Jim Messina, Ph.D., CCMHC, NCC, DCMHS Assistant Professor Troy University, Tampa Bay Site Using DSM-5 for Quality Clinical Assessment, Diagnosis & Treatment Plans
Learning Objectives PART 1 • Status of the new DSM-5 • Categories and changes in DSM-5 • Impact of DSM-5 for Clinical Mental Health Counselors • Openings for Integrated Behavioral Medicine Specialty • Openings for Co-Occurring Disorders Treatment Specialty • Opening for Trauma Specialty • Trauma Focused Therapeutic Diagnosis and Treatment Planning using the Adverse Childhood Experience (ACE Factors) Screening, the DSM-5 for Principal and Provisional Diagnoses along with Identifying Other Condition That May be a Focus of Clinical Attention • Integrated Behavioral Medicine Diagnosis and Treatment Planning using the ICD Codes for Common Medical Conditions resulting in Mental Health Disorders PART 2 • Using DSM-5 for Improved Clinical Assessment, Diagnosis and Treatment Planning
Websites on DSM-5 • Official APA DSM-5 site: www.dsm5.org • DSM-5 on: www.coping.us
Timeline of DSM-5 • 1999-2001 Development of Research Agenda • 2002-2007 APA/WHO/NIMH DSM-5/ICD-11 Research Planning conferences • 2006 Appointment of DSM-5 Taskforce • 2007 Appointment of Workgroups • 2007-2011 Literature Review and Data Re-analysis • 2010-2011 1st phase Field Trials ended July 2011 • 2011-2012 2nd phase Field Trials began Fall 2011 • July 2012 Final Draft of DSM-5 for APA review • May 2013 Publication Date of DSM-5
Revision Guidelines for DSM-5 • Recommendations to be grounded in empirical evidence • Any changes to the DSM-5 in the future must be made in light of maintaining continuity with previous editions for this reason the DSM-5 is not using Roman numeral V but rather 5 since later editions or revision would be DSM-5.1, DSM-5.2 etc. • There are no preset limitations on the number of changes that may occur over time with the new DSM-5 • The DSM-5 will continue to exist as a living, evolving document that can be updated and reinterpreted over time
Focus of DSM-5 Changes • DSM-5 is striving to be more etiological-however disorders are caused by a complex interaction of multiple factors and various etiological factors can present with the same symptom pattern • The diagnostic groups have been reshuffled • There is a dimensional component to the categories to be further researched and covered in Section III of the DSM-5 • Emphasis was on developmental adjustment criteria • New disorders were considered and older disorders were to be deleted • Special emphasis was made for Substance/Medication Induced Disorders and specific classifications for them are listed for Schizophrenia; Bipolar; Depressive, Anxiety, Obsessive Compulsive; Sleep-Wake; Sexual Dysfunctions; and Neurocognitive Disorders.
Definition of Mental Disorder 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. Mental disorders 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 death of a loved one, is not a mental disorder. Socially deviant behavior (e.g., political, religious or sexual) and conflicts that are primarily between the individual and society are not mental disorders unless the deviance or conflict results from a dysfunction in the individual, as described above. (American Psychiatric Association (2013). Diagnostic and Statistical Manual of Mental Disorders-Fifth Edition DSM-5. Arlington VA: Author, p. 20.)
Why identify a mental disorder diagnosis? The diagnosis of a mental disorder should have clinical utility: • Helps to determine prognosis • Helps in development of treatment plans • Helps to give an indication of potential treatment outcomes A diagnosis of a mental disorder is not equivalent to a need for treatment. Need for treatment is a complex clinical decision that takes into consideration: • Symptom severity • Symptom salience (presence of relevant symptom e.g., presence of suicidal ideation) • The client's distress (mental pain) associated with the symptom(s) • Disability related to the client's symptoms, risks, and benefits of available treatment • Other factors such as mental symptoms complicating other illness
DSM-5 Diagnostic Categories • Neurodevelopmental disorders • Schizophrenia Spectrum and Other Psychotic Disorders • Bipolar and Related Disorders • Depressive Disorders • Anxiety Disorders • Obsessive Compulsive and Related Disorders • Trauma- and Stressor-Related Disorders • Dissociative Disorders • Somatic Symptom and Related Disorders • Feeding and Eating Disorder • Elimination Disorders • Sleep-Wake Disorders • Sexual Dysfunctions • Gender Dysphoria • Disruptive, Impulse-Control, and Conduct Disorders • Substance-Related and Addictive Disorders • Neurocognitive Disorders • Personality Disorders • Paraphilic Disorders • Other Mental Disorders
Obvious Changes in DSM-5 (1) • The DSM-5 will discontinue the Multiaxial Diagnosis, No more Axis I,II, III, IV & V-which means that Personality Disorders will now appear as diagnostic categories and there will be no more GAF score or listing of psychosocial stressor or contributing medical conditions • The Multi-axial model will be replaced by Dimensional component to diagnostic categories
Obvious Changes in DSM-5 (2) • Developmental adjustments will be added to criteria • The goal has been to have the categories more sensitive to gender and cultural differences • Diagnostic codes will change from numeric to alphanumeric e.g., Obsessive Compulsive Disorder will change from 300.3 to F42 • Diagnostic codes will change from numeric ICD-9-CM codes on September 30, 2015 to alphanumeric ICD-10-CM codes on October 1, 2015 e.g., Obsessive Compulsive Disorder will change from 300.3 to F42 • They have done away with the NOS labeling and replaced it with Other Specified... or Unspecified
What Replaces NOS? NOS is replace by either: Other specified disorder or Unspecified disorder type are to be used if the diagnosis of a client is too uncertain because of: 1. Behaviors which are associated with a classification are seen but there is uncertainty regarding the diagnostic category due to the fact that • The client presents some symptoms of the category but a complete clinical impression is not clear • The client responds to external stimuli with symptoms of psychosis, schizophrenia etc. but does not present with a full range of the symptoms need for a complete diagnosis 2. The client has been unwilling to provide information due to an unwillingness to be with the clinician or angry about being brought in to be seen or the there is too brief a period of time in which the client has been seen or the clinician is untrained in the classification Rules for use of Other Specific or Unspecified This designation can last only six months and after that a specific diagnostic category has to be determined for the diagnosis of the client.
Respect for Age, Gender & Culture in DSM-5 Each diagnostic definition, where appropriate will incorporate: 1. Developmental symptom manifestation – regarding the age of client 2. Gender specific disorders 3. Cultural sensitivity in regards to certain behaviors
1. Principal Diagnosis Principal Diagnosis is to be used when more than one diagnosis for an individual is given in most cases as the main focus of attention or treatment: • In an inpatient setting, the Principal diagnosis is the condition established to be chiefly responsible for the admission of the individual • In an outpatient setting, the Principal diagnosis is the condition established as reason for visit responsible for care to be received The Principal diagnosis is often harder to identify when a substance/medication related disorder is accompanied by a non-substance-related diagnosis such as major depression since both may have contributed equally to the need for admission or treatment. • Principal diagnosis is listed first and the term "Principal diagnosis" follows the diagnosis name • Remaining disorders are listed in order of focus of attention and treatment
2. Provisional Diagnosis “Provisional" can be used when there is strong presumption that the full criteria will be met for a disorder but not enough information is available for a firm diagnosis. It must be recorded "provisional" following the diagnosis given The provisional diagnoses are often found in the “differential diagnosis” section within each disorders section of the DSM-5
3. Other Condition That May Be a Focus of Clinical Attention • Replaces the Psychosocial Stressors (Axis 4) and GAF Score (Axis 5) • Other Conditions that May Be a focus of Clinical Attention ARE NOT mental disorders • They are meant to draw attention to additional issues which may be encountered in clinical practice (p.715) • Should be documented to help identify factors which could impact the treatment planned
Categories of Other Conditions That May Be a Focus of Clinical Attention • Relational • Educational and Occupational Problems • Housing and Economic Problems • Other Problems Related to the Social Environment • 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
1A. Categories of: Relational Problems in Other Conditions That May Be a Focus of Clinical Attention • Problems Related to Family Upbringing • Other Problems Related to Primary Support Group • Child Maltreatment and Neglect Problems • Child Physical Abuse (Confirmed or Suspected) • Child Sexual Abuse (Confirmed or Suspected) • Child Neglect (Confirmed or Suspected) • Child Psychological Abuse (Confirmed or Suspected) • Other Circumstance Related to Child Maltreatment • Encounter for MH Services for being a victim • Personal history (past history) as a child • Encounter for MH Services as a perpetrator
1B. Categories of: Relational Problems in Other Conditions That May Be a Focus of Clinical Attention • Adult Maltreatment and Neglect Problems • Spouse or Partner Violence, Physical(Confirmed or Suspected) • Spouse or Partner Violence, Sexual(Confirmed or Suspected) • (Confirmed or Suspected) • Spouse or Partner Neglect (Confirmed or Suspected) • Spouse or Partner Abuse, Psychological (Confirmed or Suspected) • Adult Physical Abuse by Nonspouse • Other Circumstance Related to Adult Maltreatment • Encounter for MH Services for being a victim • Personal history (past history) as a victim • Encounter for MH Services as a perpetrator
What does a DSM-5 Diagnosis look like? Principal Diagnosis: • 303.90 (F10.20) Alcohol Use Disorder Moderate • 304.30 (F12.20) Cannabis Use Disorder Severe Provisional Diagnosis: • 291.89 (F10.14) Substance/Medication-Induced Depressive Disorder with Moderate Alcohol Use Disorder Other Condition That May Be a Focus of Clinical Attention • V61.10 (Z63.0) Relationship Distress with Spouse or Intimate Partner • V61.8 (Z63.8) High Expressed Emotion Level within Family • V62.5 (Z65.3) Problem Related to Other Legal Circumstances
ICD Codes Relationship to DSM-5 • The World Health Organization (WHO) is revising International Classification of Diseases and Related Health Problems (ICD-10) so that by 2015, ICD-11 will come out • DSM-5’s Codes are only the ICD-CM codes (CM = Clinically Modified to fit a Nation’s cultural makeup) • October 1, 2015, ICD-10 codes are in effect!
Implementation Date Change The ICD-10 is the basis for ICD-10-CM codes which according to the DSM-5 was to be required as of October 1, 2014 in the United States as the codes to be used in all clinical reports and for insurance and third party reimbursement billing. However on April 1, 2014, the Protecting Access to Medicare Act of 2014 (PAMA) (Pub. L. No. 113-93) was enacted, which said that the Secretary may not adopt ICD-10 prior to October 1, 2015. Accordingly, the U.S. Department of Health and Human Services expects to release an interim final rule in the near future that will include a new compliance date that would require the use of ICD-10 beginning October 1, 2015. The rule will also require HIPAA covered entities to continue to use ICD-9-CM through September 30, 2015.
Which codes do we use? • Codes used in clinical reports & insurance or 3rd party billing are the ICD codes • ICD codes are the only HIPAA approved codes in the USA • The DSM system is simply a diagnostic aid to help us sort out what ICD-CM code that is applicable for our clients
Organization of IDC-10-CM Codes • F01-F09 Mental disorders due to known physiological conditions • F10-F19 Mental and behavioral disorders due to psychoactive substance use • F20-F29 Schizophrenia, schizotypal, delusional, and other non-mood psychotic disorders • F30-F39 Mood (affective) disorders • F40-F48 Anxiety, dissociative, stress-related, somatoform and other nonpsychotic mental disorders • F50-F59 Behavioral syndromes associated with physiological disturbances and physical factors • F60-F69 Disorders of adult personality and behavior • F70-F79 Intellectual disabilities • F80-F89 Pervasive and specific developmental disorders • F90-F98 Behavioral and emotional disorders with onset usually occurring in childhood and adolescence • F99 Unspecified mental disorder
Descriptive Manual for ICD • The WHO publishes what is called “the Blue Book” with descriptive explanations of their Mental, Behavioral Disorders. It is free from WHO and is available on their website • The difference between the APA DSM system and the WHO ICD model is that the WHO model is free which make no one money
Specific Changes Per Diagnostic Category in DSM-5
Neurodevelopmental Disorders 1. Intellectual Disability (Intellectual Developmental Disorder) no longer relies on IQ used as specifier because it is the adaptive functioning that determines levels of support required. • IQ measures are less valid in the lower end of the IQ range • Still accepted that people with intellectual disability have scores two standard deviations or more below the population mean, including a margin for error which is generally +5 points. Thus on tests with standard deviations of 15 and mean of 100 the score for mild would involve 65-75 (70+5). 2. Asperger's Syndrome is lumped into Autism Spectrum since it is at the milder end of the Spectrum 3. Childhood disintegrative disorder, Rett's disorder and Pervasive developmental disorder not otherwise specified are also now incorporated into the Autism Spectrum Disorder 4. Autism Spectrum Disorder is now characterized by deficits in two domains: • Deficits in social communication and social interaction • Restricted repetitive patterns of verbal and nonverbal communication.
Schizophrenia and Other Psychotic Disorders 1.Changes for Criteria A for Schizophrenia were made: • 1) elimination of the special attribution of bizarre delusions and Schneiderian first-rank auditory hallucinations (two or more voices conversing), leading to the requirement of at least two Criterion A symptoms for any diagnosis of schizophrenia • 2) the addition of the requirement that at least one of the Criterion A symptoms must be delusions, hallucinations, or disorganized speech. 2. DSM-IV-TR subtypes of schizophrenia were eliminated 3. Schizoaffective disorder is reconceptualized as a longitudinal rather than a cross sectional diagnosis and requires that a major mood episode be present for a majority of the total disorder's duration after Criterion A has been met 4. Schizotypal Personality Disorder is now listed in this category
Bipolar and related disorders 1. Bipolar is now a free standing category 2. Bipolar was taken out of the mood disorder category 3. Diagnostic criteria now include both changes in mood and changes in activity or energy
Depressive Disorders 1. Dysthymia is now called Persistent Depressive Disorder 2. Disruptive Mood Dysregulation Disorder has been added for children up to age 18 years who exhibit persistent irritability and frequent episodes of extreme behaviors 3. Premenstrual Dysphoric Disorder has been added
Anxiety Disorders 1. No longer has PTSD in this category 2. No longer has OCD in this category 3. Social Phobia is now called Social Anxiety Disorder 4. Panic Disorder and Agoraphobia are unlinked and each now have their own separate criteria 5. Separation anxiety disorder and selective mutism are now classified as anxiety disorders
Obsessive-Compulsive and Related Disorders 1. OCD is now a stand alone category 2. Body Dysmorphic Disorder is now listed under OCD 3. Hoarding has been added under the category of OCD 3. Trichotillomania (Hair-Pulling Disorder) is listed under OCD 4. Excoriation (Skin Picking Disorder) is listed under OCD
Trauma and Stressor Related Disorders 1 Trauma related disorders are now a stand alone category 2. Reactive Attachment Disorder is now listed here 3. Disinhibited Social Engagement Disorder has been added 4. PTSD is listed here 5. PTSD in Preschool Children has been added 6. Acute Stress Disorder is listed here and requires qualifying traumatic events as explicit as to whether they were experienced directly, witnessed or experienced indirectly 7. Adjustment Disorders are now listed here and conceptualize as a heterogeneous array of stress-response syndromes that occur after exposure to a distressing (traumatic or nontraumatic) event.
Dissociative Disorders 1. Dissociative Fugue has been removed from this category and is now a specifier of dissociative amnesia 2. Derealization is included in the name and symptom structure of the former depersonalization disorder to become: Depersonalization/Derealization disorder.
Somatic Symptom Disorder 1. Replaced Somatiform Disorders category with this category 2. Somatization Disorder; Pain Disorder; Hypochondriasis and undifferentiated somatoform disorder were eliminated 3. Complex Somatic Symptom Disorder was added 4. Simple Somatic Symptom Disorder was added 5. Illness Anxiety Disorder was added and replaces Hypochondriasis 6. Conversion Disorders (Functional Neurological Disorder) have modified criteria to emphasize essential importance of neurological examination, in recognition that relevant psychological factors may not be demonstrable at time of diagnosis 7. Psychological factors affecting other medical conditions has been added to this category and along with Factitious disorder both have been placed among the somatic symptom and related disorders because somatic symptoms are predominant in both disorders
Feeding and Eating Disorders 1. Pica was moved to this category 2. Rumination Disorder was moved to this category 3. The "feeding disorder of infancy or early childhood” has been renamed: Avoidant/Restrictive Food Intake Disorder 4. Binge Eating Disorder was added
Elimination Disorders 1. This category was created as freestanding category 2. Enuresis was moved to this category 3. Encopresis was move to this category
Sleep-Wake Disorders 1. Primary Insomnia renamed Insomnia Disorder 2. Primary Hypersomnia joined with Narcolepsy without Cataplexy 3. Cheyne-Stokes Breathing added 4. Obstructive Sleep Apnea Hypopnea added 5. Idiopathic Central Sleep Apnea added 6. Congenital Central Alveolar Hypoventilation added 7. Rapid Eye Movement Behavior Disorder added 8. Restless Leg Syndrome added
Sexual Dysfunctions 1. Male orgasmic disorder renamed Delayed Ejaculation 2. Premature (Early) Ejaculation renamed 3. Dyspareunia and Vaginismus were combined into Genito-Pelvic Pain/Penetration Disorder 4. Sexual Aversion Disorder combined in other categories 5. For females-sexual desire and arousal disorders have been combined into one disorder: Female sexual interest/arousal disorder
Gender Dysphoria 1 This is a new diagnostic class 2. It emphasizes the phenomenon of "gender incongruence" rather than cross-gender identification per se. 3. Posttransition specifier has been added to identify individuals who have undergone at least one medical procedure or treatment to support new gender assignment
Disruptive, Impulse Control, and Conduct Disorders 1. This is a new diagnostic class and combines "Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence" and the "Impulse-control Disorders Not Elsewhere Classified"2. Oppositional Defiant Disorder was added here 3. Trichotillomania removed from this category 4. Conduct Disorder now in this freestanding category 5. Antisocial Personality Disorder added to this category as well as in Personality Disorders Category
Substance Abuse and Addictive Disorders Only 3 qualifiers are used in the category: • Use - replaces both abuse and dependence • Intoxication and Withdrawal remain the same 2. Nicotine Related renamed Tobacco Use Disorder 3. Caffeine Withdrawal added 4. Cannabis Withdrawal added 5. Polysubstance Abuse categories discontinued 6. Gambling added to this category
Neurocognitive Disorders 1. Category replaces “Delirium, Dementia, and Amnestic and Other Cognitive Disorders” Category 2. Now distinguishes between Minor and Major Disorders 3. Replace wording of Dementia "due to" with Neurocognitive Disorder "Associated with" for all the conditions listed 4. Added new Neurocognitive Disorders: • Fronto-Temporal Lobar Degeneration • Traumatic Brain Injury • Lewy Body Disease 5. Renamed Head Trauma to Traumatic Brain Injury 6. Renamed Creutzfeldt-Jakob Disease to Prion Disease
Personality Disorders Cluster A Personality Disorders • 301.0 (F60.0) Paranoid Personality Disorder • 301.20 (F60.1) Schizoid Personality Disorder • 301.22 (F21) Schizotypal Personality Disorder Cluster B Personality Disorders • 301.7 (F60.2) Antisocial Personality Disorder • 301.83 (F60.3) Borderline Personality Disorder • 301.50 (F60.4) Histrionic Personality Disorder • 301.81 (F60.81) Narcissistic Personality Disorder Cluster C Personality Disorders • 301.82 (F60.6) Avoidant Personality Disorder • 301.6 (F60.7) Dependent Personality Disorder • 301.4 (F60.5) Obsessive-Compulsive Personality Disorder Other Personality Disorders • 310.1 (F07.0) Personality Change Due to Another Medical Condition Specify whether Labile type; Disinhibited Type; Aggressive Type; Apathetic Type; Paranoid Type; Other Type; Combined Type; Unspecified Type • 301.89 (F60.89) Other Specified Personality Disorder • 301.9 (F60.9) Unspecified Personality Disorder
Paraphilic Disorders 1. They all carried over to DSM-5 2. New names for them all but the category remains the same 3. Overarching change is the addition of course specifiers • in a controlled environment • in remission 4. Distinction between paraphilias and paraphilic disorder was made: • Paraphilic disorder is a paraphilia that is currently causing distress or impairment to the individual or a paraphilia whose satisfaction has entailed personal harm, or risk of harm, to others. • Paraphilia is a necessary but not a sufficient condition for having a paraphilic disorder, and a paraphilia by itself does not automatically justify or require clinical intervention
Conditions Designated for Further Study in DSM-5 in Section III • Attenuated Psychosis Syndrome • Depressive Episodes with Short-Duration Hypomania • Persistent Complex Bereavement Disorder • Caffeine Use Disorder • Internet Gaming Disorder • Neurobehavioral Disorder Associated with Prenatal Alcohol Exposure • Suicidal Behavior Disorder • Nonsuicidal Self-Injury
Possible Disorders Discussed But Not Included in Section III of DSM-5 • Dissociative Trance Disorder • Anxious Depression • Factitious disorder imposed on another • Hypersexual Disorder • Olfactory Reference Syndrome • Paraphilic Coercive Disorder
Behavioral Medicine Specialization Based on the DSM-5
Definition of Behavioral Medicine Behavioral Medicine is the interdisciplinary field concerned with the development and the integration of behavioral, psychosocial, and biomedical science knowledge and techniques relevant to the understanding of health and illness, and the application of this knowledge and these techniques to prevention, diagnosis, treatment and rehabilitation. (Definition is provided by Society of Behavioral Medicine on their website at: http://www.sbm.org/about )