ERIC Identifier: ED366890
Publication Date: 1994-04-00
Author: Hinkle, J. Scott
Source: ERIC Clearinghouse on
Counseling and Student Services Greensboro NC.
Psychodiagnosis for Counselors: The DSM-IV. ERIC Digest.
The profession of counseling is growing rapidly as reflected by the
proliferation of professional community mental health counseling graduate
programs. Graduates of these programs are providing counseling services in
mental health centers, psychiatric hospitals, employee assistance programs, and
various other community settings. At the foundation of effective mental health
care is problem conceptualization and treatment planning which rely on the
establishment of a valid diagnosis. This has caused an increase in the number of
graduate community mental health counseling programs requiring course work in
abnormal behavior, psychopathology, and psychodiagnosis. As a result,
utilization of the "Diagnostic and Statistical Manual of Mental Disorders,
Fourth Edition" (DSM-IV) (APA) (1994) also has been dramatically increased in
counselor education training. Skill in its use is undoubtedly necessary when
assessing counseling clients seeking services in community mental health
Utilization of the DSM-IV within the counseling profession is not, however,
without controversy. Assigning a diagnosis to a client is uncomfortable for many
counselors. The disadvantages associated with using the DSM have included the
promotion of a mechanistic approach to mental disorder assessment, the false
impression that the understanding of mental disorders is more advanced than is
actually the case, and an excessive focus on the signs and symptoms of mental
disorders to the exclusion of a more in-depth understanding of the client's
problems including human development. Relatedly, Wakefield (1992) has recently
argued that the DSM concept of "mental disorder" would better serve people if it
were referred to as a "harmful dysfunction." He has based this on numerous
citations that have suggested psychodiagnosis is used to control or stigmatize
behavior that is actually more socially undesirable than disordered.
Conversely, advantages to implementing the DSM have included the development
of a common language for discussing diagnoses, an increase in attention to
behaviors, and facilitation of the overall learning of psychopathology. Seligman
(1990) has indicated that knowledge of diagnosis is important for counselors so
that they may provide a diagnosis for clients with insurance coverage and inform
clients if their counseling will be covered by medical insurance. In addition, a
DSM diagnosis assists with accountability and record keeping, treatment plan,
communication with other helping professionals, and identification of clients
with issues beyond areas of expertise.
MAJOR PSYCHODIAGNOSTIC FEATURES OF THE DSM-IV
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
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
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
THE MULTIAXIAL SYSTEM
Diagnoses in the DSM-IV are coded by
the "multiaxial system" which incorporates five axes. All diagnoses except for
Personality Disorders are coded on Axis I. Only Personality Disorders and Mental
Retardation are coded on Axis II. Axis III is for physical disorders and
conditions. 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:
Adjustment Disorder with Depressed Mood
Partner Relational Problem
Diagnosis deferred on Axis II
stressors: change of jobs
3 - Moderate (acute circumstances)
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.
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
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
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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:
Wakefield, J. C. (1992). The concept of mental disorder: On the boundary
between biological facts and social values. "American Psychologist," 47,