Trends and implications of proposed changes to the DSM-5 for vulnerable populations

A wide range of professionals, including counselors, use the Diagnostic and Statistical Manual of Mental Disorders (4th ed., text rev.; DSM-IV-TR; American Psychiatric Association, 2000; hereinafter referred to as the DSM when used in the general sense) to diagnose mental disorders, create treatment plans, evaluate treatment effectiveness, and receive reimbursement for services. Counselors also use the DSM to conduct clinical trials, obtain grants, make legal decisions, teach mental health courses, develop new pharmacological treatments, engage in research, decide qualification for disability status, and initiate public policy (Eriksen & Kress, 2006; Frances & Widiger, 2012). The manual is an important and influential publication that is currently unmatched by any other text in regard to power and influence within the mental health field (Duffy, Gillig, Tureen, & Ybarra, 2002). In May 2013, the American Psychiatric Association is expected to release the newest version of the DSM, the DSM-5 (American Psychiatric Association, 2010b). With this proposed revision of the manual, the American Psychiatric Association hopes to increase the clinical utility of the DSM and update the manual to reflect current research findings. Professionals across mental health professions, including psychiatry, psychology, and counseling, have elicited calls of concern regarding many of the proposed changes (American Psychological Association, 2011; Frances & Widiger, 2012; Jones, 2011; Locke, 2011; Obiols, 2012; Wakefield, 2010). The authors generally directed their criticisms at the lack of empirical evidence to support proposed changes in nosology, lowered diagnostic thresholds, the creation of new disorders, and the lack of sufficient attention to contextual influences in diagnosis (Locke, 2011, 2012). For nondominant and vulnerable populations (e.g., racial/ethnic minorities, sexual minorities, women, children, older adults, and individuals with disabilities), for whom disproportionate diagnostic rates are established in research, the criticisms may be magnified (Feisthamel & Schwartz, 2009; Kress, Eriksen, Rayle, & Ford, 2005; Paniagua, 2001). In this article, we present a historical overview of mental disorder diagnoses for vulnerable populations to establish an understanding of the experiences of nondominant groups within the diagnostic system. We then provide a summary of trends of the proposed changes to the DSM from current literature, including the influence of the medical model, the attention to nosology, and lowered thresholds. We summarize these trends through a conceptual review of the literature related to the DSM-5 (see www.dsm5.org) and correspondence among mental health professionals regarding the potential changes. Finally, we discuss the implications of these trends for vulnerable populations and discuss recommendations for reflection and advocacy among the counseling profession. * Diagnostic Prevalence and Vulnerable Populations The DSM is a socially constructed guidebook to clinically significant distressed functioning that greatly influences individuals, groups, and institutions across the world (Alarcon, 2009; Kutchins & Kirk, 1997; Wakefield, 2007). Individuals who significantly digress from this socially constructed norm and experience clinically significant distress are considered to have a mental disorder. Despite many contextual and developmental influences on human functioning, such as oppression, poverty, and discrimination, only one view is predominantly represented in the DSM-IV-TR (American Psychiatric Association, 2000), namely, the belief that mental distress is rooted within an individual and can be determined by identifying a particular set of symptoms and evaluating for clinical significance (Kress et al., 2005; Wakefield, 2007). The authors of the DSM strive to create a value-free scientific document; however, research and history suggest that societal norms and political agendas often influence the DSM development process. …