According to the DSM-IV, mental disorders are conceptualized as clinically significant behavioral or psychological syndromes or patterns that occur in a "person" and are associated with "distress" (a painful symptom) or "disability" (impairment in one or more important areas of functioning) or with increased risk of suffering death, pain, disability, or an important loss of freedom. In addition, the syndrome or pattern must not be an expectable response to a particular event (APA, 1994).
Although the DSM system can be difficult to interpret for those with limited clinical experience or personal familiarity with mental disorders, it is relatively easy for experienced counselors to learn. Each DSM-IV contains specific diagnostic criteria, the essential features and clinical information associated with the disorder, as well as differential diagnostic considerations. Information concerning diagnostic and associated features, culture, age, and gender characteristics, prevalence, incidence, course and complications of the disorder, familial pattern, and differential diagnosis are included. Many diagnoses require symptom severity ratings (mild, moderate, or severe) and information about the current state of the problem (e.g., partial or full remission).
The DSM-IV contains fifteen categories of mental disorders. "Disorders Usually First Diagnosed in Infancy, Childhood or Adolescence" focuses on developmental disorders and other childhood difficulties. "Delirium, Dementia, Amnestic and Other Cognitive Disorders" include Alzheimer's conditions and Vascular Dementia. "Mental Disorders Due to a General Medical Condition" include anxiety and mood difficulties as well as personality change due to physical complications. "Substance Related Disorders" consist of drug and alcohol abuse and dependence. "Schizophrenia and Other Psychotic Disorders" are a continuum of difficulties that stress lack of contact with reality as well as Delusional Disorders. "Mood Disorders" and "Anxiety Disorders," including Major Depression and Posttraumatic Stress Disorder are featured diagnoses often used by counselors. "Somatoform Disorders, Factitious Disorders, Dissociative Disorders, Sexual and Gender Identity Disorders, Eating Disorders, Sleep Disorders, Impulse Control Disorders, Adjustment Disorders," and "Personality Disorders" are among the other diagnostic categories in the DSM-IV. In addition, several lesser disorders referred to as V Codes are included (e.g., Parent-Child Relational Problem, Partner Relational Problem, Bereavement, and Occupational Problem). Due to the V Codes' "minor status," they are typically not covered by third party payers.
THE MULTIAXIAL SYSTEM
Diagnoses in the DSM-IV are coded by the "multiaxial system" which incorporates five axes.
1. All diagnoses except for Personality Disorders are coded on Axis I.
2. Only Personality Disorders and Mental Retardation are coded on Axis II.
3. Axis III is for physical disorders and conditions.
4. Axes IV and V represent Severity of Psychosocial and Environmental Problems and Global Assessment of Functioning (GAF), respectively, and are used for treatment planning and prognosticating. For example, a full multiaxial diagnosis would be presented as:
AXIS III: None
--Psychosocial stressors: change of jobs
--Severity: 3 - Moderate (acute circumstances)
--Current GAF: 66
--Highest GAF Past Year: 80
When considering a DSM-IV diagnosis, the frequency, intensity, and duration of symptoms as well as premorbid functioning must be addressed.
Professional counselors utilizing DSM-IV diagnoses yield sizeable power that can be interpreted as oppressive to some groups of people. Third party interests (i.e., insurance carriers) also may bring nonscientific values into the diagnostic process.
In accurate psychodiagnosis depends on ethnocultural and linguistic sensitivity (Malgady, Rogler & Constantino, 1987). Clients of lower socioeconomic class may experience, define, and manifest mental disorders differently from middle- and upper-class clients. Moreover, the DSM's lack of focus on the problematic features of a social context may be perpetuating the oppression of certain groups of people (e.g., women).
Gender and race of clinician also have been found to impact an accurate psychodiagnosis (Loring & Powell, 1988). Counselors using the DSM-IV will need to be keenly aware of the implications associated with its use as well as the impact a diagnosis may have on a client's treatment--within and outside of the counseling process.
In conclusion, the DSM-IV is not the only psychodiagnostic nomenclature in existence, but it is the most popular and is here to stay. Counselors have utilized it in a professional manner in the past, use the DSM-IV today, and will use the DSM-V in the future. An up-to-date understanding of this diagnostic system and its vast implications in counseling will be imperative to the effective and ethical delivery of professional community mental health counseling services.
American Psychiatric Association. (1994). "Diagnostic and statistical manual of mental disorders" (4th ed.). Washington, DC: Author.
Loring, M. & Powell, B. (1988). Gender, race, and DSM-III: A study of the objectivity of psychiatric diagnostic behavior. "Journal of Health and Social Behavior," 29, 1-22.
Hinkle, J. S. (in press). The DSM-IV is coming: Prognosis and implications for mental health counselors. "Journal of Mental Health Counseling."
Malgady, R. G., Rogler, L. H., & Constantino, G. (1987). Ethnocultural and linguistic bias in mental health evaluation of Hispanics. "American Psychologist," 42, 228-234.
Pavkov, T. W., Lewis, D. A., & Lyons, J. S. (1989). Psychiatric diagnoses and racial bias: An empirical investigation. "Professional Psychology: Research and Practice," 20, 364-38.
Perry, S., Frances, A., & Clarkin, J. (1990). "A DSM-III-R casebook of treatment selection." New York: Brunner/Mazel.
Seligman, L. (1990). "Selecting effective treatments: A comprehensive systematic guide to treating adult mental disorders." San Francisco: Jossey-Bass.
Wakefield, J. C. (1992). The concept of mental disorder: On the
boundary between biological facts and social values. "American
Psychologist," 47, 373-388.