The whispers, controversy and speculation surrounding the possible contents of the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) seemingly began as soon as professionals opened the cover to the DSM-IV text revision back in 2000. Later this month, that speculation will finally end as the American Psychiatric Association unveils the final version of the DSM-5.
Although the American Psychiatric Association recently released the manual’s table of contents online, it has otherwise kept a tight lid on the final product, leading to a large dose of guesswork concerning how changes to the DSM might affect the way that mental health professionals practice and pursue insurance reimbursement.
Counseling Today asked several American Counseling Association members who have been carefully following the development of the DSM-5 to offer their insights regarding what changes to expect and the implications these changes could have for counselors and the clients they serve.
Look who’s talking
- Brande Flamez is a core faculty member in the Counselor Education and Supervision Department at Walden University and supervises the LEAD program at the Garcia Center for at-risk youth in Corpus Christi, Texas. She serves on the American Counseling Association Governing Council, was recently elected president-elect of the Association for Humanistic Counseling and is the incoming chair of the ACA Publications Committee.
- Carman S. Gill is president-elect of the Association for Spiritual, Ethical and Religious Values in Counseling and a member of ACA’s DSM-5 Proposed Revision Task Force. She also serves as chair of counseling programs at Argosy University, Washington, D.C.
- K. Dayle Jones is associate professor and coordinator of the mental health counseling program at the University of Central Florida, where she teaches courses on assessment and diagnosis of mental disorders. She is a member of the World Health Organization’s International Advisory Group for the revision of the International Classification of Diseases (ICD-11) section on mental and behavioral disorders. A past chair of ACA’s DSM-5 Proposed Revision Task Force, she also wrote Counseling Today’s “Inside the DSM-5” column.
- Monica Kintigh is a licensed professional counselor, consultant and trainer in private practice who serves on ACA’s DSM-5 Proposed Revision Task Force. She is a past member-at-large for the American College Counseling Association and formerly worked at the Texas Christian University Counseling Center.
- Casey A. Barrio Minton is associate professor and counseling program coordinator at the University of North Texas and president-elect of the Association for Assessment and Research in Counseling. Her focus is clinical mental health counseling, and she is particularly interested in how the DSM affects the ways that counselors render services. She regularly teaches graduate-level courses in diagnosis and treatment planning.
- Paul R. Peluso chairs the ACA DSM-5 Proposed Revision Task Force. He is an associate professor in the Florida Atlantic University Department of Counselor Education and editor-in-chief of Measurement and Evaluation in Counseling and Development.
- Joshua Watson is an associate professor in the counselor education program at Mississippi State University-Meridian, where he regularly teaches courses in diagnosis and assessment in the clinical mental health specialization. He has more than 13 years of clinical experience in a number of mental health settings and is a past president of the Association for Assessment and Research in Counseling.
The DSM-5 won’t be available for purchase until later in May. What do we know about its contents with a fairly high degree of certainty?
Paul R. Peluso: One of the things that we do know for certain is that the multiaxial diagnostic system that has been in place since DSM III in 1980 is being done away with. I think this might be one of the more disorienting elements of DSM-5 for practitioners as they try to conceptualize disorders on just one axis. There has not been a lot of “official” discussion about what this will look like or how this will work, so I would bet that this could be very disconcerting initially. We will see how long it takes to get over this disorientation.
Another thing we know for certain is what the titles of diagnoses will be, and as a result, what has been included or excluded. This is because the American Psychiatric Association has released the table of contents for the DSM-5 (available at psychiatry.org/dsm5). Some of the things the table of contents revealed were that diagnoses that were rumored to be eliminated were not — for example, some personality disorders — and that other disorders were incorporated into new categories — for example, Asperger’s disorder. However, what we do not know is what the final diagnostic criteria will be.
Carman S. Gill: We know there are philosophical and structural changes to the manual, as well as changes to key diagnoses. For example, the bereavement clause has been removed from major depressive disorder, and Asperger’s is no longer a stand-alone diagnosis but part of autism spectrum disorder.
Joshua Watson: The overall layout of the DSM will be changing. Chapters will be reordered to align with the World Health Organization’s ICD-11 (International Classification of Diseases, 11th edition). Additionally, this reordering was done to position chapters based on their relatedness to one another in terms of symptoms, characteristics and diagnostic criteria. This should help those counselors who are attempting to make a differential diagnosis with their clients.
Despite much opposition, the creation of the proposed autism spectrum disorder will be appearing in the DSM-5. This new disorder collapses the previous DSM-IV diagnoses of autistic disorder, Asperger’s disorder, childhood disintegrative disorder and pervasive developmental disorder into a single diagnosis.
There had been discussion of consolidating the personality disorders into a single personality spectrum disorder, but the decision was made to hold off on that change. Although the 10 categorical personality disorders listed in DSM-IV remain, Section 3 of the new DSM encourages clinicians to further research how these disorders could better be represented and treated on a continuous spectrum.
K. Dayle Jones: The multiaxial system has been eliminated. There will be no separation of disorders that are currently identified in the DSM-IV as Axis I Clinical Disorders, Axis II Personality Disorders and Mental Retardation and Axis III General Medical Conditions. Furthermore, Axis IV Psychosocial and Environmental Problems and Axis V Global Assessment of Functioning have been removed.
Monica Kintigh: There has been more feedback solicited from professionals outside of psychiatry this time than in past revisions. There has also been an attempt to make the DSM-5 more closely linked with ICD codes.
Many of the thresholds for diagnosis have been lowered, and some diagnoses have been added that might appear to identify a wide margin of the population. There has been more of an attempt for clinicians to use assessments for diagnosis and ongoing treatment rather than categorical checklists.
Brandé Flamez: Four principles guided the revision of the DSM:
1) clinical utility, 2) research evidence, 3) continuity with previous editions and 4) no prior restraints placed on the level of change permitted between the DSM-IV and DSM-5. Keeping these four principles in mind, work groups assessed what elements do not meet the needs of clinicians. They worked on improving diagnostic criteria that are not precise, reducing “not otherwise specified” disorders, how better to assess the severity of symptoms, how to treat disorders that often occur together, such as depression and anxiety, and how to include assessment of symptoms that may not be included in the criteria.
The use of dimensional assessment will also be included. Current Axis I-III will be collapsed, and we will no longer use the Global Assessment of Functioning (GAF) scale.
Casey A. Barrio Minton: It is fair to say that the DSM-5 will include a major reorganization to align with the American Psychiatric Association’s beliefs regarding the origins and development of various mental disorders. Although specific revisions have not yet been revealed, I expect we will see a general loosening of diagnostic thresholds so that more people will meet criteria for mental disorders via DSM-5 as compared with via DSM-IV.
Many potential changes within the DSM-5 have been discussed online, in print and in the media. What potential change has grabbed your attention? Which potential changes are most likely to grab the attention of practicing counselors?
Brandé Flamez: A dimensional assessment has been included to improve the sensitivity and specificity of the criteria. It appears that these changes will help counselors recognize differences from person to person and more accurately diagnose people and lead to a more focused treatment. Currently, the DSM-IV disorders are arranged by categories that include a specific list of symptoms for each mental illness. In this system, a person either has a symptom or not, and to receive a certain diagnosis, a person would be required to have a certain number of symptoms to receive a diagnosis. If this number is not met, the disorder cannot be diagnosed. With the new dimensional approach, clinicians would rate the presence and severity of the symptoms — very severe, severe, moderate and mild — the frequency and duration. The rating system can help track our clients’ progress and document all symptoms, not just the symptoms related to the diagnosis.
In terms of diagnoses, the proposed autism spectrum disorder and posttraumatic stress disorder (PTSD) grabbed my attention. The Neurodevelopmental Disorders Work Group’s recommendation of the autism spectrum disorder has received a lot of attention in the media and literature. Current disorders such as autistic disorder, Asperger’s disorder, childhood disintegrative disorder and pervasive developmental disorder not otherwise specified will be a new category called autism spectrum disorder. The symptoms of these four disorders will represent a continuum from mild to severe instead of a simple yes-or-no diagnosis to the specific disorder.
PTSD will be included in a new chapter on trauma- and stressor-related disorders. The proposed changes include adding “directly” in Criterion A1 and that PTSD in preschool children is a subtype of PTSD instead of a separate diagnosis. Dissociative symptoms subtype has also been proposed. More attention is given to symptoms, and there will be four distinct diagnostic clusters rather than three.
Also, hoarding disorder is being added to the DSM-5.
Casey A. Barrio Minton: There has been much discussion regarding the American Psychiatric Association’s movement to dimensional assessments in addition to the more traditional categorical assessments. In particular, a number of professionals voiced concern regarding validity and reliability of new dimensional assessments which would, in essence, dictate how clinicians go about diagnosing disorders versus what symptoms they see that lead to a diagnosis.
I doubt we will see inclusion of the dimensional assessments in the DSM-5 to the degree feared by many. However, I believe it is critical that we attend to this shift in philosophy. In particular, professional counselors will benefit from understanding how to take a holistic approach to assessment, and they must be able to evaluate clinical implications of utilizing assessment measures with unknown validity.
I believe professional counselors will be anxious to see the degree to which criteria have changed for disorders most frequently diagnosed in practice: substance use disorders (and the proposed collapsing of substance abuse and dependence), mood disorders (and the proposed removal of rule-outs related to bereavement) and anxiety disorders (and the general loosening of some criteria).
Monica Kintigh: Diagnosis of any substance use disorder will no longer be divided between use and dependence. The threshold is much lower for diagnosis with alcohol use disorder, for example, which may impact college counselors.
Diagnosis of autism spectrum disorder has been broadened with discrete categories that will include what might have been diagnosed as Asperger’s in the past. Some children formerly diagnosed with Asperger’s may find a diagnosis in the communication disorders and/or under autism spectrum disorder.
Disruptive mood dysregulation disorder falls under depressive disorders. This is a childhood disorder that can be diagnosed for severe recurrent temper outbursts to common stressors.
Carman S. Gill: One major change that grabbed my attention was the price tag! The DSM-5 starts at $199 per copy. That’s a big increase and a lot for counselors to pay.
In terms of diagnoses, I wonder about the changes to substance abuse and dependence. Substance use disorders, including alcohol use disorder, are no longer characterized as abuse and dependence, but seen on a continuum of symptoms from mild to severe. This is consistent with the paradigm shift to a dimensional way of conceptualizing the DSM.
Also of note is disruptive mood dysregulation disorder. This disorder is grouped with depressive disorders and is intended for individuals ages 6-18. It is seemingly in response to repeated diagnosis of bipolar disorder in those under 18 and follows a bipolar path.
Joshua Watson: Perhaps the biggest change will be the shift to dimensional assessment of client presenting problems. Although this change has the potential to strengthen the services counselors can offer to their clients, it will represent a fundamental change from current practice and take some getting used to for counselors.
K. Dayle Jones: Many changes in the DSM-5 revised disorders involved reducing symptom requirements needed for diagnosis. Counselors may find these changes blur the boundary between normality and pathology.
Paul R. Peluso: I think one of the longer-term changes that will grab counselors’ attention is the change in the diagnosis of personality disorders. According to the last proposed revision, personality disorders were going to be assessed on five categories of functionality. Narrative prototypes that focus on the client’s experience of the particular personality issue replace the symptom-focused diagnostic criteria that we are used to. Many practitioners familiar with this believe that this might be better in the long run for clients to understand their particular personality disorder and even accept it, which is often a precursor to change.
I think another area that will catch clinicians’ attention immediately is the reported reduced thresholds for many disorders. For example, in substance use disorder and alcohol use disorder the thresholds for receiving a diagnosis were, at last report, lowered, which allows for more individuals to be identified as having a disorder. The same is reported to be true with attention-deficit/hyperactivity disorder (ADHD). In addition, with ADHD, attention-deficit disorder is no longer a separate diagnosis. To what degree this is beneficial or harmful to clients remains to be seen. Counselors will need to pay attention to this.
What specific ways might changes in the DSM-5 affect counselors?
Casey A. Barrio Minton: We are still uncertain regarding specific effects on professional counseling practice, and effects are likely to vary depending on specific work settings. For example, counselors who work with individuals previously diagnosed with autism spectrum disorders may find that their clients need to undergo new assessments to determine whether they still meet diagnostic criteria and, if so, still qualify for educational and supportive services. Counselors who work in systems that require a diagnosis of substance dependence to qualify for services might find themselves needing to find new ways to classify impairment under the new, more general, substance use disorder.
I’ve heard some counselors speculate that the anticipated loosening of diagnostic thresholds will mean that more clients are able to access services through public mental health and private insurance. But managed mental health care systems can only handle so much. If, indeed, the DSM-5 leads to “rising” rates of mental illness and, in turn, rising rates of help seeking, I suspect professional counselors will find themselves in the midst of systematic changes regarding who qualifies for what services under what circumstances.
Joshua Watson: These changes will have a significant impact on the practice of counselors. For one, this move to a dimensional-based assessment model will mean that the multiaxial diagnostic system we have used for the past 33 years will no longer be used. Under the old model, Axis I was reserved for major mental disorders, Axis II for personality disorders and mental retardation, and Axis III for medical illnesses. In the new model, these three axes are collapsed into one single axis that would include all psychiatric and medical illnesses. Additionally, the GAF score rating system commonly included on Axis V will no longer be used. This foundational change will affect the way counselors diagnose their clients, structure treatment plans and interact with managed care and other third-party reimbursement sources.
Carman S. Gill: The underlying paradigm shift will be difficult to transition to. In terms of the diagnoses I commented on earlier, I believe the transition from abuse and dependence to one continuum will result in difficulty in conceptualization and communication of diagnosis until the integration is complete, which could take years. Also, most studies on this continuum and its cutoff score indicate high rates of diagnosis of substance abuse.
Disruptive mood dysregulation disorder may be helpful for counselors struggling to conceptualize the symptoms exhibited by some younger clients. The fear, however, is that once the diagnosis is made, the likelihood of medicating the client — as opposed to trying to help the client develop coping skills and wellness behaviors — increases dramatically.
Paul R. Peluso: I think that with the DSM-5, as with a lot of medicine today, consumers are becoming advocates for themselves. They are becoming savvy about their own health care, and this will include their mental health care. As a result, if DSM-5 is not a quality product, I think we are going to see clients use the power of the Internet and social media to voice their concerns. They will become advocates for change.
Counselors will need to likewise become savvy. Whereas before, when DSM-IV or even DSM-IV-TR came out, many licensed counselors could not diagnose, today, diagnosis is within their scope of practice legally. In the past, I think counselors played a more passive role because they did not have as much of a direct role in diagnosis. Almost 20 years after DSM-IV and 13 years after DSM-IV-TR, this has changed radically. Counselors en masse are much more sophisticated in their knowledge base and training, and they have a much more active role to play in understanding the power to diagnose — and the impact of this on clients. As a result, I think you are going to see many counselors embracing their ethical obligations under the core ethical principle of justice to advocate for their clients’ needs as diagnostic criteria change.
Monica Kintigh: Counselors will need to be more aware of assessment criteria and need to learn the scaling criteria for each diagnosis, which was different for each diagnosis during the field trials. Additionally, the new DSM-5 may completely reorganize diagnosis and assessment of personality disorders.
What else do counselors really need to know about the impending release of the DSM-5? Why should they be paying attention?
K. Dayle Jones: There is confusion among all mental health professionals about when to start using the DSM-5. There is no mandated date as of yet that a counselor must begin using the DSM-5.
Monica Kintigh: At this point, we don’t really know what changes were made after the last opportunity for feedback, which was in June 2012. However, we can expect that the DSM-5 will be different enough that we will want to be attending workshops and working in consultation with others as we begin to use this tool to help us understand our clients. School counselors, who typically do not use the DSM as a diagnostic tool, will also want to be familiar with the changes to better serve the students on their campuses.
Paul R. Peluso: Counselors should pay attention for two reasons. First, I think there will be a number of changes to the reimbursement schedules from insurance companies. Now that counselors are participating in insurance reimbursement more than ever, this will be very important. Again, no one knows yet how insurance companies will react to DSM-5, nor do we know how they will react to the presumed regular updates.
On a bigger scale, counselors will need to decide whether the DSM is still a worthwhile diagnostic system or if they should migrate to another one. For example, the ICD, currently in its 10th edition, is a diagnostic system developed by the World Health Organization and used internationally. Many counselors may be unaware that the ICD is also the source for the numeric codes that are currently associated with the DSM-IV-TR diagnoses. The DSM-5 will reportedly have both the ICD-9 and ICD-10 codes associated with them. This is because not all physicians use ICD-10. However, the ICD-11 is currently under development and is scheduled to be released in 2015. The bottom line is that counselors who are concerned about DSM-5 should begin to inform themselves and look beyond the traditional diagnostic system.
Brandé Flamez: As previously mentioned, the DSM-5 will include new disorders — for example, hoarding disorder — while other disorders will be collapsed, some disorders will be removed and others will undergo a name change. It is important to understand that the only disorders that have been finalized were released in a report on Dec. 1, 2012. All other disorders are still subject to revisions until the DSM-5 comes out.
Counselors should be aware that the manual is used for assessing and diagnosing disorders; it will not include treatment for any disorder. Because most managed care companies require a DSM diagnosis to bill for services, I think counselors can benefit from starting to familiarize themselves
with the foundational changes and how these changes might affect any of their current clients.
Carman S. Gill: Like it or not, billing drives a lot of what we do in terms of diagnosis. There is not much turnaround time to become familiar with the changes. Starting now, or as soon as possible, is imperative, which is why I personally appreciate the American Counseling Association’s advocacy and information on this topic.
Joshua Watson: While many counselors may choose to use the DSM as more of a guide in their work with clients, it remains important to be current on all the new changes because most managed care companies require a DSM diagnosis to bill for services delivered. Understanding the changes and how clients should now be diagnosed using the dimensional-based approach will facilitate the counseling process for all parties involved.
Casey A. Barrio Minton: It is critical that professional counselors understand ways in which new DSM-5 criteria may influence clients’ access to services, help-seeking behaviors and mental health stigma. Some individuals may be motivated to seek services after learning that what they are experiencing is not “normal” or “healthy.” Others may be discouraged or stigmatized regarding a label indicating that they are mentally ill, even if such a label would not have been applied the day before the DSM-5 was released.
As counselors, we also need to consider emerging neurobiological evidence regarding distress, while not losing track of the holistic, strength-based and developmental foundations that make our profession unique. My favorite DSM quote comes from Amundson, and I think it is critical that we remember it now: At the end of the day, the DSM is simply a “collection of tales of suffering and complaint.” As professionals, it’s up to us to decide what we do with that suffering and complaint.
Any additional thoughts that you’d like to share?
Brandé Flamez: The release of the final version of the DSM-5 will take place May 18-22 at the American Psychiatric Association’s 2013 Annual Meeting in San Francisco. In the meantime, counselors, counselor educators and students can begin to familiarize themselves with the upcoming changes. There have been several inaccurate media reports speculating on new diagnoses that might appear, leading to confusion about the DSM-5. The DSM-5 website has a great deal of information concerning the future manual. However, one should note that the information on the website is not final, and counselors will want to familiarize themselves with the final changes in May.
Carman S. Gill: I think it is imperative that counselors have multiple learning opportunities as soon as possible to master this material. This edition of the DSM may not be what we were looking or hoping for, but it will happen. I’d rather we as a profession be ahead of the curve and be able to conceptualize — even reframe — from a counseling standpoint for the benefit of our clients.
Paul R. Peluso: As we move forward into the next few years, I believe there will be an emergence of “counselor science” — a science based on universal human questions, but from a unique counseling perspective rather than a psychological, educational or sociological one. I think it is a shame that counselors were shut out of the DSM-5 process, with limited exception in the field trials. We have the opportunity to assert our legitimacy, rather than wait for it to come from others, as we evaluate the benefits of DSM-5 from a counseling perspective.
In addition to being helpers, healers and advocates, we are also scientists. Over the last 15 or more years, our discipline has taken great strides to apply scientific rigor to evidence-based practices, outcome-informed learning and peer-reviewed empirical articles. Today, we can claim to be full-fledged scientists of counseling regardless of whether a counselor enjoys the nuances of statistical procedures or if a counselor never intends to publish a single article. As such, we have the right — and the obligation — to call into question any process or procedure, as well as its output, that does not submit to the fundamental rigors of scientific research. In the end, I believe that through this period of time, counselors may see themselves asserting their legitimacy as scientists and leading the call for change in the field.
Jonathan Rollins is the editor-in-chief of Counseling Today. Contact him at firstname.lastname@example.org.