessing and diagnosing. Culture impacts all aspects of diagnosis and treatment, including how and when treatment is sought; power differentials between clients and mental health professionals; the age, gender, ethnicity, race, religion, sexual orientation, and socioeconomic status of both clients and mental health professionals; how illness is defined by both; and how problems are conceptualized and addressed within the context of culture (Lewis-Fernández et al., 2014; Tomlinson-Clarke & Georges, 2014).
Two decades of experience using the Outline for Cultural Formulation (OCR), which was introduced in the DSM-IV (APA, 1994), evolved into the Cultural Formulation Interview (CFI) now contained in the DSM-5, comprised of 16 semi-structured questions designed to collect data in a more consistent and efficient manner. Like other dimensional, cross-cutting and severity measures developed specifically for the DSM-5, the CFI was field tested at 12 sites representing several countries to determine feasibility and usefulness (Lewis-Fernández et al., 2014). For the first time, culture in its varied manifestations has been intentionally incorporated into the DSM nosology through a specific assessment instrument. “The CFI follows a person-centered approach to cultural assessment…designed to avoid stereotyping, in that each individual’s cultural knowledge affects how he or she interprets illness experience and guides how he or she seeks help” (APA, 2013, p. 751). Counselors are encouraged to utilize the CFI as a way to understand their clients more meaningfully and to aid in clinical utility.
The TPC Special Issue: Counseling and the DSM-5
Because the DSM-5 is a tool for mental health professionals to utilize in their conceptualization of client distress, understanding how to use the DSM effectively is at the heart of this special issue published by The Professional Counselor (TPC). Readers will find a variety of articles that will assist mental health professionals by providing important context for most of the salient changes within the DSM-5 (APA, 2013) from the perspective of professional counseling. Inherent in each of these contributions is the theme of getting back to the basics in not only understanding the DSM-5 conceptually, but also providing ideas for putting concepts into practice.
An essential element in understanding and using the DSM-5 effectively is exploring the foundational and historical roots of this complex nosology. Dailey, Gill, Karl, and Barrio Minton (2014); Gintner (2014); and Kress, Barrio Minton, Adamson, Paylo and Pope (2014) offer excellent overviews of salient changes within the DSM-5 that impact clinical practice, including how the DSM has evolved over time. While there is necessary redundancy on key points (e.g., elimination of the multiaxial format, implementation of cross-cutting symptom measures, closer alignment with the ICD coding system), each article provides an important and unique perspective. Dailey et al. (2014) offer important perceptions on changes within the DSM-5 including how changes evolved historically and the philosophical foundations behind those changes, especially those that clash with the philosophical underpinnings of counseling. The authors review the implications of such changes for professional counselors. Gintner (2014) provides an excellent context regarding the harmonization of the DSM-5 with the ICD, the inclusion of cross-cutting symptom measures and dimensional assessment, and how the manual is organized. The article focuses on how counselors might respond to these changes. Kress et al. (2014) offer an important perspective on the removal of the multiaxial convention used by mental health professionals for over three decades and the implications for counselors in the practice of assessment and diagnosis. These authors provide an important context for the decision to terminate the multiaxial system including advantages and disadvantages of DSM-5 changes.
King (2014) describes the practical application of diagnostic criteria and the use of cross-cutting dimensional assessments. This perspective offers a backdrop on which to compare current practice and how it may alter with use of the DSM-5. This article focuses on clinical utility and ensuring that the DSM-5 remains a guide to assessment, diagnosis and treatment. Schmit and Balkin (2014) give a comprehensive review of the cross-cutting, dimensional and severity measures from the perspective of psychometric instrumentation, including the practical application of validity and reliability. These authors underscore DSM-5 assessments as soft measures and provide important cautions to counselors using these instruments in their work with clients, including the importance of developing multiple data points.
Understanding specific diagnostic categories is essential to good clinical practice. Welfare and Cook (2014); Kenny, Ward-Lichterman and Abdelmonem (2014); and Jones and Cureton (2014) provide solid descriptions of specific diagnostic criteria and emphasize areas essential to our understanding of developmental and demographic strata. Welfare and Cook (2014) tackle chronic and persistent mental illness manifested in diagnoses within the following categories: schizophrenia spectrum and other psychotic disorders, bipolar and related disorders, and depressive disorders. Clinical examples help contextualize the process of assessing and diagnosing these disorders and provide a detailed example of effectively utilizing each step of the diagnostic process. Kenny et al. (2014) provide a cogent overview of the changes made to the “Feeding and Eating Disorders” chapter, including the addition of binge eating and avoidant/restrictive food intake disorders, severity criteria for anorexia nervosa based on body mass indexes, and how the diagnosis of eating disorder not otherwise specified (EDNOS) has changed as a result. Jones and Cureton (2014) offer important perspectives on significant changes to the “Trauma- and Stressor-Related Disorders” chapter and how these changes may impact clinical practice. The authors discuss how diagnostic criteria have been developed for both children and adults and how cross-cutting symptoms (e.g., panic and dissociation) manifest in a range of disorders. Another significant change to this category is the acknowledgement of sexual abuse as a traumatic event; this takes post-traumatic stress disorder (PTSD) out of the often associated realm of combat veterans and into more common and insidious manifestations of trauma.
Counselors should consider the aforementioned changes to the DSM-5 in the context of their counselor identity. Maintaining professional identity and promoting a wellness- and strength-based perspective continues to be an important concern for the counseling profession and the training of counselors. Tomlinson-Clarke and Georges (2014) provide an overview of maintaining professional identity in the process of assessment and diagnosis within a system representing the medical model. A particular strength is the inclusion of how multicultural competency is crucial in using the DSM-5 effectively, which is an essential basic foundation to sound practice. Implications for counselor preparation also are a focus. Finally, Frances (2014) provides a critical commentary of how the DSM has been used by pharmaceutical companies to leverage significant profits at the cost to consumers of mental health services and our economy. As the former chair of the DSM-IV task force, Frances reminds counselors and other mental health professionals of their essential place within treatment and cautions counselors to use the DSM in a balanced manner. His comments are consistent with advocacy inherent in our profession for treatments that promote client resilience, and address psychosocial and environmental factors that impact client functioning.
This special TPC issue on counseling and the DSM-5 provides a compilation of articles covering the history of the DSM, structural and categorical changes, the process of diagnosis, implications for practice, and cautions and criticisms. These articles validate the unique and important perspective counselors bring to their work, and challenge all mental health professionals to use the DSM-5 accurately. The DSM continues to evolve, and its advocates have made significant strides in reaching out to a variety of professionals; one manifestation of this outreach is the development of the DSM-5 website (see http://www.psychiatry.org/practice/dsm/dsm5). Counselors have the opportunity to use the DSM-5, provide feedback directly to the APA, and help shape and influence future editions of this diagnostic tool. This is an important way counselors can advocate for their clients as well as their profession, and shape how the DSM is used to help treat those suffering from mental and emotional distress.
Conflict of Interest and Funding Disclosure
The author reported no conflict of interest or funding contributions for the development of this manuscript.
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Matthew R. Buckley, NCC, is a faculty member in the Mental Health Counseling program at Walden University, Minneapolis, MN. Correspondence can be addressed to Matthew R. Buckley, Walden University, 100 Washington Avenue South, Suite 900, Minneapolis, MN 55401-2511, email@example.com.
Gary G. Gintner
The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) includes numerous alterations to specific disorders, as well as fundamental conceptual and organizational changes. The purpose of this article is to review three fundamental conceptual changes in DSM-5: the harmonization of the manual with the International Statistical Classification of Diseases and Related Health Problems, the introduction of spectrum disorders and dimensional ratings, and the new organization of the manual. For each change, potential benefits and shortcomings are discussed in terms of innovation, limitations and clinical implications.
Keywords: DSM-5, ICD-10, classification, diagnosis, spectrum disorders
The DSM is probably one of the most widely referenced texts in the mental health field. Considering this scope of influence, the release of its latest edition, DSM-5 (American Psychiatric Association [APA], 2013), has garnered considerable interest among professionals, patient advocacy groups and the public alike (Paris, 2013). Reactions have ranged from enthusiastic support (McCarron, 2013) to concern (Welch, Klassen, Borisova, & Clothier, 2013) and even calls to reject the manual’s use outright (Frances, 2013; Frances & Widiger; 2012). The strength of this reaction—both positive and negative—reflects the scope of change. DSM-5 attempts to integrate almost 20 years of burgeoning research in psychopathology, classification and treatment outcomes that have emerged since the publication of DSM-IV (APA, 1994), the last major revision of the manual’s criteria sets. While DSM-5 has made numerous alterations to specific disorders, fundamental conceptual and organizational changes have had the most substantial impact on reshaping the manual (APA, 2013; Regier, Kuhl, & Kupfer, 2013).
The purpose of this article is to review three of these fundamental conceptual changes: the harmonization of the manual with the ICD, the introduction of spectrum disorders and dimensional ratings, and the new organization of the manual. For each of these innovations, three questions will be addressed. First, what was the basis for introducing the change as an innovation to the manual? Here the rationale and potential contribution of the change will be discussed. Special attention will be paid to issues such as enhanced diagnostic accuracy, coverage and clinical utility. Second, does the innovation have any potential drawbacks or limitations? For example, to what extent could the innovation contribute to over or underdiagnosis, limit access to treatment, or pose some harm like increased stigmatization? Third, what are the practical consequences of the innovation relative to how clinical mental health counselors provide care for their clients? This section considers the impact on day-to-day practice and how the diagnostic process itself may be transformed. The conclusion section ties these three threads of innovations together and discusses implications for mental health practice in the 21st century.
DSM and ICD Harmony
There are two major classification systems for mental disorders: the DSM, used primarily in North America, and the ICD, used worldwide under the auspices of the World Health Organization (WHO). The ICD is a much broader classification encompassing causes of death, illness, injury and related health issues with one chapter dedicated to mental and behavioral disorders (Stein, Lund, & Nesse, 2013). As part of the United Nations Charter, countries around the world have agreed to use the ICD codes to report mortality, morbidity and other health information so that uniform statistics can be compiled. In the United States, the ICD codes are the official codes approved by the Health Insurance Portability and Accountability Act (HIPAA), which are used by insurance companies, Medicare, Medicaid and other health-related agencies (Goodheart, 2014). The code numbers that the DSM has always used are derived from whatever the official version of ICD is at that time. Currently, the ninth revision of the ICD (ICD-9; WHO, 1979) is the official coding system in the United States. The 10th revision of the ICD (ICD-10; WHO, 1992/2010) is scheduled to go into effect on October 1, 2015.
The DSM and ICD classifications of mental disorders have a number of similarities, but also have important differences. Both are descriptive classifications that categorize mental disorders based upon a constellation or syndrome of symptoms and signs. Symptoms are the client’s reports of personal experiences such as feeling sad, anxious or worried. Signs, on the other hand, are observable client behaviors such as crying, rapid speech, and flat affect. Structurally, both manuals group related mental disorders into either chapters (DSM) or diagnostic blocks (ICD). The names and diagnostic descriptions for many of the mental disorders in the ICD are similar to those in the DSM, a consequence of collaboration over the years and a shared empirical pool from which both have drawn.
Despite these similarities, there are significant disparities. First, DSM criteria are very specific and detailed, while the ICD relies more on prototype descriptions with less detailed criteria and minimal background information to guide the diagnostic process (First, 2009; Paris, 2013; Stein et al., 2013; WHO, 1992). Second, since DSM-III (APA, 1980), the DSM has used a multiaxial system that notes not only relevant mental and medical disorders, but also other diagnostic information such as environmental factors (Axis IV) and level of functioning (Axis V). The ICD, on the other hand, has always employed a nonaxial system that simply lists medical disorders, mental disorders, and other health conditions. These differences in complexity reflect the constituencies that each manual is designed to serve: The DSM is primarily used by licensed mental health professionals with advanced degrees, while the ICD needs to be accessible to a range of health care professionals worldwide with a broad range of educational backgrounds (Kupfer, Kuhl, & Wulsin, 2013; WHO, 1992).
A third discrepancy is that the names and descriptions for many disorders differ, which at times reflects marked conceptual differences (First, 2009). For example, in ICD-10 (WHO, 1992) bulimia nervosa has to be characterized by a “morbid dread of fatness” (p. 179), a concept akin to anorexia, while DSM-IV-TR (Text Revision; APA, 2000) requires that self-evaluation be “influenced” (p. 549) by only body shape or weight. As another example, the definition of the type of trauma that qualifies for post-traumatic stress disorder (PTSD) is much broader in ICD-10 (allowing for events that are exceptionally threatening or catastrophic) than in DSM-IV-TR (requiring that the event must be associated with actual or threatened death, serious injury, or threat to the physical integrity). These ICD-DSM disparities have led to difficulties comparing research results, collecting health statistics, communicating diagnostic information and reaching similar diagnostic decisions (APA, 2013; First, 2009; Widiger, 2005). Like conversing in two different languages, the diagnosis has often been lost in translation.
From the outset of the DSM-5 development process there was a concerted effort to address these disparities. Joint meetings of representatives from APA and WHO met regularly throughout the process in an effort to make the manuals more compatible (APA, 2013; Regier et al., 2013). The goal was to find ways of harmonizing structural, conceptual and disorder-specific differences. The results of this process have had immediate effects on the look of DSM-5 and will have long-term effects on the harmonization of DSM-5 with the upcoming ICD-11, expected to be released in 2017 (APA, 2013; Goodheart, 2014).
The most significant impact of the harmonizing effort is the discontinuation of the multiaxial system in DSM-5. Axes I–III, the diagnostic axes (APA, 2000), are now collapsed into a nonaxial system, consistent with the ICD format. Psychosocial and environmental problems (formerly Axis IV) can be noted using ICD-10’s codes for problems and situations that influence health status or reasons for seeking care. These are usually referred to as Z codes and were formerly termed V codes in DSM-IV-TR. Axis V’s Global Assessment of Functioning (GAF) has been removed and replaced by an ICD measure for disability, the World Health Organization Disability Assessment Schedule (WHODAS) 2.0 (APA, 2013). Unlike the GAF, however, this rating is not required and serves only as an ancillary tool.
The following is an example of how a DSM-5 diagnosis might be listed using ICD-9’s nonaxial system in ICD-9:
296.42 Bipolar I disorder, current episode manic, moderate severity, with mixed features
307.83 Borderline personality disorder
V62.29 Other problem related to employment
The order of diagnoses would indicate that the bipolar disorder was the principal diagnosis and either the focus of treatment or reason for visit. In this example, borderline personality disorder is a secondary diagnosis. The V code is noted because it is an important area to target in the treatment plan.
There were three major reasons for abandoning the multiaxial system. First, health professionals in general medicine found it difficult to use because it was so different from the ICD format (Kupfer et al., 2013). Second, the multiaxial system contributed to the idea that mental disorders were qualitatively different from medical disorders, a dated dualistic distinction between mind and body (APA, 2013; Kupfer et al., 2013; Lilienfeld, Smith, & Watts, 2013). Third, research had shown that distinctions between Axes I and II were artificial and did not reflect that these axes actually overlapped considerably (Lilienfeld et al., 2013). Thus, the multiaxial system seemed to create artificial distinctions that did not seem valid (Lilienfeld et al., 2013). The ICD, on the other hand, offered a more simplified system that allowed a diverse group of health professionals to code disorders using a similar format.
Substantial harmonization of the manuals, however, will happen in the future. Not much could be done with harmonizing ICD-10 (WHO, 1992), a manual of the DSM-IV (APA, 1994) era, the organization and conceptual framework of which were well established (APA, 2013; Goodheart, 2014). The forthcoming ICD-11 will adopt much of DSM-5’s organizational restructuring (discussed below) and include a number of the new DSM-5 disorders (APA, 2013; Goodheart, 2014).
Despite the potential contribution of this harmonization, there are three major drawbacks to consider. First, the loss of the multiaxial system may compromise the richness of the diagnostic assessment. In a sense, the multiaxial system was holistic in that it provided a way of noting prominent psychiatric conditions, maladaptive personality functioning, medical conditions, relevant stressors and environmental problems, and overall functioning. What will prompt clinicians to consider these important domains remains unclear. Noting V codes and assessing disability using the WHODAS 2.0 may be an alternative. However, these tasks are not required in the diagnostic workup and, if history is any guide, will probably be underutilized.
A second consideration is that consilience with the ICD clearly makes the DSM-5 a “medical classification” (APA, 2013, p. 10) and as David Kupfer, the Task Force Chair of DSM-5, has put it, “psychiatric disorders are medical disorders” (Kupfer et al., 2013, p. 388). The DSM espouses that it is atheoretical (APA, 2013; Lilienfeld et al., 2013), but the momentum is clearly swinging toward the central role of biological factors. This risks a reductionistic conceptualization of mind as simply brain. Alternative perspectives that recognize the importance of contextual, psychological, developmental and cultural factors, fundamental to the mental health counseling tradition (Gintner & Mears, 2009), may suffer as a result. The picture is more ominous considering the National Institute of Mental Health’s initiative, Research Domain Criteria (RDoC), designed to develop the next generation of psychiatric classification based upon underlying etiology of “brain disorders” (p. 749) and the identification of biomarkers (e.g., laboratory tests) to direct treatment selection (Insel et al., 2010). The direction in which the diagnostic train is heading is clear. The question is whether the track can be altered to one that is more balanced and biopsychosocial.
A third concern is that efforts to harmonize the manuals do not address many of the disparities between DSM-5 and ICD-9 or ICD-10. This is particularly true of the new disorders that DSM-5 has added, which lack clear ICD-9 or ICD-10 counterparts. The ICD codes that have been selected often do not map well onto these disorders. For example, the code for DSM-5’s hoarding disorder translates to ICD-9’s and ICD-10’s obsessive-compulsive disorder (OCD). Ironically, hoarding disorder was added because research showed that 80% of the time individuals with this condition did not meet criteria for OCD. As another example, binge eating disorder was added to DSM-5 to recognize individuals who had a pattern of maladaptive bingeing episodes, but did not have the compensatory behaviors (e.g., purging) characteristic of bulimia nervosa. The ICD code selected for this disorder was, nevertheless, bulimia nervosa. Because ICD is updated annually, it may be that more appropriate codes will be made available in future years. Thus, while ICD-DSM consilience has occurred, at least to this point, it has been superficial and restricted to the nonaxial formatting of the diagnosis. Clearly, it may enhance the curb appeal of DSM-5 to the medical community, but the real interior renovation is yet to occur, awaiting ICD-11.
The demise of the multiaxial system means that mental health counselors must be more intentionally biopsychosocial in their diagnostic assessments. More meat can be put on the bare-bones nonaxial system by systematically assessing these biological, psychological and sociocultural factors. This can be accomplished by always assessing whether any important contextual factors can be noted using the V codes, which will be termed Z codes when ICD-10 goes into effect. The WHODAS 2.0, the retired GAF, and other functioning measures can be recruited to assess impairment. While these measures are not part of the formal diagnosis, they can be noted in the chart and inform treatment planning.
Many insurance companies require a multiaxial diagnosis. The GAF score was often used to justify level of care. At the time of this writing, it is not clear what insurance companies will do with these modifications. The decision here will be important. What insurance companies require, for better or worse, often has profound impact on what clinicians do and the kind of clinical care they deliver.
Spectrum Disorders and Dimensionality
Both the DSM and ICD classify mental disorders into discrete categories. Clinicians make a yes-no decision about whether or not an individual has a disorder, based upon the particular criteria. But it has long been known that this categorical approach is fraught with problems (First & Westen, 2007; Widiger, 2005). First, comorbidity is common and there is some question as to whether comorbid conditions such as depression and anxiety are distinct or are really different expressions of some shared underlying dysfunction (Lilienfeld et al., 2013). Second, clinicians have used the not otherwise specified (NOS) category 30–50% of the time, indicating that a sizable proportion of phenomena have a varied presentation that existing categories do not capture (Widiger, 2005). This is problematic because NOS is not particularly informative in terms of describing the condition or making decisions about treatments. Finally, a categorical system assumes that each disorder is homogenous and that disorder occurs at the particular cut point. There is no recognition of subthreshold symptoms, and there is the assumption that those who do fulfill the criteria are qualitatively similar. This view is at odds with data showing that symptoms vary considerably in terms of severity and accompanying features (First & Tasman, 2004). In this sense, categorical assignment loses potentially useful clinical information about the condition and about what treatment strategies might be indicated.
DSM-5 attempts to address this issue by introducing dimensionality to supplement the categorical approach (APA, 2013). While categories indicate differences in kind, dimensions describe variations in degree (Lilienfeld et al., 2013). From this perspective, mental disorders are considered to lie on a continuum, like blood pressure. Theoretically, the spectrum can run from optimal functioning to significant impairment. Markers of morbidity or adverse outcome determine where on the spectrum the cut point for disorder is drawn. In the case of blood pressure, for example, it is 140/90. This dimensionality allows for more fine-grained determination of not only severity or impairment, but also improvement or deterioration. Over the past 30 years, research has shown that many mental disorders appear to be more dimensional and heterogeneous than suggested by ICD’s or DSM’s purely categorical system (First & Westen, 2007; Helzer, 2011; Paris, 2013).
Dimensionality is incorporated into DSM-5 in three general ways. First, DSM-5 has added several formal spectrum disorders, which combine highly related disorders. Autism spectrum disorder merges together DSM-IV-TR’s autism disorder, Asperger’s disorder, childhood disintegrative disorder and pervasive developmental disorder NOS. Research has shown that these four conditions share many common symptoms, and the differences are more a matter of degree (APA, 2013; Tsai & Ghaziuddin, 2014). Another spectrum disorder is substance use disorder, which blends the former categories of abuse and dependence. The somatic spectrum is captured by somatic symptoms disorder, which merges what was formerly somatization disorder, pain disorder and undifferentiated somatoform disorder. For each of these spectrum disorders, DSM-5 provides a severity rating as well as other specifiers to note degree of impairment and complicating features.
A second way that dimensionality is infused into DSM-5 is that severity ratings and an expanded list of specifiers have been placed within the existing categories. In a sense, DSM-5 tries to dimensionalize the category. While this was done to some extent in previous editions, DSM-5 broadens this effort throughout the manual. For example, a number of new specifiers were added to describe mood episodes such as anxious distress (presence of comorbid anxiety), mixed features (presence of symptoms from the opposite mood pole), and peripartum onset (onset of symptoms sometime during pregnancy through one month post-delivery). The addition of these notations can be helpful in making treatment-planning decisions (First & Tasman, 2004). For example, severity ratings are an important consideration in deciding whether to use psychotherapy or medication for the treatment of major depressive disorder (APA, 2010). Feature specifiers like anxious distress and mixed features have been shown to increase suicide risk and portend a more complicated treatment regime (APA, 2013; Vieta & Valentí, 2013).
A third way that dimensionality is being promoted in DSM-5 is through the availability of a variety of online assessment measures (APA, 2014). These are rating scales that fall into three general categories. First, there are disorder-specific measures that correspond closely to the diagnostic criteria. These measures could be used to buttress the more clinical assessment that relies on the diagnostic criteria. They could also provide a means of assessing the client’s baseline and response to treatment over time. Measures are available for a range of disorders including depression, many of the anxiety disorders, PTSD, acute stress disorder and dissociative symptoms. Versions are available for adults as well as children aged 11–17. Most of these are self-completed but some are clinician-rated. A second type of measure is the WHODAS 2.0, discussed earlier, which assesses domains of disability in adults 18 and older. A third type of measure is referred to as cross-cutting symptom measures (CCSM). Similar to a broadband assessment of bodily systems in medicine, these measures assess common psychiatric symptoms that may present across diagnostic boundaries and may be clinically significant to note in the overall treatment plan. Level 1 CCSM is a brief survey of 13 domains of symptoms (e.g., depression, anxiety, psychosis, obsessions, mania). A more in-depth Level 2 assessment measure is available for a domain that indicates a significantly high rating. These measures can be reproduced and used freely by researchers and clinicians and can be downloaded at http://www.psychiatry.org/practice/dsm/dsm5/online-assessment-measures. Use of these types of measure is hoped to add surplus information that can aid diagnosis, case monitoring and treatment planning.
Dimensions are not only intuitively appealing, but also seem to be a better reflection of nature (Lilienfeld et al., 2013). Notwithstanding, serious concerns have been raised. First, determining the appropriate cut point on these dimensions is critical in terms of determining true psychopathology. If the bar is set too low, there is a danger of pathologizing normal behavior. If set too high, those who need treatment may be excluded and denied services. At this point, data suggest that at least for autism spectrum disorder and substance use disorder, the bar might be set too high. For both, DSM-5 criteria tend to miss people on the more benign end of the spectrum. For example, those who formerly might have been diagnosed with mild to moderate Asperger’s, pervasive developmental disorder NOS, or substance abuse may no longer qualify for a diagnosis (Beighley et al., 2013; Mayes, Black, & Tierney, 2013; Peer et al., 2013; Proctor, Kopak, & Hoffmann, 2013). On the other hand, Frances (2013) has suggested that the threshold for somatic symptoms disorder is set too low, pathologizing many with normal worry about their medical illnesses.
A second concern is that lumping mild and more severe disorders into a unitary spectrum disorder can have unintended social effects, especially for people on the more benign end of the spectrum. For example, those who formerly were diagnosed with Asperger’s disorder will now be labeled with autism spectrum disorder. A college student who was diagnosed with alcohol abuse using DSM-IV-TR criteria will now carry the same diagnosis as someone who is considered an alcoholic and dependent (Frances, 2013). One unanswered question is the impact of these types of name changes on perceived stigma and consequent help seeking.
A final concern is that the dimensional measures were released prematurely without adequate testing and without sufficient guidelines for their use (Jones, 2012; Paris, 2013). While some of the measures are well established (e.g., Patient Health Questionnaire [PHQ]-9; APA, 2014), others have little to no psychometric support (e.g., Clinician-Rated Severity of Autism Spectrum and Social Communication Disorders). Scoring guidelines are made available, but information about the measure’s psychometric properties and norming are lacking. There also is no information on who is qualified to use these measures and what type of training they should have. Thus, while dimensionality may be an important innovation in the development of the DSM classification system, there are significant challenges ahead in calibrating these dimensions, refining the measures and considering social consequences.
Will dimensionality help or hinder the diagnostic process? On one level, the additional information about the condition may shift counselors’ fundamental way of thinking about treatment from “curing” clients (dichotomous) to helping them move toward more optimal points on the spectrum (dimensional). The availability of dimensional measures has the potential of improving diagnostic accuracy and providing a measure of treatment outcome (Segal & Coolidge, 2007). It may open the door to more measurement-based care, in which these ratings can be used to assess more precisely the need for care and the extent to which clients are profiting from treatment. This process may be more feasible to administer, score and record if these measures can be stored on tablets or mobile applications.
In terms of using these dimensional measures, however, the unanswered question is—at what cost? Clinicians are already busy, and anything that encumbers that process even more will be resisted (Paris, 2013). Criteria sets are now a bit more complex to navigate because of the added severity rating and feature specifiers. It will take considerable time to learn and master the range of measures that have been posted online, much less research their psychometric appropriateness for the situations in which they will be used. The wild card is whether managed care will require these types of measures as a way of documenting need for treatment and response to provided services. At this point, clinicians would be best served to proceed cautiously, ensuring that the measures they use are reliable and valid for the client population intended.
The New Organization of DSM-5
How was it decided in previous editions of the DSM which chapters to include and which disorders to place in each of them? While some research guided this process, tradition and clinical consensus were the primary sources that informed the organization of these earlier manuals (First & Tasman, 2004; Regier et al., 2013; Widiger, 2005). DSM-5 took a radically different approach, drawing upon research that examined how disorders actually cluster together. In this section, the new framework is examined and potential benefits and costs discussed.
The DSM-5 manual is divided into three major sections. Section I provides an introduction, a discussion of key concepts such as the definition of a mental disorder, and guidelines for recording a diagnosis. Section II is the meat of the manual and contains all the mental disorders and other conditions that can be coded with their diagnostic criteria and background information. Section III includes tools for enhancing the diagnostic process, such as some of the dimensional measures discussed earlier, the WHODAS 2.0, and a Cultural Formulation Interview designed to assess the impact of culture on the clinical presentation. This section also includes a list of proposed mental disorders that require further study (e.g., Internet gaming disorder) and an alternative system for diagnosing personality disorders.
Table 1 lists DSM-5’s major categories (chapters) of mental disorders. Two general principles determined the sequence of chapters and the placement of disorders within chapters. First, disorders were grouped into similar clusters based upon shared underlying vulnerabilities, risk factors, symptoms presentation, course and response to treatment (APA, 2013). Groups that are positioned next to each other share more commonalities than those placed further apart. For example, bipolar disorder follows schizophrenia spectrum because they share a number of vulnerability factors (APA, 2013). Next to bipolar disorder is the chapter on depressive disorders. However, the sequence of chapters indicates that depressive disorders are more distantly related to schizophrenia spectrum. Next, internalizing disorders characterized by depression, anxiety and somatic symptoms are listed in adjacent chapters because of common risk factors, treatment response and comorbidity (APA, 2013). Externalizing disorders, noted by their impulsivity, acting out and substance use, are placed in the latter part of the manual.
Sequence of Chapters in Section II
|Neurodevelopmental DisordersSchizophrenia Spectrum and Other Psychotic DisordersBipolar and Related DisordersDepressive DisordersAnxiety Disorders
Obsessive-Compulsive and Related Disorders
Trauma- and Stressor-Related Disorders
Somatic Symptom and Related Disorders
Feeding and Eating Disorders
Disruptive, Impulse Control, and Conduct Disorders
Substance-Related and Addictive Disorders
Other Mental Disorders
Medication-Induced Movement Disorders and Other Adverse Effects of Medication
Other Conditions That May Be a Focus of Clinical Attention
This shared commonality principle is also evident in the placement of disorders within chapters. As a result, a number of disorders have been transferred to different chapters. For example, DSM-IV-TR’s chapter on sexual and gender identity disorders contained sexual dysfunctions (e.g., premature ejaculation), paraphilias (e.g., exhibitionism) and gender identity disorder. Research showed that these three were not highly related, so they have been moved into different chapters, each of which is more proximally located to related disorders (APA, 2013). As another example, DSM-IV-TR’s anxiety disorders chapter has been divided into three separate chapters: anxiety disorders that are more fear-based (e.g. phobias); obsessive-compulsive and related disorders, which are characterized by preoccupations and repetitive behaviors (e.g., body dysmorphic disorder); and trauma- and stressor-related disorders. The latter is akin to a stress-response spectrum that ranges from severe reactions like PTSD to milder reactions characteristic of an adjustment disorder. It is hoped that these organizational changes will help clinicians locate disorders as well as identify related comorbidities (APA, 2013).
A second organizational principle is that the DSM-5 framework reflects a life-span perspective, both across and within chapters. Neurodevelopmental disorders (e.g., autism spectrum disorder, attention-deficit/ hyperactivity disorder [ADHD]) are listed first because they typically emerge early in life. Schizophrenia spectrum disorders also frequently have antecedents that manifest themselves in childhood (APA, 2013). Next are disorders that usually appear in adolescence and early adulthood, such as bipolar disorders, depressive disorders and anxiety disorders. In the middle and back of the manual are disorders that emerge in adulthood or late adulthood, such as personality disorders and neurocognitive disorders (e.g., dementia related to Alzheimer’s disease).
A developmental perspective also is infused into the organization of each chapter. DSM-IV-TR’s chapter on disorders of infancy, childhood and adolescence has been eliminated, and these disorders have been redistributed throughout the manual into relevant chapters. Each chapter is developmentally organized with disorders that emerge in childhood listed first, followed by those that appear in adolescence and adulthood. For example, oppositional defiant disorder and conduct disorder have been moved to the beginning of the chapter on disruptive, impulse control and conduct disorders. In addition, the criteria sets now include developmental manifestations of symptoms. For example, the ADHD criteria set includes both child and adult examples of the various symptoms. There also is an expanded section on development and course for each of the disorders, which explains how symptoms typically unfold over the life span. It is hoped that these types of changes will help clinicians recognize age-related manifestations of symptomatology (Kupfer et al., 2013; Pine et al., 2011).
The intent of the DSM-5 initiative was to develop a more valid organizational structure grounded in research. In the end it also may help to uncover common etiological factors—the holy grail of classification efforts (Insel et al., 2010; Stein et al., 2013). Certainly, these changes will help with differential diagnosis. The organization provides a better map of the relationship between disorders and how the diagnostic landscape may change over the life span.
The new organization of the DSM-5 has been generally well received (Stein et al., 2013). One major concern that has been raised, however, is the decision to dismantle the chapter on child and adolescent disorders (Pine et al., 2011). Now there is not one place where the range of childhood disorders is listed. The neurodevelopment disorders—the remnant of the former child and adolescent chapter—is largely limited to disorders that manifest with early developmental delays and problems with language, learning, motor behavior, thinking or attention. Missing, however, are a broader range of behavior problems and anxiety disorders that the former chapter included. The problem is that many of these disorders can co-occur. For example, about 30–50% of children with conduct disorder have a specific learning disorder (Gintner, 2000). The wide separation of conditions such as these in the manual may interfere with accurate detection, especially among those who are not familiar with child and adolescent disorders.
Mental health counselors have a new organization to master. Anecdotally, probably one of the most common comments I hear about the new manual is, “Where do I find X now?” Understanding the new organization of the manual will require more than simply looking over the new structure. It will be critical to read the manual to understand why disorders were grouped in a particular chapter. Chapters that are either newly introduced in the manual or that were significantly altered will certainly need to be carefully reviewed. These include the chapters on neurodevelopmental disorders, obsessive-compulsive and related disorders, trauma- and stressor-related disorders, substance-related and addictive disorders, and neurocognitive disorders.
Importantly, the new DSM-5 message is that the structure is designed to indicate relationships within chapters and between chapters. This is a different way of thinking diagnostically. For example, in considering possible diagnostic alternatives, the clinician can first ask this broad question: Is this on the internalizing or externalizing spectrum? If the condition seems more internalizing, then the possible chapters have been winnowed down, and progressively more specific questions can be asked to locate the disorder in the particular chapter. The organization also alerts the diagnostician that adjacent chapters may hold comorbid conditions or even unexplained subthreshold symptoms. To take advantage of this diagnostic aid, however, it will be critical for mental health counselors to learn their way around this new framework.
These conceptual changes define the new look of DSM-5. ICD’s consilience, dimensionality and the organizational restructuring have fundamentally transformed DSM-5 into a 21st-century document that reflects the current state of knowledge in the mental health profession. The good news is that these changes may make the manual a better reflection of nature (i.e., research has shown it to be more valid) compared to previous editions. As a result, the way counselors diagnose and how they think about mental disorders is changing. Hopefully, such change will not only result in better care, but will also help researchers identify the deeper etiological substrates of mental disorders.
In science, progress also can have a dark side. While the DSM-5 incorporates the latest research, the entire development process and critical review highlight the primitive state of knowledge in the profession. While the spectrums and dimensions will no doubt transform the way mental health professionals diagnose, at this point they are crude and may help certain client populations, but hurt others. Harmonization with the ICD will probably take the DSM-5 to a broader audience of health providers. But it also further medicalizes the DSM-5 and will steer it perilously close to a biologically-based classification system. It will be up to mental health counselors and allied mental health professionals to help correct the course and find the middle way exemplified in the biopsychosocial model. Until then, DSM-5’s advances will be tempered by these potential limitations.
Conflict of Interest and Funding Disclosure
The author reported no conflict of interest or funding contributions for the development of this manuscript.
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Erika L. Schmit, Richard S. Balkin
The American Psychiatric Association introduced emerging measures to the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) classification system. The authors present a primer on dimensional assessment and a review of the emerging measures endorsed by the American Psychiatric Association. The development of the emerging measures is discussed in light of the 1999 Standards for Educational and Psychological Testing and the DSM-5 criteria, showing that the measures lack conformity to various evidences of validity and lack alignment with the DSM-5 criteria. Hence, counselors should be cautious in the adoption of such measures because the measures may not augment comprehensively the categorical system of diagnosis currently endorsed by the American Psychiatric Association.
Keywords: diagnosis, dimensional assessment, DSM-5, measures, American Psychiatric Association
Historically, counselors relied on the categorical system of diagnosis employed by the American Psychiatric Association (APA) and included in the variations of the Diagnostic and Statistical Manual of Mental Disorders (DSM). Jones (2012) highlighted the introduction of dimensional measures for diagnosis in the fifth edition of the DSM (DSM-5). Whereas a categorical approach to diagnosis classifies a diagnosis as either present or absent, a dimensional approach to diagnosis entails using measures to evaluate the extent to which symptoms exist (Jones, 2012). Hence, the dimensional approach provides a continuum to evaluate symptoms, whereas a categorical system does not. The APA (2013g) affirmed that the measures in the DSM-5 are to be used in conjunction with other diagnostic materials and that they are designed to provide a dimensional approach to diagnosis, as opposed to a categorical approach. The purpose of this article is to review the dimensional measures in conjunction with diagnostic criteria and standards for psychological measures.
The dimensional approach to diagnosis does have certain advantages, such as the ability to address comorbid symptoms and an increased utility in research (Bjelland et al., 2009; Jones, 2012; Kraemer, Noda, & O’Hara, 2004). However, categorical approaches to diagnosis are more easily operationalized (Bjelland et al., 2009) and dimensional diagnoses can be converted easily to cut-points to provide a categorical system (Kraemer et al., 2004). Clinical utility is a primary concern with implementing dimensional classifications for diagnoses (Livesley, 2007). With respect to the medical model, physicians diagnose and treat an illness; hence, an illness is present (and therefore treated) or is not present. Dimensional diagnoses present a different paradigm in which a disorder exists on a continuum. If a disorder is only somewhat present, the justification for treatment often becomes ambiguous, and consequently, the processes of charting the course of the diagnosis and conducting research become ambiguous as well. However, given the propensity of researchers to utilize instruments that measure constructs on a continuum, dimensional classifications may offer a method of demonstrating variability within a diagnosis (Helzer, van den Brink, & Guth, 2006). Dimensional classifications may be more helpful in measuring symptoms related to personality disorders (Livesley, 2007), anxiety and depression (Bjelland et al., 2009), and substance use (Helzer et al., 2006), due to the employment of different treatment modalities based on symptom severity. For example, medication management may not be considered with mild depression even though it may be effective; however, it may become a stronger consideration with moderate or severe depression (Stewart, Deliyannides, Hellerstein, McGrath, & Stewart, 2012).
Livesley (2007) advocated for integrating categorical and dimensional classifications for diagnoses. However, Helzer et al. (2006) indicated that a dimensional diagnosis must be associated with the operational definition of the said diagnosis, which implies that dimensional assessments must address the appropriate content to obtain a valid measure of the intended classification (i.e., diagnosis). What follows is an overview of evidences of validity for measures and an evaluation of dimensional measures advocated by the APA (2013g).
Cross-Cutting Symptom Measures
The APA (2013g) provided a section in the DSM-5 titled “Emerging Measures and Models” (p. 729) that contained “tools and techniques to enhance the clinical decision-making process, understand the cultural context of mental disorders, and recognize emerging diagnoses for further study” (p. 731). At the forefront of this section the APA introduced cross-cutting symptom measures (CCSMs), which are utilized for consideration across diagnostic symptoms. The DSM-5 only includes a few CCSMs, but the APA’s website (2014) offers access to a comprehensive list of CCSMs. CCSMs include two levels; Level 1 is concise, including 1–4 items on each domain, while Level 2 is more comprehensive, including a measure for each domain. The Level 1 CCSMs are more general measures that include symptoms across domains consistent with common diagnostic categories (e.g., depression, anxiety; APA, 2013g) and assess a wider scope of time (i.e., two weeks). The Level 1 CCSMs are designed for adults (23 items across 13 domains) or children (25 items across 12 domains). Adults and children/adolescents between the ages of 11 and 17 may complete self-report versions. A parent/guardian version is available for children between the ages of 6 and 17.
The Level 2 CCSMs are utilized after finding threshold scores from Level 1 measures. Level 2 measures contain more detailed symptom investigation that can help with diagnosis and treatment, including assessment of a shorter time period (i.e., 7 days). Level 2 measures include such symptoms as depression, anger, mania, anxiety, somatic symptoms, sleep disturbance, repetitive thoughts and behaviors, substance abuse, inattention, and irritability. Certain measures address how often the individual has been bothered by a symptom within a time period of 7 days, and others ask the individual to pick a statement in a cluster that best represents the way he or she has been feeling within the past 7 days. Similar to the Level 1 measures, adults and children/adolescents between the ages of 11 and 17 may complete a self-report version; a parent/guardian version is available for children between the ages of 6 and 17. These measures are to be used at the early stages of treatment and throughout the treatment process.
When comparing the Level 2 measures advocated by the APA (2013g) to the emotional and behavioral symptoms included in the DSM-5 diagnoses, many crucial criteria are absent, thereby inadequately addressing validity evidence based on test content. This dearth of missing criteria may indicate a lack of consistency between the measures and the DSM-5 diagnostic criteria. Furthermore, the Level 2 measures focus more on specific symptoms than on actual diagnoses. For example, the CCSMs include assessments of anger, which is a symptom of many disorders in the DSM-5, but not a disorder itself. In addition, common psychometric properties, such as the reporting of reliability estimates of the scores, are not readily apparent, if published at all. Therefore, standards related to the alignment of the instruments with DSM symptoms (i.e., evidence based on test content) are circumspect. As Helzer et al. (2006) reported, the dimensional approach to diagnosis must align with the definition of the diagnosis in the DSM-5.
Connecting Validity Standards to CCSMs
Pertinent to the utilization of the emerging measures for the purposes of diagnosis and clinical decision making is the extent to which the measures align with diagnostic criteria and are useful. The American Educational Research Association (AERA), the American Psychological Association, and the National Council on Measurement in Education (NCME) jointly publish the Standards for Educational and Psychological Testing. AERA et al. (1999) outlined issues related to instrument development, fairness and bias, and application of results to various settings (e.g., educational, vocational, psychological). With respect to evaluating research, issues of test construction, specifically evaluating validity and reliability, need to be addressed. According to AERA et al., “validity refers to the degree to which evidence and theory support the interpretations of test scores entailed by proposed uses of test” (1999, p. 9). Validity, therefore, is not simply about the alignment of an instrument with theory and research, but also about how the scores are used. The most recent edition of the standards was published in 1999, which represented the fourth edition of the joint publication and the sixth publication by at least one of the representative bodies. As of August 2013, AERA et al. approved a revision to the 1999 Standards; however, a publication date is pending the development of a new agreement regarding how the revised Standards will be managed and published (AERA et al., 2009). Thus, the 1999 Standards represent the most current edition for measurement guidelines.
AERA et al. (1999) identified five evidences for evaluating the validity of a measure: (a) evidence based on test content, (b) evidence based on response processes, (c) evidence based on internal structure, (d) evidence based on relationships to other variables and (e) evidence based on consequences of testing. Evidence based on test content is specifically related to the extent to which the items are aligned with existing theory and the operational definition of the construct. Evidence of test content often is established through documentation of a review of extant literature and expert review. Evidence based on response processes includes an analysis of how respondents answer or perform on given items. In counseling research, some documentation about how respondents interpret the items may be noted. Evidence based on internal structure refers to the psychometric properties of the instrument. For example, items on a scale should be correlated as they measure the same construct, but they should not be overly correlated, as that could indicate that the items are not measuring anything unique. Generally, factor analysis and reliability estimates are used to indicate adequate factor structure and accurate and consistent responses for scores. Evidence based on relationships to other variables is usually demonstrated through some type of correlational research in which the scores on an instrument are correlated with scores on another instrument. Hence, how an instrument correlates to another instrument provides evidence that the same construct is being measured. Evidence based on consequences of testing refers to the need to document the “intended and unintended consequences” of test scores (AERA et al., 1999, p. 16). The choice of using scores on an instrument should be aligned with theory and practice.
Evidence of Validity for the Emerging Measures
To address the psychometric properties of each of the measures is outside the scope of this article. The APA promoted various measures with common psychometric properties reported extensively in research, while other measures’ psychometric properties were not as evident (Aldea, Rahman, & Storch, 2009; Allgaier, Pietsch, Frühe, Sigl-Glöckner, & Schulte-Körne, 2012; Altman, Hedeker, Peterson, & Davis, 1997; Feldman, Joormann, & Johnson, 2008; Han et al., 2009; Livianos-Aldana & Rojo-Moreno, 2001; Storch et al., 2007; Storch et al., 2009; Stringaris et al., 2012; Titov et al., 2011). From the reported measures, fairly strong psychometric properties were apparent. However, not all of the measures promoted have extensive reports (e.g., PROMIS measures). In addition, some measures do not adequately parallel the DSM-5 diagnoses that one might expect. The following sections include detailed comparisons of emerging measures and their corresponding DSM-5 diagnoses. The overall purpose of this manuscript is to identify the measures’ level of congruency with DSM-5 criteria. Thus, counselors need to be aware that certain measures may provide different information about a disorder, and therefore, counselors should make informed choices regarding whether to follow the DSM-5’s criteria. The DSM-5 criteria are a major source for providing diagnoses; and counselors should be cautious when interpreting measures, particularly when the measures are inconsistent with DSM-5 criteria.
Emotional Measures. When comparing the symptoms on the PROMIS Emotional Distress—Depression—Short Form (PROMIS Health Organization [PHO] and PROMIS Cooperative Group, 2012g) for adults to symptoms in the DSM-5 on depressive disorders, the former seems to lack many crucial symptoms for depression (APA, 2013g). Containing eight statements—each asking how often the individual has been bothered by the symptom with a time period of 7 days—the measure lacks clarity as to what depression actually looks like. Common symptoms of depression such as lack of pleasure in activities, lack of appetite, weight loss, sleep loss, fatigue and thoughts of death are not addressed. The APA (2013g) noted that irritability can be a mood shown in children with the diagnoses. The parent and pediatric measures (PHO and PROMIS Cooperative Group, 2012h; 2012i) fail to include the aforementioned mood symptom, nor do they mention thoughts of death. Therefore, the DSM-5 criteria for depression appear to be more inclusive than the PROMIS Short Form criteria.
The PROMIS Emotional Distress—Anger—Short Form, the PROMIS Emotional Distress—Calibrated Anger Measure—Pediatric, and the PROMIS Emotional Distress—Calibrated Anger Measure—Parent (PHO and PROMIS Cooperative Group, 2012a, 2012b, 2012c) are comprised of five to six short statements (e.g. “I felt angry”) completed on a 1 (never) to 5 (always) scale. Anger is included in many diagnoses, but the closest example in the DSM-5 is the chapter titled “Disruptive, Impulse-Control, and Conduct Disorders,” whose disorders can include angry moods (APA, 2013g, p. 461). Although this chapter of the DSM-5 is most likely intended for children and adolescents, all the criteria listed in the DSM-5 for angry/irritable mood from the diagnosis of oppositional defiant disorder (ODD) are included in the PROMIS measures for anger. Furthermore, because anger is present in many diagnoses in DSM-5, all measures can be helpful in providing information on anger depiction with individuals.
The PROMIS Emotional Distress—Anxiety—Short Form (PHO and PROMIS Cooperative Group, 2012d) for adults includes seven items that measure symptoms observed in an individual experiencing anxiety (e.g., “I felt anxious,” “I felt fearful”). The adult measure examines both the feelings of anxiety and fear but, unlike the child measure, omits specific places or situations where fear or anxiety is experienced. The pediatric and parent measures (PHO and PROMIS Cooperative Group, 2012e, 2012f) are more detailed, examining a few situations and places (e.g., home and school) while the adult measure (PHO and PROMIS Cooperative Group, 2012d) examines only feelings associated with anxiety (e.g., fearful, anxious, worried). When comparing anxiety measures to DSM-5 criteria, the measures lack many important criteria, particularly the adult measure which focuses on specific feelings only.
Mania is a symptom most often seen in bipolar and related disorders in the DSM-5 (APA, 2013g). The Altman Self-Rating Mania Scale (ASRM; Altman et al., 1997) is utilized for mania depiction. The five clusters focus on happiness, self-confidence, sleep, talk and activeness. When compared to the DSM-5 criteria for mania, the ASRM is lacking in certain areas such as distractibility, racing thoughts and high-risk activity involvement (APA, 2013g). Also, the ASRM does not address the importance of an irregular mood disturbance (i.e. elevated, expansive or irritable). The measure does not encompass all symptoms needed for mania, whereas the DSM-5 criteria are more expansive.
Behavioral Measures. The somatic symptom measures, which were modified from the Patient Health Questionnaire Physical Symptoms (PHQ-15; Spitzer, Williams, & Kroenke, n.d.-a, n.d.-b, n.d.-c), examine different somatic symptoms and the frequency of each symptom in a given week. The modified somatic symptom measures inform the individual and his or her clinician of the severity of symptoms such as headaches, shortness of breath and stomach pain. The main difference between the symptoms measured by the scales and those discussed in the “Somatic Symptom and Related Disorders” chapter of the DSM-5 is that the scales do not include any analysis of the excessive thoughts and feelings associated with the somatic symptoms (APA, 2013g, p. 309). The modified somatic symptom measures tell the client or clinician if and how much a symptom is present, but unlike the DSM-5 criteria, they do not focus on the individual’s actual concern over the symptom. The DSM-5 is not focused on the child population for most somatic disorders, but it does describe the most common symptoms of somatic symptom disorder as abdominal pain, headaches, fatigue and persistent nausea. Children can exhibit somatic symptoms, but they rarely worry about these symptoms before adolescence (APA, 2013g). The adult, child and parent/guardian versions of the somatic symptom measure are similar, but with two exclusions on the child and parent/guardian version (“menstrual cramps or other problems with your periods WOMEN ONLY” and “pain or problems during sexual intercourse”; Spitzer et al., n.d.-a, n.d.-b, n.d.-c).
The PROMIS—Sleep Disturbance—Short Forms (PHO and PROMIS Cooperative Group, 2012j, 2012k, 2012l) are utilized to determine sleep issues in the past week. The measures contain such questions as “my sleep was refreshing” and “I had trouble sleeping” (PHO and PROMIS Cooperative Group, 2012j, 2012k). The sleep-wake disorders in the DSM-5 include individual discontent with sleep, which can result in distress and impairment (APA, 2013g). Therefore, the PROMIS measures lack in that they do not have statements regarding whether the sleep disturbance is affecting the individual’s life negatively. The DSM-5 (APA, 2013g) does include different manifestations of certain symptoms for children (e.g., a child may struggle to fall asleep without a caregiver). Symptoms in children can occur because of particular situations such as inconsistent sleep schedule and conditioning issues. The onset of some sleep disorders happens in late adolescence or adulthood, with the exception of narcolepsy, which has an average onset in childhood and adolescence/young adulthood. Also, nightmare disorder happens most often in children and adolescence (APA, 2013g).
The repetitive thoughts and behaviors measures, which were adapted from the Florida Obsessive-Compulsive Inventory (FOCI) Severity Scale (Part B) and the Children’s Florida Obsessive-Compulsive Inventory (C-FOCI) Severity Scale, each include five items directing the individual to rate each question. The questions are focused on time, distress, control, avoidance and interference of the thoughts or behaviors (Goodman & Storch, 1994a, 1994b). The “Obsessive-Compulsive and Related Disorders” chapter in the DSM-5 examines main symptoms such as obsessions and compulsions (APA, 2013g, p. 235). Although the DSM-5 specifically identifies the symptoms as obsessions and compulsions, the adaptations of the FOCI and C-FOCI identify the symptoms as simply thoughts and behaviors. The FOCI and C-FOCI include fairly similar symptoms of obsessive-compulsive disorder with simpler terms and language. The FOCI does not include the anxiety portion, but does ask about distress. Also, the FOCI and C-FOCI do not include a specific repetitive behaviors component (Goodman & Storch, 1994a, 1994b). For the most part these two measures are very similar. Each of the five questions is focused on the same topic; the minor difference is language. For example, the adult scale asks how much distress the thoughts/behaviors cause, while the child version asks how much they bother the child. The adult measure utilizes the word work while the child measure uses the word job (Goodman & Storch, 1994a, 1994b). The measures have components similar to DSM-5 criteria, but there are inconsistencies between the two.
The Level 2—Substance Use—Adult measure, adapted from the National Institute on Drug Abuse (NIDA)-Modified ASSIST (NIDA, n.d.-a), includes 10 items that measure how often an individual used a substance in the past two weeks. The substances included are painkillers, stimulants, sedatives or tranquilizers, marijuana, cocaine or crack, club drugs, hallucinogens, heroin, inhalants or solvents, and methamphetamine. The interviewee answers from 0–4 based on how many days the substance is used. The measure does not include alcohol, tobacco or caffeine as substances (NIDA, n.d.-a). In DSM-5, the chapter “Substance-Related and Addictive Disorders” focuses on substance addictions as well as process or behavioral addictions (APA, 2013g, p. 481). The Level 2—Substance Use—Adult measure and the criteria for substance use disorders in the DSM-5 have very little in common besides the use of a substance. The DSM-5 contains topics such as intoxication, withdrawal, social impairment, risky use, behavioral issues, psychological issues and all of their related symptoms (APA, 2013g). The possible symptoms of substance use are important to examine when treating an individual who has used a substance, and therefore the expanded criteria of the DSM-5 are necessary. The parent and child versions (NIDA, n.d.-b, n.d.-c) of the substance use measures (15 items each) are longer than the adult version (10 items). The parent and child versions include tobacco, alcohol, steroids and other medicines, while the adult version does not. None of the above measures examine caffeine use (NIDA, n.d.-a, n.d.-b, n.d.-c).
The Swanson, Nolan, and Pelham, version IV (SNAP-IV; Swanson, 2011) for inattention in children aged 6–17 is an eight-item measure answered by a parent or guardian of the child. The items can be answered on a scale of 0 (not at all) to 3 (very much). The items center on the lack of attention to certain people, items and behaviors, such as organizing tasks, paying attention to details, and being distracted (Swanson, 2011). Inattention in children is included in the attention-deficit/hyperactivity disorder in the DSM-5 (APA, 2013g, p. 59). Items 1–8 on the SNAP-IV (Swanson, 2011) are worded very similarly to the inattention items in the DSM-5 (APA, 2013g), with only minor changes. The only DSM-5 item not included in SNAP-IV regards forgetfulness of daily activities (APA, 2013g). The SNAP-IV measure and the DSM-5 criteria appear to be relatively equal in diagnostic usefulness.
The irritability measures, identified as Affective Reactivity Index (ARI; Stringaris et al., 2012), for parent/guardian of child age 6–17 and child age 11–17, contain the same items and are rated either 0 (not true), 1 (somewhat true), or 2 (certainly true). Anger is a topic used in three of the seven items. Other main topics include annoyance, temper and irritability (Stringaris et. al., 2012). The irritability measures can be compared to the “Angry/Irritable Mood” section of the ODD diagnosis in DSM-5 (APA, 2013g, p. 462). The three criteria here are included in each measure, making both resources useful.
Disorder-Specific Severity Measures. The disorder-specific severity measures are similarly complementary to diagnostic criteria in the DSM-5 and are made for those who have met or are close to meeting a diagnosis. The two types of measures included are self-administered (adult and child age 11–17) and clinician-administered. Disorders included in the self-administered measures are depression, separation anxiety disorder, specific phobia, social anxiety disorder (social phobia), panic disorder, agoraphobia, generalized anxiety disorder, post-traumatic stress symptoms, acute stress symptoms, and dissociative symptoms (APA, 2014). Disorders and symptoms included in the clinician-administered measures are autism spectrum and social communication disorders, psychosis symptoms, somatic symptom disorder, ODD, conduct disorder, and nonsuicidal self-injury (APA, 2013b, 2013a, 2013f, 2013e, 2013c, 2013d).
Generally, the disorder-specific severity measures have a different time frame for meeting criteria for symptoms than the DSM-5 does and do not discuss significant distress or proportion to danger. Few, if any, differences exist between the adult and child measures. The clinician-rated measures are short and lack clarity on definitions. For example, the measures on ODD as well as nonsuicidal self-injury do not include the construct definitions (APA, 2013e, 2013d).
Self-Administered Measures. The Severity Measure for Depression—Adult and Severity Measure for Depression—Child Age 11–17 (Spitzer et al., n.d.-d, 2002), which were adapted from the Patient Health Questionnaire-9 (PHQ-9), include nine items rated from 0 (not at all) to 3 (nearly every day) with a time period of the past 7 days. The first two items on these measures are similar to the first two symptoms needed for major depressive disorder in the DSM-5, both referring to depressed mood and decreased interest or pleasure (APA, 2013g). These measures include somewhat of a weight component similar to that of the DSM-5, although the weight items on the measures examine appetite/overeating, while symptoms in the DSM-5 examine an extra component of weight loss/gain or appetite changes. The components regarding sleeping and psychomotor symptoms, fatigue, worthlessness, concentration and thoughts of death on the measures are all similar to criteria in the DSM-5, although worded differently. Irritability is added to an item on the child measure (Spitzer et al., 2002), but was not included in the adult measure (Spitzer et al., n.d.-d). The child measure’s item on eating refers to “poor appetite, weight loss, or overeating,” (Spitzer et al., 2002) whereas the adult measure does not mention weight loss (Spitzer et al., n.d.-d); similarly, one DSM-5 criterion for major depressive disorder states, “in children, consider failure to make expected weight gain” (APA, 2013g, p. 161). In spite of a few differences, the Severity Measures for Depression are mostly consistent with DSM-5 criteria for major depressive disorder.
The Severity Measure for Separation Anxiety Disorder—Adult and Severity Measure for Separation Anxiety Disorder—Child Age 11–17 (Craske et al., 2013g, 2013h) include 10 items examining the past 7 days based on a scale of 0 (never) to 4 (all of the time). The statements focus on separation and thoughts, behaviors and feelings behind the separation (Craske et al., 2013g, 2013h). The 10 items from the measure are mostly similar to criteria for separation anxiety disorder in the DSM-5 (APA, 2013g). Items 1 and 2 on the measures (which refer to terror, fear, fright, anxiety, worry and nervousness) appear similar to the distress from separation criteria in the DSM-5 with different wording. Thoughts of bad things happening, avoidance of places, physical symptoms of anxiety and difficulty sleeping are similar criteria to those in the DSM-5. The four items included in the measures but not in the DSM-5 criteria are as follows: “when separated, left places early to go home,” “spent a lot of time preparing for how to deal with separation,” “distracted myself to avoid thinking about being separated,” and “needed help to cope with separation” (Craske et al., 2013g, 2013h). Although these measures and the DSM-5 contain similar criteria for separation anxiety disorder, the measure includes items that may not be congruent to DSM-5 criteria.
The Severity Measure for Specific Phobia—Adult and Severity Measure for Specific Phobia—Child Age 11–17 (Craske et al., 2013k, 2013l) have 10 items that include five different groups of phobias, including (a) driving, flying, tunnels, bridges or enclosed spaces; (b) animals or insects; (c) heights, storms or water; (d) blood, needles or injections; and (e) choking or vomiting. The individual completing the form chooses one phobia and answers items according to that phobia on a scale of 0 (never) to 4 (all of the time; Craske et al., 2013k, 20131). The measures include more items than the criteria in the DSM-5. Items 1 and 2 (terror, fear, fright; anxiety, worry, nervousness) on the measures resemble criterion A (fear or anxiety) in the DSM-5 for specific phobia (APA, 2013g, p. 197). Physical symptoms (e.g., racing heart, tense muscles) are not included in the DSM-5 criteria. Avoidance of a situation is included both in the measures and in the DSM-5. The items in the measures which are not included in the DSM-5 are “spent a lot of time preparing for, or procrastinating about (i.e., putting off), these situations,” “distracted myself to avoid thinking about these situations” and “needed help to cope with these situations” (Craske et al., 2013k, 2013l). The specifiers in the DSM-5 (animal, natural environment, blood-injection-injury, situational and other) are similar to phobias included in the measures (APA, 2013g, p. 198). The DSM-5 states that “in children, the fear or anxiety may be expressed by crying, tantrums, freezing, or clinging” (APA, 2013g, p. 197), and this information is not included in the child version of this measure.
The Severity Measure for Social Anxiety Disorder (Social Phobia)—Adult and Severity Measure for Social Anxiety Disorder (Social Phobia)—Child Age 11–17 (Craske et al., 2013i, 2013j) are 10-item measures completed on a scale of 0 (never) to 4 (all of the time). The social situations described in the measures are the same as those described in the DSM-5 for social anxiety disorder (social phobia; APA, 2013g). Items 1, 2 and 3 on the measures are similar to criteria A and B in the DSM-5. Physical symptoms such as racing heart and tense muscles are included in the measures but are not included in the DSM-5 criteria. Avoidance of social situations is included in both the measures and the DSM-5 criteria. There are items included in the measures that are not included in the DSM-5 criteria, such as “spent a lot of time preparing what to say or how to act in social situations” and “distracted myself to avoid thinking about social situations” (Craske et al., 2013i, 2013j). One DSM-5 criterion states that “the social situations almost always provoke fear or anxiety” (APA, 2013g, p. 202), an item which is not present in the measures. In the DSM-5 there are a few differences for children with social anxiety disorder. Anxiety has to take place with peers and not only with adults. Furthermore, fear/anxiety can be expressed through crying, tantrums, freezing, clinging, shrinking or not speaking. These differences are not included in the child version of the measure (Craske et al., 2013j).
The Severity Measure for Panic Disorder—Adult and Severity Measure for Panic Disorder—Child Age 11–17 (Craske et al., 2013e, 2013f) are 10-item measures completed on a scale of 0 (never) to 4 (all of the time). The measures provide a definition and the symptoms of a panic attack in an individual (Craske et al., 2013e, 2013f). This information is similar to the definition of panic disorder in the DSM-5 (APA, 2013g). The measures include six of the 13 symptoms included in the DSM-5. Items on the measures that are not included in the DSM-5 criteria include “left situations early, or participated only minimally, because of panic attacks,” “spent a lot of time preparing for, or procrastinating about (putting off), situations in which panic attacks might occur,” “distracted myself to avoid thinking about panic attacks” and “needed help to cope with panic attacks” (Craske et al., 2013e, 2013f). The DSM-5 includes certain symptoms that the measures do not, including choking feelings, pain in chest, nausea, sensations of chills or heat, sensations of numbness or tingling, and derealization or depersonalization (APA, 2013g, p. 208). The measures have an item on sleeping issues, which was not included in the DSM-5.
The Severity Measure for Agoraphobia—Adult and Severity Measure for Agoraphobia—Child Age 11–17 (Craske et al., 2013a, 2013b) are 10-item measures to be completed on a scale of 0 (never) to 4 (all of the time). The instructions for the measures include situations on which to base the items (e.g., being in crowds or public spaces, traveling). The criteria for agoraphobia in the DSM-5 include significant distress caused by at least two of the following five situations: “being outside of the home alone,” “using public transportation,” “standing in line or being in a crowd” and being in “open spaces” and/or “enclosed spaces” (APA, 2013g, p. 217). The fear and anxiety experienced and the avoidance of situations are included in both the measures and the DSM-5 criteria. Although avoidance is included in the measures, the reason for the avoidance is not. Items included in the measures but not in the DSM-5 criteria include “had thoughts about panic attacks, uncomfortable physical sensations, getting lost, or being overcome with fear in these situations”; “spent a lot of time preparing for, or procrastinating about (putting off), these situations”; “distracted myself to avoid thinking about these situations”; and “needed help to cope with these situations” (Craske et al., 2013a, 2013b). Also, two items on physical sensations from the measures are not present in the DSM-5 criteria (APA, 2013g; Craske et al., 2013a, 2013b).
The Severity Measure for Generalized Anxiety Disorder—Adult and Severity Measure for Generalized Anxiety Disorder—Child Age 11–17 (Craske et al., 2013c, 2013d) are 10-item scales completed on a scale from 0 (never) to 4 (all of the time). Differences are found when comparing the measures to generalized anxiety disorder in the DSM-5 (APA, 2013g). The measures do not include the following DSM-5 criteria: anxiety and worry occurring for 6 months or more, difficulty controlling worry, the anxiety and worry perhaps being associated with difficulty concentrating and irritability, and the anxiety and worry causing distress (APA, 2013g, p. 222). The measures include the following items that the DSM-5 does not: “avoided, or did not approach or enter, situations about which I worry”; “left situations early or participated only minimally due to worries”; “spent lots of time making decisions, putting off making decisions, or preparing for situations, due to worries”; “sought reassurance from others due to worries”; and “needed help to cope with anxiety” (Craske et al., 2013c, 2013d). Also, item 3 on the measures (“had thoughts of bad things happening”) is similar to criterion A in the DSM-5 (“anxiety and worry . . . about a number of events or activities”) with different wording (APA, 2013g, p. 222; Craske et al., 2013c, 2013d).
The National Stressful Events Survey PTSD Short Scale (NSESSS; Kilpatrick, Resnick, & Friedman, 2013c) contains nine items and is to be completed on a scale of 0 (not at all) to 4 (extremely). The criteria for post-traumatic stress disorder (PTSD) in the DSM-5 include a list of possible stressful events and situations (APA, 2013g). The NSESSS does not include a list of stressful events and situations for the individual. Criteria and items that are the same or similar on the NSESSS and in DSM-5 PTSD criteria include flashbacks, emotional (NSESSS) or psychological distress (DSM-5), avoidance, negative feelings about self, distorted cognitions and blame, negative emotional states, loss of interest in activities, anger and irritability, self-destructive behavior, hypervigilance and startle response (APA, 2013g; Kilpatrick et al., 2013c). The items/criteria may be worded and/or organized differently but they have the same meaning. Although all items on the NSESSS are included in the DSM-5’s criteria for PTSD, the DSM-5 includes additional criteria beyond what the NSESSS measures, which suggests the DSM-5 as being more thorough of the two, and indicates the inconsistencies of the NSESSS when compared to the DSM-5 criteria. The following criteria from the DSM-5 are not included in the NSESSS: dreams, physiological reactions, dissociative amnesia, detachment/estrangement from others, inability to experience positive emotions, concentration issues and sleep issues. There are notes in the DSM-5 for application to children. Children may partake in recurring play/reenactment having to do with the traumatic event. Dreams with unrecognizable content may occur (APA, 2013g). The criteria above were not included in the child version of the NSESSS (Kilpatrick, Resnick, & Friedman, 2013d). Also, the DSM-5 has a different section for children 6 and under, but the NSESSS is to be completed by children 11–17 (APA, 2013g; Kilpatrick et al., 2013d).
The National Stressful Events Survey Acute Stress Disorder Short Scale (NSESSS; Kilpatrick et al., 2013a) for severity of acute stress symptoms includes seven items and is to be completed on a scale of 0 (not at all) to 4 (extremely). Six out of the seven items on this measure are the same as those on the measure for PTSD above. Items that are also included in acute stress disorder in the DSM-5 are flashbacks, emotional (NSESSS) or psychological distress (DSM-5), detachment, avoidance, hypervigilance, startle response and irritability/anger (APA, 2013g). Similar to the NSESSS for PTSD, all seven items on the NSESSS for acute stress disorder are included in the DSM-5 criteria, but certain DSM-5 criteria are not included in the NSESSS. The criteria not included are as follows: dreams, inability to experience positive emotions, dissociative amnesia, sleep disturbance and concentration issues. There are notes in the DSM-5 for application to children. Children may partake in recurring play/reenactment having to do with the traumatic event. Dreams with unrecognizable content may occur. The criteria above were not included in the child version of the NSESSS (Kilpatrick et al., 2013b). Neither of the NSESSS measures fully assess an individual for the DSM-5 criteria for PTSD or acute stress disorder.
The Brief Dissociative Experiences Scale (DES-B)—Modified (Dalenberg & Carlson, 2010a) has eight items and is completed on a scale of 0 (not at all) to 4 (more than once a day) in the past 7 days. When comparing this measure to dissociative disorders in the DSM-5, it is hard to find a specific criterion that matches closely to items on the scale (APA, 2013g, p. 291). The closest criterion is found under dissociative identity disorder (DID; APA, 2013g). Although the wording is different, disruption of identity and gaps in recollections are both present in the DES-B and DSM-5 criteria for DID. Some items on the DES-B are also included in depersonalization/derealization disorder (APA, 2013g, p. 302). Both depersonalization and derealization symptoms are included in DES-B. There is one note under DID in the DSM-5 applicable to children: symptoms in children are not better justified by imaginary or fantasy play. This is not included in the child version of the DES-B (Dalenberg & Carlson, 2010b). Although items included in the measures are present in DSM-5 criteria, overall, the measures are inconsistent with DSM-5 criteria.
Clinician-Rated. The Clinician-Rated Severity of Autism Spectrum and Social Communication Disorders is a measure that assesses “the level of interference in functioning and support required as a result of: a) any social communication problems AND b) any restricted interests and repetitive behaviors” (APA, 2013b). The two disorders included are autism spectrum disorder (APA, 2013g, p. 50) and social (pragmatic) communication disorder (APA, 2013g, p. 47). The clinician must choose one of these disorders. The clinician rates the two items above (social communication and restricted interests /repetitive behaviors) based on levels 0 (none), 1 (mild; requiring support), 2 (moderate; requiring substantial support), and 3 (severe; requiring very substantial support). The measure does not go into detail about these disorders’ diagnostic criteria, but the DSM-5 offers a detailed account (APA, 2013b, 2013g). Besides simply stating the two issues above, the measure fails to include specific criteria from the DSM-5.
The Clinician-Rated Dimensions of Psychosis Symptom Severity (APA, 2013a) is a measure that rates symptoms of psychosis based on presence and severity in the last 7 days. The eight domains included in the measure are hallucinations, delusions, disorganized speech, abnormal psychomotor behavior, negative symptoms (restricted emotional expression or avolition), impaired cognition, depression and mania. The clinician rates the symptoms either 0 (not present), 1 (equivocal), 2 (present, but mild), 3 (present and moderate) or 4 (present and severe; APA, 2013a). According to the DSM-5, the five main features of psychotic disorders include delusions, hallucinations, disorganized speech, grossly disorganized or catatonic behavior, and negative symptoms (APA, 2013g, pp. 96, 99). These main features are included in the measure as well as three others. Schizophreniform disorder (APA, 2013g, p. 96) and schizophrenia (APA, 2013g, p. 99) include the five main features for criteria in the DSM-5 but not the last three included in the measure, which are impaired cognition, depression and mania (APA, 2013a). Other disorders, such as depressive or bipolar disorders with psychotic features, would include either a depressive or manic symptom (APA, 2013g, 2013a). Because the measure assesses psychosis symptoms that are consistent with DSM-5, this measure could be useful in determining severity but not consistent with any specific diagnosis.
The Clinician-Rated Severity of Somatic Symptom Disorder (APA, 2013f) includes three items in which the clinician rates somatic symptoms based on presence and severity in the last 7 days. The scale is to be completed from 0 (not at all) to 4 (very much). The main themes of the three questions are concerns, anxiety, and time and energy (APA, 2013f). The somatic symptom disorder in the DSM-5 includes the three themes above in criterion B with similar wording, but also includes criteria not present in the measure (APA, 2013g, p. 311), so the measure is again inconsistent with DSM-5 criteria.
The Clinician-Rated Severity of ODD (APA, 2013e) and the Clinician-Rated Severity of Conduct Disorder (APA, 2013c) both include only one item to assess based on the presence and severity of any ODD or conduct disorder symptoms (APA, 2013g). The scales are to be completed from level 0 (none) to level 3 (severe). The items simply state, “Rate the level or severity of the OPPOSITIONAL DEFIANT problems that are present for this individual” (APA, 2013e) and “Rate the level or severity of the conduct problems that are present for this individual” (APA, 2013c). The criteria for diagnosis are not listed in the measures but can be found under ODD and conduct disorder in the DSM-5 (APA, 2013g). Although the criteria for both are absent in the measures, APA refers clinicians to the DSM-5, which suggests that the measures completely parallel the diagnostic criteria.
The Clinician-Rated Severity of Nonsuicidal Self-Injury (APA, 2013d) is a one-item measure that examines the presence and severity of any nonsuicidal self-injury problems that have happened in the past year. The scale is to be completed based on five levels, including 0 (none), 1 (subthreshold), 2 (mild), 3 (moderate), and 4 (severe). The item simply states, “Rate the level or severity of the NONSUICIDAL SELF-INJURY problems that are present for this individual” (APA, 2013d). The symptoms are not listed but can be found under nonsuicidal self-injury in the DSM-5 (APA, 2013g, p. 803). Similarly to the previous measures stated, the APA directs clinicians to the DSM-5, which again indicates an alignment to diagnostic criteria.
Implications for Counseling Practice
The APA (2013g) endorsed dimensional assessment to be used in conjunction with categorical diagnoses. An effort to establish measurement protocols in a process often deemed rather subjective is laudable. The APA indicated that the assessment system was an “emerging” (2013g, p. 729) system, which indicates a rather circumspect decision by the APA. The DSM system represents a system of classifying diagnoses, whose current framework is 20–30 years old and widely established (Jones, 2012). Given the influence of the DSM system of diagnosis (e.g., reimbursement, research studies, treatment planning), the publication of the emerging measures that fail to meet basic standards of testing and measurement could be confusing to counselors expecting that scores of the emerging measures would provide consistent and accurate information about severity and be consistent with diagnostic classifications in the DSM-5.
The presence of validity evidence across the emerging measures is inconsistent, based on erratic reporting of psychometric information and lack of alignment with diagnostic criteria, such as what was documented regarding the disorder-specific severity measures. Although many of the measures were validated for clinical use, other measures lack this information. Perhaps the most basic critique of the system is that the publication of these measures lack alignment with the very diagnostic categories they are supposed to evaluate.
Evidence based on test content (AERA et al., 1999) is perhaps the most basic type of evidence for providing validity evidence of measures. The process entails that instruments that are developed be aligned with published research and expert review. Hence, the presence of dimensional measures that are supposed to align with the DSM-5 classification system but fail to be comprehensive in the breadth of symptoms covered could be a serious limitation of these emerging measures.
Professional counselors should be cautious in the adoption of the dimensional measures. Many quality measures already exist that adequately align with the categorical diagnostic system of the APA. For example, in the development of the Beck Depression Inventory (BDI)-II, Beck, Steer, and Brown (1996) updated the initial BDI to align with the diagnostic symptoms of depression used in the DSM-IV. The APA should follow similar processes in terms of content alignment and the collection and analysis of data to provide evidence of psychometric properties; counselors must be aware that adherence to this process was not systematically implemented. Both the CCSMs and severity measures were designed to review general symptoms commonly apparent across a broad range of clients and to “be administered both at initial interview and over time to track the patient’s symptom status and response to treatment” (APA, 2013g, p. 733). However, the variability with respect to the diagnostic classifications and absence of psychometric properties limits the potential for these measures to provide accurate and valid assessments.
The measures may be helpful in confirming clinical impressions or identifying potential problem areas that warrant further exploration. To some degree, however, counselors should be aware of potential ethical dilemmas that could arise from using the emerging measures endorsed by the APA. According to the American Counseling Association (ACA), “counselors have a responsibility to the public to engage in counseling practices that are based on rigorous research methodologies” (2014, p. 8). Clearly, the extent to which the published emerging measures represent rigorous research is at issue. APA does identify the measures as “emerging” (2013g, p. 729), thereby acknowledging the preliminary nature of the dimensional assessments. From a public health standpoint, the consequences of basing diagnoses or justifying clinical care or improvement solely on the emerging measures could be egregious. As third-party payers and managed care companies scramble to adopt the new classification system, the presence of the emerging measures could be mistaken as an endorsement for their adoption by organizations (e.g., managed care companies) that lack the understanding of the measurement and evaluation principles. The presence of the emerging measures in the DSM-5 presents an incomplete system that may not augment comprehensively the categorical system of diagnosis currently endorsed by the APA (2013g). Counselors using the emerging measures should employ other well-established measures and protocols to corroborate their clinical impressions and findings.
Counselors should be careful when interpreting the results of instruments that lack adequate empirical data to support respondent results; they should also qualify any conclusions, diagnoses, or recommendations that are based on assessments or instruments (ACA, 2014, p. 12). When emerging measures are used for diagnostic classification or to denote changes in symptoms or distress, counselors should identify the extent to which the findings from the dimensional assessment match the clinical impressions or findings from other assessment tools. Assessment tools, in general, provide information that should not stand alone (Balkin & Juhnke, 2014), and the use of the dimensional measures is not an exception to this rule.
Conflict of Interest and Funding Disclosure
The author reported no conflict of interest or funding contributions for the development of this manuscript.
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Erika L. Schmit is a doctoral student at Texas A&M University – Corpus Christi. Richard S. Balkin, NCC, is an Associate Professor and Assistant Dean at Texas A&M University – Corpus Christi. Correspondence can be addressed to Erika L. Schmit, Texas A&M University – Corpus Christi, Counseling and Educational Psychology Department, College of Education, ECDC 232, 6300 Ocean Drive, Unit 5834, Corpus Christi, TX 78412-5834, firstname.lastname@example.org.