Making Friends with the DSM: Practicing Per DSM5 A Workshop Taught by Christina G. Watlington, Ph.D. Corporate University of Providence, Providence Service Corporation

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What do you think of DSM-5?

Warm-up! Bumper cars

Part I Brief DSM History Lesson

Why Do We Have A DSM …To assist trained clinicians in the diagnosis of their patients’ mental disorders as part of case formulation assessment that leads to a fully integrated treatment plan for each individual We have a new DSM to assist with: 1.Accurate diagnosis 2.Case Formulation 3.Treatment Planning

A Short History of the DSM 1952: DSM-I (106) 1968: DSM-II (182) 1980: DSM-III (265) 1987: DSM-III-R (292) 1994: DSM-IV 2000: DSM-IV-TR 2013: DSM-5

Major Changes of the DSM5 ICD/DSM harmony Discontinuation of multiaxial system Spectrum disorders and dimensional ratings Greater recognition of the influence of age, gender and culture New organization of chapters

Online Enhancements The 5 is correct. No more roman numerals! Available online at PsychiatryOnline.org

DSM5 Concerns Disruptive Mood Dysregulation Disorder for tantrums? Major depressive disorder includes normal grief? Minor neurocognitive disorder for normal forgetting in old age? -Francis (2012)

Welcome DSM5

Part II Getting Acquainted with the DSM5

DSM5 Sections Section I: DSM-5 Basics Section II: Diagnostic Criteria and Codes Major Changes Section III: Emerging Models end Measures

What is the ICD-9 & ICD-10? ICD-International Classification of Diseases Standard diagnostic tool for epidemiology, health management & clinical purposes Medical diagnoses Codes are used for reimbursement

Diagnostic Codes Changed diagnostic codes from numeric to alphanumeric Codes in DSM-IV-TR were ICD-9CM codes Examples ICD-9ICD-10 OCD300.3F42 PTSD309.81F43.1

The DSM5 Paradigm Shift Removed NOS and replaced with: 1.Other specified ___________ disorder Specific reason given for choosing this category. Example: Other specified depressive episode with insufficient symptoms. 2.Unspecified _________ disorder.

Use of Other Specified & Unspecified An individual with clinically significant depressive symptoms, lasting 4 weeks but whose symptomatology falls short of the dx threshold for a MDE = “other specified depressive disorder, depressive episode with insufficient sxs.” Use unspecified when the clinician is not able to further specify and describe the clinical presentation

Multiaxial System 1.New nonaxial documentation of diagnosis 2.Combined former axis I, II, and III 3.Eliminated Axis 4: use V codes (Z codes) Example: Parent-Child relational problem V (Z62.820) 4.Eliminated Axis V: Proposed use of WHODAS

Other Changes  Replace the categorical approach to diagnosis with a dimensional approach  Greater emphasis on comorbidity  Removal of developmental trajectory in organizing classification of disorders  Cultural Issues

Definition of a Mental Disorder 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.

What is NOT a mental disorder 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 dysfunction in the individual as described.

Writing a Diagnosis I Locate the disorder that meets criteria Write out the name of the disorder: –Ex.: Posttraumatic Stress Disorder Now add any subtype or specifiers that fit the presentation: –Ex.: Posttraumatic Stress Disorder, with dissociative symptoms, with delayed expression Add the code number (located either at the top of the criteria set or within the subtypes or specifiers): –Two code numbers are listed, one in bold (ICD-9) and one in parentheses (ICD-10), for example, (F43.10) DSM 5 Criteria Sets\PTSD.docx

Writing a Diagnosis II Before October 1, 2015, use the bolded ICD-9 code: Posttraumatic Stress Disorder, with dissociative symptoms, with delayed expression Starting October 1, 2015 use the ICD-10 code that is in parentheses: F43.10 Posttraumatic Stress Disorder, with dissociative symptoms, with delayed expression Order of multiple diagnoses: The focus of treatment or reason for visit is listed first (principal diagnosis), followed by the other diagnoses in descending order of clinical importance

Table of Contents 1.Neurodevelopmental D/Os 2.Schizophrenia Spectrum & Other Psychotic D/Os 3.Bipolar & Related D/Os 4.Depressive D/Os 5.Anxiety D/Os 6.Obsessive- Compulsive & Related D/Os 7.Trauma & Stressor-Related Disorders 8.Dissociative D/Os 9.Somatic Symptom & Related D/Os 10. Feeding & Eating D/Os 11. Elimination D/Os 12.Sleep-Wake D/Os 13. Sexual Dysfunctions 14. Gender Dysphoria 15. Disruptive, Impulse-Control & Conduct D/Os 16. Substance-Related & Addictive D/Os 17. Neurocognitive D/Os 18. Personality D/Os 19. Paraphilia D/Os 20. Other Mental D/Os

Organization Within Chapters Diagnostic Criteria for particular disorder – Subtypes and Specifiers – Coding and Recording Procedures Connection: Open up to any chapter of the DSM5 and identify the dx criteria and explanatory text information for that disorder! Explanatory text information for that disorder – Diagnostic features – Associated features – Prevalence – Development and course – Risk and prognostic factors – Culture-related diagnostic issues – Gender-related diagnostic issues – Suicide risk – Functional consequences – Differential diagnosis – Comorbidity

Section II: Chapter Comparison DSM-IV- TR to DSM5 DSM-IV-TRDSM5 Disorders first diagnosed in infancy, childhood and development DELETED disorders reorganized under other chapters Delirium, Dementia and Amnestic and Other Cognitive Disorders RENAMED Neurocognitive Disorders Mental Disorder due to a general medical condition nos DELETED Substance related disordersRENAMED Substance use and addictive disorders

Section II: Chapter Comparison DSM-IV- TR to DSM5 (cont) DSM-IV-TRDSM5 Schizophrenia and other psychotic disorders RENAMED Schizophrenia spectrum and other psychotic disorders Mood DisordersSPLIT INTO 2 CHAPTERS Bipolar and related Disorders Depressive Disorders Somataform DisordersRENAMED Somatic symptom and related disorders Sexual and Gender Identity DisordersBROKEN INTO 3 SECTIONS Sexual dysfunction Gender Dysphoria Paraphillic Disorders

Section II: Chapter Comparison DSM-IV- TR to DSM5 (cont.) DSM-IV-TRDSM5 Adjustment DisorderCHAPTER ELIMINATED Moved to trauma and stress related disorders Other conditions that may be a focus of clinical attention SEVERAL DISORDERS SHIFTED TO “Other Mental Disorders”

BREAK

Review of Some DSM5 Diagnoses See Website

Name That Diagnosis Anthony is a 6 year old male referred for evaluation due to difficulties adjusting to kindergarten. His mother reports that Anthony dislikes going to school and will often cry or say that he is sick in order to avoid going to school. Anthony’s mother did not report any pregnancy or delivery complications and reported that Anthony met all developmental milestones at an average or faster than average rate. She reported that he has always been a picky eater and is also fussy about this clothing (e.g., doesn’t like to have tags on his clothes, won’t wear shirts that aren’t soft cotton.) She noted that Anthony began speaking at an early age (1.5) and that he is very verbal and likes to talk about his interest in cars and car engines.

Anthony Case Example Cont She noted with pride that Anthony can talk for hours about different types of cars and car engines. She noted that his favorite activity is to play with matchbox cars at home and that he spends hours lining up his cars and building small cities and gets upset if his play is disrupted (i.e., his younger brother picks up a car without permission). Anthony’s teacher has noted that Anthony tends to play by himself, seldom engages with other children, and gets agitated if other children attempt to engage in play with him. She noted that he is doing well academically but seems disinterested in participating in class activities. For example, when asked a question in class he will either remain silent or respond with a comment that is minimally related to the question. Anthony’s mother reports that she feels he is bored at school since he is already starting to read and other children are still learning their numbers and colors.

Investigation of Changes Break up in groups of 3 Review packet on changes and review DSM5. Bullet point 3-5 changes to share with the group and how it might impact your work. Group 1: Neurodevelopmental disorders Group 2: Depressive disorders Group 3: Anxiety disorders Group 4: Trauma- and Stressor Related disorders

Presentations

Lunch & Case Presentations

Quick Energizer

Assessment Practice WHODAS 2.0 Cross-Cutting Symptom Measure: Adult CFI

Can we find treasure in this experience?

Continue Learning Use the resources in the virtual classroom at Take the 2 DSM-5 courses in the Relias/Essential learning LMS. Explore Read the DSM-5. For tech help,

CE Credit for Workshop Be sure you have signed your attendance in and out! You will receive with directions to access course evaluation & print certificate on the Relias learning LMS. Save your certificate. Save a copy of the course flier for your records.

American Psychiatric Association (2013). Diagnostic and statistical Manual of Mental Disorders, Fifth Edition (DSM-5 ™). Arlington, VA, American Psychiatric Association. American Psychiatric Association (2013). Multiple materials from retrieved Frances, A. (2012, Dec). “The ten worst diagnoses in the DSM-5,” Psychology Today. Ginter, G. (2014). DSM-5: What Counselors Need to Know. Powerpoint from Louisana State University. Retrieved: June 2, 2014 from: Greenberg, G. (2013). The Book of Woe: The DSM-5 and the Unmaking of Psychiatry. New York: Oxford Press. Klott, J. (2013). Revolutionizing Diagnosis & Treatment Using the DSM-5. CMI educational institute. Munson, C. (2013). Using DSM-5: A brief summary. Handout packet #1, retrieved from Munson, C. (2013). Using DSM-5: A brief summary. Handout packet #2, retrieved from Paris, J. (2013). The Intelligent Clinician’s Guide to the DSM-5. New York: Oxford University press. Practice Cases. Retrieved June 2, 2014 from: References