Neurobiological Foundations

The revision process spawned conversations regarding what constitutes a mental disorder, including new conceptualizations regarding the line between medical and mental disorder. Initially, the DSM-5 Task Force proposed a reformulation in the definition of mental disorder to be “a behavioral or psychological syndrome or pattern that occurs in an individual” and “that reflects an underlying psychobiological dysfunction” (APA, 2012; italics added). The proposed revision generated a firestorm of controversy regarding the questionable foundation upon which APA could claim all mental disorders as having psychobiological roots. Ultimately, APA rejected the proposed revision in favor of a more balanced definition in which the disturbance “reflects a dysfunction in the psychological, biological, or developmental processes underlying mental functioning” (APA, 2013a, p. 20).

Still, the DSM-5 includes enhanced attention to neurobiological foundations as evidenced by reconceptualization of most disorders usually first diagnosed in infancy, childhood, and adolescence as neurodevelopmental disorders, and most cognitive disorders as neurocognitive disorders. APA (2013a) noted one purpose of the structural reorganization as to “encourage further study of underlying pathophysiological processes that give risk to diagnostic comorbidity and symptom heterogeneity” (p. 13). It is important to remember that this reorganization was not always clear-cut and without controversy. For example, ADHD is placed with the Neurodevelopmental Disorders chapter rather than relocated to the Disruptive Behavior Disorders chapter as previously conceptualized. Throughout the DSM-5, narrative descriptions include additional attention to genetic and physiological elements of disorders.

Subtle shifts in language also reflect movement toward biological explanations of disorder within the DSM-5. As we discuss below, removal of the multiaxial system means mental disorders will no longer be differentiated from medical disorders in diagnostic formulations. In addition, APA replaced general medical condition with another medical condition throughout the DSM-5. This subtle shift implies that mental disorders are medical disorders at their core.

Ivey and Ivey (1998) were astute in their observation that “developmental orientation, however, does not rule out biological factors—rather environment interacts with personal biology. The issue is finding balance between personal and environmental factors” (p. 336). Miller and Prosek (2013) advocated for renewed attention to the impact of this movement toward biological explanations of emotional problems, especially for vulnerable populations. Certainly, emerging neuroscience research holds much promise for facilitating understanding regarding complexities of the brain, experiences, and disorder. Still, overreliance on biological explanations without attention to the interaction with personal and environmental factors could lead to increased pathologizing, unnecessary pharmacological treatments, and unknown long-term effects on clients. There is also question within the counseling community that this focus may cause counselors to stray from the profession’s humanistic roots (Montes, 2013).

For now, we urge professional counselors to seek additional training regarding neuroscience and implications for counseling and remain alert to opportunities and challenges for our profession. Scholars such as Badenoch (2008) and Siegel (2006, 2010, 2011) offer a number of trainings and readings regarding interpersonal neurobiology that are accessible to professional counselors, consistent with our professional foundations, and directly relevant to counseling practice.

Movement to Nonaxial Diagnosis

Beginning with the DSM-III (APA, 1980), the multiaxial system was designed to ensure that mental health providers were conceptualizing clients in a biopsychosocial manner. Axes I and II included psychological disorders, Axis III provided space to note medical conditions, Axis IV required attention to psychosocial and environmental stressors, and Axis V provided space for rating degree of distress and impairment in functioning. In contrast, DSM-5 (APA, 2013a) simply includes a notation that “Axis III has been combined with Axes I and II. Clinicians should continue to list medical conditions that are important to the understanding or management of an individual’s mental disorder(s)” (p. 16). In addition to listing all medical and mental health concerns as part of the diagnosis, DSM-5 users are advised to include separate notations regarding psychosocial stressors, environmental concerns, and impairments or disability.

As noted by APA (2013a), previous iterations of the DSM never required mental health providers to report diagnoses in a multiaxial manner. Still, multiaxial diagnosis quickly became part of everyday diagnostic decisions and conversations. Insurance companies frequently requested notations for each of the axes and sometimes determined level of care and progress based on Global Assessment of Functioning (GAF) ratings. Scholars concerned with cultural implications of DSM diagnosis, context of distress, and professional identity frequently pointed to Axis IV as a place where counselors could ensure attention to external influences on client wellness (e.g., Eriksen & Kress, 2006; Ivey & Ivey, 1998; White Kress et al., 2005; Zalaquett et al., 2008). Some even proposed developing an Axis VI in which practitioners could note theoretical foundations or conceptualizations (Eriksen & Kress, 2006).

Regardless of reporting formats recommended by APA, professional counselors would do well to remember that the DSM is a diagnostic guide rather than a theoretical framework or treatment manual. The removal of the multiaxial system in favor of nonaxial diagnosis need not affect how professional counselors make sense of or respond to client concerns. Rather, counselors can still conceptualize clients in manners consistent with our unique foundations, and we can still bring empowerment, strengths-based, and wellness-oriented approaches to all clients, even those who present with significant disruptions in functioning. Counselors who find the DSM-5 nonaxial diagnostic format incomplete may take steps to incorporate more holistic assessment in routine assessment and treatment planning practices. In the next two sections, we attend more specifically to logistics of coding and recording of diagnoses within the DSM-5.