DSM5577 - SECTION 2: OVERVIEW OF THE DSM-5
Section II: Overview of the DSM-5
In laying the groundwork for understanding the use of the DSM and the diagnostic process in general, this section will briefly cover the following information:
- What is the DSM-5?
- How was the DSM created?
- Historically, how have mental disorders been classified?
- Specifically, how have mental disorders been classified in the United States?
- How does the assessment process lead to the designation of a diagnosis?
What is the DSM-5
The DSM-5 is the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (American Psychiatric Association, 2013). It was created to give an official nomenclature for mental health disorders that apply to a wide variety of health contexts. The DSM is the most highly used diagnostic classification system in the United States. The DSM-5 represents a significant update to the DSM-IV-TR, which it replaces. The DSM-5 adds several new diagnoses, deletes or replaces several other diagnoses and makes some changes to diagnostic criteria in this transition.
How was the DSM Created?
The DSM-5 was a product of 13 work groups responsible for each of the five sections. The work groups were composed of representatives from many professions, including social workers, physicians, psychiatrists, counselors and nurses to cover different perspectives on mental health assessment. The DSM first edition was originally published in 1952; the current DSM-5 (Text Revision) was finalized in December of 2012 and published in May of 2013.
History of Classification of Mental Disorders
The International Classification of Diseases, or ICD, is a tool used in the medical community to have a common language for diagnosis, health management and clinical purposes. This tool addresses all forms of medical and mental health disorders, and laid the foundation for an attempt to apply principles of diagnostic formulation to mental disorders. The ICD traces its roots back to the 1890s at which time the first attempt was made by the American Public Health Association to unify ideas about how to classify diseases in ways that had clinical utility.
In the 6th edition of the ICD (ICD6), the first attempt was made to include mental and nervous disorders as part of the classification and diagnostic process. The ICD is currently in its 10th edition, and is supervised and updated by the World Health Organization (WHO).
The American Psychiatric Association created the first version of the Diagnostic and Statistical manual, the DSM-I, in 1952, coinciding with the 6th edition of the ICD (ICD-6). The classification of mental and nervous disorders at this time was based upon work engaged in by the US Military during World War II, where psychiatrists had been charged with helping to select and treat large numbers of soldiers involved in the war effort. A military group had produced a classification system called Medical 203 that created nomenclature to describe various kinds of mental disturbances. Much of that information was incorporated into the first DSM.
The DSM-II followed in 1968, coinciding with the 1975 publication of the ICD-9. Because psychodynamic psychotherapy was still the predominant way in which psychiatrists practiced, this edition, like DSM-I, framed many of the mental disorders within the framework of psychodynamic principles.
The DSM-III was released in 1980 followed by a revised update in 1987, the DSM-III-R. The goal of the DSM-III was to create increased uniformity and validity for mental health diagnoses, based upon observable signs and symptoms that could be identified by any clinician who assessed the same patient. Prior to the release of this volume, there were substantial differences between diagnoses in America and Europe, which were largely resolved with this new DSM. Additionally, this edition established a clear focus on the need for research to provide evidence based support for mental health diagnosis.
The DSM-IV appeared in 1994, coinciding with the release of ICD-10, and a revised edition, the DSM-IV-TR, was published in 2000. The DSM-IV included the use of a multi-axial system for diagnosis that was discontinued with the release of the DSM-5. An examination of the multi-axial system and the reasons for its discontinuation will be covered later.
As noted, as of May 2013, the DSM-5 superseded the DSM-IV-TR as the tool for establishing diagnosis.
Clearly, in the period from 1952 to the present, the knowledge and understanding concerning the factors that contribute to the development of mental health disorders has advanced considerably. The creative hypotheses of Freud and the early pioneers of psychiatry and psychology have been revised, and frequently overturned, by a substantial body of research. In addition, entirely new methods of viewing and understanding the neurological and psychological processes that lead to mental health problems have been developed.
In particular, advances in neuroscience, supported by entirely new brain imaging technologies, have significantly altered our understandings of what forces are involved in the development of various kinds of mental disorders. The result of this substantial increase in research is that most diagnoses have empirical literature available to confirm diagnoses.
At the same time, there have also been efforts to remove certain kinds of cultural bias from diagnostic categories, separating out the culturally or even biologically “different” from what may be more universally labeled as “disordered”. DSM-III’s position determining homosexuality to be a different expression of sexuality instead of a mental disorder represents the clearest example of this kind of change. A similar effort is seen in the DSM-5, as certain paraphilias have been reconceptualized in the latest attempt to separate out the “different” from the “disordered”.
A history of the DSM and the classification of mental disorders would not be complete without some reference to the political forces within the psychiatric community and the culture at large that have influenced decisions about what does and does not become part of the DSM. Suffice it to say that updates and revisions to the DSM have not been made without considerable conflicts and disagreements between various factions and points of view as final decisions were made.
Each edition of the DSM has generated its own sets of conflicts and tensions within the various factions that operate in the field of mental health, but the release of the DSM-5 may have brought the controversy in this area to a new level. There is some important history here for the mental health clinician to understand.
The psychiatrist at the center of the development of DSM-III wrote a scathing indictment of the DSM-5, condemning a number of items that did not fit his view of the goals and purposes of a systematic, research backed approach to diagnosis. Additionally, the National Institute of Mental Health, which had partnered with the American Psychiatric Association to work on the development of the DSM-5, decided right before the release of the DSM-5 that it would break with the DSM in its future research, and would create its own classification system. (Decker, 2013)
Criticisms of the DSM-5 have insinuated that the developers of the new manual may have made certain changes in too close association with players that have financial interests in the medicalization of problems, most importantly the pharmaceutical industry. Questions were raised about financial conflicts of interests, and the Task Force and Work Group members creating the DSM-5 were asked by the APA to disclose their financial interests and limit their financial conflicts of interests. (Collier, 2010)
So what does this mean for the conscientious clinician who is attempting to engage in good practice? The principles noted in the introductory section still apply here. At its best, the DSM represents our most conscientious efforts to incorporate an evolving body of knowledge into a manual of definitions of human behavior, allowing for better alignment of treatment approaches with underlying problems. In establishing a diagnosis, aim for what best explains the presentation of symptoms and best leads to a plan of action to help the client.
Statistic: Up to one-half of all visits to primary care physicians are due to conditions that are caused or exacerbated by mental or emotional problems (CFHC, 1998).
Currently, more than 70% of visits to primary care physicians (PCPs) are related to psychosocial issues. One-quarter of adults experience a mental illness in a given year, and more than half receive no treatment, according to the National Alliance on Mental Illness. (Olsen, NAMI, Medical Economics 2014.)
Mental Disorders
According to the World Health Organization, mental health is defined as “a state of well-being in which every individual realizes his or her own potential, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to her or his community.”
The term mental disorder suggests a state of being that deviates from a state of mental health. As constituted in the DSM-5, “A mental disorder is a syndrome characterized by clinically significant disturbance in an individual’s cognition, emotional regulation, or behavior that reflects a dysfunction in the psychological, biological, or developmental processes underlying mental functioning. “
The DSM-5 goes on to say, “An expectable or culturally approved response to a common stressor or loss, such as the death of a loved one, is not a mental disorder. Socially deviant behavior (e.g., political, religious, or sexual) and conflicts that are primarily between the individual and society are not mental disorders unless the deviance or conflict results from a dysfunction in the individual, as described above.”
In addition to these concepts, the DSM-5 asks the clinician to consider if the condition, in addition to being experienced as creating significant distress on the part of the individual, also creates some impairment in the patient’s social, occupational or other functioning. If the condition is not distressing to the individual and does not create functional problems for the patient in major life areas, the clinician should proceed cautiously in terms of creating a diagnosis for the condition.
There are also significant differences across cultures in terms of what are considered normal and deviant behaviors or experiences. For instance, there are a number of cultures for which religious or spiritual experiences may involve behaviors that in other cultures might be considered symptoms of a mental disturbance, i.e., visions, voices, or communication with loved ones who have died. As the field of mental health has moved to a greater awareness of cross-cultural differences, these understandings have begun to be incorporated into standards for establishing diagnosis.
Assessment and the Biopsychosocial Model
For a clinician to be successful in arriving at the most accurate diagnosis using the DSM-5, it is essential to have both the knowledge and the proper tools for engaging in a robust assessment process. It is also essential to understand the proper role of each party who will be engaged in the assessment process and to understand and respect the appropriate boundaries that will allow the clinician to operate within his/her area of competence.
This can get complicated, given the realities of the healthcare system of the 21st Century in the United States. It is not unusual for the mental health clinician to be the first point of intersection between a client and the healthcare system, serving as a de facto gatekeeper for care. For instance, clients who lack insurance and do not have an established relationship with a primary care physician or do not use any other healthcare services may be offered a free Employee Assistance Program from their place of employment where they seek out services for a mental health problem. Or they may simply assess their own problems and determine that their health care needs are related to some kind of mental health disturbance. Their initial interaction with the health care system turns out to be the first assessment session with a mental health clinician.
If the clinician who provides that service is not prepared to engage in a thorough assessment process, one that covers biological, psychological and social arenas – the biopsychosocial assessment that is essential to good practice - then he/she may not ask the questions that illuminate the need for additional care: medical services, psychological testing, or psychiatric treatment, services that are beyond the scope of practice for the master’s level clinician.
To drive this point home, there are numerous medical conditions with symptoms that mimic the kinds of mental health problems that are routinely seen in a clinician’s practice. Clients experiencing problems with their thyroid, for example, may present with mood and energy swings that can appear to be related to anxiety, depression, hyperactivity, or bipolar disorder. If the client focuses on the mental health aspects of their condition, instead of the underlying medical causes, they may think they need to see a mental health clinician instead of a physician.
Without the essential knowledge base required to know what to look for, the less experienced clinician may overlook the underlying medical causes and not make the necessary referral to the medical professional. This is why differential diagnosis requires a broader base of knowledge than simply mental health disorders. For a deeper look at this specific aspect of the assessment process, it is recommended that clinicians consider taking yourceus.com’s course entitled, “Differential Diagnosis: Identifying Common Medical Conditions Frequently Misdiagnosed as Mental Health Problems.”
Here are the areas that should be covered in a thorough assessment process:
Components of Assessment:
Biological, Psychological, Social
- Gather a history of past and current problems, signs and symptoms, and challenges
- Gather a history of past and current strengths and resources: skill based, relationship based, socially based
- Gather medical history, including surgeries, major injuries, medications past and present
- Gather mental health history, including current and prior counseling or psychiatric care
- Gather a wellness history: sleep, exercise, nutrition including supplements, self-care
- Gather a history of religious or spiritual life and its importance and relevance for the well-being of the client
- Conduct a comprehensive mental status check
- Conduct a substance use assessment
- Gather a history of past and current suicidal and homicidal thoughts and actions
- Gather a history of past and current domestic violence and physical, emotional and/or sexual abuse
- Establish client goals for treatment and their vision for outcomes
There are also conditions for which clients may seek help from a mental health professional that may only be accurately diagnosed through the use of psychological tools such as psychometric tests. Numerous kinds of neurological disturbances that present themselves as cognitive and emotional impairments require accurate and objective testing tools to create an accurate diagnosis and define the most appropriate treatment plan.
The use of many of these tools is typically restricted to those mental health clinicians – typically psychologists – who have been thoroughly trained in the use of these measures. The specialized nature of these skills is why only psychologists are empowered by the state in which they practice to administer them and interpret their results.
Master’s level clinicians in most states will not be permitted to use these tools directly in their practice. However, in instances where it is considered vital to gathering accurate assessment data, they are expected to be knowledgeable enough to identify signs and symptoms of these kinds of difficulties and professional enough to make appropriate referrals for psychological testing. They are also expected to be familiar enough with the results of these tools to be able to incorporate their conclusions into the overall assessment picture.
Likewise, there are other kinds of problems with mental health diagnoses that are more appropriately assessed and diagnosed by medical or psychiatric professionals. Their training and experience permit them to correctly define the nature of the problem, and then provide the client with the medical intervention, such as medication and medication management, that may be needed to treat those problems. Psychotic disorders would be one example where a psychiatrist’s care would be indicated, and sleep disorders would be an example of where another kind of medical specialist would be indicated to provide the assessment process and determine the diagnosis.
The conscientious clinician will not only understand where appropriate boundaries are drawn around these areas of concern, he/she will also be prepared to utilize additional resources to direct the client to the appropriate level of diagnostic care.
As noted above, there are not only knowledge elements essential to a successful assessment process, but also resource elements that are useful for a competent and thorough assessment process. In order to gather the right information in an effective and efficient way, it is helpful to have well-designed assessment forms and templates that support the assessment process.
Below you will find a tool for a managing the mental status check components of the biopsychosocial assessment, addressing numerous areas that must be covered in a thorough assessment process:
Mental Status Checklist
Symptom Inventory / Mental Status (0=None 1=Mild 2=Moderate 3= High 4-Severe 5-Extreme )
__Generalized Anxiety __Weight change __Suspiciousness
__ Phobias __Impaired memory __Paranoid ideation
__ Panic Attacks __Irritability __ Bizarre Behaviors
__Depersonalization __ Anger control problems _Delusions
__Obsessions/Compulsions __ Aggressiveness __Confusion
__Depression __Impulsiveness __Agitation __Psychomotor retardation __Focus/concentration problems
__Low energy __Distractibility __ Dissociation
__Fatigue __Negative Self Image __ Hallucinations
__Withdrawal __Disorientation __ Loose Associations
__Hopelessness __Mania/Hypomania __ Flight of Ideas
__Sleep disturbance __Tremors __Intrusive thoughts
__ Tangential/Circumstantial thinking
Symptom Inventory / Mental Status (0=None 1=Mild 2=Moderate 3= High 4-Severe 5-Extreme )
Mood: __ Normal __Anxious __Depressed __Irritable __Euphoric __Expansive __Dysphoric __Calm
Affect:__Normal __Unconstrained __Blunted/Restricted __Inappropriate __Labile __Flat
Behavior: __Normal __Aggressive __Impulsive __Angry __Oppositional __Agitated __Explosive
Social Relating / Executive Functioning (0=None 1=Mild 2=Moderate 3= High 4-Severe 5-Extreme)
Eye Contact: __Normal __Fleeting __Avoidant __Staring __Other: ______________
Facial Expression: __Responsive __Flat __Tense __Anxious __Sad __Angry
Attitude Toward Clinician: __Normal/Cooperative __Uninterested __Passive __Guarded __Dramatic __Manipulative __Suspicious __Rigid __Sarcastic __Resistant __Critical __Irritable __Hostile __Threatening
Appearance: __Normal __Disheveled __Unclean __Inappropriate __Unhealthy looking Insight: __Good __Impairments in insight Decision Making: __Good __Impairments in decision making
Reality Testing: __Good __Impairments in reality testing Judgment: __Good __Impairments in judgment Interpersonal Skills: __Normal __Impaired Intellect: __Average or above __Impaired
There may also be instances in which a more detailed checklist might be indicated for a specific area of examination. This more detailed checklist will be most helpful if the signs and symptoms align with signs and symptoms noted in the DSM-5 in the section that addresses diagnoses in the area being studied. For instance, below is a detailed checklist for signs and symptoms of anxiety:
(0=None 1=Mild 2=Moderate 3= High 4-Severe 5-Extreme )
Generalized Anxiety as manifested by:
__Feelings of apprehension or dread
__Trouble concentrating
__Feeling tense and jumpy
__Anticipation of negative outcomes
__Heightened irritability
__Restlessness or unsettled feeling
__Vigilance for signs of danger
__Muscle fatigue associated with tenseness
You may also wish to differentiate whether the level of anxiety noted is by self-report on the part of the client, or by behavioral indicators noted by the clinician in the course of examination. It is not unusual for clients to under- or over-estimate the level of symptoms that are being presented. Should this process be warranted, then your mental status form might look like this:
(0=None 1=Mild 2=Moderate 3= High 4-Severe 5-Extreme )
Generalized Anxiety as manifested by:
Feelings of apprehension or dread ___By self-report ___By observation
Trouble concentrating ___By self-report ___By observation
Feeling tense and jumpy ___By self-report ___By observation
Anticipation of negative outcomes ___By self-report ___By observation
Heightened irritability ___By self-report ___By observation
Restlessness or unsettled feeling ___By self-report ___By observation
Vigilance for signs of danger ___By self-report ___By observation
__Muscle fatigue ___By self-report ___By observation
associated with tenseness
For support in this aspect of practice, it may be helpful to view yourceus.com’s course entitled, “Psychosocial Assessment: A Comprehensive Overview for Mental Health Clinicians.”
Because substance abuse problems are so common and so frequently seen comorbidly with other conditions, a mental status check should also include a detailed record of the client’s current and prior use of psychoactive substance. This might look like this:
Drug/ETOH Use (Please rate amount and frequency, present and past: e.g., 2B = moderate, infrequent)
(Amount of use ratings: 0=No use 1=Light or limited use 2=Moderate use 3=Heavy use 4=Extreme use)
(Frequency of use modifier: A=Almost never B=Infrequent / Occasional C=Regular, not constant D=Constant)
Current use Past use
Alcohol ___ ___
Marijuana ___ ___
Cocaine ___ ___
Other (list): _____________________ ___ ___
Other (list): _____________________ ___ ___
Other (list): _____________________ ___ ___
Other (list): _____________________ ___ ___
To add some additional detail, you may also want to record a somewhat expanded record of aspects of substance use that would indicate the presence of a problem.
Substance Use Problem Effects (0=None 1=Mild 2=Moderate 3= High 4-Severe 5-Extreme)
Current use Past use
Used alcohol/drugs more than intended ____ ____
Spent more time using/drinking than ____ ____ intended
Neglected some usual responsibilities ____ ____ because of alcohol or drugs
Wanted or needed to cut down on ____ ____ drinking or drug use in past year
Someone has objected to client’s ____ ____ drinking/drug use
Preoccupied with wanting to use ____ ____ alcohol or drugs
Used alcohol or drugs to relieve ____ ____ emotional discomfort, such as sadness, anger, or boredom
Comments:
Additionally, it is also recommended that an examination of the client’s current and past history of safety issues be addressed: homicidal thoughts and actions, suicidal thoughts and actions, and history of abuse – physical, emotional, sexual, domestic violence – from both the perspective of a victim and a perpetrator.
A thorough, well-designed assessment process will gather information - both verbal and non-verbal - from the client. Non-verbal indicators may include such items as appearance, body language and facial expressions. While a primary focus should include examination of the client’s strengths, the diagnostic process will be driven by a thorough understanding of the client’s sources of problems.
A complete assessment will also gather information from other sources, including reports from family members (with the client’s permission), as well as reports, test results, and case files from other professionals. The tools used to structure and record this assessment process will include forms that record information about the client’s mental status, signs and symptoms, strengths, social supports, current stressors, use of alcohol and other psychoactive substances, medical and medication history, family history, and developmental history.
A well-designed assessment process looks for and records indicators of a history of safety risks (both suicidal and homicidal), as well as spiritual and cultural influences on the client. Environmental factors that are relevant to the client’s current functioning, and any other information about the client’s life that improves understanding of their current state are also assessed. It is also useful to determine - at all points during treatment - the client’s level of motivation to address the concerns that have brought them into treatment, as well as the level of resistance to change and contributors to that resistance.
Assessment, as a defined process, is composed of two key elements: 1) collecting patient data of the type noted above, and 2) monitoring case progress, as the treatment proceeds forward to address the disorder that has been clarified through the assessment, diagnosis and the treatment plan developed with client input.. Assessment is a continuous and ongoing process that continues throughout the course of treatment. Diagnoses may change as new information becomes available from ongoing assessment – or as the clients' conditions improve or deteriorate over time. Accordingly, the treatment plan may be altered to adapt to the changing conditions and to what is and is not working as the case progress is monitored.
While most organizations and conscientious clinicians will employ a reasonably comprehensive initial assessment form, it is also important to consider the design of the forms and templates utilized to record the ongoing assessment process that takes place during the course of each treatment session. Given how rapidly some symptoms may change with certain clients, it may be helpful to have a condensed version of the assessment process incorporated into the progress note template recorded for each session. This may include a brief mental status report, safety check for violence, suicidality and homicidality, auditory or visual hallucinations and other signs of psychosis, substance use history, as well as an update to the ‘situation’ (reason for client visit today) and ‘symptomatology’.
Pursuant to the initial assessment process, including appropriate referrals to other providers, one or more diagnoses will be generated that best describe the case presented by the client. Any diagnosis may be updated as the client’s presentation changes over time and those changes accurately recorded in the client’s case file.
The intent and purpose of establishing and recording a client’s diagnosis is to create an optimally accurate picture about a client’s current state and help define what treatment approaches will be most effective in improving a client’s functioning. The validity of the diagnosis will be dependent upon several assumptions about assessment:
1) Is the assessment empirically-based – meaning based on research and statistics?
2) Has the assessment been made from both a systems and an ecological perspective, capturing the full picture of the client and her/his functioning within the environment(s) in which he/she exists?
3) Has the assessment accurately measured the essential factors that shape a fully formed understanding of the case?
4) Have the practitioners engaged in a conscientious process of evaluating their practice methods, and determined that their assessment processes are sufficiently well-designed to capture the right data concerning the client?
5) Are the practitioners sufficiently knowledgeable about the development and use of a wide variety of assessment methods, so that the clinician may direct the process towards the use of the assessment tools and methods that produce the most essential information necessary to understand the case?
Statistic: Depression and anxiety disorders — the two most common mental illnesses — annually affect 9.5 million and 18.1 million American adults respectively (NIMH, 2014).
What are the key tools that may be legitimately utilized by Master’s level clinicians?
The most common methods for assessment of patient functioning are patient self-report and self-monitoring, derived from a well-constructed process of asking questions in a safe therapeutic environment, and/or asking the patient to maintain a record over time of his/her thoughts, feelings, and behaviors. Many clinicians engage in the process of monitoring this information by assigning their patients the task of keeping logs, journals, diaries, and/or by providing structured forms, web sites, or applications for their electronic devices that help track key information about moods, feelings, thoughts and behaviors under different sets of circumstances. This information is then discussed during the treatment sessions.
Some of these tools may ask the patient to utilize rating scales that track changes to the level or degree of functioning in certain areas. The use of these tools can help the clinician to gain insight into patient’s day-to-day functioning and any internal or external circumstances that contribute to changes over time.
Additionally, during the course of treatment sessions, the clinician will have an opportunity to engage in direct behavioral observation of the client. In individual therapy, this will allow the clinician to assess numerous factors related to the client’s functioning, e.g., resiliency in the face of emotional challenges during the treatment, or transference reactions to the interventions. In couples or family therapy, it will also allow for behavioral observation about the manner in which the client interacts within her/his system(s). All of these factors allow for improved case conceptualization.
Within treatment models oriented towards skill building, clinicians may also engage in role play and hypothetical situations to explore the client’s responses and capabilities for handling the building of complex interpersonal effectiveness skills. As skills improve, assessment will need to occur on a continuous basis to provide an up to date picture of the client’s state. This will allow for ongoing development of a treatment plan that will keep the client on the road to further progress.
Standardized Measures
In addition to the assessment methods noted above, there are a number of standardized assessment and screening tools that can be utilized to gather what are considered to be more objective measures of the client’s mental health and the presence of psychological problems. This includes tools like the Minnesota Multiphasic Personality Inventory (MMPI), the Wechsler Adult Intelligence Scale (WAIS) and the corresponding tool for children (WISC), and tools that are designed to uncover problems with neurological functioning or learning disabilities.
There are also increasing numbers of screening tools that are administered and/or scored through computerized processes, such as the SASSI for uncovering the presence of substance use problems, or a variety of inventories to assess a client’s level of depression, anxiety, and other symptomatology. While the use of more objective measures of problem assessment is encouraged, Master’s level clinicians must proceed cautiously and insure that appropriate professional boundaries are being observed.
Not only is it important to understand where the boundaries are drawn between screening tools that may be utilized by Master’s level clinicians and psychometric tests that are the domain of licensed psychologists, it is also important to understand that the use of any objective measuring tool consists of both a tool and a process. It must be clear that 1) you are sanctioned by the state in which you practice to use the screening tool, and 2) that you have the professional expertise to utilize the tool correctly within your area of competence.
If there is any doubt as to whether these two conditions are being met, seek out guidance and consultation from a professional qualified to point you in the right direction. There are both legal and ethical considerations in play that may create a threat to your license to practice.
For the benefit of trainees, a link to a web site has been included that contains a sizeable list of the current psychometric tools that are available to supplement the assessment process. Here is that link:
Assessment to Diagnosis
When enough information has been gathered from the assessment to arrive at a diagnosis, you refer to the DSM-5 to get the numeric code(s) for all conditions contributing to the client’s mental health difficulties – including medical conditions, medications, and environmental factors - and list them in the client’s record. There are several ways in which this process has changed and been expanded since the last edition of the DSM. Later in this course, we will examine how this will look under the guidelines of the DSM-5.