By Nancy Summers Published by Brooks Cole Cengage Learning 2009 Fundamentals of Case Management Practice: Skills for the Human Services, Third Edition Chapter Seventeen Using the DSM By Nancy Summers Published by Brooks Cole Cengage Learning 2009

WHAT IS THE DSM? DSM stands for the Diagnostic and Statistical Manual of Mental Disorders. It is used by numerous agencies and services besides mental health. The final diagnosis is the responsibility of a physician or senior staff person. The first DSM was published in 1952 to try to standardize psychiatric diagnoses and the language used to describe them. We are now using DSM IV - TR (Text revision) which is more reliable, free of jargon, and uses a multi-axial diagnosis. Person or individual is used instead of patient. Disorder is used instead of disease or illness.

DIMENSIONS USED IN MULTIAXIAL DIAGNOSIS Axis I: All clinical syndromes listed in the DSM-IV are coded on this axis except personality disorders and mental retardation. Axis I includes developmental disorders and other conditions that might be a focus of clinical attention. - V71.09 No diagnosis on Axis I - 799.9 Diagnosis deferred on Axis I (meaning too little time or information to establish a diagnosis) Axis II: Coded on this axis are personality disorders, mental retardation, significant maladaptive personality traits, and habitual defense mechanisms. - V71.09 No diagnosis on Axis II - 799.9 Diagnosis deferred on Axis II Axis III: This axis is used for all general medical conditions that are relevant to planning and understanding the patient’s diagnosis. International Classification of Diseases (ICD-10) codes can be used here. - None (meaning no medical conditions) - Deferred Axis IV: Psychosocial and environmental problems that affect the prognosis, management, or treatment of the case are coded here. Axis V: This axis is for the rating on the Global Assessment of Functioning (GAF) scale, which is usually a single number between 1 and 100 indicating the current level of functioning the patient possesses.

WHEN THERE IS NO DIAGNOSIS ON THAT AXIS No diagnosis on axis I or II - Use V71.09 to indicate no diagnosis. Use 799.9 to indicate diagnosis deferred. No diagnosis on Axis III Write “none” meaning no medical conditions. A zero on Axis V Means there is not enough information to assign a GAF.

MAKING THE CODE All disorders in the DSM have a numerical code. The code has 3 whole numbers followed by a decimal point and one or two additional numbers. The form of the code looks like this XXX.XX. EXAMPLE: A person comes in with obvious depression which we call Major Depressive Episode. The number for that is 296. _ _. 296.21 = mild depression 296.22 = moderate depression 296.23 = severe without psychotic features 296.24 = severe with psychotic features 296.25 = partial remission 296.26 = full remission

THE TWO NUMBERS BEYOND THE DECIMAL POINT The Two numbers beyond the decimal point can refer to: Subtypes - the clinician is to “specify type”. For instance there are 7 different types of delusional disorder. Modifiers - the clinician is to “specify if” certain factors are present in this diagnosis. For instance, in pedophilia (202.2) specify if the person is attracted to males, females or both. Modifiers for past and present - all diagnosis are made in the present but sometimes it helps to know if there is a history of the diagnosis. Modifiers for course and severity - the 5th digit can indicate how severe or mild the disorder is or whether the disorder is in remission.

ADDITIONAL INFORMATION Reason for visit modifiers - If a person has more than one diagnosis it is important to write “reason for Visit” next to the one that brought the person into the agency. The primary diagnosis goes first. Provisional diagnosis - when it is not clear what the diagnosis will be the clinician can write “provisional” after it. Some disorders require a time lapse before they can be confirmed. For instance, Panic Attack (300.01) requires at least one panic attack followed by at least a month of persistent worry about having more attacks. Not otherwise specified - or NOS means the disorder does completely meet all the criteria, but meets most of them for that category of disorders. Unspecified - used when a disorder exists but there is not enough information to know what the disorder is.