1. Welcome to Unit 6, Using the DSM and the Mental Status Exam. With Craig Owens (Prof C or Craig)

2. Unit 6 Assignments No Project – Woo Hoo!! Seminar Reading, chapters 17 and 18 Two Discussion Boards

3. Seminar 6, Agenda Apply the learning from Unit 5! DSM – The five Axes DSM Multiaxial Assessment practice The Mental Status Exam Quick Review of Unit 6 Project Questions – Tonight’s seminar is almost all lecture so please ask questions or add your ideas as I am presenting

4. Applying the learning! What was the most significant thing you learned in last week’s discussion about the first interview and/or getting a brief social history during a crisis assessment?

5. 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

6. 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.

7. 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.

8. 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.

9. 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

10. 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.

11. 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.

12. Let’s Practice, as I read each item, post which DSM axis you believe it relates to: Migraine headaches Housing problems Cancer Schizophrenia Paranoid Personality Disorder Cystic Fibrosis A stressful divorce Impaired social functioning Alcohol dependence Alzheimer’s dementia Domestic violence Generalized Anxiety Axis I – Clinical Disorders Axis II – Personality Disorders, Mental Retardation Axis III – General Medical Conditions Axis IV – Psychosocial and Environmental Problems

13. Fundamentals of Case Management Practice: Skills for the Human Services, Third Edition Chapter Eighteen The Mental Status Examination By Nancy Summers Published by Brooks Cole Cengage Learning 2009

14. WHAT TO OBSERVE General Appearance Appearance - observe how well clients take care of themselves,their hygiene and dress. look at physical characteristics. note posture and gait. Attitude and personal style - Note hostility or warmth, whether the person is demanding or passive, playful or withdrawn. Behavior and psychomotor activity - Observe posture, mannerisms and motor activity. Note tremors. Speech and language - look at how the person speaks. Is it pressured, emotional, impoverished? Does the person make up words. Watch for various aphasias such as inability to understand or produce language, trouble expressing thoughts, or uses fluent, bizarre nonsensical speech.

15. WHAT TO OBSERVE Emotions Mood - notice client’s moods. Are they happy, anxious, euphoric, sad? Affect - watch for the underlying flow of moods. Are they appropriate, blunted, withdrawn, excited, labile? Neurovegetative signs of depression - in major depression body functioning often becomes irregular. Listen for complaints about falling asleep, staying asleep, weight loss or gain, constipation, or loss of appetite.

16. WHAT TO OBSERVE Cognitive Functioning Orientation and level of Consciousness - observe anything from a coma to just lethargic. Ask clients if they know who they are, where they are, and the date Attention and Concentration - Can the person remain focused during the interview? Can the person concentrate on one thing for an extended period of time. Memory - note head injuries, difficulty with short and long term memory, amnesia. Ability to abstract and generalize - Can clients take a proverb and explain its abstract meaning or are they concrete and literal? Can they see similarities and differences? Information and Intelligence - do clients know information known by the general public? Be sensitive to culture and education.

17. WHAT TO OBSERVE Thought and Perception Disordered Perceptions - look for hallucinations ( a sensory perception in the absence of external stimuli) or illusions (a misinterpretation of actual external stimuli. being estranged from self or the environment. Thought Content - note how clients think. Have they distorted a portion of reality or a delusion (an inappropriate idea from which the person cannot be dissuaded using normal arguments or evidence. Thought Processes - watch how clients think. Look at things such as racing thoughts, spontaneity, illogical ideas, incoherent speech, or flight of ideas.

18. WHAT TO OBSERVE Suicidality, Homicidality, and Impulse Control You have a clinical and legal obligation to assess whether the person is a danger to themselves or to others. Note if the client’s history shows impulsivity. Listen for thoughts regarding suicide or homicide. 1. Does the client have thoughts? 2. Is the client actually making plans? 3. Does the client have the plan all developed, including the means and the timetable? If the client has a fully developed plan and the means to carry it out the situation is more serious. Take all thoughts or expressions of suicide or homicide seriously and explore these with the client.

19. WHAT TO OBSERVE Insight and Judgment Insight - Check to see if clients understand they have problems and the role they might play in those problems. Can clients describe their ideas as to why they have these problems? Judgment - Note it clients are able to critically evaluate their situations and make good decisions about the best course of action to take.

20. WHAT TO OBSERVE Reliability (Accuracy of the Client’s Report) State briefly your impressions of clients’ reliability and accuracy in giving you the details of their situations. If clients have distortions such as delusions or hallucinations the information they give is likely to be unreliable.

21. WHAT TO OBSERVE The Environment Make a note of the surroundings in which the person lives. Does furniture block the doors? Are there strange wires, odd decorations or window coverings. Be careful not to mistake poverty for an inappropriate environment. Be sure what you are seeing is really a manifestation of mental illness and not some other reason for keeping things that way. Note how the person keeps the home. Are there unusual collections of trash, spoiled food, clutter or unwashed dishes? Is there urine or feces in the home and neglected pets?

23. Nice Work! Questions? Prof C at his favorite spot, cooking clams and lobsters on the beach!