dsm-5 Drill Down Presenter: Diana Pals, LCPC Developed by: Idaho-I MHCA
Major Changes of DSM5 1. Elimination of 5 Axis Diagnosis 2. Inclusion of ICD 10 3. Addition of V Codes/ T & Z Codes 4. Consolidation of Aspergers, Autism, PDD
Major Changes of DSM5 5. Restructuring SUD into single disorder with varying severity 6. Integration of emerging genetic & neuroimaging research 7. Symptom severity assessment
Positives of DSM5 1. Broad Collaboration 2. Inclusion of Cultural Considerations 3. More Descriptive Diagnosis 4. Reorganized to reflect etiology & shared factors
Positives of DSM5 5. Recognition of life span issues related to specific disorder. 6. Gender & cultural notes for individual diagnosis. 7. Removed diagnostic criterion not relevant across cultural groups. 8. 30% international in each work group
Three Major Sections 1. The Basics 2. Diagnostic Criteria & Codes 3. Emerging Measures & Models -
Introduction: coding & reporting procedures • Procedures • First list focus of treatment or reason for first visit • Exception: If a mental disorder is caused by a medical condition then list medical condition first (ICD coding rule). • Other diagnosis codes are listed in descending order of clinical importance including V/Z codes Sample Text V62.21 Problem Related to Current Military Deployment Status 301.89 Other Specified Personality Disorder (mixed personality features-dependent and avoidant symptoms) 327.26 Comorbid Sleep-Related Hypoventilation 300.4 Persistent Depressive Disorder (Dysthymia), With anxious distress, In partial remission, Early onset, With pure dysthymic syndrome, Moderate V62.89 Victim of Crime (state the crime) 278.00 Overweight or Obesity WHODAS: 63
Whodas • World Health Organization Disability Assessment Schedule. • Can be self-administered by the client or proxy administered by the clinician. Download for free at: www.psyciatry.org/practice/dsm/dsm5/onlineassessmentmeasures(also in the back of the DSM 5, p 747) • Inventories cover the following aspects of functionality: • Cognition • Mobility • Self-care • Getting along or socialization • Life activities and • Participation
Guidelines for Assessement • Name of client: DOB: • Pre-natal environment and conditions of delivery • Age of mother during pregnancy • Early infancy development • Age of onset of symptoms • Course of illness development • Description of symptoms • Severity of symptoms • Cultural considerations • School years development • Temperamental status • Genetic issues in the family • History of mental illness in the family • Full Medical history of client and family • Areas of impairment • Level of impairment severity • Substance use /medication use history- assess which came first…the use or the disorder
Substance-related & addictive disorders • Substance Use Disorders • No More Substance Abuseand Substance Dependence • *Critical* to Read & Follow Recording Procedures and Coding Notes • Few changes from the DSM-IV-TR with substance abuse and dependence criteria combined into one list • Nearly all substances are defined under the same overarching criteria • Criteria for intoxication, withdrawal, substance/medication-induced disorders, and unspecified substance-induced disorders • Threshold Criteria= 2 of 11 symptoms • Impaired Control (Criteria 1-4) • Social Impairment (Criteria 5-7) • Risky Use (Criteria 8-9) • Pharmacological criteria (criteria 10-11) • *Removed: recurrent legal problems criterion • *Added: craving or a strong desire or urge to use a substance
Prevalence of autism spectrum disorders • 1 in 88 children • 1 in 54 boys • 1 in 252 girls • 78% increase from 2002
Pervasive developmentaldisorders (DSM-IV-TR) • PDD included • Autistic Disorder • Rhett’s Disorder • Childhood Disintegrative Disorder • Asperger’s Disorder • Pervasive Developmental Disorder, NOS
Asperger’s disorder (dsm-iv-tr) • Impairment in social interactions (at least 2) • Restricted repetitive and stereotyped patters of behavior, interest, and activities (at least one) • Significant impairment in social, occupational, or other important areas of functioning • No clinically significant language delay • No clinically significant delay in cognitive development or ADLs • Not better accounted for by another PDD or Schizophrenia
Pervasive developmental disorder, Nos (DSM-IV-TR) • Severe and pervasive impairment in reciprocal social interactions, and • Impairment in either verbal or nonverbal communication skills or stereotyped behavior • Does not meet criteria for a specific PDD, schizophrenia, schizotypal PD, or Avoidant PD
Why the change in dsm-5? • Improve accuracy of diagnosing • Describe specific symptoms • *No significant changes overall
Autism spectrum disorder Dsm-5 Criterion Described Part A • Persistent deficits in social communications and social interactions across multiple contexts, as manifested by the following, currently or by history • Deficits in social-emotional reciprocity • Deficits in nonverbal communicative behaviors used for social interactions • Deficits in developing, maintaining, and understanding relationships
Autism spectrum disorder dsm-5 (CONT.) Part B • Restricted, repetitive patterns of behavior, interests, or activities, as manifested by at least two of the following, currently or by history • Stereotyped or repetitive motor movements, use of objects, or speech • Insistence on sameness, inflexible adherence to routines, or ritualized patterns of verbal or nonverbal behavior • Highly restricted, fixated interests that are abnormal in intensity or focus • Hyper-or hypo-reactivity to sensory input or unusual interest in sensory aspects of the environment (*new criteria) **Both Part A & B must be present to diagnose
Autism spectrum disorderdsm-5 (cont.) Part C • Symptoms must be present in the early developmental period (but may not become fully manifest until social demands exceed limited capabilities, or may be masked by learned strategies in later life). Part D • Symptoms cause clinically significant impairment in social, occupational, or other important areas of current functioning Part E • These disturbances are not better explained by intellectual disability or global developmental delay.
Autism spectrum disorderspecifiers/modifiers • With or without accompanying intellectual impairment • With or without accompanying language impairment • Associated with a known medical or genetic condition or environmental factor • Associated with another neurodevelopmental, mental, or behavioral disorder • With catatonia
Autism spectrum disorderlevel of severity • Level 1: Requiring Support • Level 2: Requiring Substantial Support • Level 3: Requiring Very Substantial Support
Focus is now on history & otherassociated factors History & Associated Factors now considered in the diagnosis of Autism Spectrum Disorder include: Age of perceived onset Pattern of onset Culture-related issues Gender-related issues
Autism spectrum disorderdifferential diagnosis • Rhett’s Syndrome • Selective mutism • Language disorders • Intellectual Disabilities without Autism Spectrum Disorder • Stereotypical movement disorder • Attention-deficit/hyperactivity disorder • Schizophrenia
Major changes in the dsm-5 • Spectrum of Disorders • Focus on two key areas instead of three • More focus on history • Addition of Specifiers and Modifiers • Social Communication Disorder (SCD)
Implications of the change • Elimination of Asperger’s Disorder and PDD, NOS • Better history screening • Comorbid diagnoses • Hopefully better services • Intellectual Disability • New Testing Measures
Concerns about the new criteria • Spectrum vs. Individual Diagnosis • Too Stringent • Social Communication Disorder • Educational Needs • Third Party Payers
Treatment for autism • Team Approach • Medical Care-pediatrician, neurologist, psychiatrist, gastroenterologist • Early intervention/behavioral approaches • Speech Therapy • Occupational Therapy • Physical Therapy • Nutritionist
Types of early interventions for autism spectrum disorder • Applied Behavioral Analysis • Pivotal Response Treatment • Verbal Behavior • Early Start Denver Model • Floortime • Relationship Development Intervention • TEACCH
Where to find services for autism spectrum disorder • Screenings • Local testing • Children’s Hospitals • Local Universities • Community Mental Health Centers • Private Practitioners Specializing in ASD • Autismspeaks.org—Tool kits • Support Groups
Dsm-5 layout for mood disorders • Divided into 2 sections designed to assist in diagnosing problems with mood. • 1. Criteria and description of all disorders, including diagnostic features, associated features, and differential diagnostic issues • 2. Definitions of Specifiers that provide greater description of the current or most recent mood episode. • Recognition is important: bipolar disorder is often missed; average time for non-MD to correctly diagnose is 8.9 years; for an MD it is 6.5 years (Ghaemi, as cited in Quinn, 2008). • TIPS: Always check for a mood disorder in any new client and NEVER assume mood disorder is client’s only diagnosis.
What is a mood episode? • Mood episodes are building blocks of (most) mood disorders. • Quality of mood (high or low) • Required time • Required symptoms • Degree of disability • Exclusions not result of GMC or substance use
Classic triad of manic episode Heightened self-esteem Pressured Speech Increased motor activity
Building blocks of mood disorders: manic episode • Must meet five (5) criteria • Mood that is abnormally elevated and expansive (sometimes irritable) • Heightened mood has existed for a minimum of one week. • Must meet 3 of the following criteria: • 1. increased self esteem • 2. decreased sleep • 3. Pressured speech • 4. racing thoughts • 5. increase in physical activity • 6. goal agitation • 7. risk taking behavior • Has resulted in significant social, personal, and/or occupational impairment • Does not violate exclusions of GMC & substance induced • At least one lifetime manic episode is required for the diagnosis of Bipolar I.
Building blocks of mood disorders: hypomanic episode • “Watered down” version of a manic episode • Quality of mood that is euphoric, but without the driven quality present in a manic episode • Mood must be qualitatively different from normal non-depressed mood • Disturbance in mood is observable by others • Is NOT severe enough to cause marked impairment • Client must have symptoms for a period of four (4) days • Same number of symptoms from the same list required for manic episode: At least three (3) symptoms must be present during previous four (4) days. If mood is irritable than four (4) symptoms are required. Hypomanic episodes are common in Bipolar I Disorder, but are not required for a diagnosis of Bipolar I Disorder.
Building blocks of mood disorders: Major depressive episode • One of the most common problems for why people seek help. • Must meet following criteria: • Depressed mood or loss of interest or pleasure • Existed most of the day, nearly every day, for at least 2 weeks. • Accompanied by at least five (5) symptoms, where one (1) symptom must be depressed mood or loss of pleasure • Death wishes/suicidal ideation • Mood disturbance cannot be due to a GMC or use of substances • Major Depressive episodes are common in Bipolar I Disorder, but are not required for a diagnosis of Bipolar I Disorder.
Bipolar I disordercoding & recording issues • Big changes to coding & recording from the DSM-IV TR. • If you suspect a Bipolar I diagnosis, then you need to determine the following related to the current or most currentepisode • (a) severity, (b) if psychotic features are present, and (c) remission status • Note: Current severity and psychotic features are only indicated if full criteria are met for a manic or major depressive episode.
Bipolar I disorder: diagnostic coding Bipolar I disorder, Current or most recent episode manic Choose one of the following for coding purposes: • Mild, 296.41 (F31.11) • Moderate, 296.42 (F31.12) • Severe, 296.43 (F31.13) • With psychotic features, 296.44 (F31.2) • In partial remission, 296.45 (F31.73) • In full remission, 296.46 (F31.74) • Unspecified, 296.40 (F31.9)
Bipolar I disorder: diagnostic coding Bipolar I disorder, Current or most recent episode depressed Client’s current or most recent episode is depressed and criteria have been met for at least one manic episode Choose one of the following for coding purposes: • Mild, 296.41 (F31.31) • Moderate, 296.52 (F31.32) • Severe, 296.53 (F31.4) • With psychotic features, 296.54 (F31.5) • In partial remission, 296.55 (F31.75) • In full remission, 296.56 (F31.76) • Unspecified, 296.50 (F31.9)
Bipolar I disorder: diagnostic coding Bipolar I disorder, current or most recent episode hypomanic Client’s current or most recent episode is hypomanic and criteria have been met for at least one manic episode Choose one of the following for coding purposes: • Severity and psychotic specifiers do not apply, always code 296.40 (F31.0). • In partial remission: 296.45 (F31.73) • In full remission: 296.46 (F31.74) • Unspecified, 296.40 (F31.9)
Bipolar I disorder: diagnostic coding Bipolar I disorder, current or most recent episode unspecified Client’s current or most recent episode is unspecified and criteria have been met for at least one manic episode • Choose the following for coding purposes: Severity, psychotic, and remission specifiers do not apply, always code 296.7 (F31.9)
Making the bipolar I disorder diagnosis For Bipolar I Disorder, the symptoms must not be better accounted for by schizoaffective disorder, schizophrenia, schizophreniform, delusional disorder, or other psychotic disorder exclusions. The clinician has the option to add other specifiers that are not associated with a code (applies only to the current or most recent episode, except with rapid cycling). • With anxious distress • With mixed features • With rapid cycling (applies to course of disorder rather than to most recent episode) • With melancholic features • With atypical features • With mood-congruent psychotic features • With mood-incongruent psychotic features • With catatonia (coding note: Use additional code 293.89 (F06.1) • With peripartum onset • With seasonal pattern (applies only to current or most recent depressive episode