DSM-5 ™ in Action: Chapter 3 Understanding What’s New and Applying It in Clinical Practice by Sophia F. Dziegielewski, PhD, LCSW © 2014 S. Dziegielewski

After completion of the workshop, participants will be able to:  Describe the rationale and resulting changes between DSM-IV-TR and DSM-5.  Identify when to use the principal and the provisional diagnosis. © 2014 S. Dziegielewski

Starts with gathering information:  Biomedical  Psychological  Social  Cultural  Spiritual © 2013 S. Dziegielewski

 Making the Diagnostic Assessment  Removal of the Multiaxial System © 2014 S. Dziegielewski

 Limited usage.  Address stigma and misperceptions related to use of Axis I and Axis II.  Better utilize the “other conditions that may be the focus of clinical attention” already in the coding system. © 2014 S. Dziegielewski

Axis I Axis II Axis III Axis IV Axis V © 2014 S. Dziegielewski

DSM-IV-TR Major Clinical Syndromes, Pervasive Developmental Disorders, Learning Disorders, Motor Skills Disorders, Communication Disorders, and Other Conditions That May Be the Focus of Clinical Attention Clinical Syndromes (e.g., Mood Disorders, Schizophrenia, Dementia, Anxiety Disorders, Substance Disorders, Disruptive Behavior Disorders, etc.) © 2014 S. Dziegielewski

DSM-IV: Selected Other Conditions That May Be a Focus of Clinical Attention  Academic Problem: underachievers  Childhood or Adolescent Antisocial Behavior: isolated acts  Adult Antisocial Behavior: e.g., professional thieves, dealers  Borderline Intellectual Functioning: IQ between 71 and 84  Malingering: voluntary mental or exaggerated physical symptoms, with an obvious recognizable goal  Bereavement Medication-Induced Movement Disorders:  Neuroleptic Malignant Syndrome and Tardive Dyskinesia  Acculturation Problem: exposure to living in a new culture  Aging-Associated Cognitive Decline: normal aging causes stress or impairment © 2014 S. Dziegielewski

Personality Disorders Mental Retardation (Intellectual Disability in DSM-5) Borderline Intellectual Functioning (IQ 71-84) © 2014 S. Dziegielewski

Nonaxial documentation of a diagnosis and eliminate Axes I, II, and III  Replace with criteria and severity specifiers  Utilize dimensional assessments © 2014 S. Dziegielewski

 This is generally the reason for the visit and is generally listed first.  If there are multiple diagnoses, the reason for the visit should always be listed first.  Use phrase (principal diagnosis) or (reason for visit) © 2014 S. Dziegielewski

 If the principal diagnosis is a mental disorder that is attributed to a medical disorder, the medical disorder (according to the ICD) is listed first.  Examples to follow. © 2014 S. Dziegielewski

 Alzheimer’s Disease (G30.9) (List this medical diagnosis first) Major Neurocognitive Disorder Specify whether: Due to Alzheimer’s disease (principal diagnosis) or (reason for visit) © 2014 S. Dziegielewski

 Malignant Lung Neoplasm [F06.2]  Psychotic Disorder Due to Another Medical Condition (principal diagnosis) Specify whether: With delusions (F06.2) Specify whether: With hallucination (F06.0) © 2014 S. Dziegielewski

 Inpatient: The reason for admission.  Outpatient: The reason that any types of outpatient services are provided. © 2014 S. Dziegielewski

Provisional means:  It is believed the criteria will be met but at the time do not have enough information.  Or time frame has not been met.  Generally list (provisional) AFTER the principal diagnosis. © 2014 S. Dziegielewski

Two reasons it can be used: 1. Criteria are not met but believe they will be. Ex: major depressive episode could also have bipolar, inadequate history. 2. Time frame criteria are not met yet. Ex: Schizophreniform if one month but six months not met, and the professional cannot wait for possible recovery, so this is used. © 2013 S. Dziegielewski

 List the principal diagnosis first. (If criteria are met, can have more than one; take into account comorbidity and list them all.)  List the provisional diagnosis (after the principal one) if relevant.  Provide supportive information. © 2014 S. Dziegielewski

Post-Traumatic Stress Disorder (Principal Diagnosis) Specify whether with dissociative symptoms Specify if delayed expression ICD-9 code: ICD-10 code: F43.10 © 2014 S. Dziegielewski

 General Medical Conditions Hearing Impairment Vision Impairment Mixing Medical and Mental Physical (medical) conditions relevant to the condition being treated are listed here. © 2014 S. Dziegielewski

 The phrase “general medical condition” is replaced with “another medical condition” where relevant across all disorders. © 2014 S. Dziegielewski

 Removed index with the ICD medical codes that used to be placed on Axis III © 2014 S. Dziegielewski

 DSM-IV-TR Psychosocial and Environmental Problems/Stressors The stressors can be clarified with specifics: problems with primary support problems related to social environment educational problems— occupational problems housing problems— economic problems problems with access to health care services problems related to interaction with the legal system and other psychosocial problems © 2014 S. Dziegielewski

 No more formal listing.  The stressors can be listed in the descriptions if desired.  Consider using V or Z codes (Other Conditions That May Be the Focus of Clinical Attention) © 2014 S. Dziegielewski

 ICD-9-CM usually termed V codes  ICD-10 CM (usually Z codes) Divided into areas: 8 categories (see next slide) © 2014 S. Dziegielewski

 Relational Problems e.g., Problems related to family upbringing  Abuse and Neglect e.g., Child maltreatment and neglect problems  Educational and Occupational Problems  Housing and Economic Problems  Problems Related to Crime or Interaction With the Legal System  Other Health Service Encounters for Counseling and Medical Advice  Problems Related to Other Psychosocial, Personal, and Environmental Circumstances  Other Circumstances of Personal History © 2014 S. Dziegielewski

Relational Problems  Problems Related to Family Upbringing 1. Parent–Child Relational Problem (V61.20 ICD-9-CM or Z ICD-10-CM) 2. Sibling Relationship Problem 3. Upbringing Away From Parents 4. Child Affected by Parental Relationship Distress © 2014 S. Dziegielewski

 Other Problems Related to the Primary Support Group  Disruption of the Family by Separation or Divorce  High Expressed Emotion Level Within the Family  Uncomplicated Bereavement (a normal reaction to the death of a loved one) © 2014 S. Dziegielewski

Abuse and Neglect Child Maltreatment and Neglect Problems  Child Physical Abuse (Physical Abuse, Confirmed; Physical Abuse, Suspected)  Other Circumstances Related to Child Physical Abuse  Child Sexual Abuse  Child Neglect  Child Psychological Abuse © 2014 S. Dziegielewski

Educational and Occupational Problems Educational Problems; Occupational Problems Housing and Economic Problems Other Problems Related to the Social Environment Phase of Life Problem; Problem Related to Living Alone; Acculturation Difficulty; Social Exclusion or Rejection; Target of (Perceived) Adverse Discrimination or Persecution; Unspecified Problem Related to the Social Environment © 2014 S. Dziegielewski

Adult Maltreatment and Neglect  Spouse or Partner Violence, Physical  Spouse or Partner Violence, Sexual  Spouse or Partner Violence, Neglect  Spouse or Partner Violence, Psychological  Adult Abuse by Nonspouse or Nonpartner © 2014 S. Dziegielewski

Educational and Occupational Problems Educational Problems; Occupational Problems; Housing Problems, Economic Problems Other Problems Related to the Social Environment Phase of Life Problem; Problem Related to Living Alone; Acculturation Difficulty; Social Exclusion or Rejection; Target of (Perceived) Adverse Discrimination or Persecution; Unspecified Problem Related to the Social Environment  © 2014 S. Dziegielewski

 Problems Related to Crime or Interaction With the Legal Environment  Other Health Service Encounters for Counseling or Medical Advice  Problems Related to Other Psychosocial, Personal, and Environmental Circumstances (Self- harm, military deployment, etc.) © 2014 S. Dziegielewski

 Other Circumstances of Personal History  Problems Related to Medical or Other Health Care © 2014 S. Dziegielewski

Examples  Overweight or Obesity: This condition is the focus of clinical intervention.  Malingering (see next slide)  Wandering Associated with a Mental Disorder  Borderline Intellectual Functioning: Does not qualify as mild intellectual disability © 2014 S. Dziegielewski

Intentional production of false or grossly exaggerated symptoms (i.e., avoiding military duty, work, obtaining drugs, etc.) Four areas to strongly suspect malingering: 1. Attorney refers or self-referred during litigation or while criminal charges are pending. 2. Marked discrepancy with what individual claims and what are the objective findings. 3. Lack of cooperation during the diagnostic evaluation and following treatment regime. 4. The presence of antisocial personality disorder. © 2014 S. Dziegielewski

Global Assessment of Functioning (GAF)  GAF is a scale of 100 points.  The higher the number, the higher the level of functioning.  Covers both symptomology and level of functioning.  The highest level of functioning is determined and rated. © 2014 S. Dziegielewski

 WHODAS Disability (was Axis V, no more GAF) © 2014 S. Dziegielewski

 Adult self-administered version (age 18 and older)  Assesses disability across 6 domains (36-item measure)  Measure over the past 30 days  Online there is a caregiver version (e.g., with dementia) © 2014 S. Dziegielewski

Comparable to GAF  0 = None (GAF score greater than 70)  1 = Mild  2 = Moderate  3 = Severe  4 = Very Severe (GAF score under 31) © 2014 S. Dziegielewski

 Clinicians started reporting that as of July 2013 the GAF was no longer being required to support Social Security Disability claims.  What do you think it will be replaced with and when? © 2014 S. Dziegielewski

 Subtypes “Specify whether” Mutually exclusive and exhaustive Homogeneous subgroupings within a diagnosis  Specifiers “Specify if” Not mutually exclusive and exhaustive Can have more than one; better explains the particular diagnosis  Specify current severity: Mild, moderate, or severe © 2014 S. Dziegielewski

Specify whether:  Combined presentation  Predominantly inattentive presentation  Predominately hyperactive/impulsive presentation © 2014 S. Dziegielewski

 Depressive Disorders and Bipolar Disorders  Allow for feelings of anxiety, do not need a separate diagnosis  Use specify if: With anxious distress © 2014 S. Dziegielewski

 Not on diagnostic listing in the front table but in the text, typo?  High levels of anxiety related to: 1. High probability of suicide risk 2. Longer duration of the illness 3. Greater likelihood of treatment NONRESPONSE Information taken from APA (2013) p. 184 © 2014 S. Dziegielewski

 Need at least two of the following, most days 1. Feeling keyed up and tense 2. Feeling unusually restless 3. Difficulty concentrating (worry) 4. Fearing something awful will happen 5. Feeling individual might lose control Specify current severity: Mild–2 symptoms, Moderate=3 symptoms Moderate-Severe=4-5, Severe=4-5 WITH motor agitation © 2014 S. Dziegielewski

 Know your scope of practice!  Identify the problem(s) and how it interferes with functioning. Problem behavior recognition Problem behavior identification Treatment plan © 2013 S. Dziegielewski

© 2014 S. Dziegielewski

 Identify two major changes that occurred in DSM-5 in Section One.  Elimination of the multiaxial system and application of its replacements.  Principal and provisional diagnoses. © 2014 S. Dziegielewski