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Using DSM-5 for Quality Clinical Assessment, Diagnosis

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Title: Signs and Symptoms of Mental Illness Author: James J. Messina Last modified by: James John Messina Created Date: 2/12/2005 2:29:09 PM Document presentation format – 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
Objectives Workshop
  • 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
    Principle 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
  • Using DSM-5 for Improved Clinical Assessment,
    Diagnosis and Treatment Planning

3
Websites on DSM-5
  • Official APA DSM-5 site www.dsm5.org
  • DSM-5 on www.coping.us

4
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

5
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

6
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.

7
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.)

8
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

9
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

10
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

11
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, 2014 to
    alphanumeric ICD-10-CM codes on October 1,
    2014 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 

12
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.

13
Principle Diagnosis
  • Principle 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 principle diagnosis
    is the condition established to be chiefly
    responsible for the admission of the individual
  • In an outpatient setting, the principle diagnosis
    is the condition established as reason for visit
    responsible for care to be received 
  • The principle 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. 
  • Principle diagnosis is listed first and the term
    "principle diagnosis" follows the diagnosis name
  • Remaining disorders are listed in order of focus
    of attention and treatment 

14
Provisional Diagnosis
  • Specifier "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

15
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

16
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
    (CMClinically Modified to fit a Nations
    cultural makeup)
  • October 1, 2014, ICD-10 codes are in effect!

17
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

18
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

19
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

20
  • Specific Changes
  • Per Diagnostic Category
  • in DSM-5

21
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.

22
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

23
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

24
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 

25
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

26
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

27
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. PSTD 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.

28
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.

29
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

30
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

31
Elimination Disorders
  • 1. This category was created as freestanding
    category
  • 2. Enuresis was moved to this category
  • 3. Encopresis was move to this category

32
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

33
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

34
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

35
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

36
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

37
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

38
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

39
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

40
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

41
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

42
Other Conditions That May Be a Focus of Clinical
Attention (V Codes and TZ Codes)
  • Relational Problems
  • Problems Related to Family Upbringing
  • Other Problems Related to Primary Support Group
  • Abuse and Neglect
  • Child Maltreatment and Neglect Problems
  • Child Physical Abuse Child Sexual Abuse Child
    Neglect Child Psychological Abuse
  • Adult Maltreatment and Neglect Problems
  • Spouse or Partner Violence, Physical Spouse or
    Partner Violence, Sexual Spouse or Partner
    Neglect Spouse or Partner Abuse, Psychological
    Adult Abuse by Nonspouse or Nonpartner Adult
    Sexual abuse by nonspouse or nonpartner Adult
    Psychological abuse by nonspouse or nonpartner

43
Other Conditions That May Be a Focus of Clinical
Attention Continued
  • Educational and Occupational Problems
  • Housing and Economic Problems
  • Other Problems Related to Social Environment
  • Problems Related to Crime or Interaction with
    Legal System
  • Other Health Services Encounters for Counseling
    and Medical Advice
  • Problems Related to Other Psychosocial, Persons
    and Environmental Circumstances
  • Other Circumstance of Personal History
  • Problems Related to Access to Medical and Other
    Health Care
  • Nonadherence to Medical Treatment

44
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

45
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

46
Co-Occurring Disorders Treatment Specialty Focus
  • Substance /Medication Induced Disorders
  • Schizophrenia
  • Bipolar Disorder
  • Depressive Disorders
  • Anxiety Disorders
  • Obsessive Compulsive Disorder
  • Sleep-Wake Disorders
  • Sexual Dysfunctions
  • Neurocognitive Disorders

47
Trauma Focused Therapeutic Diagnosis Treatment
Planning
  • Adverse Childhood Experience (ACE Factors)
    Screening
  • DSM-5 for Principle and Provisional Diagnoses
  • Identifying Other Condition That May be a Focus
    of Clinical Attention

48
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

49
Then Identify Diagnosis based on ACE
  • Principle
  • Provisional
  • Other Conditions that May Be a Focus of Clinical
    Attention (V codes until October 2014 and TZ code
    beginning October 2014)

50
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

51
Steps to formulate an initial tentative diagnosis
  1. Do a thorough Psychosocial History
  2. Do a Mental Status Examination
  3. Develop a Diagnosis using DSM-5

52
  • STEP 1
  • Complete Psychosocial History

53
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

54
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?

55
Third Determine if client is on any
psychotropic medications
  • What medications?
  • Level of prescription?
  • Who prescribed medications?
  • For what are the medications prescribed?

56
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?

57
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

58
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?

59
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?

60
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?

61
Ninth List liabilities client brings to 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

62
Tenth Rate Client on ACE Scale
  • Identify Relevant ACE (Adverse Childhood
    Experiences)
  • 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

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  • Step 2
  • Mental Status Examination

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

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  • Step 3
  • Formulate Tentative Diagnosis

66
Formulate Tentative Diagnosis
  • You are ready to make a tentative Diagnosis using
    DSM-5 Including
  • Principle Diagnoses
  • Any Provisional Diagnosis
  • Any relevant Other Conditions That May Be a Focus
    of Clinical Attention

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DSM-5 Single Diagnosis
  • Use DSM-5 Most Appropriate Classification
  • Include relevant rule-out diagnoses
  • Compare clients symptoms lists with those
    contained in DSM-5 to get to most appropriate
    tentative Principle diagnosis
  • Then list any and all secondary diagnosis if the
    clients symptoms match up for such
    classifications
  • Also list Provisional diagnoses if the clients
    presentation allows for these additional
    diagnoses
  • List all relevant V (T,Z) Code for Other
    Conditions That May Be a Focus of Clinical
    Attention
  • Each must be listed with number description
    just like the principal diagnosis

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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

69
Application with Real Case
  • 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

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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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