Diagnostic Tests

Diagnosis of Mental Disorders

Professional counselors in clinical practice are tasked with assessing, diagnosing, and treating mental disorders. It is essential for counselors to be familiar with diagnostic classification systems used by mental health professionals and the common diagnostic categories seen in the populations they work with. This section provides an overview of the DSM-5 and the mental disorders that professional counselors may come across in their clinical practice.

1. Using the DSM-5

The Diagnostic and Statistical Manual of Mental Disorders (DSM) is a widely used publication by the American Psychiatric Association. The current edition, DSM-5, serves as a key resource for mental health practitioners in the United States. It provides a comprehensive framework for assessing and diagnosing mental disorders. The DSM-5 offers clear definitions of various mental disorders and outlines their associated symptoms. It is important to note that the manual takes an atheoretical approach, meaning that diagnoses are not based on any specific counseling theory. The manual also includes information on the causation of certain disorders when there are specific factors involved. For a diagnosis to be made, a client typically needs to experience symptoms that significantly impact their academic, occupational, social, or other important areas of functioning.

Diagnosis of mental disorders is a huge content area and not a major focus on the NCE or CPCE. Thus, the summary information presented below consists of just the names of selected disorders and the essential diagnostic features of each. For further, in-depth information on any of these disorders, you need consult the DSM-5.

2. Neurodevelopmental Disorders

The disorders discussed in this category are typically diagnosed before adulthood, although some may have been present in childhood but were not identified until after the age of 18.

  • Intellectual developmental disorder (formerly known as mental retardation) is a developmental disorder characterized by significantly below-average intellectual ability (IQ < 70) and impaired adaptive functioning before the age of 18. Intellectual ability is typically assessed using standardized intelligence tests, while adaptive functioning is evaluated based on age-appropriate independent living skills. It is further categorized into four subtypes: mild, moderate, severe, and profound.
  • Specific learning disorder is diagnosed when a person’s academic achievement, as measured by standardized tests, is below expected levels considering their age and intellectual ability. This disorder often manifests as difficulties in reading, math, or written expression.
  • Motor disorders encompass conditions such as developmental coordination disorder, which involves significant impairment in gross or fine motor coordination skills, stereotypic movement disorder, and tic disorders. Tic disorders, including Tourette’s disorder, are characterized by sudden, repetitive vocalizations or motor movements that occur multiple times a day and have an onset before the age of 18.
  • Attention-deficit/hyperactivity disorder (ADHD) is characterized by a persistent pattern of inattention, hyperactivity, and impulsivity that begins before the age of five. It is more commonly diagnosed in males and affects 3% to 7% of school-age children.
  • Autism spectrum disorders involve profound impairments in multiple areas of development, including communication, social interactions, and restricted and repetitive patterns of behavior and interests. Autism spectrum disorders are pervasive and have a significant impact on daily functioning.

3. Schizophrenia Spectrum and Other Psychotic Disorders

The disorders in this category share common psychotic symptoms such as hallucinations, delusions, disorganized thoughts/speech, catatonic or disorganized behavior, or negative symptoms (flattened affect, alogia).

  • Schizophrenia is characterized by the presence of two or more of these psychotic symptoms occurring for most of the time during an active phase period of at least one month within a disturbance period of at least six months. Social or occupational functioning is significantly impaired, and the onset of schizophrenia typically occurs in late adolescence through young adulthood.
  • Schizophreniform disorder has similar symptoms to schizophrenia but with a duration of less than six months (with a one-month active phase). Social or occupational functioning problems may not be present, and the diagnosis may be provisional until the six-month threshold is reached, at which point a diagnosis of schizophrenia may be made.
  • Schizoaffective disorder involves a combination of concurrent symptoms of active-phase schizophrenia (two or more weeks of hallucinations and delusions) and a mood disorder (such as depression or mania).
  • Delusional disorder is characterized by non-bizarre delusions persisting for at least one month without prominent concurrent symptoms of schizophrenia or mood disorders. These delusions may revolve around themes like being followed or deceived by a spouse.
  • Brief psychotic disorder involves the presence of a psychotic symptom (e.g., hallucinations, delusions, disorganized speech, catatonic or disorganized behavior) lasting for at least one day but less than one month.

4. Bipolar and Related Disorders

Bipolar and related disorders encompass the following:

  • Bipolar I disorder, characterized by one or more manic or mixed episodes, without a history of a major depressive episode. Bipolar I disorder has a genetic component and affects males and females equally.
  • Bipolar II disorder, which involves experiencing at least one major depressive episode and one hypomanic episode. It is more frequently diagnosed in females compared to males.
  • Cyclothymic disorder, characterized by recurring periods of depression and hypomania lasting at least two years in adults (one year in children or adolescents).

5. Depressive Disorders

Depressive disorders encompass the following:

  • Major depressive disorder, characterized by one or more major depressive episodes without the presence of a manic, hypomanic, or mixed episode. This disorder is diagnosed more frequently in females compared to males.
  • Persistent depressive disorder (dysthymic disorder), characterized by a chronically depressed mood that persists for most days over a minimum period of two years (one year in children and adolescents). Many symptoms resemble those of a major depressive episode, but the individual does not experience the intense impairment typically seen during a two-week acute episode. Instead, the symptoms are milder and more persistent. This disorder is often diagnosed during early adulthood.

6. Anxiety Disorders

Anxiety disorders encompass various conditions characterized by significant levels of anxiety and avoidance that impact important areas of life.

  • Agoraphobia involves intense anxiety related to being in situations where escape may be difficult or embarrassing, often associated with the possibility of experiencing a panic attack. Agoraphobia can occur with or without a history of panic attacks. Panic disorder is characterized by recurrent panic attacks, with or without agoraphobia.
  • Specific phobia is an intense and persistent fear of a particular situation or object, such as flying, animals, insects, or enclosed spaces. Social anxiety disorder (social phobia) involves a strong and enduring fear of performance or social situations where one might be scrutinized or embarrassed, such as public speaking or being bullied.
  • Generalized anxiety disorder is marked by excessive anxiety that persists on most days for at least six months. It is accompanied by at least three of the following symptoms: restlessness, fatigue, difficulty concentrating, irritability, muscle tension, and sleep disturbances. The anxiety symptoms cannot be attributed to another disorder.
  • Separation anxiety disorder manifests as excessive anxiety when separated from an attachment figure (e.g., mother). The anxiety must persist for at least four weeks and have an onset before the age of 18, significantly affecting academic or social functioning.

7. Obsessive-Compulsive and Related Disorders

Obsessive-compulsive and related disorders encompass newly recognized conditions like hoarding disorder and excoriation (skin picking) disorder, as well as several previously categorized disorders that are now included in this group.

  • Obsessive-compulsive disorder (OCD) involves the presence of recurrent obsessions (thoughts, impulses, or images) that cause significant distress. These obsessions are not simply excessive worries about everyday life situations, and the individual finds it challenging to control or suppress them. Additionally, compulsions are repetitive behaviors or mental acts (such as counting or praying) aimed at reducing distress, but they are not logically connected to the feared outcome they are meant to prevent.
  • Body dysmorphic disorder is characterized by a preoccupation with an imagined defect in one’s appearance or an exaggerated perception of a minor flaw. This preoccupation cannot be better explained by another mental disorder, such as anorexia nervosa.
  • Trichotillomania involves the repeated pulling of one’s hair, resulting in noticeable hair loss. Individuals with trichotillomania experience feelings of tension before hair pulling and derive pleasure or satisfaction from the act.

8. Trauma- and Stressor-Related Disorders

Trauma- and stressor-related disorders encompass a range of reactions to traumatic or stressful events.

  • Posttraumatic stress disorder (PTSD) develops after exposure to a traumatic event involving actual or threatened death or injury, with the individual experiencing feelings of horror or helplessness. Symptoms include persistent re-experiencing of the event, avoidance of reminders, and heightened arousal. PTSD is diagnosed after one month following the trauma.
  • Acute stress disorder shares similarities with PTSD but is diagnosed within one month of the trauma. It may transition to PTSD if symptoms persist beyond that time frame.
  • Adjustment disorders involve psychological responses to identifiable stressors, resulting in more significant impairment than expected. Symptoms must begin within three months of the stressor, and typically resolve within six months unless the stressor is chronic.

9. Dissociative Disorders

Dissociative disorders involve a disruption in normal integrated functions of consciousness, memory, identity, or perception. Onset of these disorders may be sudden or gradual; the duration may be transient or chronic; and they are not due to another mental disorder, substance, or general medical condition. The dissociative disorders include the following:

  • Dissociative amnesia is an inability to recall important (and usually traumatic) information that is beyond ordinary forgetfulness. Dissociative identity disorder (formerly multiple personality disorder) is the presence of two or more distinct identities or personalities recurrently taking control of the person’s behavior, along with an inability to recall important personal information.
  • Depersonalization/Derealization disorder encompasses feelings of detachment from one’s mental processes or body (e.g., dreamlike state), without loss of contact with reality.

10. Somatic Symptom and Related Disorders

Somatic symptom and related disorders involve physical symptoms that resemble those of a general medical condition but cannot be fully explained by a medical condition, substance use, or other mental disorder. These disorders are not intentionally produced and cause significant distress or impairment.

  • Somatic symptom disorder is characterized by a history of persistent physical complaints that span several years and result in significant impairment. Importantly, these complaints cannot be fully attributed to a general medical condition and often exceed what would be expected based on such a condition.
  • Conversion disorder involves the presence of symptoms or deficits in voluntary motor or sensory functions that are preceded by stressors or psychological conflicts. These symptoms cannot be explained by a general medical condition or substance use, and they are not intentionally produced.
  • Factitious disorder involves the deliberate feigning of physical or psychological symptoms in order to assume the role of being sick. Unlike malingering, individuals with factitious disorder do not seek external rewards such as financial gain or avoidance of legal responsibilities.

11. Feeding and Eating Disorders

Feeding and eating disorders are characterized by severe disruptions in eating behaviors. Childhood feeding disorders include pica and rumination disorders. Obesity is not classified as a mental disorder unless it is driven by psychological factors. Alongside binge eating disorder, there are two primary eating disorders observed in adolescents and adults:

  • Anorexia nervosa involves a persistent refusal to maintain a body weight within the normal range for age and height, typically falling below 85% of the expected weight. Individuals with this disorder also exhibit an intense fear of gaining weight and a distorted body image.
  • Bulimia nervosa is characterized by recurrent episodes of binge eating, during which a person consumes a significantly large quantity of food within a two-hour period and experiences a lack of control over eating. To prevent weight gain, compensatory behaviors such as vomiting, laxative use, or excessive exercise are employed. Binge-eating and compensatory actions occur at least three times per week for a minimum of three months, accompanied by a distorted body image.

12. Elimination Disorders

Elimination disorders encompass challenges in controlling bowel and urinary functions that are not attributed to a general medical condition.

  • Encopresis refers to the involuntary depositing of feces in inappropriate locations, such as the floor, clothing, or furniture.
  • Enuresis involves the involuntary urination in inappropriate places, such as bedding and clothing, either during nighttime sleep (nocturnal) or during the day (diurnal).

13. Sleep–Wake Disorders

Sleep-wake disorders can be classified into primary disorders or those caused by another mental disorder, general medical condition, or substance use. They encompass a range of conditions such as insomnia disorder, hypersomnolence, narcolepsy/hypocretin deficiency, obstructive and central sleep apneas, circadian rhythm sleep-wake disorder, nightmare disorder, rapid eye movement sleep behavior disorder, and restless legs disorder. It is important to consider the underlying cause of sleep disorders and code them accordingly, whether it is due to a mental disorder, medical condition, or substance use.

14. Sexual Dysfunctions

Sexual dysfunctions encompass difficulties in the sexual response cycle or experiencing pain during intercourse. They can manifest as erectile disorder, female orgasmic disorder, premature ejaculation, and genito-pelvic pain and penetration disorder.

15. Gender Dysphoria

The concept of gender dysphoria has replaced gender identity disorder and is now categorized based on the age of onset (children, adolescents, or adults). It refers to an enduring identification with a gender different from one’s assigned sex and a sense of discomfort or distress related to one’s sex or gender role.

16. Disruptive, Impulse Control, and Conduct Disorders

Many mental disorders exhibit impulsive features; however, they are often classified under other categories in the DSM, such as ADHD, paraphilias, and substance-related disorders. The impulse disorders included in this section have been separated due to their distinct characteristics. They significantly impair functioning in important areas of life and are not better explained by another mental disorder, general medical condition, or substance use.

  • Intermittent explosive disorder involves episodes of aggressive impulses that are greatly disproportionate to the social context, resulting in serious acts of assault or property damage.
  • Conduct disorder encompasses persistent patterns of behavior that violate the rights of others or social rules, such as cruelty, theft, bullying, fighting, and rape, in individuals under 18 years of age.
  • Oppositional defiant disorder involves a recurring pattern of defiant, disobedient, hostile, and negative behaviors directed towards authority figures. Individuals diagnosed with conduct disorder cannot simultaneously be diagnosed with oppositional defiant disorder.

17. Substance-Related and Addictive Disorders

Substances encompass drugs of abuse, medications, and toxins. Substance use disorders are classified into various categories, including alcohol, cannabis, amphetamine, cocaine, hallucinogen, inhalant, nicotine, opioid, phencyclidine, and sedative, hypnotic, or anxiolytic. Additionally, a diagnosis of unknown dependence is possible. In the past, distinctions were made between abuse, dependence, and intoxication. Substance abuse refers to a pattern of harmful substance use that interferes with important responsibilities, poses physical risks, leads to legal issues, or causes persistent interpersonal conflicts. Substance dependence involves ongoing substance use despite noticeable impairment, such as tolerance, withdrawal symptoms, a desire to cut down use, or a reduction in other activities due to substance use. Substance intoxication occurs when the ingestion of a substance results in maladaptive behavior, including mood swings, impaired judgment, and compromised social or occupational functioning.

18. Neurocognitive Disorders

This group of conditions encompasses changes in cognitive abilities, where individuals experience a decline in their previous higher levels of functioning, leading to present deficiencies. These changes are attributed to either a general medical condition or substance use.

  • Delirium is characterized by disturbances in consciousness (e.g., awareness of the environment) and cognition (e.g., disorientation, memory problems) that arise due to a general medical condition or substance use. Delirium typically develops over several hours and fluctuates in severity throughout the day.
  • Neurocognitive disorder involves memory impairment and at least one other cognitive deficiency (e.g., language, motor, and executive functioning). This condition is caused by either a general medical condition (e.g., Alzheimer’s disease, Parkinson’s disease, HIV) or substance use.

19. Personality Disorders

Personality disorders are enduring patterns of behavior and internal experiences that deviate significantly from societal and cultural norms. They are characterized by their pervasive nature across different contexts, stability over time, onset in adolescence or adulthood, and significant impairment in functioning. The DSM-5 outlines several personality disorders, including:

  • Schizotypal personality disorder: A pattern of discomfort in relationships, distorted perception, and eccentric behaviors.
  • Antisocial personality disorder: A pattern of disregard for others’ rights and frequent violations of social norms.
  • Borderline personality disorder: A pattern of unstable relationships, self-image, emotions, and impulsive behaviors.
  • Narcissistic personality disorder: A pattern of grandiosity, a strong need for admiration, and a lack of empathy for others.
  • Avoidant personality disorder: A pattern of social avoidance, feelings of inadequacy, and hypersensitivity to criticism or rejection.
  • Obsessive-compulsive personality disorder: A pattern of perfectionism, excessive control, and a preoccupation with orderliness.

These personality disorders reflect significant deviations from expected behavior and can have a profound impact on an individual’s life and relationships.

20. Paraphilic Disorders

Paraphilic disorders encompass intense sexual fantasies, urges, or behaviors that often involve nonhuman objects or the humiliation of one’s partner or children. They include exhibitionistic, fetishistic, frotteuristic, pedophilic, sexual masochism, sexual sadism, and voyeuristic disorders. These disorders revolve around atypical sexual interests and may cause distress or harm to oneself or others.