Chapter 2 In this chapter, we highlight major structural modifications of the DSM-5 (APA, 2013), including removal of the multiaxial system and changes to chapter order; philosophical changes, such as the proposed use of dimensional and new cross-cutting assessments; and major diagnostic changes from the DSM-IV-TR to the DSM-5. To help readers better understand the revision process and the philosophy behind it, we begin with a brief description of the historical background and evolution of the DSM. The original DSM, published by the APA in 1952, was psychiatry’s first attempt to standardize the classification of mental disorders. Developed by the APA Committee on Nomenclature and Statistics, the DSM-I (APA, 1952) served as an alternative to the sixth edition of the ICD (WHO, 1949), which, for the first time, included a section for mental disorders (APA, 2000). Differing slightly from the ICD, which primarily served as an international system to collect health statistics, the DSM-I focused on clinical utility and was grounded in psychodynamic formulations of mental disorders (Sanders, 2011). This version highlighted prominent psychiatrist Adolf Meyer’s (1866–1950) psychobiological view, which posited that mental disorders denoted “reactions” of the personality to biological, psychological, or social aspects of client functioning (APA, 2000). The DSM-I included three categories of psychopathology (organic brain syndromes, functional disorders, and mental deficiency) and 106 narrative descriptions of disorders in about as many pages. Only one diagnosis, adjustment reaction of childhood/adolescence, was applicable to children (Sanders, 2011). Meyer’s influence was abandoned in the initial revision of the DSM-II published in 1968. This version contained 11 categories and 182 disorders (APA, 1968). Similar to the previous version, the development of the DSM-II coincided with the development of the WHO’s (1968) revised ICD-8. Although only incremental changes were evident, the focus of the manual shifted from causality to psychoanalysis, as evidenced by the removal of the word reactions and retention of terms such as neuroses and psychophysiologic disorders (Sanders, 2011). With the intent on reform, this shift was significant because separation meant removing unverified or speculative diagnoses from the manual. Critics, however, argued that actual separation of diagnostic labels from etiological origins would not actually occur until the next revision (Rogler, 1997). Work on the third version, DSM-III, began in 1974 and continued until the edition was published in 1980. A considerable divergence from previous editions, the DSM-III represented a dramatic shift with inclusion of descriptive diagnoses and emphasis on the medical model (APA, 1980; Wilson, 1993). This profound reframing introduced a biopsychosocial model to diagnostic assessment with an emphasis on empirical evidence that represented a clear follow-through on previous attempts to separate the DSM from psychoanalytic origins. Supporters claimed “theoretical neutrality” of the DSM-III (Maser, Kaelber, & Weise, 1991, p. 271). As Rogler (1997) argued, “The DSM-III was an official attempt to abruptly, not gradually, reduce reliance on the vagaries of the diagnosticians’ subjective understandings by specifying sets of diagnostic criteria” (p. 9). With the publication of the DSM-III, mental health professionals repositioned themselves toward positivistic, operationally defined symptomatology based on specific descriptive measures (Wilson, 1993). This modification included the introduction of explicit diagnostic criteria (i.e., a checklist) as opposed to narrative descriptions. The DSM-III also introduced the multiaxial system and diagnostic classifications free from specific theoretical confines or etiological assumptions. This version integrated demographic information such as gender, familial patterns, and cultural features into diagnostic classifications (Sanders, 2011). On the basis of these philosophical changes, professional counselors began to emphasize the structured interview and insisted on empirically validating DSM-III diagnostic criteria. The age of empirically based treatments had arrived, and widespread use of the DSM-III, as opposed to the ICD-9 (WHO, 1975), became commonplace. Wilson (1993) wrote, The biopsychosocial model [alone] did not clearly demarcate the mentally well from the mentally ill, and this failure led to a crisis in the legitimacy of psychiatry by the 1970s. The publication of DSM-III in 1980 represented an answer to this crisis, as the essential focus of psychiatric knowledge shifted from the clinically-based biopsychosocial model to a research-based medical model. (p. 399) Intended only to be a minor change to the third version, the revised DSM-III-R (APA, 1987) renamed, added, and deleted categories; made changes to diagnostic criteria; and increased reliability by incorporating data from field trials and diagnostic interviews (APA, 2000; Blashfield, 1998; Scotti & Morris, 2000). Despite these innovations, the DSM-III and DSM-III-R were profoundly criticized. The manual had increased from 106 to 297 diagnoses (APA, 1987). Descriptions of Axis I disorders topped at 300 pages whereas explanations of Axis IV and V disorders totaled only two pages, leading many to question the multiaxial system (Rogler, 1997). Additionally, critics questioned field trials and claimed lack of objectivity among researchers, further contributing to strong criticism of the DSM-III and DSM-III-R. Heavy critique of the DSM-III and its revision led to relatively mild changes to the DSM-IV, published in 1994. Despite few changes, the revision process was considerable and involved a steering committee, 13 work groups, work group advisors, extensive literature reviews, and numerous field trials to ensure clinical utility. The DSM-IV (APA, 1994) included 365 diagnoses; and at 886 pages, it was almost 7 times the length of the DSM-I. A “text revision” (DSM-IV-TR) was published in 2000 and included additional empirically based information for each diagnosis as well as changes to diagnostic codes for the purpose of maintaining consistency with the ICD (APA, 2000). In the DSM-IV-TR (APA, 2000), wording of the manual was modified in an attempt to differentiate people from their diagnoses. For example, phrases such as “a schizophrenic” were modified to read “an individual with schizophrenia” (Scotti & Morris, 2000). Like their predecessors, the DSM-IV and DSM-IV-TR were heavily critiqued by helping professionals (Eriksen & Kress, 2006). Many felt the manual leaned too heavily on the medical model with its rigid classification system, despite claims of diagnostic neutrality (Eriksen & Kress, 2006; Ivey & Ivey, 1998; Scotti & Morris, 2000). Issues of comorbidity, questionable reliability, and controversial diagnoses were hot topics among critics; the multiaxial system continued to be controversial (Houts, 2002; Malik & Beutler, 2002). Because of the changing nature of how the DSM was being used and by whom, many practitioners began demanding that a more holistic or dimensional approach be used and that psychometrically sound assessments be included (Kraemer, 2007). Other critics, specifically those directly involved in writing the DSM-5, advocated for incorporating scientific advances from psychiatric research, genetics, neuroimaging, cognitive science, and pathophysiology (functional changes associated with or resulting from disease or injury) into diagnostic nosology (Kupfer & Regier, 2011). Some counselors, in particular, believed that overreliance on DSM diagnoses can “narrow a counselor’s focus by encouraging the counselor to only look for behaviors that fit within a medical-model understanding of the person’s situation” (Eriksen & Kress, 2006, p. 204). In contrast to those who support the medical model, many counselors use diagnosis as only one aspect of understanding the client. Most counselors view individuals as having strengths and difficulties across myriad emotional, cognitive, physiological, social, occupational, cultural, and spiritual areas. Counselors recognize the whole person and nurture a strength-based approach to achieve wellness, not simply reduce symptomatology. Myers, Sweeney, and Witmer (2000) defined wellness as A way of life oriented toward optimal health and well-being, in which body, mind, and spirit are integrated by the individual to live life more fully within the human and natural community. Ideally, it is the optimum state of health and well-being that each individual is capable of achieving. (p. 252) The controversial issues of rigid classification, comorbidity, questionable reliability, and controversial diagnoses were the driving force of numerous structural and philosophical changes included in the DSM-5. Information regarding these major changes is provided in the next section. The DSM-5 includes approximately the same number of disorders as the DSM-IV-TR. This goes against a popular trend within health care to increase, rather than decrease, the number of diagnoses available to practitioners (APA, 2013). Despite being similar in number, several major changes affect the manual as a whole. Unlike the previous version that was organized by 16 diagnostic classes, one general section, and 11 appendixes, the DSM-5 is divided into three sections, 20 diagnostic classes, two general sections for medication-induced problems and other conditions that may be a focus of clinical attention, and seven appendixes. It also lists two sets of ICD codes, using ICD-9-CM (CDC, 1998) codes as the standard coding system with ICD-10-CM (CDC, 2014) codes in parentheses. ICD-10-CM codes are included because as of October 1, 2014, all practitioners must be in alignment with HIPAA, which requires use of ICD-10-CM codes. For more information, Part Four of this Learning Companion comprehensively reviews how diagnostic coding systems will change and implications of these modifications for counselors. Section I of the DSM-5 provides a summary of revisions and changes as well as information regarding utilization of the revised manual. Section II includes all diagnoses broken into 20 separate chapters ordered by similarity to one another. Because comorbid symptoms are clustered together, counselors can now better differentiate between disorders that are distinctively different but have similar symptom characteristics or etiology (e.g., body dysmorphic disorder vs. obsessive-compulsive disorder; acute stress disorder vs. adjustment disorder). Section III includes conditions that require further research before they can be considered for adoption in an upcoming version of the DSM, dimensional assessment measures, an expanded look at how practitioners can better understand clients from a multicultural perspective, and a proposed model for diagnosing personality disorders. Section III (see pp. 749–759 of the DSM-5) includes special attention to diverse ways in which individuals in different cultural groups can experience and describe distress. The manual provides a Cultural Formulation Interview (pp. 750–757 of the DSM-5) to help clinicians gather relevant cultural information. Expanding on information provided in the DSM-IV-TR, the Cultural Formulation Interview calls for clinicians to outline and systematically assess cultural identity, cultural conceptualization of distress, psychosocial stressors related to cultural features of vulnerability and resilience, cultural differences between the counselor and client, and cultural factors relevant to help seeking. The DSM-5 also includes descriptions regarding how different cultural groups encounter, identify with, and convey feelings of distress by breaking up what was formerly known as culture-bound syndromes into three different concepts. The first concept is cultural syndromes, a cluster of co-occurring symptomatology within a specific cultural group. The second is cultural idioms of distress, linguistic terms or phrases used to convey suffering within a specific cultural group. The third concept is cultural explanation or perceived cause, mental disorders unique to certain cultures that serve as the reason for symptoms, illness, or distress. This breakdown improves clinical utility by helping clinicians more accurately communicate with clients, so that they are able to differentiate disorders from nondisorders when working with clients from varied backgrounds. Section III of the DSM-5 also provides an alternative model for diagnosing personality disorders. This model is a radical change from the current diagnostic structure, introducing a hybrid dimensional-categorical model, which evaluates symptomatology and characterizes five broad areas of personality pathology. As opposed to separate diagnostic criteria, this proposed model identifies six personality types with a specific pattern of impairments and traits. We review this model and the Cultural Formulation section in Part Four of this Learning Companion. One of the most far-reaching structural modifications to the DSM-5 is the removal of the multiaxial system and discontinuation of the Global Assessment of Functioning (GAF) scale. Table 2.1 includes a comparison of the traditional multiaxial and the new nonaxial system. Axes I, II, and III are now combined with the assumption that there is no differentiation between medical and mental health conditions. Rather than list psychosocial and contextual factors affecting clients on Axis IV, counselors will now list V codes or 900 codes (used for conditions related to neglect, sexual abuse, physical abuse, and psychological abuse) as stand-alone diagnoses or alongside another diagnosis as long as the stressors are relevant to the client’s mental disorder(s). An expanded listing of V codes is included in the DSM-5. Although the DSM-5 does not include direction for formatting, counselors may also use special notations for psychosocial and environmental considerations relevant to the diagnosis. Similarly, counselors will no longer note a GAF score on Axis V. Rather, the DSM-5 advises that clinicians find ways to note distress and/or disability in functioning, perhaps using the World Health Organization Disability Assessment Schedule 2.0 (WHODAS 2.0; WHO, 2010) as a dimensional assessment of functioning. Again, the manual does not include directions for formatting or presenting this assessment. Table 2.1 Comparison of Multiaxial Versus Nonaxial Systems Note Counselors are not qualified to diagnose medical conditions. However, it is important to record all historical medical information. Counselors must work closely with medical professionals to identify any medical conditions. Once ICD-10-CM is implemented (October 2014), all codes in the Other Conditions That May Be a Focus of Clinical Attention chapter of the DSM-5 will change. Z codes will replace V codes, and T codes will replace 900 codes. The only exception is V62.89 borderline intellectual functioning, in which the ICD-10-CM code is R41.83. (See APA, 2013, pp. 715–727.) The advantage to dropping the multiaxial system confirms what counselors from a wellness perspective have been claiming for decades—that differentiation among emotional, behavioral, physiological, psychosocial, and contextual factors is misleading and conveys a message that mental illness is unrelated to physical, biological, and medical problems. Combining these axes has the potential to be more inclusive, embracing more aspects of client functioning. However, practitioners will need to be intentional and systematic when incorporating more holistic assessments and notations into the diagnostic process so that their diagnoses do not become a simple listing of primary DSM-5 disorders. Note The DSM-5 has dropped the GAF scale because of a lack of clinical utility and reliability. The WHODAS 2.0 (WHO, 2010) has been included in Section III of the manual. This scale is used in the ICD as a standardized assessment of functioning for individuals diagnosed with mental disorders. The DSM-5 notes, however, that “it has not been possible to completely separate normal and pathological symptom expressions contained in diagnostic criteria” (APA, 2013, p. 21). Counselors who use the WHODAS 2.0 are responsible for ensuring they do so in accordance with the ACA Code of Ethics (ACA, 2014); this includes ensuring appropriateness of instruments through review of psychometric properties, appropriateness for client population, and appropriate use of interpretation. This is particularly important because the DSM-5 does not include information regarding the validity or reliability of the WHODAS 2.0. Critics of the multiaxial system argued that the system is cumbersome and ambiguous, thus providing poor clinical utility (Bassett & Beiser, 1991; Jampala, Sierles, & Taylor, 1986; Paris, 2013). Furthermore, many clinicians will agree that although the multiaxial system was well intentioned, client reports typically stopped at Axis I. In cases where Axis II was listed, some clients would feel stigmatized by their diagnostic label (Aviram, Brodsky, & Stanley, 2006; Fritz, 2012). Enhanced attention to V codes within the nonaxial system may also help counselors emphasize a client’s entire worldview and systemic context in a way that informs the therapeutic process. If used intentionally, movement to a nonaxial system may help increase client understanding, remind counselors that medical and psychosocial issues are just as important as mental health diagnoses, and reduce stigma. Challenges of moving to a nonaxial system include conceptual lack of clarity regarding how clinicians are going to implement the nonaxial system. If clinicians struggled to use holistic assessment within a multiaxial system that essentially required some attention to psychosocial and environmental issues and overall distress and disability, will they actually take the time to incorporate these elements into a more ambiguous format? We anticipate problems with interpretation, specifically regarding the combination of Axes I, II, and III, within the counseling profession and among interdisciplinary teams. Although counselors can include subjective descriptors next to the client’s diagnosis, there is no telling whether these will carry over to the next clinician or if they will make sense to a different party. Other challenges include delays as insurance companies and governmental agencies update their claim forms and reporting procedures to accommodate DSM-5 changes. Major challenges for both counselors and clients are to be expected as helping professionals, insurance and service providers, and public or private institutions move toward nonaxial documentation of diagnosis. With these new changes, diagnoses will be cited listing the primary diagnosis first, followed by all psychosocial, contextual, and disability factors. For example, a client presents with depressive symptoms during withdrawal of a severe cocaine use disorder. She has just revealed that she is being sexually abused by her husband who just kicked her out of her home. This client would receive a diagnosis of 292.84 cocaine-induced depressive disorder, with onset during withdrawal. An additional diagnosis of 304.20 severe cocaine use disorder would also be recorded, as well as 995.83 spouse violence, sexual, suspected, initial encounter and V60.0 homelessness. Any subsequent notations related to a mental health diagnosis would follow. More information regarding recording diagnoses can be found in Chapter 17 of this Learning Companion. Overall organization of chapters within the DSM changed significantly to reflect a developmental approach to listing diagnoses. Diagnoses are now ordered in terms of similar symptomatology with presumed underlying vulnerabilities grouped together. This organization is indicative of the life-span (i.e., developmental) approach taken by the DSM-5 Task Force. Readers will notice that disorders more frequently diagnosed in childhood, such as intellectual and learning disabilities, are renamed as neurodevelopmental disorders and appear at the beginning of the manual. Diagnoses more commonly seen in older adults, such as neurocognitive disorders, appear at the end of the DSM-5. This modification more closely follows the ICD and was intended to increase practitioners’ use of the manual for differential diagnosis. Other structural changes include significant modifications to overall classification of disorders. The mood disorders section has been separated into two distinct classes: depressive disorders and bipolar and related disorders. Anxiety disorders have been broken out into three separate diagnostic chapters: anxiety disorders, obsessive-compulsive and related disorders, and trauma- and stressor-related disorders. In another large structural and philosophical change, the DSM-5 eliminated disorders usually diagnosed in infancy, childhood, or adolescence. Disorders within this section were incorporated into a new neurodevelopmental disorders chapter or, if not presumed to be neurodevelopmental in nature, relocated to other specific sections of the DSM-5. The DSM-5 Task Force justified this change because many of the disorders in this section are also seen in adulthood (e.g., ADHD; Jones, 2013), and many disorders seen in childhood may be precursors to concerns in adulthood. This section, originally created for convenience, led clinicians to erroneously believe there was a clear distinction between “adult” and “childhood” disorders. Critics felt this division was confusing and prevented clinicians from diagnosing children with “adult” disorders such as major depression or posttraumatic stress disorder (PTSD). Likewise, adults diagnosed with disorders such as ADHD have reported feeling stigmatized with limited treatment options (Katragadda & Schubiner, 2007). In terms of structure, diagnoses that were removed from this section, such as childhood feeding and eating disorders, can now be found within their associated sections, just later in the manual. For example, the feeding and eating disorders section of the DSM-5 now includes pica and rumination. Other comprehensive structural changes include the removal of labeling disorders as not otherwise specified (NOS) so practitioners can be more specific and accurate in their diagnosis. As a replacement, the DSM-5 has two options for cases in which the client’s presenting condition does not meet the criteria for a specific category: other specified disorder and unspecified disorder. The use of other specified disorder allows counselors to identify the specific reason why the client does not meet the criteria for a disorder. Unspecified disorder is used when a clinician chooses not to specify a reason for not diagnosing a more specific disorder or determines there is not enough information to be more specific. This is also supportive of dimensional, rather than categorical, classification (this idea is expanded on in the next section, DSM-5 Philosophical Changes). Finally, language throughout the DSM-5 changed so that medical conditions, previously referred to as general medical conditions, are renamed another medical condition. This change reflects the philosophical assumption that mental health disorders are medical conditions. Note Clinical judgment is the driving force for whether the client’s presenting condition should be “other specified” or “unspecified.” APA is very clear in that the use of either is the decision of the clinician. Readers will also note that the DSM-5 includes both ICD-9-CM and ICD-10-CM codes. This inclusion is a response to a mandate from the U.S. Department of Health and Human Services that required all health care providers to use IDC-10-CM codes by October 2014. To ease this transition, the DSM-5 lists both code numbers in the Appendix section. This will aid in standardization among mental health care providers and will also allow for easier transition to the new ICD-10-CM codes and revised billing processes. The following list is a summary of the major structural changes in the DSM-5:
Structural, Philisophical, and Major Diagnostic Changes
History of the DSM
DSM-5 Structural Changes
Section Overview
Cultural Inclusion
Personality Disorders
Adoption of a Nonaxial System
DSM-III and DSM-IV Multiaxial System
DSM-5 Nonaxial System
Axis I: Clinical disorders and other conditions that are the focus of treatment
Combined attention to clinical disorders, including personality disorders and intellectual disability (i.e., mental retardation); other conditions that are the focus of treatment; and medical conditions continue to be listed as a part of the diagnosis.
Axis II: Personality disorders and intellectual disability (i.e., mental retardation)
Axis III: General medical conditions
Axis IV: Psychosocial and environmental stressors
Special notations for psychosocial and contextual factors are now listed by using V codes or ICD-10-CM Z codes. An expanded list of V codes has been provided in the DSM-5. In rare cases where psychosocial and contextual factors are not listed, counselors can include the specific factor as it is related to the client’s diagnosis.
Axis V: Global Assessment of Functioning (GAF)
Special notations for disability are listed by using V codes or ICD-10-CM Z codes. The World Health Organization Disability Assessment Schedule 2.0 (WHODAS 2.0) has been included in Section III and is listed on APA’s website (www.psychiatry.org) within the online assessment measures section.
Chapter Organization
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