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Using DSM-5 for Quality Clinical Assessment, Diagnosis

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Jim Messina, Ph.D., CCMHC, NCC, DCMHS Assistant Professor Troy University, Tampa Bay Site – PowerPoint PPT presentation

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Title: Using DSM-5 for Quality Clinical Assessment, Diagnosis


1
Using DSM-5 for Quality Clinical Assessment,
Diagnosis Treatment Plans
  • Jim Messina, Ph.D., CCMHC, NCC, DCMHS
  • Assistant Professor
  • Troy University, Tampa Bay Site

2
Learning Objectives
  • PART 1
  • Status of the new DSM-5
  • Categories and changes in DSM-5
  • Impact of DSM-5 for Clinical Mental Health
    Counselors
  • Openings for Integrated Behavioral Medicine
    Specialty
  • Openings for Co-Occurring Disorders Treatment
    Specialty
  • Opening for Trauma Specialty
  • Trauma Focused Therapeutic Diagnosis and
    Treatment Planning using the Adverse Childhood
    Experience (ACE Factors) Screening, the DSM-5 for
    Principal and Provisional Diagnoses along with
    Identifying Other Condition That May be a Focus
    of Clinical Attention
  • Integrated Behavioral Medicine Diagnosis and
    Treatment Planning using the ICD Codes for Common
    Medical Conditions resulting in Mental Health
    Disorders
  • PART 2
  • Using DSM-5 for Improved Clinical Assessment,
    Diagnosis and Treatment Planning

3
PART 1 Overview of DSM-5
4
Websites on DSM-5
  • Official APA DSM-5 site www.dsm5.org
  • DSM-5 on www.coping.us

5
Timeline of DSM-5
  • 1999-2001 Development of Research Agenda
  • 2002-2007 APA/WHO/NIMH DSM-5/ICD-11 Research
    Planning conferences
  • 2006 Appointment of DSM-5 Taskforce
  • 2007 Appointment of Workgroups
  • 2007-2011 Literature Review and Data
    Re-analysis
  • 2010-2011 1st phase Field Trials ended July
    2011
  • 2011-2012 2nd phase Field Trials began Fall
    2011
  • July 2012 Final Draft of DSM-5 for APA
    review
  • May 2013 Publication Date of DSM-5

6
Revision Guidelines for DSM-5
  • Recommendations to be grounded in empirical
    evidence
  • Any changes to the DSM-5 in the future must be
    made in light of maintaining continuity with
    previous editions for this reason the DSM-5 is
    not using Roman numeral V but rather 5 since
    later editions or revision would be DSM-5.1,
    DSM-5.2 etc.
  • There are no preset limitations on the number of
    changes that may occur over time with the new
    DSM-5
  • The DSM-5 will continue to exist as a living,
    evolving document that can be updated and
    reinterpreted over time

7
Focus of DSM-5 Changes
  • DSM-5 is striving to be more etiological-however
    disorders are caused by a complex interaction of
    multiple factors and various etiological factors
    can present with the same symptom pattern
  • The diagnostic groups have been reshuffled
  • There is a dimensional component to the
    categories to be further researched and covered
    in Section III of the DSM-5
  • Emphasis was on developmental adjustment
    criteria
  • New disorders were considered and older disorders
    were to be deleted
  • Special emphasis was made for Substance/Medication
    Induced Disorders and specific classifications
    for them are listed for Schizophrenia Bipolar
    Depressive, Anxiety, Obsessive Compulsive
    Sleep-Wake Sexual Dysfunctions and
    Neurocognitive Disorders.

8
Definition of Mental Disorder
  • A mental disorder is a syndrome characterized by
    clinically significant disturbance in an
    individual's cognition, emotion regulation, or
    behavior that reflects a dysfunction in the
    psychological, biological, or developmental
    processes underlying mental functioning. Mental
    disorders are usually associated with significant
    distress or disability in social, occupational,
    or other important activities. An expectable or
    culturally approved response to a common stressor
    or loss, such as 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. 
  • (American Psychiatric Association
    (2013). Diagnostic and Statistical Manual of
    Mental Disorders-Fifth Edition DSM-5. Arlington
    VA Author, p. 20.)

9
Why identify a mental disorder diagnosis?
  • The diagnosis of a mental disorder should have
    clinical utility
  • Helps to determine prognosis
  • Helps in development of treatment plans
  • Helps to give an indication of potential
    treatment outcomes
  • A diagnosis of a mental disorder is not
    equivalent to a need for treatment. Need for
    treatment is a complex clinical decision that
    takes into consideration
  • Symptom severity
  • Symptom salience (presence of relevant symptom
    e.g., presence of suicidal ideation)
  • The client's distress (mental pain) associated
    with the symptom(s)
  • Disability related to the client's symptoms,
    risks, and benefits of available treatment
  • Other factors such as mental symptoms
    complicating other illness

10
DSM-5 Diagnostic Categories
  1. Neurodevelopmental disorders
  2. Schizophrenia Spectrum and Other Psychotic
    Disorders
  3. Bipolar and Related Disorders
  4. Depressive Disorders
  5. Anxiety Disorders
  6. Obsessive Compulsive and Related Disorders
  7. Trauma- and Stressor-Related Disorders
  8. Dissociative Disorders
  9. Somatic Symptom and Related Disorders
  10. Feeding and Eating Disorder
  11. Elimination Disorders
  12. Sleep-Wake Disorders
  13. Sexual Dysfunctions
  14. Gender Dysphoria
  15. Disruptive, Impulse-Control, and Conduct
    Disorders
  16. Substance-Related and Addictive Disorders
  17. Neurocognitive Disorders
  18. Personality Disorders
  19. Paraphilic Disorders

11
Obvious Changes in DSM-5 (1)
  • The DSM-5 will discontinue the Multiaxial
    Diagnosis, No more Axis I,II, III, IV V-which
    means that Personality Disorders will now appear
    as diagnostic categories and there will be no
    more GAF score or listing of psychosocial
    stressor or contributing medical conditions
  • The Multi-axial model will be replaced by
    Dimensional component to diagnostic categories

12
Obvious Changes in DSM-5 (2)
  • Developmental adjustments will be added to
    criteria
  • The goal has been to have the categories more
    sensitive to gender and cultural differences
  • Diagnostic codes will change from numeric to
    alphanumeric e.g., Obsessive Compulsive Disorder
    will change from 300.3 to F42
  • Diagnostic codes will change from
    numeric ICD-9-CM codes on September 30, 2015 to
    alphanumeric ICD-10-CM codes on October 1,
    2015 e.g., Obsessive Compulsive Disorder will
    change from 300.3 to F42
  • They have done away with the NOS labeling and
    replaced it with Other Specified... or
     Unspecified 

13
What Replaces NOS?
  • NOS is replace by either
  • Other specified disorder or Unspecified disorder
    type are to be used if the diagnosis of a client
    is too uncertain because of
  • 1. Behaviors which are associated with a
    classification are seen but there is uncertainty
    regarding the diagnostic category due to the fact
    that
  • The client presents some symptoms of the category
    but a complete clinical impression is not clear
  • The client responds to external stimuli with
    symptoms of psychosis, schizophrenia etc. but
    does not present with a full range of the
    symptoms need for a complete diagnosis
  • 2. The client has been unwilling to provide
    information due to an unwillingness to be with
    the clinician or angry about being brought in to
    be seen or the there is too brief a period of
    time in which the client has been seen or the
    clinician is untrained in the classification
  • Rules for use of Other Specific or Unspecified
  • This designation can last only six months and
    after that a specific diagnostic category has to
    be determined for the diagnosis of the client.

14
Respect for Age, Gender Culture in DSM-5
  • Each diagnostic definition, where appropriate
    will incorporate
  • 1. Developmental symptom manifestation
    regarding the age of client
  • 2. Gender specific disorders
  • 3. Cultural sensitivity in regards to certain
    behaviors

15
1. Principal Diagnosis
  • Principal Diagnosis is to be used when more than
    one diagnosis for an individual is given in most
    cases as the main focus of attention or
    treatment
  • In an inpatient setting, the Principal diagnosis
    is the condition established to be chiefly
    responsible for the admission of the individual
  • In an outpatient setting, the Principal diagnosis
    is the condition established as reason for visit
    responsible for care to be received 
  • The Principal diagnosis is often harder to
    identify when a substance/medication related
    disorder is accompanied by a non-substance-related
    diagnosis such as major depression since both
    may have contributed equally to the need for
    admission or treatment. 
  • Principal diagnosis is listed first and the term
    "Principal diagnosis" follows the diagnosis name
  • Remaining disorders are listed in order of focus
    of attention and treatment 

16
2. Provisional Diagnosis
  • Provisional" can be used when there is strong
    presumption that the full criteria will be met
    for a disorder but not enough information is
    available for a firm diagnosis. It must be
    recorded "provisional" following the diagnosis
    given
  • The provisional diagnoses are often found in the
    differential diagnosis section within each
    disorders section of the DSM-5

17
3. Other Condition That May Be a Focus of
Clinical Attention
  • Replaces the Psychosocial Stressors (Axis 4) and
    GAF Score (Axis 5)
  • Other Conditions that May Be a focus of Clinical
    Attention ARE NOT mental disorders
  • They are meant to draw attention to additional
    issues which may be encountered in clinical
    practice (p.715)
  • Should be documented to help identify factors
    which could impact the treatment planned

18
Categories of Other Conditions That May Be a
Focus of Clinical Attention
  1. Relational
  2. Educational and Occupational Problems
  3. Housing and Economic Problems
  4. Other Problems Related to the Social Environment
  5. Problems Related to Crime or Interaction with the
    Legal System
  6. Other Health Service Encounters for Counseling
    and Medical Advice
  7. Problems Related to Other Psychosocial, Personal
    and Environmental Circumstances
  8. Other Circumstances of Personal History

19
1A. Categories of Relational Problems in Other
Conditions That May Be a Focus of Clinical
Attention
  • Problems Related to Family Upbringing
  • Other Problems Related to Primary Support Group
  • Child Maltreatment and Neglect Problems
  • Child Physical Abuse (Confirmed or Suspected)
  • Child Sexual Abuse (Confirmed or Suspected)
  • Child Neglect (Confirmed or Suspected)
  • Child Psychological Abuse (Confirmed or
    Suspected)
  • Other Circumstance Related to Child Maltreatment
  • Encounter for MH Services for being a victim
  • Personal history (past history) as a child
  • Encounter for MH Services as a perpetrator

20
1B. Categories of Relational Problems in Other
Conditions That May Be a Focus of Clinical
Attention
  • Adult Maltreatment and Neglect Problems
  • Spouse or Partner Violence, Physical(Confirmed or
    Suspected)
  • Spouse or Partner Violence, Sexual(Confirmed or
    Suspected)
  • (Confirmed or Suspected)
  • Spouse or Partner Neglect (Confirmed or
    Suspected)
  • Spouse or Partner Abuse, Psychological (Confirmed
    or Suspected)
  • Adult Physical Abuse by Nonspouse
  • Other Circumstance Related to Adult Maltreatment
  • Encounter for MH Services for being a victim
  • Personal history (past history) as a victim
  • Encounter for MH Services as a perpetrator

21
What does a DSM-5 Diagnosis look like?
  • Principal Diagnosis
  • 303.90 (F10.20) Alcohol Use Disorder Moderate
  • 304.30 (F12.20) Cannabis Use Disorder Severe
  • Provisional Diagnosis
  • 291.89 (F10.14) Substance/Medication-Induced
    Depressive Disorder with Moderate Alcohol Use
    Disorder
  • Other Condition That May Be a Focus of Clinical
    Attention
  • V61.10 (Z63.0) Relationship Distress with Spouse
    or Intimate Partner
  • V61.8 (Z63.8) High Expressed Emotion Level within
    Family
  • V62.5 (Z65.3) Problem Related to Other Legal
    Circumstances

22
ICD Codes Relationship to DSM-5
  • The World Health Organization (WHO) is revising
    International Classification of Diseases and
    Related Health Problems (ICD-10) so that by 2015,
    ICD-11 will come out
  • DSM-5s Codes are only the ICD-CM codes (CM
    Clinically Modified to fit a Nations cultural
    makeup)
  • October 1, 2015, ICD-10 codes are in effect!

23
Implementation Date Change
  • The ICD-10 is the basis for ICD-10-CM codes which
    according to the DSM-5 was to be required as of
    October 1, 2014 in the United States as the codes
    to be used in all clinical reports and for
    insurance and third party reimbursement billing.
    However on April 1, 2014, the Protecting Access
    to Medicare Act of 2014 (PAMA) (Pub. L. No.
    113-93) was enacted, which said that the
    Secretary may not adopt ICD-10 prior to October
    1, 2015. Accordingly, the U.S. Department of
    Health and Human Services expects to release an
    interim final rule in the near future that will
    include a new compliance date that would require
    the use of ICD-10 beginning October 1, 2015. The
    rule will also require HIPAA covered entities to
    continue to use ICD-9-CM through September 30,
    2015. 

24
Which codes do we use?
  • Codes used in clinical reports insurance or 3rd
    party billing are the ICD codes
  • ICD codes are the only HIPAA approved codes in
    the USA
  • The DSM system is simply a diagnostic aid to help
    us sort out what ICD-CM code that is applicable
    for our clients

25
Organization of IDC-10-CM Codes
  • F01-F09 Mental disorders due to known
    physiological conditions
  • F10-F19 Mental and behavioral disorders due to
    psychoactive substance use
  • F20-F29 Schizophrenia, schizotypal, delusional,
    and other non-mood psychotic disorders
  • F30-F39 Mood (affective) disorders
  • F40-F48 Anxiety, dissociative, stress-related,
    somatoform and other nonpsychotic mental
    disorders
  • F50-F59 Behavioral syndromes associated with
    physiological disturbances and physical factors
  • F60-F69 Disorders of adult personality and
    behavior
  • F70-F79 Intellectual disabilities
  • F80-F89 Pervasive and specific developmental
    disorders
  • F90-F98 Behavioral and emotional disorders with
    onset usually occurring in childhood and
    adolescence
  • F99 Unspecified mental disorder

26
Descriptive Manual for ICD
  • The WHO publishes what is called the Blue Book
    with descriptive explanations of their Mental,
    Behavioral Disorders. It is free from WHO and is
    available on their website
  • The difference between the APA DSM system and the
    WHO ICD model is that the WHO model is free which
    make no one money

27
  • Specific Changes
  • Per Diagnostic Category
  • in DSM-5

28
Neurodevelopmental Disorders
  • 1. Intellectual Disability (Intellectual
    Developmental Disorder) no longer relies on IQ
    used as specifier because it is the adaptive
    functioning that determines levels of support
    required.
  • IQ measures are less valid in the lower end of
    the IQ range
  • Still accepted that people with intellectual
    disability have scores two standard deviations or
    more below the population mean, including a
    margin for error which is generally 5 points.
    Thus on tests with standard deviations of 15 and
    mean of 100 the score for mild would involve
    65-75 (705).
  • 2. Asperger's Syndrome is lumped into Autism
    Spectrum since it is at the milder end of the
    Spectrum
  • 3. Childhood disintegrative disorder, Rett's
    disorder and Pervasive developmental disorder not
    otherwise specified are also now incorporated
    into the Autism Spectrum Disorder
  • 4. Autism Spectrum Disorder is now characterized
    by deficits in two domains
  • Deficits in social communication and social
    interaction
  • Restricted repetitive patterns of verbal and
    nonverbal communication.

29
Schizophrenia and Other Psychotic Disorders
  • 1.Changes for Criteria A for Schizophrenia were
    made
  • 1) elimination of the special attribution of
    bizarre delusions and Schneiderian first-rank
    auditory hallucinations (two or more voices
    conversing), leading to the requirement of at
    least two Criterion A symptoms for any diagnosis
    of schizophrenia
  • 2) the addition of the requirement that at least
    one of the Criterion A symptoms must be
    delusions, hallucinations, or disorganized
    speech.
  • 2. DSM-IV-TR subtypes of schizophrenia were
    eliminated
  • 3. Schizoaffective disorder is reconceptualized
    as a longitudinal rather than a cross sectional
    diagnosis and requires that a major mood episode
    be present for a majority of the total disorder's
    duration after Criterion A has been met
  • 4. Schizotypal Personality Disorder is now listed
    in this category

30
Bipolar and related disorders
  • 1. Bipolar is now a free standing category
  • 2. Bipolar was taken out of the mood disorder
    category
  • 3. Diagnostic criteria now include both changes
    in mood and changes in activity or energy

31
Depressive Disorders
  • 1. Dysthymia is now called Persistent Depressive
    Disorder 
  • 2. Disruptive Mood Dysregulation Disorder has
    been added for children up to age 18 years who
    exhibit persistent irritability and frequent
    episodes of extreme behaviors
  • 3. Premenstrual Dysphoric Disorder has been
    added 

32
Anxiety Disorders
  • 1. No longer has PTSD in this category
  • 2. No longer has OCD in this category
  • 3. Social Phobia is now called Social Anxiety
    Disorder
  • 4. Panic Disorder and Agoraphobia are unlinked
    and each now have their own separate criteria
  • 5. Separation anxiety disorder and selective
    mutism are now classified as anxiety disorders

33
Obsessive-Compulsive and Related Disorders
  • 1. OCD is now a stand alone category
  • 2. Body Dysmorphic Disorder is now listed under
    OCD
  • 3. Hoarding has been added under the category of
    OCD
  • 3. Trichotillomania (Hair-Pulling Disorder) is
    listed under OCD
  • 4. Excoriation (Skin Picking Disorder) is
    listed under OCD

34
Trauma and Stressor Related Disorders
  • 1 Trauma related disorders are now a stand alone
    category
  • 2. Reactive Attachment Disorder is now listed
    here
  • 3. Disinhibited Social Engagement Disorder has
    been added
  • 4. PTSD is listed here
  • 5. PTSD in Preschool Children has been added
  • 6. Acute Stress Disorder is listed here and
    requires qualifying traumatic events as explicit
    as to whether they were experienced directly,
    witnessed or experienced indirectly 
  • 7. Adjustment Disorders are now listed here and
    conceptualize as a heterogeneous array of
    stress-response syndromes that occur after
    exposure to a distressing (traumatic or
    nontraumatic) event.

35
Dissociative Disorders
  • 1. Dissociative Fugue has been removed from this
    category and is now a specifier of dissociative
    amnesia
  • 2. Derealization is included in the name and
    symptom structure of the former depersonalization
    disorder to become Depersonalization/Derealizatio
    n disorder.

36
Somatic Symptom Disorder
  • 1. Replaced Somatiform Disorders category with
    this category
  • 2. Somatization Disorder Pain Disorder
    Hypochondriasis and undifferentiated somatoform
    disorder were eliminated
  • 3. Complex Somatic Symptom Disorder was added
  • 4. Simple Somatic Symptom Disorder was added
  • 5. Illness Anxiety Disorder was added and
    replaces Hypochondriasis
  • 6. Conversion Disorders (Functional Neurological
    Disorder) have modified criteria to emphasize
    essential importance of neurological examination,
    in recognition that relevant psychological
    factors may not be demonstrable at time of
    diagnosis
  • 7. Psychological factors affecting other medical
    conditions has been added to this category and
    along with Factitious disorder both have been
    placed among the somatic symptom and related
    disorders  because somatic symptoms are
    predominant in both disorders

37
Feeding and Eating Disorders
  • 1. Pica was moved to this category
  • 2. Rumination Disorder was moved to this category
  • 3. The "feeding disorder of infancy or early
    childhood has been renamed Avoidant/Restrictive
    Food Intake Disorder 
  • 4. Binge Eating Disorder was added

38
Elimination Disorders
  • 1. This category was created as freestanding
    category
  • 2. Enuresis was moved to this category
  • 3. Encopresis was move to this category

39
Sleep-Wake Disorders
  • 1. Primary Insomnia renamed Insomnia Disorder
  • 2. Primary Hypersomnia joined with Narcolepsy
    without Cataplexy
  • 3. Cheyne-Stokes Breathing added
  • 4. Obstructive Sleep Apnea Hypopnea added
  • 5. Idiopathic Central Sleep Apnea added
  • 6. Congenital Central Alveolar Hypoventilation
    added
  • 7. Rapid Eye Movement Behavior Disorder added
  • 8. Restless Leg Syndrome added

40
Sexual Dysfunctions
  • 1. Male orgasmic disorder renamed Delayed
    Ejaculation
  • 2. Premature (Early) Ejaculation renamed
  • 3. Dyspareunia and Vaginismus were combined into
    Genito-Pelvic Pain/Penetration Disorder
  • 4. Sexual Aversion Disorder combined in other
    categories
  • 5. For females-sexual desire and arousal
    disorders have been combined into one disorder
    Female sexual interest/arousal disorder

41
Gender Dysphoria
  • 1 This is a new diagnostic class
  • 2. It emphasizes the phenomenon of "gender
    incongruence" rather than cross-gender
    identification per se.
  • 3. Posttransition specifier has been added to
    identify individuals who have undergone at least
    one medical procedure or treatment to support new
    gender assignment

42
Disruptive, Impulse Control, and Conduct
Disorders
  • 1. This is a new diagnostic class and combines
    "Disorders Usually First Diagnosed in Infancy,
    Childhood, or Adolescence" and the
    "Impulse-control Disorders Not Elsewhere
    Classified"2. Oppositional Defiant Disorder was
    added here
  • 3. Trichotillomania removed from this category
  • 4. Conduct Disorder now in this freestanding
    category
  • 5. Antisocial Personality Disorder added to this
    category as well as in Personality Disorders
    Category

43
Substance Abuse and Addictive Disorders
  • Only 3 qualifiers are used in the category 
  • Use - replaces both abuse and dependence
  • Intoxication and Withdrawal remain the same
  • 2. Nicotine Related renamed Tobacco Use Disorder
  • 3. Caffeine Withdrawal added
  • 4. Cannabis Withdrawal added
  • 5. Polysubstance Abuse categories discontinued
  • 6. Gambling added to this category

44
Neurocognitive Disorders
  • 1. Category replaces Delirium, Dementia, and
    Amnestic and Other Cognitive Disorders Category
  • 2. Now distinguishes between Minor and Major
    Disorders
  • 3. Replace wording of Dementia "due to"
     with Neurocognitive Disorder "Associated with"
    for all the conditions listed
  • 4. Added new Neurocognitive Disorders 
  • Fronto-Temporal Lobar Degeneration
  • Traumatic Brain Injury
  • Lewy Body Disease
  • 5. Renamed Head Trauma to Traumatic Brain Injury
  • 6. Renamed Creutzfeldt-Jakob Disease to Prion
    Disease

45
Personality Disorders
  • Cluster A Personality Disorders
  • 301.0 (F60.0) Paranoid Personality Disorder
  • 301.20 (F60.1) Schizoid Personality Disorder
  • 301.22 (F21) Schizotypal Personality Disorder
  • Cluster B Personality Disorders
  • 301.7 (F60.2) Antisocial Personality Disorder
  • 301.83 (F60.3) Borderline Personality Disorder
  • 301.50 (F60.4) Histrionic Personality Disorder
  • 301.81 (F60.81) Narcissistic Personality Disorder
  • Cluster C Personality Disorders
  • 301.82 (F60.6) Avoidant Personality Disorder
  • 301.6 (F60.7) Dependent Personality Disorder
  • 301.4 (F60.5) Obsessive-Compulsive Personality
    Disorder
  • Other Personality Disorders
  • 310.1 (F07.0) Personality Change Due to Another
    Medical Condition Specify whether Labile type
    Disinhibited Type Aggressive Type Apathetic
    Type Paranoid Type Other Type Combined Type
    Unspecified Type
  • 301.89 (F60.89) Other Specified Personality
    Disorder
  • 301.9 (F60.9) Unspecified Personality Disorder

46
Paraphilic Disorders
  • 1. They all carried over to DSM-5
  • 2. New names for them all but the category
    remains the same
  • 3. Overarching change is the addition of course
    specifiers
  • in a controlled environment
  • in remission
  • 4. Distinction between paraphilias and paraphilic
    disorder was made
  • Paraphilic disorder is a paraphilia that is
    currently causing distress or impairment to the
    individual or a paraphilia whose satisfaction has
    entailed personal harm, or risk of harm, to
    others. 
  • Paraphilia is a necessary but not a sufficient
    condition for having a paraphilic disorder, and a
    paraphilia by itself does not automatically
    justify or require clinical intervention

47
Conditions Designated for Further Study in
DSM-5 in Section III
  • Attenuated Psychosis Syndrome
  • Depressive Episodes with Short-Duration Hypomania
  • Persistent Complex Bereavement Disorder
  • Caffeine Use Disorder
  • Internet Gaming Disorder
  • Neurobehavioral Disorder Associated with Prenatal
    Alcohol Exposure
  • Suicidal Behavior Disorder
  • Nonsuicidal Self-Injury

48
Possible  Disorders Discussed But Not Included in
Section III of DSM-5
  • Dissociative Trance Disorder
  • Anxious Depression
  • Factitious disorder imposed on another
  • Hypersexual Disorder
  • Olfactory Reference Syndrome
  • Paraphilic Coercive Disorder

49
  • Behavioral Medicine Specialization
  • Based on the DSM-5

50
Definition of Behavioral Medicine
  • Behavioral Medicine is the interdisciplinary
    field concerned with the development and the
    integration of behavioral, psychosocial, and
    biomedical science knowledge and techniques
    relevant to the understanding of health and
    illness, and the application of this knowledge
    and these techniques to prevention, diagnosis,
    treatment and rehabilitation.
  • (Definition is provided by Society of Behavioral
    Medicine on their website at http//www.sbm.org/a
    bout )

51
Integrated Behavioral Medicine Specialty Focus
  • Neurocognitive Disorders
  • Hormonal Imbalances
  • Cardiovascular Health Conditions
  • Respiratory Difficulties
  • Chronic Health Conditions
  • Cancers Bladder, Breast, Colon, Rectal,
    Uterine-Ovarian, Kidney, Leukemia, Lung,
    Melanoma, Non-Hodgkin Lymphoma, Pancreatic,
    Prostate, Thyroid

52
Rule of Thumb in Diagnosing Medically Related
Conditions
  • First Put in the ICD code for the Medical
    Condition
  • Second Put in the mental health disorder related
    to the Medical Condition

53
Schizophrenia Psychotic Disorder Co-occurring
with Medical Condition
  • 293.81 (F06.2) Psychotic Disorder due to Another
    Medical Condition with delusions
  • 293.82 (F06.0) Psychotic Disorder due to Another
    Medical Condition with hallucinations
  • 293.89 (F06.1) Catatonic Disorder Associated with
    Another Medical Condition
  • 293.89 (F06.1) Catatonic Disorder Due to Another
    Medical Condition

54
Bipolar Co-occurring with Medical Condition
  • 293.83 (F06.33) Bipolar and Related Disorder due
    to Another Medical Condition with manic features
  • 293.83 (F06.33) Bipolar and Related Disorder due
    to Another Medical Condition with manic-or
    hypomanic-like episode
  • 293.83 (F06.34) Bipolar and Related Disorder due
    to Another Medical Condition with mixed features

55
Depressive Disorder Co-occurring with Medical
Condition
  • 293.83 (F06.31) Depressive Disorder Due to
    Another Medical Condition with depressive
    features
  • 293.83 (F06.32) Depressive Disorder Due to
    Another Medical Condition with major
    depressive-like episodes
  • 293.83 (F06.34) Depressive Disorder Due to
    Another Medical Condition with mixed features

56
Anxiety Disorder Co-occurring with Medical
Condition
  • 293.84 (F06.4) Anxiety Disorder Due to Another
    Medical Condition

57
Obsessive-Compulsive Co-occurring with Medical
Condition
  • 294.8 (F06.8) Obsessive-Compulsive and Related
    Disorder Due to Another Medical Condition
  • Specify if with obsessive-compulsive-disorder-like
    symptoms or with appearance preoccupation or
    with hoarding symptoms or with hair-pulling
    symptoms or with skin picking symptoms

58
Somatic Symptom Related Disorders
  • 300.82 (F45.1) Somatic Symptom Disorder
  • 300.7 (F45.21) Illness Anxiety Disorder
    Conversion Disorders (Functional Neurological
    Symptoms Disorder)
  • 300.11 (F44.4) Conversion Disorder with weakness
    or paralysis
  • 300.11 (F44.4) Conversion Disorder with abnormal
    movement
  • 300.11 (F44.4) Conversion Disorder with
    swallowing symptoms
  • 300.11 (F44.4) Conversion Disorder with speech
    symptoms
  • 300.11 (F44.5) Conversion Disorder with attacks
    or seizures
  • 300.11 (F44.6) Conversion Disorder with
    anesthesia or sensory loss
  • 300.11 (F44.6) Conversion Disorder with special
    sensory symptom
  • 300.11 (F44.7) Conversion Disorder with mixed
    symptoms
  • 316 (F54) Psychological Factors Affecting Medical
    Condition
  • 300.19 (F68.10) Factitious Disorder (includes
    Factitious Disorder Imposed on Self, Factitious
    Disorder imposed on Another)
  • 300.89 (F45.8) Other Specified Somatic Symptom
    and Related Disorder
  • 300.82 (F45.9) Unspecified Somatic Symptom and
    Related Disorder

59
Feeding Eating Disorders
  • 307.52 (F98.3) Pica in Children
  • 307.52 (F50.8) Pica in Adults
  • 307.53 (98.21) Rumination Disorder
  • 307.59 (50.8) Avoidant/Restrictive Food Intake
    Disorder
  • 307.1 (F50.01) Anorexia Nervosa Restricting type
  • 307.1 (F50.02) Anorexia Nervosa
    Binge-eating/purging type
  • 307.51 (F50.2) Bulimia Nervosa
  • 307.59 (F50.8) Other Specified Feeding or Eating
    Disorder
  • 307.50 (F50.9) Unspecified Feeding or Eating
    Disorder

60
Elimination Disorders
  • 307.6 (F98.0) Enuresis
  • 307.7 (F98.1) Encopresis
  • 788.39 (N39.498) Other Specified Elimination
    Disorder with urinary symptoms
  • 787.60 (R15.9) Other Specified Elimination
    Disorder with fecal symptoms
  • 788.30 (R32) Unspecified Elimination Disorder
    with urinary symptoms
  • 787.60 (R15.9) Unspecified Elimination Disorder
    with fecal symptoms

61
Sleep-Wake Disorders
  • 780.52 (G47.00) Insomnia Disorder
  • 780.54 (G47.10) Hypersomnolence Disorder
  • 347.00 (G47.419) Narcolepsy without Cataplexy but
    with hypocretin deficiency
  • 347.01 (G47.411) Narcolepsy with Cataplexy but
    without hypocretin deficiency
  • 347.00 (G47.419) Autosomal dominant cerebellar
    ataxia, deafness, and narcolepsy
  • 347.00 (G47.419) Autosomal dominant narcolepsy,
    obesity and type 2 diabetes
  • 347.10 (47.429) Narcolepsy secondary to another
    medical condition

62
  • Breathing-Related Sleep Disorders
  • 327.23 (G47.33) Obstructive Sleep Apnea Hypopnea
  • Central Sleep Apnea
  • 327.21 (G47.31) Idiopathic Sleep Apnea
  • 786.04 (R06.3) Cheyne-Stokes Breathing
  • 780.57 (G47.37) Central Sleep Apnea comorbid with
    opioid use (first code opioid use disorder if
    present.)

63
  • Sleep-Related Hyperventilation
  • 327.24 (G47.34) Idiopathic hypoventilation
  • 327.25 (G47.35) Congenital central aveolar
    hypoventilation
  • 327.26 (G47.36) Comorbid sleep-related
    hypoventilation
  • Circadian Rhythm Sleep-Wake Disorders
  • 307.45 (G47.21) Circadian Rhythm Sleep-Wake
    Disorder Delayed sleep phase type
  • 307.45 (G47.22) Circadian Rhythm Sleep-Wake
    Disorder Advanced sleep phase type
  • 307.45 (G47.23) Circadian Rhythm Sleep-Wake
    Disorder Irregular sleep-wake type
  • 307.45 (G47.24) Circadian Rhythm Sleep-Wake
    Disorder Non-24 hour sleep-wake type
  • 307.45 (G47.26) Circadian Rhythm Sleep-Wake
    Disorder Shift Work type

64
  • Parasomnias
  • 307.46 (F51.3) Non-Rapid Eye Movement Sleep
    Arousal Disorder Sleepwalking Type Specify if
    With sleep-related eating With sleep-related
    sexual behavior (Sexsomnia)
  • 307.46 (F51.4) Non-Rapid Eye Movement Sleep
    Arousal Disorder Sleep terror type
  • 307.47 (F51.5) Nightmare Disorder Specify if
    during sleep onset. Specify if With associated
    non-sleep disorder With associated other
    medical condition With associated other sleep
    disorder
  • 327.42 (G47.52) Rapid Eye Movement Sleep Behavior
    Disorder
  • 333.94 (G25.81) Restless Legs Syndrome

65
Sexual Dysfunctions
  • 302.74 (F52.32) Delayed Ejaculation
  • 302.72 (F52.21) Erectile Disorder
  • 302.73 (F52.31) Female Orgasmic Disorder Specify
    if Never experienced an orgasm under any
    situation
  • 302.72 (F52.22) Female Sexual Interest/Arousal
    Disorder
  • 302.76 (F52.6) Genito-Pelvic Pain/Penetration
    Disorder
  • 302.71 (F52.0) Male Hypoactive Sexual Desire
    Disorder
  • 302.75 (F52.4) Premature (Early) Ejaculation

66
Focus of Behavioral Medicine
  • Life-span approach to health health care for
  • Children
  • Teens
  • Adults
  • Seniors
  • In racially and ethnically diverse communities

67
Desired Impact of Behavioral Medicine
  • Changes in behavior and lifestyle can
  • Improve health
  • Prevent illness
  • Reduce symptoms of illness
  • Behavioral changes can help people
  • Feel better physically and emotionally
  • Improve their health status
  • Increase their self-care skills
  • Improve their ability to live with chronic
    illness.
  • Behavioral interventions can
  • Improve effectiveness of medical interventions
  • Help reduce overutilization of the health care
    system
  • Reduce the overall costs of care

68
Key Strategies of Behavioral Medicine
  • Lifestyle Change
  • Training
  • Social Support

69
Examples of Goalsof Lifestyle Change
  • Improve nutrition
  • Increase physical activity
  • Stop smoking
  • Use medications appropriately
  • Practice safer sex
  • Prevent and reduce alcohol drug abuse

70
Examples of Training in Behavioral Medicine
  • Coping skills training
  • Relaxation training
  • Self-monitoring personal health
  • Stress management
  • Time management
  • Pain management
  • Problem-solving
  • Communication skills
  • Priority-setting

71
Examples of Social Support
  • Group education
  • Caretaker support and training
  • Health counseling
  • Community-based sports events

72
  • Trauma Focused Therapeutic Diagnosis
  • Treatment Planning

73
Trauma and Stressor Related Disorders
  1. PTSD for Adults, Teens, Children Preschool
    Children
  2. Acute Stress Disorder
  3. Adjustment Disorders
  4. Reactive Attachment Disorder
  5. Disinhibited Social Engagement Disorder

74
Trauma Focused Therapeutic Diagnosis Treatment
Planning
  • Adverse Childhood Experience (ACE Factors)
    Screening
  • DSM-5 for Principal and Provisional Diagnoses
  • Identifying Other Condition That May be a Focus
    of Clinical Attention

75
Adverse Childhood Experiences (ACE Factors)
  • ABUSE
  • 1. Emotional Abuse
  • 2. Physical Abuse
  • 3. Sexual Abuse
  • Neglect
  • 4. Emotional Neglect
  • 5. Physical Neglect
  • Household Dysfunction
  • 6. Mother was treated violently
  • 7. Household substance abuse
  • 8. Household mental illness
  • 9. Parental separation or divorce
  • 10. Incarcerated household member

76
Identify Diagnosis based on Traumatic Events /or
ACE Factors
  • Principal
  • Provisional
  • Other Conditions that May Be a Focus of Clinical
    Attention

77
Utilize Trauma Focused Evidenced Based Practices
  • Prolonged Exposure Therapy
  • Cognitive Processing Therapy
  • EMDR or ART Therapy
  • In addition to Therapeutic Plan to address
    Principal Diagnosis

78
  • Co-occurring Substance Use Disorder and
  • Mental Health Disorder

79
Co-occurring Substance Use Disorders Mental
Health Disorder Treatment Specialty Focus
  • Substance /Medication Induced Disorders
  • Schizophrenia
  • Bipolar Disorder
  • Depressive Disorders
  • Anxiety Disorders
  • Obsessive Compulsive Disorder
  • Sleep-Wake Disorders
  • Sexual Dysfunctions
  • Neurocognitive Disorders

80
Co-occurring Substance Disorder with
Schizophrenic Induced Psychotic Disorder
  • Alcohol
  • Cannabis
  • Phencyclidine
  • Hallucinogens
  • Inhalants
  • Sedatives
  • Amphetamines
  • Cocaine

81
Co-occurring Substance Disorder with Bipolar
Related Disorders
  • Alcohol
  • Phencyclidine
  • Hallucinogens
  • Sedatives
  • Amphetamines
  • Cocaine

82
Co-occurring Substance Disorder with Depressive
Disorders
  • Alcohol
  • Phencyclidine
  • Hallucinogens
  • Inhalants
  • Opioid
  • Sedatives
  • Amphetamines
  • Cocaine

83
Co-occurring Substance Disorder with Anxiety
Disorders
  • Alcohol
  • Caffeine
  • Cannabis
  • Phencyclidine
  • Hallucinogens
  • Inhalant
  • Opioid
  • Sedative
  • Amphetamine
  • Cocaine

84
Co-occurring Substance Disorder with
Obsessive-Compulsive Disorder
  • Amphetamines
  • Cocaine

85
Co-occurring Substance Disorder with Sleep-Wake
Disorders
  • Alcohol
  • Caffeine
  • Cannabis
  • Sedative
  • Amphetamine
  • Cocaine
  • Tobacco

86
Co-occurring Substance Disorder with Sexual
Dysfunctions
  • Alcohol
  • Opioid
  • Sedative
  • Amphetamine
  • Cocaine

87
Co-occurring Substance Disorder with Delirium
Neurocognitive Disorders
  • Alcohol
  • Cannabis
  • Phencyclidine
  • Hallucinogens
  • Inhalant
  • Opioid
  • Sedative
  • Amphetamine
  • Cocaine

88
Likelihood of SUDs in people with psychiatric
diagnoses
Diagnosis Odds Ratio
Bipolar Disorder 6.6
Schizophrenia 4.6
Panic Disorder 2.9
Major Depression 1.9
Anxiety Disorder 1.7
Weiss, R.D. Smith-Connery, H. (2011).
Integrated Group Therapy for Bipolar Disorder and
Substance Abuse. New York Guilford Press.
89
Substance abuse in patients with psychiatric
illness
  • Enhanced reinforcement
  • Mood Change
  • Escape
  • Hopelessness
  • Poor Judgment
  • Inability to appreciate consequences

90
Results of SUD with Psychiatric Disorder
especially Bipolar Disorder
  • Lower medication adherence
  • Greater chance relapses
  • Increased hospitalizations
  • Homelessness
  • Suicide

91
Models of Dual Diagnosis Treatment
  • Sequential Treat SUD first then Psychiatric
    disorder
  • Parallel Treat both at same time but within
    different treatment modalities
  • Integrated Treat both at same time within the
    same treatment modality

92
Integrated Treatment Model of Treatment of
Comorbid Disorders
  • Cognitive-behavioral model focuses on parallels
    between the disorders in recovery/relapse
    thoughts and behaviors
  • Explores the interaction between the two
    disorders
  • Utilizes a single disorder paradigm bipolar
    substance abuse
  • Uses a Central Recovery Rule

93
Focus of Integrated Model
  • Dealing with the Psychiatric disorder without use
    of Alcohol /or Drugs
  • Confronting denial, ambivalence, acceptance
  • Monitoring overall mood during each week
  • Emphasis on compliance in taking psychiatric
    medications
  • Identifying and fighting triggers
  • Emphasis on wellness model of good nights
    sleep, balance nutritional intake exercise

94
Parallels in Recovery Relapse thinking between
Disorders
  • May as well thinking vs. It matters what you
    do
  • Abstinence violation effect vs. stopping taking
    psychiatric meds when anxious or depressed
  • Recovery thinking vs. relapse thinking and acting
    out
  • Remember youre always on the road to getting
    better or getting worse It matters what you do!

95
The Central Recovery Rule
  • No matter what
  • Dont drink
  • Dont use drugs
  • Take your medication as prescribed
  • No matter what
  • Weiss, R.D. Smith-Connery, H. (2011).
    Integrated Group Therapy for Bipolar Disorder and
    Substance Abuse. New York Guilford Press.

96
Part 2 Use of DSm-5 in Clinical Assessment
97
  • Completing a Thorough Clinical Assessment using
    the new
  • DSM-5 System

98
Steps to formulate an initial Tentative Diagnosis
and Treatment Plan
  1. Do a thorough Psychosocial History
  2. Do a Mental Status Examination
  3. Develop a Diagnosis using DSM-5
  4. Develop Treatment Plan
  5. 3 Goals
  6. 3 Objectives per Goal (total of 9)
  7. 1 Intervention per Objectives (total of 9)

99
  • STEP 1
  • Complete Psychosocial History

100
First Establish - WHY NOW?
  • You must be able to describe the presenting
    problem
  • Listing specific symptoms and complaints which
    would justify diagnosis
  • You must be able to list the duration of the
    symptoms or at least estimate the duration

101
Second Review clients mental health history
  • Previous treatment for mental health problems?
  • Hospitalization for psychiatric conditions?
  • As child involved in family therapy?
  • Treatment for substance abuse problems-outpatient
    or inpatient?

102
Third Determine if client is on any
psychotropic medications
  • What medications?
  • Level of prescription?
  • Who prescribed medications?
  • For what are the medications prescribed?

103
Fourth Review clients relevant medical history
  • What is current overall physical health of
    client?
  • When was last physical?
  • Is there anything currently or in the past
    medically accounting for this current mental
    health complaint?

104
Fifth Review clients family history
  • Do a genogram of the family
  • Identify psychosocial stressors within the family
    structure
  • Mental health and/or substance abuse history with
    in the family and if successfully treated

105
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106
Sixth Review clients social history
  • School history Failed grades? Academic success?
    Social interaction with peers? Highest academic
    level attained?
  • Community history Peer group? Current network of
    social support? Activities and interests sports,
    hobbies, social functioning?

107
Seventh Review clients vocational history
  • Level of current employment and commitment to
    current job?
  • Relevant past employment history length of
    tenure on past jobs, job hopping, relationships
    with work peers?
  • Level of satisfaction with current employment?

108
Eighth List clients strengths
  • Identify those strengths which make the client a
    good candidate for successful therapy to address
    the here and now mental health problem
  • How motivated for therapy is client?
  • How insightful to symptoms?
  • How psychologically minded is client?
  • How verbal and intelligent?

109
Ninth List liabilities client bringsto therapy
  • Level of present social support system?
  • Mandated for freely coming to therapy?
  • Perceptual problems which could interfere e.g.
    hearing, vision, etc.
  • Risk of decompensating (relapsing) if not treated

110
Tenth Rate Client on ACE Scale
  • Identify Relevant ACE (Adverse Childhood
    Experiences)
  • Abuse http//www.cdc.gov/ace/index.htm
  • 1. Emotional Abuse
  • 2. Physical Abuse
  • 3. Sexual Abuse
  • Neglect
  • 4. Emotional Neglect
  • 5. Physical Neglect
  • Household Dysfunction
  • 6. Mother was treated violently
  • 7. Household substance abuse
  • 8. Household mental illness
  • 9. Parental separation or divorce
  • 10. Incarcerated household member

111
Eleventh (Optional) Use Report on Assessments
  • 1. DSM-5 Self-Rated Level 1 Cross-Cutting Symptom
    MeasureAdult, 11-17, Parent Report for Children
  • 2. DSM-5 Level 2 Adult Scale by PROMIS anger,
    depression, mania, repetitive thoughts, sleep
    disturbance, substance use
  • 3. DSM-5 Level 2 Children Scale by PROMIS
    (Parent Report) 11-17 anger, anxiety,
    depression, inattention, irritability, mania,
    sleep disturbance, substance use
  • http//www.psychiatry.org/practice/dsm/dsm5/online
    -assessment-measures

112
  • 4. DSM-5 Disorder-Specific Severity Measures
  • Agoraphobia, Generalized Anxiety, Panic Disorder,
    Separation Anxiety, Specific Phobia, Acute
    Stress, PTSD
  • 5. WHO Disability Measure
  • World Health Organization Disability Assessment
    Schedule
  • 6. DSM-5 Personality Inventories
  • The Personality Inventory for DSM-5 - Adult
    Children
  • 7. DSM-5 Early Development Home Background
  • Clinician and Parent/Guardian
  • 8. DSM-5 Cultural Formulation Interviews 

113
Patient Health Questionnaire (PHQ) forms at
http//www.phqscreeners.com/
  1. PHQ assesses Depression, Anxiety, Eating
    Disorders and Alcohol Abuse
  2. PHQ-9 Depressive Scale from PHQ
  3. GAD-7 Anxiety Screener from PHQ
  4. PHQ-15 Somatic Symptom Scale from PHQ
  5. PHQ-SADS Includes PHQ-9, GAD-7, PHQ-15 plus
    panic measure
  6. Brief PHQ PHQ-9 and panic measures plus items on
    stressors womens health

114
  • Step 2
  • Mental Status Examination

115
Mental Health Status ExamMental Health Status
Exam Rates Clients
  • Mood
  • Concentration
  • Activity level
  • Thoughts
  • Memory
  • Judgment
  • Appearance
  • Consciousness
  • Orientation to person, place time
  • Speech
  • Affect

116
  • Step 3
  • Formulate Tentative Diagnosis

117
Formulate Tentative Diagnosis
  • You are ready to make a tentative Diagnosis using
    DSM-5 Including
  • Principal Diagnosis
  • Provisional Diagnosis
  • Other Conditions That May Be a Focus of Clinical
    Attention

118
DSM-5 Diagnosis Model
  • Use DSM-5 Most Appropriate Classification
  • Compare clients symptoms lists with those
    contained in DSM-5 to get to most appropriate
    tentative Principal diagnosis
  • Then list any and all secondary Principal
    diagnoses if the clients symptoms match up for
    them
  • Also list Provisional Diagnoses if the clients
    presentation allows for these additional
    diagnoses
  • List all relevant ICD Codes for Other Conditions
    That May Be a Focus of Clinical Attention
  • Each must be listed with number description
    just like the principal diagnosis

119
It is important to remember
  • The Diagnosis given a client is tentative
    dependent on gathering more data in future
    anticipated treatment
  • Diagnoses can ALWAYS be changed to address
    changes with the individuals presentation
    functioning

120
Impact of DSM-5 for Mental Health Clinicians
  • Openings for Integrated Behavioral Medicine
    Specialty
  • Openings for Trauma Specialty
  • Openings for Co-Occurring Disorders Treatment
    Specialty

121
Application with Real Cases
  • You will now break into groups of 4 or 5 members
    to work on the following five cases and be
    prepared to give your complete DSM-5 Model
    Diagnosis for each case

122
Best of Luck in Using the DSM-5
  • My hope is that this helped to get you ready to
    use the DSM-5 to show your competency and
    clinical expertise in ways you have never been
    able to do given the limitation of the
    deficiencies of the previous DSM models.
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