DSM-5: Just the Basics (Excerpt from 6 hr CEU training) Debbie Spaeth, LMFT, LPC, LADC Quest MHSA, LLC

Diagnostic & Statistical Manual of Mental Disorders - 5 Purpose: Assist trained clinicians in Dx of Mental Dis’ as part of case formulation assessment that leads to a fully informed (cultural/social) Tx Plan for each individual. Manual makes NO recommendations for Tx or Forensics- Compentency/Criminal Resp./Disability Dx Criteria Sets: Summarize characteristic syndromes of signs/symptoms that point to underlying disorder, follows developmental path Published by American Psychiatric Association

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. MD's 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 the death of a loved one, is not a MD. Socially deviant behavior (political/religious/sexual) and conflicts that are primarily between the individual and society are not MD unless the deviance/conflict results from a dysfunction in the individual, as described above.

DSM-5: Diagnostic Elements Assessment Dx Criteria and Descriptors Subtypes and Specifiers Course Severity

Hierarchy determined by order of the Focus of Tx Principal Diagnosis Hierarchy determined by order of the Focus of Tx Primary Dx - reason for appointment or admission Secondary Dx - lesser focus Tertiary Dx - least focus Comorbidity = MH Dx first and Medical 2nd

Consider patient’s functional status separately from Dx or symptoms No Multi-Axial Consider patient’s functional status separately from Dx or symptoms Axis I, II, & III are combined IV is now displayed in V and ICD Z codes V/GAF is now WHODAS - World Health Org Disability Assess Schedule, 36 item self admin w/domains

Development and course Risk and prognostic factors Diagnostic Criteria 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

Culture/Gender Related Issues Suicide Risk Functional Consequences Dx Criteria - Cont Culture/Gender Related Issues Suicide Risk Functional Consequences Differential Diagnosing Comorbidity

Provisional & Differential Dxs #1: Does not meet full criteria Strong presumption that full criteria will be met “provisional” is written after Dx on record #2: Differential Dx = similar but distinct “Other Specified”- title, w/insufficient symptoms “Unspecified”- clinician does not reveal specifics

Usual Dx is the current presentation of Patient Course Usual Dx is the current presentation of Patient Can be full presentation Recurrent presentation Previous Dx noted by partial or full remission

Indicated “Specify Current Severity” criteria set Intensity Frequency Duration Symptom Count Indicated “Specify Current Severity” criteria set

Descriptive Features Specifiers Additional Information that can inform Tx Planning “with poor insight”

WHO, CMS, CDC, Prevention’s Nat Cent Health Stat International Coding WHO, CMS, CDC, Prevention’s Nat Cent Health Stat Purpose: Data Collection, Billing, Mortality/Effect Official Date: October 14, 2014 Oklahoma Date: Can begin January 1, 2014 ICD-9 and ICD-10 are included in the Manual DSM and ICD-11 plan towards unity

Digits 1-3 relate to the diagnostic category 4, 5, & 6th digit coding Digits 1-3 relate to the diagnostic category Allows increased specificity of Dx Subtypes: mutually exclusive phenominological subgroupings w/in a Dx, indicated by “Specify whether” instruction in the criteria set. Specifiers: not mutually exclusive, so multiple spcifiers may be listed, indicated by “Specify” or “Specify if” instruction in the criteria set.

Subtype/Specifiers and ICD-9 & 10 International Statistical Classification of Diseases and Related Health Problems - World Health Org. Majority of the Subtypes and Specifiers cannot be coded in ICD-9 or 10 systems (Medicaid/MCR), but some 4 & 5th codes covered in ICD Use S&S in the Dx Title on documentation if not supported in ICD coding

Diagnosis & Format, examples 1) 312.81 (F91.1) Conduct Disorder, child onset, w/ limited prosocial emotions, severe V61.03 (Z63.5) Disruption of Fmaily by Divorce; 995.54 (T74.12XD) Subsequent encounter; V60.2 (Z59.5) Extreme Poverty 2) 314.01 (F90.2) Attention-deficit hyperactivity disorder, combined presentation; Other factors: V62.3 (Z55.9) Academic underachievement 3) Case #2: 301.81 (F60.81) Narcissistic Personality Disorder; V62.29 (Z56.9) Other Problem Rltd to Employment 4) 300.01 (F41.0) Panic Disorder; Other factors: 995.81 (T74.11XD) Spouse/Partner Violence, subsequent encounter; V61.03 (Z63.5 Disruption of family by divorce (recent); V60.2 (Z59.7) Low income;.

Measures and Models

Cross-Cutting Symptom Measure Adult Self-rated Level 1 CCSM - pg 738/9 13 domains: Depression, Anger, Mania, Anxiety, Somatic Symptoms, Suicidal Ideation, Psychosis, Sleep, Memory, Repetitive Thoughts/Behaviors, Dissociation, Personality Functioning, and Substance Use Mild or Greater = Further Inquiry for Level 2 All Level 2 tools - www.psychiatry.org/dsm5

Parent/Guar rated Level 1 for 6-17 yoa, pg 740/1 CCSM contd. Parent/Guar rated Level 1 for 6-17 yoa, pg 740/1 12 domains: Somatic Symptoms, Sleep, Inattention, Depression, Anger, Irritabiity, Mania, Anxiety, Psychosis, Retetitive Thoughts/Behaviors, Substance Use, and Suicidal Ideation/Attempts Mild or Greater = Further Inquiry for Level 2 All Level 2 tools - www.psychiatry.org/dsm5

Other Assessment Tools Clinician-Rated Dimensions of Psychosis Symptom Severity World Health Organization Disability Assessment Schedule 2.0 (WHODAS 2.0)

Cultural Formulation Interview (CFI) pgs. 752-7 Definition of Problem Perceptions of Cause/Context/Support Self-Coping and Past/Current Help Seeking Patient or Informant

Alternative Personality Disorders Model Level of Personality Functioning Scale Self - Identity & Self Direction Level of Impairment Scale: 0 none - 4 extreme Interpersonal - Empathy & Intimacy Definitions of Personality Dis Trait Domains/Facets

Attenuated Psychosis Syndrome Study Conditions Attenuated Psychosis Syndrome Depressive Episodes w/Short-Duration Hypomania Persistent Complex Bereavement Disorder Caffeine Use Disorder Internet Gaming Disorder Neurobehavioral Dis Assoc w/Prenatal Alcohol Exp Suicidal Behavior Disorder/Nonsuicidal Self Injury

Glossary of Cultural Concepts of Distress Appendix DSM-IV to DSM-5 changes Glossary of Terms Glossary of Cultural Concepts of Distress Alphabetical/Numerical Listings ICD 9 and 10 Listings Index

Debbie Spaeth, LMFT, LPC, LADC DSpaeth@questmhsa.com