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Changes in DSM-5: A Counselor Educator’s Review
By:
Debra Leggett, Ph.D. and Dr. Beverly Mustaine, Ed.D.
Abstract
The purpose of this study is to provide a basic overview of the new DSM-5 system of
classification for mental disorders, highlighting differences from the DSM-4 TR. Researchers
reviewed the rationale for the development of the new revision and provided an overview of the
new format of the DSM-5 and the new aids for new disorder conceptualizations and coding. The
researchers systematically explored the presentation of disorders, emphasizing changes in
classification and the distinct approach used to conceptualize a symptom cluster in a different
domain. The modifications in the DSM-5 are especially important to Counselor Educators,
supervisors, and doctoral students, all of whom supervise interns who need to learn the new
coding system.
Purpose of this study
The purpose of this paper is to explore the differences between the DSM-IV-TR and the
DSM-V. These differences are salient because these researchers are clinicians in private practice
and need to stay current if the field. In addition, they are Counselor Educators and supervise
beginning master’s level and doctoral level interns. Providing them with the most up-to-date
information is vital to their development as clinicians and counselors. Accomplishing this study
satisfied the requirements for a continuing education course in psychopathology diagnosis and
treatment required by the State of Florida for licensure (FL Department of Health, 2014).
Goals
For this study, the researchers will explore the new DSM-5 system of classification for
mental disorders. Initially, they will provide a basic overview of the DSM-5. They will explore
the rationale for the development of the new revision. Next, they will discuss the new format
and recommendations for use of the manual, as well as the cautions indicated by the team of
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professionals that developed it. The researchers will next look at the presentation of disorders,
noting where changes have occurred in classification and a different approach taken to
conceptualizing a symptom cluster in another domain.
Overview
The DSM was first published in 1844 as a way to organize through statistical
classification the symptoms and condition of patients in mental institutions (APA, 2013). The
primary purpose was to improve communication between health care providers about the types
of individuals being treated in these hospitals. The manual has been revised four times since
World War II, refining “a diagnostic classification system for psychiatrists, primary care
physicians, and mental health professionals” (APA, 2013, p.6). The primary purpose has not
changed; it provides a common language for describing mental disorders between providers and
greater utility in treatment planning.
Rationale
The APA determined in 1999 to evaluate the emerging research on mental disorders that
did not support former classification. In conjunction with the World Health Organization
(WHO) Division of Mental Health, the World Psychiatric Association, and the National Institute
of Mental Health (NIMH), a research agenda was developed to explore the strengths and
challenges of the classification system. These groups purposely set out to harmonize the DSM
with the International Classification of Disease (ICD), increasing the validity of the descriptions.
Thus, a shared organizational structure became a focus. An intensive six-year research plan was
implemented that included literature reviews and secondary analyses, development of new
diagnostic criteria, publication of preliminary drafts on a Web site created specifically for DSM5 public comment, publications and presentations regarding the process, field trials in which new
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criteria were tested, and final revision of criteria and text (APA, 2013, p.7). According to the
researchers, there were large areas of commonality, which demonstrated the strength of certain
areas of the body of research. Discrepancies were identified in other areas that often relied upon
clinical judgment about where the symptoms should be classified due to incomplete or even
conflicting data (APA, 2013, p. 11). Therefore, some symptom patterns that were comorbid or
exhibited shared risk factors were relocated within the classification system. For example,
attention deficit/hyperactivity disorder (ADHD) has been placed with neurodevelopmental
disorders, but there was strong data to support placing ADHD among disruptive, impulse control,
conduct disorders (APA, p. 11). The research teams understood that the current categorization
scheme might not fully capture the “complexity and heterogeneity of mental disorders” and
anticipate more changes as the DSM is aligned with the ICD-11.
New Format
The DSM-5 included formatting changes to benefit practitioners. A dimensional
approach to diagnosis was presented, capturing the “widespread sharing of symptoms and risk
factors across many disorders that is apparent in studies of comorbidity,” (APA, 2013, p. 12).
Disorders were re-grouped according to symptom traits. Within each grouping, disorders were
presented in lifespan order. When reviewing the symptoms present for each disorder,
consideration was given to cultural and gender differences to promote understanding of the
criteria within a unique cultural context. The previous five-Axial system was reformatted to
reflect current usage. These changes in format facilitate ease of use as well as diagnosis and
billing.
In consideration of the recommendations for an altered classification structure, the work
groups examined whether there were empirical findings that would scientifically validate
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possible new groupings of disorders that shared symptom traits. They identified eleven
indicators: “shared neural substrates, family traits, genetic risk factors, specific environmental
risk factors, biomarkers, temperamental antecedents, abnormalities of emotional or cognitive
processing, symptom similarity, course of illness, high comorbidity, and shared treatment
response” (APA, 2013, p. 12). The researchers suggested that these validation findings were
helpful for suggesting groupings of disorders, rather than for empirical validity for specific
disorder diagnostic criteria. These groupings are intended to inspire future research that explores
the origins of disease and the pathophysiological commonalities between disorders as well as
serving as a base for replication studies to increase the validity of findings (APA, p. 13).
In addition to developing a dimensional approach to diagnosis, the developers of the
DSM-5 infused ICD-9 and ICD-10 codes into the classification system. When DSM-5 was
published, the ICD-9 was still being widely used, but a schedule was implemented to move to
ICD-10 codes in October 2014. Due to this schedule, both ICD-9 and 10 codes are provided
before the name of the disorder in the classification and in the presentation of the specific criteria
(APA, 2013). These diagnostic and statistical codes are used for data collection and billing
purposes. In addition, the use of these codes promotes consistency internationally for recording
of the prevalence and mortality rates for identified health conditions (APA, 2013, p. 23).
Another change to provide more clinical utility was the reorganization of disorders along
developmental and lifespan approaches. The DSM-5 reader begins with consideration of
disorders that present early in life (e.g., neurodevelopmental and schizophrenia spectrum, as well
as other psychotic disorders, APA, p.13), followed by those disorders that commonly present
during adolescence into young adulthood like depressive and anxiety disorders. These changes
help the clinician clarify the boundaries between normal human functioning and dysfunction or
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pathology (Mustaine, 2013). Following the lifespan approach, the clinician then finds the
diagnoses related to adulthood and the elderly (e.g., neurocognitive disorders, APA, 2013, p. 13).
In addition, groups of internalizing or externalizing disorders, neurocognitive disorders, and
other disorders organize the chapters following neurodevelopmental disorders.
The DSM-5 developers recognized that the boundaries between normal behavior and
pathology vary across cultures, therefore tolerance for specific symptoms and behaviors will
change across social contexts. “Cultural meanings, habits, and traditions … contribute to either
stigma or support” according to the DSM authors, creating the need to consider all behavior
within the social context. In lieu of the culture-bound syndrome of the DSM-IV, this group
recommended three concepts (cultural syndrome, cultural idiom of distress, and cultural
explanation or perceived cause) to aid the clinician in cultural understanding. The cultural
syndrome is a cluster of co-occurring symptoms found within a specific cultural group. The
cultural idiom of distress is an expression or a way of speaking about suffering among a cultural
group. The cultural explanation or perceived cause may provide accepted explanations for the
etiology of symptoms within a cultural group (APA, pp. 14-15).
In addition to cultural variations, the authors of the DSM-V included sex and gender
differences as considerations to improve diagnostic specificity. Gender-specific criteria where
identified were added to the organization of symptoms. Some gender-related specifiers were
added (e.g., perinatal onset of a mood episode). A section was added to address gender-related
diagnostic issues. To further enhance clinical utility, the Not Otherwise Specified (NOS)
designation was excluded and two options provided: other specified disorder and unspecified
disorder. The first designation allows the clinician to provide an explanation for why a client
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was not given a specific disorder diagnosis due to unmet criteria. Unspecified disorder allows
more latitude when the clinician is unable to further specify the client’s presentation.
The developers of DSM-5 decided to eliminate the multiaxial system of diagnosis
(Mustaine, 2013). Instead, the three previous axes (I – Clinical Disorders, II – Personality
Disorders and Mental Retardation, III – General Medical Conditions) would now be reported as
the principle diagnosis or, if needed, a provisional diagnosis. Clinicians agreed that the main
reason a client presents for counseling is the principle diagnosis (except when the mental
disorder is caused by a medical condition), thus it would be listed first. Any additional diagnoses
would be presented in order of importance to treatment. As with previous versions of the DSM,
a provisional diagnosis is assigned when the clinician believes the criteria will be met but there is
not enough information available to make a formal diagnosis. For example, a clinician
considering Criteria B for Schizophreniform Disorder finds that “An episode of the disorder lasts
at least 1 month but less than 6 months,” APA 2013, p. 97). As the presentation of symptoms
may be currently occurring, a provisional diagnosis must be used when the clinician has to
diagnose before the client recovers from the episode (Mustaine, 2013).
As well as restructuring the first three axes into principle or provisional diagnoses, the
DSM-5 developers combined the former Axis IV – Psychosocial and Environmental Problems
(DSM-IV-TR) with Other Conditions That May Be a Focus of Clinical Attention. This
classification takes into account the psychosocial stressors and environmental factors that may
impact diagnosis, treatment, and prognosis (Mustaine, 2013).
Finally, the Global Assessment of Functioning (GAF) evaluation that was summarized on
Axis V of the DSM-IV was eliminated and replaced with the World Health Organization’s
Disability Assessment Schedule (WHODAS) (APA, 2013, pp. 745-748). The WHODAS
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Schedule 2.0 is a 36-item measure used to assess adults (ages 18 and older). It provides
information regarding function across six domains, (a) understanding and communicating, (b)
getting around, (c) self-care, (d) getting along with people, (e) life activities (home, work,
school), and (f) participation in life activities (APA, 2013, p. 745). Participants are asked to
respond to each question regarding the amount of difficulty they have completing activities on a
five point Likert-type scale ranging from 1 to 5 (1 = None, 2 = Mild, 3 = Moderate, 4 = Severe, 5
= Extreme or cannot do). The scores reported for each question are simply summed for each of
the six domains. A more complex weighted method of scoring is available through the use of a
computer program available from the WHO Web site. This approach weights responses
according to the difficulty level for each item. Then the weighted scores are summed and
converted to a z score which would be similar to the former Global Assessment of Functioning
(GAF) (on a scale of 0 – 100). The developers of DSM-5 recommended use of the measure at
regular intervals as clinically indicated to track the individual’s level of disability over time
(APA, 2013, p. 746).
Changes in Presentation of Disorders
Section II of the DSM-5 includes the diagnostic criteria and codes. It contains 20
chapters classifying disorders and two additional categories. Further reorganization was based
upon similar characteristics among disorders or how related they appear. Then, disorders were
clustered based on the presence of internalizing or externalizing symptoms. Internalizing
clusters are those that have prevalent symptoms of anxiety, depression, and somatic symptoms,
while externalizing clusters are those that involve prevalent symptoms of conduct, impulse
control, and substance use (Mustaine, 2013).
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Anxiety disorders, for example, were differentiated between externalizing symptoms and
internalizing symptoms. Internal states of excessive fear and anxiety and resulting behavioral
changes are characteristic of Anxiety Disorders. The focus of this category is on the emotional
fear response to real or perceived imminent threat or the anticipation or anxiety of future threat.
These fears are sometimes reduced by pervasive avoidance behaviors. Panic attacks may occur
as fears exacerbate. The chapter on Anxiety Disorders clearly differentiates between
developmentally normative fear or transient fear or anxiety, and fear or anxiety that is out of
proportion to the stage of development and cultural context of the client. As a result of these
changes, Reactive Attachment Disorder, Disinhibited Social Engagement Disorder, PTSD, Acute
Stress Disorder, and Adjustment Disorders are now included in Trauma and Stressor-Related
Disorders. These disorders include exposure to a traumatic or stressful event from which clients
may exhibit internalizing symptoms like fear and anxiety, but may also demonstrate anhedonic
and dysphoric symptoms, externalizing angry and aggressive symptoms, or dissociative
symptoms (APA, 2013). As mentioned earlier, the chapters are presented in lifespan order, with
disorders occurring in infants, children, and adolescents listed first in each respective chapter.
This categorization eliminated the need for the chapter on Child Disorders in the DSM-IV-TR.
Aids to Evaluate Clients
An entire section (III) is included with conditions that require future research, cultural
formulations, and other information. This approach is based upon a rapidly-growing body of
work calling for a more dimensional rather than categorical approach to diagnosis (APA, 2013).
This information provides the clinician with “tools and techniques to enhance the clinical
decision-making process” (APA, 2013, p. 733). To implement the dimensional approach
indicated from the clinical and research perspectives, the developers developed cross-cutting
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symptom measures. Following the organic medical model, it considers the subtle changes in
different symptom domains to facilitate diagnosis. The measure has two levels. In response to
Level 1 questions, adult clients answer a brief survey consisting of 23 questions over 13
symptom domains (or 12 for children). The domains are depression, anger, mania, anxiety,
somatic symptoms, suicidal ideation, psychosis, sleep problems, memory, repetitive thoughts and
behaviors, dissociation, personality functioning, and substance use (Adult) (APA, 2013, p. 735).
Severity measures corresponding to disorder criteria are collected both at the initial interview and
over time to track the symptoms and response to treatment. Adult client’s endorsing Mild or
greater symptoms may be considered for further assessment utilizing the DSM-5 Level 2 CrossCutting Symptom Measure for that domain (except for substance use, suicidal ideation, and
psychosis; APA, 2013, p. 735). In the child version, any rating of mild (i.e. 2) or greater may
indicate a more thorough assessment of those domains, except for inattention and psychosis.
Assessing for cross-cutting symptoms allows the clinician to document those symptoms
characteristic of more than one disorder without adding a second diagnosis (Mustaine, 2013).
Both versions of the Level 2 Cross-Cutting Symptom Measure can be found online at
www.psychiatry.org/dsm5.
Discussion of Changes
In the following section, the reader will find a brief discussion of the changes from DSMIV-TR to DSM-V. Changes in wording reflect the cultural change in the profession regarding
how the disorders are conceptualized.
Neurodevelopmental disorders. The category of intellectual disability or intellectual
developmental disorder has replaced the former classification for mental retardation. In line with
the purpose of the classification system, this has become the commonly accepted language
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regarding this spectrum of disorder. These clients may present with deficits in general mental
ability (e.g., reasoning, problem-solving, abstract thinking, judgment, as well as academic and
experiential learning; APA, 2013, p. 31). The individual must demonstrate a lack of functioning
in areas like independence and social responsibility, or failure to meet developmental milestones
in intellectual functioning (Global development delay). The impaired functioning may result
from an injury or a neurocognitive disorder that has been undiagnosed. In another change from
previous versions, this system of classification uses adaptive functioning, not IQ scores to
determine severity (i.e., Mild, Moderate, Severe, Profound; APA, 2013).
Schizophrenia spectrum and other psychotic disorders. Schizophrenia has been reconceptualized along a gradient of psychopathology. The term “Spectrum” is used to indicate
that some researchers are still unclear as to whether schizophrenia is one disorder or a
combination of disorders, which is why the five subtypes in DSM-IV-TR have been eliminated.
The severity criteria have been revised. Relocating these disorders to the beginning of the
manual indicates the strong relationship with neurocognitive disorders and the likelihood of a
strong genetic link among the psychotic disorders. Clients are diagnosed on the spectrum based
on the number and degree of deficits, ranging from schizotypal personality disorder to
schizophrenia; therefore, the chapter is organized from least to most severe (Mustaine, 2013;
APA, 2013, pp. 87 – 122).
All disorders in this chapter continue to be defined by the presence of one or more of the
following: delusions, hallucinations, disorganized speech, disorganized behavior (positive
symptoms), and negative symptoms. The five negative symptoms are diminished emotional
expression (replaced affective flattening in the DSM IV-TR) avolition, alogia, anhedonia, and
asociality.
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Bipolar and related disorders. Interestingly for clinicians, Bipolar and Related
Disorders fall between the Schizophreniz Spectrum and Psychotic Disorders and the Depressive
Disorders. This strategic placement recognizes the link between the two categories in terms of
symptomotology, family history, and genetics (APA, 2013). In this chapter, the clinician will
find the classification of Bipolar I and II, Cyclothymic Disorder, Substance/medication-induced
Bipolar and Related Disorder, Bipolar and Related Disorder due to Another Medical Condition,
Other Specified Bipolar and Related Disorder, and Unspecified Bipolar and Related Disorder.
Criteria for the episodes that constitute bipolar disorders remain unchanged (Mustaine, 2013).
There are two new specifiers for Bipolar I and II Disorders, With anxious distress, and With
mixed features (APA, 2013, p. 149). Subsequently, what used to be a Mixed Episode is now a
specifier (i.e., with mixed features) that can be applied to a current episode of mania, hypomania,
or depression (p. 149 150). With anxious distress has been added as a new specifier for
Cyclothymic Disorder as well.
Depressive disorders. The chapter on Depressive disorders includes Major Depressive
iDsorder, Persistent Depressive Disorder (what was termed Dysthymia and Major Depressive
Disorder, Chronic in DSM-IV-TR ), Substance/Medication-Induced Disorder and Other
Specified Depressive Disorder, and Unspecified Depressive Disorder. Additionally, the DSM-5
has added two new disorders: Premenstrual Dysphoric Disorder (PDD) and Disruptive Mood
Regulation Disorder (DMRD). PDD was presented in the Appendix of DSM-IV-TR as under
further study. DMRD is specific to children who present with extreme irritability and emotional
dysregulation (Mustaine, 2013). This category emerged to address over-diagnosis of Bipolar
Disorder in children. DMRD was strategically placed here based upon the research finding that
children exhibiting this symptom pattern typically develop unipolar depressive disorders or
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anxiety disorders as they mature into adulthood (APA, 2013). All the disorders in this chapter
share a common demonstration of sad, empty, or irritable mood. This mood expression must be
accompanied by somatic and cognitive changes resulting in significant dysfunction. To
differentiate among the disorders, the clinician must look at the duration, timing, or presumed
etiology (APA, 2013). Two new specifiers have been added for the Depressive disorders: With
mixed features and With anxious features.
Anxiety disorders. The organization of the anxiety disorders chapter is quite different in
DSM-5. In DSM-IV-TR, the anxiety disorders included OCD, PTSD, and Acute Stress
Disorder. However in DSM-5, these have been separated into three chapters: Anxiety Disorder,
Obsessive-Compulsive and Related Disorders, and Trauma- and Stressor-Related Disorders.
This was done to group the disorders according to similarities. OCD was removed from the
Anxiety Disorders chapter and a new chapter, Obsessive-Compulsive and Related Disorders, was
developed in order to communicate emerging evidence that OCD, Hoarding (also a new disorder
in DSM-5), and Body Dysmorphic Disorder are related. A new chapter titled Trauma- and
Stressor-Related Disorders was developed to indicate that the disorders included in that chapter
result from exposure to a traumatic or stressful event. PTSD and Acute Stress Disorder were
removed from the anxiety disorder chapter and are now located here. Adjustment Disorders are
now included in the trauma-related chapter as well. Separation Anxiety Disorder and Selective
Mutism, which were located in the Disorders Usually Diagnosed in Childhood or Adolescence in
the DSM-IV-TR, are now located in the Anxiety Disorders chapter. The Anxiety Disorders still
have excessive fear and anxiety as well as behavioral disturbances as the essential features.
There are three changes to the disorders now included in the Anxiety Disorders chapter
(i.e., Separation Anxiety Disorder; Selective Mutism; Specific Phobia; Social Anxiety Disorder;
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Panic Disorder; Agoraphobia; and Generalized Anxiety Disorder). In the DSM-IV-TR, there
were three potential diagnoses that involved panic: Panic Disorder Without Agoraphobia, Panic
Disorder With Agoraphobia, and Agoraphobia Without a History of Panic Disorder. DSM-5 now
has separate criteria for Agoraphobia and Panic Disorder and has added a specifier for Social
Anxiety Disorder, performance only. The criteria for Agoraphobia, Specific Phobia, and Social
Anxiety Disorder (formerly Social Phobia) no longer require the person to recognize the anxiety
as unreasonable or excessive. However, the anxiety must be out of proportion to the actual
danger or threat after taking into account cultural context and the symptoms must last at least six
months in adults and at least four weeks in children (Mustaine, 2013). Finally, Selective Mutism
was relocated to anxiety disorders though the criteria remain the same.
Obsessive-Compulsive and Related Disorders. Obsessive-Compulsive and Related
Disorders is a new chapter in the DSM-5. The disorders included in this section are OCD, Body
Dysmorphic Disorder (no longer considered a somatoform disorder as in DSM-IV-TR),
Hoarding Disorder (new to the DSM-5), Trichotillomania (hair pulling disorder, no longer
considered an impulse control disorder as in DSM-IV-TR), and Excoriation (Skin Picking
Disorder, new to the DSM-5). These disorders have been grouped together because they share
many of the same characteristics. OCD is the primary diagnosis in this chapter, and the criteria
remain the same as in DSM-IV-TR. The symptoms include obsessions, compulsions, or both. In
the DSM-IV-TR, the only specifier was With poor insight. In the DSM-5, there are 4 potential
specifiers: With good or fair insight (i.e., client recognizes that obsessive-compulsive beliefs are
definitely or probably not true or that they may or may not be true); With poor insight (i.e, client
thinks obsessive-compulsive beliefs are probably true); and With absent insight/delusional
beliefs (client is completely convinced that obsessive-compulsive beliefs are true). The
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additional specifier is Tic-related (i.e., client has a current or past history of a tic disorder)
(Mustaine, 2013).
Body Dysmorphic Disorder has been moved from Somatoform disorders to this category.
The essential feature continues to be preoccupation with one or more perceived defects or flaws
in physical appearance that are not observable or appear slight to others. In DSM-IV-TR, the
criteria was, “Preoccupation with an imagined defect in appearance. If a slight physical anomaly
is present, the person’s concern is markedly excessive” (p. 510). In the DSM-IV-TR, there were
no additional specifiers; however, in the DSM-5, there are four specifiers. With muscle
dysphoria (i.e., preoccupation with the idea that his or her body build is too small or
insufficiently muscular) is used even if the person is preoccupied with other body areas, which
often is the case. Additionally, there are three insight specifiers: With good or fair insight (i.e.,
client recognizes that body dysmorphic beliefs are definitely or probably not true or that they
may or may not be true); With poor insight (i.e, client thinks body dysmorphic beliefs are
probably true); and With absent insight/delusional beliefs (client is completely convinced that
body dysmorphic beliefs are true).
According to Mustaine (2013), Hoarding Disorder was previously considered a symptom
of Obsessive-Compulsive Personality Disorder, but now is considered a discrete disorder based
upon research. It may have a neurobiological etiology. Approximately 75% of those with
hoarding disorder have a co-occurring mood or anxiety disorder (i.e., Major Depressive
Disorder, Social Anxiety Disorder, and GAD). Twenty percent of clients have symptoms that
meet diagnosis for OCD. There is one specifier and three insight specifiers: With excessive
acquisition (i.e., difficulty discarding items is accompanied by excessivie acquisition of items
that are not needed or for which there is no space, 80-90% of clients will meet this specifier);
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With good or fair insight (i.e., client recognizes that hoarding-related beliefs are definitely or
probably not true or that they may or may not be true), With poor insight (i.e., client thinks
hoarding-related beliefs are probably true); and With absent insight/delusional beliefs (i.e., client
is completely convinced that hoarding-related beliefs are true).
Trauma- and Stressor-Related Disorders. All of the disorders in this new chapter in
the DSM-5 involve exposure to a traumatic or stressful event. These disorders include Reactive
Attachment Disorder, Disinhibited Social Engagement Disorder, PTSD, Acute Stress Disorder,
and Adjustment Disorders (previously in its own chapter in the DSM-IV-TR). PTSD and Acute
Stress Disorders were removed from the anxiety disorder section because many individuals who
have these disorders do not have anxiety or fear-based symptoms, but rather have anhedonia,
dysphoria, externalizing angry or aggressive symptoms, or dissociative symptoms. This is true
for Adjustment Disorders as well. Internalizing (i.e., anxiety) symptoms, externalizing (i.e.,
anger or aggression) symptoms, or a combination of both may occur.
Both RAD and Disinhibited Social Engagement Disorder require the criteria of marked
absence of adequate caregiving during childhood which results in a trauma response. The
extreme insufficient caretaking is considered to be significant to the etiology of these disorders.
RAD symptoms include emotional withdrawal or inhibition toward caregivers, limited positive
affect and or emotional responsiveness toward others, and rarely or minimally responding to
others when comforted. The new diagnosis of DSED includes symptoms of actively
approaching and interacting with unfamiliar adults in a variety of possible ways. For both, the
child must have a developmental age of 9 months and may have two specifiers: Persistent (i.e.,
disorder has been present for more than 12 months), and Severe (i.e., child exhibits all symptoms
of the disorder, with each manifesting at relatively high levels).
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In reclassifying PTSD to the Trauma- and Stressor-Related Disorders, this chapter of the
DSM-5 demonstrates altered criteria. There are separate criteria for children 6 years or younger
than those of adults (APA, 2013, pp. 272 - 274). In children, only one symptom of avoidance or
negative thoughts or mood is required (as opposed to the 2 required for adults). Additionally,
Criterian A provides more detail as to what type of stressor qualifies as a traumatic event (i.e.,
actual or threatened death, serious injury, or sexual violence) and differentiates between
experiencing an event and witnessing the event (direct exposure). In the new chapter, the
symptoms have been separated into four clusters: (a) intrusion symptoms (Criteria A); (b)
persistent avoidance (Criteria C); (c) negative alterations in mood and cognitions (Criteria D);
and (d) Criteria E marked arousal and reactivity (Mustaine, 2013). Three new symptoms were
added to the criteria:

Criteria D3 – distorted thoughts about the cause or consequences of the traumatic
event that lead client to blame self or others,

D4 – persistent negative emotional state (i.e., fear, horror, anger, guilt, or shame),
and

E2- reckless or self-destructive behavior.
The specifier With delayed onset has been changed to With delayed expression, but continues to
mean that the person did not meet full diagnostic criteria until 6 months after the occurrence of
the traumatic event or stressor. There are three new specifiers that can be applied to both adults
and children, With Dissociative Symptoms, Depersonalization, and Derealization.
The changes to Acute Stress Disorder are similar to those made in PTSD. More detail is
provided as to what type of stressor qualifies as a traumatic event, and differentiation is made
between the person who experiences a traumatic event and the person who witnesses such event.
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Logically, Adjustment Disorders follow here in this chapter as they are conceptualized as
emotional or behavioral responses to a significant life stressor that exceeds the distress that
would be normally expected.
Dissociative Disorders. Dissociative disorders follow traumatic disorders in the DSM-5
as these frequently occur in the aftermath of trauma. Characteristics include disruption of
“consciousness, memory, identity, emotion, perception, body representation, motor control, and
behavior” (APA, 2013, p. 291). Individuals experience positive dissociative symptoms as
“unbidden intrusions into awareness and behavior, with accompanying losses of continuity in
subjective experience” and negative symptoms such as amnesia (p. 291).
Depersonalization/derealization disorder symptoms include experiences of being detached from
one’s mind, self, or body, or from surroundings. Inability to recall autobiographical information
is a defining symptom of Dissociative Amnesia. Dissociative Identity Disorder continues to be
characterized by two or more distinct personality states. Criterion B now addresses the gaps in
memory recall of personal life events, loss of dependable memory (e.g., what occurred this
morning, learned skills like how to drive), and finding evidence of actions or tasks they do not
recall completing. These gaps are more significant than ordinary forgetting.
Somatic Symptom and Related Disorders. The chapter on Somatic Symptoms and
Related Disorders is also new to the DSM-5. The clinician will find diagnoses of Somatic
Symptom Disorder, Illness Anxiety Disorder, Conversion Disorder, Psychological Factors
Affecting Other Medical Conditions, Factitious Disorder, Other Specified Somatic Symptom and
Related Disorder, and Unspecified Somatic Symptom and Related Disorder. These all share
somatic symptoms associated with significant dysfunction. As with somataform disorders, these
disorders are usually presented in a medical setting. In the introduction to this chapter, the
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authors urge caution, stating, “It is not appropriate to give an individual a mental disorder
diagnosis solely because a medical cause cannot be demonstrated,” (APA, 2013, p. 309).
Feeding and Eating Disorders. The chapter on Feeding and Eating Disorders is new to
the DSM-5. Several disorders that were in the Feeding and Eating Disorders of Infancy or Early
Childhood in the DSM-IV-TR (i.e., Pica, Rumination Disorder) and one that was previously
titled Feeding Disorder of Infancy or Early Childhood that is now Avoidant/Restrictive Food
Intake Disorder are incorporated in this chapter. Anorexia Nervosa and Bulimia Nervosa
(previously in a chapter titled Eating Disorders) have been added to this chapter as well as a new
disorder, Binge-Eating Disorder, that was previously in the Appendix for Further Study in the
DSM-IV-TR. The criteria for Anorexia Nervosa remains the same except the requirement that
postmenarcheal women have missed three consecutive periods has been eliminated.
Additionally, Criterion A has been revised to describe restriction of energy intake leading to
significantly low body weight given the individual’s age, sex, stage of development, and physical
health. Significantly low weight is less than what is minimally normal or expected for children
and adolescents (APA, 2013; Mustaine, 2013). These changes have resulted with fewer clients
being diagnosed with Eating Disorder NOS because they now meet the criteria for Anorexia
Nervosa. The subtypes remain Restricting Type and Binge-Eating/Purging Type. The chapter
now includes two new remission specifiers, Partial remission and In full remission. Also,
current severity is indicated by Body Mass Index (BMI). Note that severity in Bulimia Nervosa
is based upon the number of episodes of binge eating. Additionally, in Bulimia Nervosa, Criteria
C, the occurrence of binge eating and inappropriate compensatory behaviors has been changed
from twice a week to once a week for three months.
Other Disorders with Physical Symptoms
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Following the eating disorders chapter, information is provided on other disorders that
include symptoms that may indicate either physical or emotional components. Elimination
Disorders, Sleep-Wake Disorders, and Sexual Dysfunctions are chapters more commonly
utilized by medical practitioners. The information there will help the clinician decide whether
there is a need to do a medical referral with a client, and/or how to work in conjunction with a
medical diagnosis provided by a physician.
Gender Dysphoria. In the chapter on Gender Dysphoria, a definition and description is
provided, with developmentally appropriate criteria for children, adolescents, and adults. The
term describes “an individual’s affective/cognitive discontent” with his or her gender assignment
(APA, 2013, p. 451), but is typically used in treatment settings. This incongruence between
one’s assigned gender (usually based upon the sex at birth, i.e., male/female, or other), and one’s
gender identity (the social identification), may be reflected in both affective and cognitive
distress.
Disruptive, Impulse-Control, and Conduct Disorders. While AD/HD, Conduct
Disorder, and Oppositional Defiant Disorder were included in the chapter titled Disorders
Usually First Diagnosed in Infancy, Childhood, or Adolescence in the DSM-IV-TR, these are
now located in a new chapter in the DSM-5 titled Disruptive, Impulse-Control, and Conduct
Disorders. Intermittent Explosive Disorder, Kleptomania, Pyromania, Pathological Gambling,
which were located in the chapter titled Impulse-Control Disorders Not Elsewhere Covered,
have also been relocated to the chapter titled Disruptive, Impulse-Control, and Conduct
Disorders. AD/HD has been moved to the chapter related to neurodevelopmental disorders.
While the underlying causes of these disorders vary, the commonality among them is a
lack of emotional and behavioral self-regulation that is manifested in behaviors that clearly
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violate the rights of others and/or bring the person into significant conflict with social norms or
authority figures. They occur more frequently in males than females and tend to have first onset
in childhood or adolescence. These disorders have been linked to a common externalizing
spectrum associated with personality dimensions labeled disinhibition (i.e., orientation toward
immediate gratification leading to impulsive behaviors driven by current thoughts, feelings and
external stimuli, without regard for past learning or consideration of future consequences)
(Mustaine, 2013).
Substance-Related and Addictive Disorders. Major changes have been made to the
DSM-5 section on alcohol and other substance-related disorders starting with the new title (e.g.,
in DSM-IV-TR, the title of the section was Substance-Related Disorders; in the DSM-5, the title
is Substance-Related and Addictive Disorders). This section now includes Gambling Disorder
that was previously in the Impulse-Control Disorders. Internet Gaming Disorder (pp. 795 –
798), new to the DSM-5, is included in Section III under Areas for Further Study.
Another significant change in the DSM-5 was the combination of abuse and dependence
into one category, Substance Use Disorders, which may be applied to all classes of substances
except for caffeine. The reason for this change is that research indicated that these were not two
distinct disorders; rather, they occur on a continuum. Therefore, the clinician now codes this
disorder based on severity (i.e., Mild to Severe according to how many symptoms the client
meets). Added to the DSM-5 are two new diagnoses: Cannibus Withdrawal and Caffeine
Withdrawal. In the DSM-IV-TR, the person had to meet three symptoms for dependence and
one for abuse. To earn a diagnosis of Substance Use Disorder, the person only has to meet two
within a 12-month period. The second group of substance-related disorders is the same,
Substance-Induced Disorders (i.e., intoxication, withdrawal, and substance-induced mental
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disorders) (Mustaine, 2013). The third group is new, titled Non-Substance-Related Disorders,
which currently consists of one behavioral disorder, Gambling Disorder. The essential feature of
Gambling Disorder is persistent and recurrent problematic gambling behavior that leads to
impairment or distress. The disorder was reclassified as an impulse control disorder and was
given three types of specifiers, Episodic or persistent, In early remission or Sustained remission,
and Severity (Mild – Severe, based upon number of symptoms met). Finally, Polysubstance
Dependence has been removed from the DSM-5. The client is diagnosed with as many types of
use disorders as apply using the codes from each specific substance (Mustaine, 2013).
Neurocognitive Disorders. The Neurocognitive Disorders (NCDs) were identified in
DSM-IV-TR as Dementia, Delirium, Amnestic, and Other Cognitive Disorders. The
classification begins in this chapter with Delirium, followed by symptom clusters or syndromes
of major NCD, mild NCD, and their etiological subtypes (APA, 2013, p. 591). The medical
conditions that underlie these disorders have undergone extensive study and are still being
studied. The primary symptom is impairment in cognitive function that is acquired, not
developmental. “The NCDs are those in which impaired cognition has not been present since
birth or very early life,” representing a significant deviation in cognitive functioning (APA,
2013, p. 591). A helpful table is provided in the text beginning on page 593 to provide examples
of the neurocognitive domains and assessments.
Personality Disorders. The general definition of personality disorder included in this
chapter continues to be “an enduring pattern of inner experience and behavior that deviates
markedly from the expectations of the individual’s culture, is pervasive and inflexible, has onset
in adolescence or early adulthood, is stable over time, and leads to distress or impairment” (p.
645). To the ten disorders already described in previous editions, DSM-5 adds Personality
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Change Due to Another Medical Condition. This chapter updates the material found in DSMIV-TR. However, Section III includes a proposed model for personality disorder diagnosis and
conceptualization developed by the DSM-5 Personality and Personality Disorders Work Group
(APA, 2013). The inclusion of both approaches to diagnosis allows continuity of care among
current clinicians in practice. Discussion of the new model holds promise as it considers
personality functioning and pathological personality traits.
Paraphilic Disorders. The chapter entitled Paraphilic Disorders includes the
classification of Voyeuristic Disorder, Frotteruistic Disorder, Sexual Masochism Disorder,
Sexual Sadism Disorder, Pedophilic Disorder, Fetishistic Disorder, and Transvestic Disorder.
These remain specific classifications as they are relatively common in relation to other paraphilic
disorders, and some of them include behaviors that are classified as criminal offenses (APA,
2013). Thus, the Other Specified and Unspecified Paraphilic Disorders are still indispensible
diagnoses in some cases. As with any DSM diagnosis, a disorder results when significant
distress or impairment occurs as a result of a behavior, in this instance the paraphilia.
Summary
In this review, the authors explored many of the differences between the DSM-IV-TR
and the DSM-5. The differences are important to clinicians that need to stay current in the field
of counseling and to Counselor Educators and supervisors who will be working with interns that
must learn a new coding system. Additionally, many students who are admitted to clinical mental
health counseling and counselor education and supervision programs have been in clinical
practice and are familiar with the DSM-IV-TR; however, they have not been exposed to the
DSM-5 and have great anxiety about understanding it and using it. Students in Counselor
Education and Supervision doctoral programs are responsible for supervising master’s students
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in their clinical experiences. As clinicians are often expected to provide a diagnosis within the
first session, the doctoral students must be familiar with the DSM-5 in order to adequately teach
the interns the use of the new manual. Finally, counselor educators responsible for teaching a
course in psychopathology also need to be current in their understanding and knowledge of the
DSM-5 so they can competently and confidently convey this new information to students. A
rationale was provided for the purpose, structure, content and utility of the DSM-5. The
discussion included recommendations and cautions for use of the manual. The researchers
systematically explored the presentation of disorders, noting where changes have occurred in
classification and a different approach taken to conceptualizing a symptom cluster in another
domain. Finally, this study will provide the authors with an expanded knowledge base that will
facilitate further licensure in another state as well as inform their work supervising counseling
interns and teaching curriculum in diagnosis.
References
American Psychiatric Association (2000). Diagnostic and Statistical Manual of Mental Disorders,
Fourth Edition Text Revision. Arlington, VA, American Psychiatric Association.
American Psychiatric Association (2013). Diagnostic and Statistical Manual of Mental Disorders, Fifth
Edition. Arlington, VA, American Psychiatric Association.
Florida Department of Health (2014). Licensing and registration, Licensed Mental Health Counselor.
Retrieved from http://floridasmentalhealthprofessions.gov/licensing.
King, J. H. (2014). Assessment and diagnosis of anxiety, somatic symptom and related disorders.
Counseling Today, 56(12), 12-15.
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Mustaine, B. (2013). Notes for a lecture on the DSM-5. Beverly Mustaine, presentation for the Florida
Counseling Association, Tampa, Fl.
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