Journal of Research and Practice in K-20 Education 29 Volume 1, 2015

Transcription

1 Journal of Research and Practice in K-20 Education 29 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

2 Journal of Research and Practice in K-20 Education 30 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 DSM- 5 public comment, publications and presentations regarding the process, field trials in which new

3 Journal of Research and Practice in K-20 Education 31 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

4 Journal of Research and Practice in K-20 Education 32 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 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

5 Journal of Research and Practice in K-20 Education 33 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 ). 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

6 Journal of Research and Practice in K-20 Education 34 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 ). The WHODAS

7 Journal of Research and Practice in K-20 Education 35 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).

8 Journal of Research and Practice in K-20 Education 36 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

9 Journal of Research and Practice in K-20 Education 37 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 Cross- Cutting 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 Discussion of Changes In the following section, the reader will find a brief discussion of the changes from DSM- IV-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

10 Journal of Research and Practice in K-20 Education 38 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 ). 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.

11 Journal of Research and Practice in K-20 Education 39 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 ). 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

12 Journal of Research and Practice in K-20 Education 40 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;

13 Journal of Research and Practice in K-20 Education 41 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

14 Journal of Research and Practice in K-20 Education 42 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);

15 Journal of Research and Practice in K-20 Education 43 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).

16 Journal of Research and Practice in K-20 Education 44 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 ). 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.

17 Journal of Research and Practice in K-20 Education 45 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

18 Journal of Research and Practice in K-20 Education 46 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

19 Journal of Research and Practice in K-20 Education 47 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

20 Journal of Research and Practice in K-20 Education 48 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 ), 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

21 Journal of Research and Practice in K-20 Education 49 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

22 Journal of Research and Practice in K-20 Education 50 Change Due to Another Medical Condition. This chapter updates the material found in DSM- IV-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

23 Journal of Research and Practice in K-20 Education 51 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 King, J. H. (2014). Assessment and diagnosis of anxiety, somatic symptom and related disorders. Counseling Today, 56(12),

24 Journal of Research and Practice in K-20 Education 52 Mustaine, B. (2013). Notes for a lecture on the DSM-5. Beverly Mustaine, presentation for the Florida Counseling Association, Tampa, Fl.