1 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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Workshop Agenda Warm-up Activities* A Bit of History Paradigm Shift Overview of Changes (via manual walkthrough) Practicing with cases Assessment I promise you 3 energizers throughout the 4 hours

Warm-up! Bumper cars

Part I: History and Paradigm Shift

What do you think of DSM-5?

DSM5 The 5 is correct. No more roman numerals! Available online at PsychiatryOnline.org

Paradigm Shift Includes… Some diagnostic changes Removal of “NOS” Removal of multi-axial system Dimensional approach Developmental and life span influence Cultural issues Gender differences Suicide risk

Sample Diagnosis Axis I: Major depressive disorder, recurrent, moderate Axis II: V71.09 No diagnosis Axis III: Hypertension Axis IV: Problems with primary support group Axis V: GAF= 48(current) (F33.1) Major depressive disorder, recurrent, moderate; hypertension, V62.9 (Z60.9) Unspecified problem related to social environment

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

What is the DSM? Diagnostic & Statistical manual of Mental Disorders of the American Psychiatric Association Psychiatry’s bible? DSM-5 first major revision in thirty years

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

DSM5 Tools & Enhancements Clinical Rating Scales WHODAS 2.0 Cultural Formulation Interview

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

Purposes for Diagnosis 1. Process in a therapeutic relationship to help support client self understanding. 2. Professional communication 3. Clients and families may find validation that there is a sickness or disability and have hope for treatment. 4. Diagnosis is a research tool aiding investigation and discovery regarding categories of human suffering. (Paris, 2013)

Defining Diagnosis in DSM-5 Diagnosed behaviors should NOT be an expected or culturally sanctioned response to an event. Diagnosed behaviors may or may NOT be medical or biological illnesses DSM-5 diagnoses are conditions people HAVE they do not define who people are

Good News Most of the diagnostic elements have remained intact. ICD-9 and ICD-10 codes are both listed in the DSM5

Brain Break

Part II: The Changes

Stewie Throws a Tantrum

The DSM5 Paradigm Shift Replace the categorical approach to diagnosis with a dimensional approach Underlying Vulnerabilities Improved Dx Treatment Approaches Symptom Characteristics

The DSM5 Paradigm Shift Increase understanding of gender difference Increase awareness of suicide risk

The DSM5 Paradigm Shift/Culture Important for effective diagnostic assessment and clinical management Cultural issues between provider and client Overall cultural assessment -Flett (2014)

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

Untangling a Diagnosis

Break

Diagnostic Jigsaw Groups- Phase 1 Same diagnostic sections together! Build your expertise with your diagnosis-- 1.Tell everyone what page to go to in DSM-5 2.Present your DSM-IVTR diagnosis 3.Present your DSM-5 diagnosis 4.Ask questions and take time to find things in the narrative that you didn’t know before.

Diagnostic Jigsaw Pairs- Phase 2 Pair with people who were not in your home group! Learn about other diagnoses 1.Tell partner DSM-5 page 2.Present your DSM-IV-TR diagnosis with descriptive detail 3.Present your DSM-5 diagnosis 4.Ask questions and take time to find things in the manual that you didn’t know before. 5.Summarize key nuggets

Diagnostic Jigsaw Groups- Phase 3 Return to “home” group! Consolidate new insights about other diagnoses. 1.Round robin-- everyone has a turn 2.Share about diagnoses you learned about in phase 2. 3.Elaborate on something you wrote down that you learned in pair sharing.

Diagnostic Jigsaw Groups- Phase 4 Big Group! 1.What are your takeaway pearls? 2.What are steps regions need to take to continue this transition?

Brain Break

Part III: Assessment

We can no longer afford to make referrals to specialty providers lacking outcomes data or we know to be poor performers with high error rates, high costs, and poor outcomes. - National Council for Behavioral Health, 2013 The New Mindset

Clinical Rating Scales Rationale for adding: Measurement-informed care Dimensional assessment of severity Assessment of broad range of symptoms Adjunct to clinical evaluation Types Cross-cutting symptom measures Disorder-specific severity measures Disability measures Personality Inventories

Cultural Formulation Addresses the importance of cultural competence in dx and tx The CFI – A set of 16 questions Cultural identity of the individual Cultural conceptualization of distress Psychosocial stressors & cultural features of vulnerability and resiliency Cultural features of the relationship between the individual and clinician Overall cultural assessment

Easy Access to Assessment Measures Can be freely used by clinicians for use with clients They can be downloaded at online-assessment-measures Or

 Measure what is important to clients and achieve excellent outcomes on those measures.  Use a treat-to-target, team-based care approach to achieve these successes at the client level.  The client, with support of their care team, identifies their care goals – at least one clinical and one personal. We Want Excellent Outcomes

 Outcome tools relevant to the clinical goals are used to collect baseline information and measurable targets are set.  Professional and self-care plans are developed, drawing from scientific evidence about the client’s background, conditions, and goals.  Frequent measurement is made and, if a client isn’t reaching their targets, the care plan and self-care plan are changed.  Client-level outcome data are collected in a central repository, evaluated on a regular basis, and used to continuously improve care We Want Excellent Outcomes

“Whenever I was doing a questionnaire, it felt like a tick box exercise. I didn’t know why I was doing it. In fact no one seemed to understand the point of the questionnaire; it was just a standard process. Eventually I stopped thinking what I wrote on it as it just seemed pointless. The questionnaire was always just whisked away from me as soon as I had finished it, never to be seen again...” From the Voice of the Client

How To Include Assessments in Treatment Plans (Example) Goal: Improve overall mood Objectives: – Report 7-8 hours of sleep, as recorded on sleep log – Report a reduction in score on the Level 2 Depression Inventory (parent/guardian) from a 69 (moderate) in week 2 to at least a 55 (mild) by week 8

Practice

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.

References 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: 5%20LCA%20Preconf.pdf 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 pdf pdf 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: