Using DSM-5 for Quality Clinical Assessment, Diagnosis

1
Using DSM-5 for Quality Clinical Assessment,
Diagnosis Treatment Plans

• Jim Messina, Ph.D., CCMHC, NCC, DCMHS
• Assistant Professor
• Troy University, Tampa Bay Site

2
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

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PART 1 Overview of DSM-5
4
Websites on DSM-5

• Official APA DSM-5 site www.dsm5.org
• DSM-5 on www.coping.us

5
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

6
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

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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.

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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.)

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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

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DSM-5 Diagnostic Categories

1. Neurodevelopmental disorders
2. Schizophrenia Spectrum and Other Psychotic
   Disorders
3. Bipolar and Related Disorders
4. Depressive Disorders
5. Anxiety Disorders
6. Obsessive Compulsive and Related Disorders
7. Trauma- and Stressor-Related Disorders
8. Dissociative Disorders
9. Somatic Symptom and Related Disorders
10. Feeding and Eating Disorder
11. Elimination Disorders
12. Sleep-Wake Disorders
13. Sexual Dysfunctions
14. Gender Dysphoria
15. Disruptive, Impulse-Control, and Conduct
    Disorders
16. Substance-Related and Addictive Disorders
17. Neurocognitive Disorders
18. Personality Disorders
19. Paraphilic Disorders

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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

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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 

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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.

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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

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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 

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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

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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

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Categories of Other Conditions That May Be a
Focus of Clinical Attention

1. Relational
2. Educational and Occupational Problems
3. Housing and Economic Problems
4. Other Problems Related to the Social Environment
5. Problems Related to Crime or Interaction with the
   Legal System
6. Other Health Service Encounters for Counseling
   and Medical Advice
7. Problems Related to Other Psychosocial, Personal
   and Environmental Circumstances
8. Other Circumstances of Personal History

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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

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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

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What does a DSM-5 Diagnosis look like?

• Principal Diagnosis
• F10.20 Alcohol Use Disorder Moderate
• F12.20 Cannabis Use Disorder Severe
• Provisional Diagnosis
• F10.14 Substance/Medication-Induced Depressive
  Disorder with Moderate Alcohol Use Disorder
• Other Condition That May Be a Focus of Clinical
  Attention
• Z63.0 Relationship Distress with Spouse or
  Intimate Partner
• Z63.8 High Expressed Emotion Level within Family
• Z65.3 Problem Related to Other Legal
  Circumstances

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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-5s Codes are only the ICD-CM codes (CM
  Clinically Modified to fit a Nations cultural
  makeup)
• October 1, 2015, ICD-10 codes are in effect!

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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. 

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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

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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

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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

27

• Specific Changes
• Per Diagnostic Category
• in DSM-5

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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 (705).
• 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.

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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

30
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

31
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 

32
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

33
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

34
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.

35
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/Derealizatio
  n disorder.

36
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

37
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

38
Elimination Disorders

• 1. This category was created as freestanding
  category
• 2. Enuresis was moved to this category
• 3. Encopresis was move to this category

39
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

40
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

41
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

42
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

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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

44
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

45
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

46
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

47
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

48
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

49

• Behavioral Medicine Specialization
• Based on the DSM-5

50
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/a
  bout )

51
Integrated Behavioral Medicine Specialty Focus

• Neurocognitive Disorders
• Hormonal Imbalances
• Cardiovascular Health Conditions
• Respiratory Difficulties
• Chronic Health Conditions
• Cancers Bladder, Breast, Colon, Rectal,
  Uterine-Ovarian, Kidney, Leukemia, Lung,
  Melanoma, Non-Hodgkin Lymphoma, Pancreatic,
  Prostate, Thyroid

52
Rule of Thumb in Diagnosing Medically Related
Conditions

• First Put in the ICD code for the Medical
  Condition
• Second Put in the mental health disorder related
  to the Medical Condition

53
Schizophrenia Psychotic Disorder Co-occurring
with Medical Condition

• F06.2 Psychotic Disorder due to Another Medical
  Condition with delusions
• F06.0 Psychotic Disorder due to Another Medical
  Condition with hallucinations
• F06.1 Catatonic Disorder Associated with Another
  Medical Condition
• F06.1 Catatonic Disorder Due to Another Medical
  Condition

54
Bipolar Co-occurring with Medical Condition

• F06.33 Bipolar and Related Disorder due to
  Another Medical Condition with manic features
• F06.33 Bipolar and Related Disorder due to
  Another Medical Condition with manic-or
  hypomanic-like episode
• F06.34 Bipolar and Related Disorder due to
  Another Medical Condition with mixed features

55
Depressive Disorder Co-occurring with Medical
Condition

• F06.31 Depressive Disorder Due to Another Medical
  Condition with depressive features
• F06.32 Depressive Disorder Due to Another Medical
  Condition with major depressive-like episodes
• F06.34 Depressive Disorder Due to Another Medical
  Condition with mixed features

56
Anxiety Disorder Co-occurring with Medical
Condition

• F06.4 Anxiety Disorder Due to Another Medical
  Condition

57
Obsessive-Compulsive Co-occurring with Medical
Condition

• F06.8 Obsessive-Compulsive and Related Disorder
  Due to Another Medical Condition
• Specify if with obsessive-compulsive-disorder-like
  symptoms or with appearance preoccupation or
  with hoarding symptoms or with hair-pulling
  symptoms or with skin picking symptoms

58
Somatic Symptom Related Disorders

• F45.1 Somatic Symptom Disorder
• F45.21 Illness Anxiety Disorder Conversion
  Disorders (Functional Neurological Symptoms
  Disorder)
• F44.4 Conversion Disorder with weakness or
  paralysis
• F44.4 Conversion Disorder with abnormal movement
• F44.4 Conversion Disorder with swallowing
  symptoms
• F44.4 Conversion Disorder with speech symptoms
• F44.5 Conversion Disorder with attacks or
  seizures
• F44.6 Conversion Disorder with anesthesia or
  sensory loss
• F44.6 Conversion Disorder with special sensory
  symptom
• F44.7 Conversion Disorder with mixed symptoms
• F54 Psychological Factors Affecting Medical
  Condition
• F68.10 Factitious Disorder (includes Factitious
  Disorder Imposed on Self, Factitious Disorder
  imposed on Another)
• F45.8 Other Specified Somatic Symptom and Related
  Disorder
• F45.9 Unspecified Somatic Symptom and Related
  Disorder

59
Feeding Eating Disorders

• F98.3 Pica in Children
• F50.8 Pica in Adults
• F98.21 Rumination Disorder
• F50.8 Avoidant/Restrictive Food Intake Disorder
• F50.01 Anorexia Nervosa Restricting type
• F50.02 Anorexia Nervosa Binge-eating/purging type
• F50.2 Bulimia Nervosa
• F50.8 Other Specified Feeding or Eating Disorder
• F50.9 Unspecified Feeding or Eating Disorder

60
Elimination Disorders

• F98.0 Enuresis
• F98.1 Encopresis
• N39.498 Other Specified Elimination Disorder with
  urinary symptoms
• R15.9 Other Specified Elimination Disorder with
  fecal symptoms
• R32 Unspecified Elimination Disorder with urinary
  symptoms
• R15.9 Unspecified Elimination Disorder with fecal
  symptoms

61
Sleep-Wake Disorders

• G47.00 Insomnia Disorder
• G47.10 Hypersomnolence Disorder
• G47.419 Narcolepsy without Cataplexy but with
  hypocretin deficiency
• G47.411 Narcolepsy with Cataplexy but without
  hypocretin deficiency
• G47.419 Autosomal dominant cerebellar ataxia,
  deafness, and narcolepsy
• G47.419)Autosomal dominant narcolepsy, obesity
  and type 2 diabetes
• G47.429 Narcolepsy secondary to another medical
  condition

62

• Breathing-Related Sleep Disorders
• G47.33 Obstructive Sleep Apnea Hypopnea
• Central Sleep Apnea
• G47.31 Idiopathic Sleep Apnea
• R06.3 Cheyne-Stokes Breathing
• G47.37 Central Sleep Apnea comorbid with opioid
  use (first code opioid use disorder if present.)

63

• Sleep-Related Hyperventilation
• G47.34 Idiopathic hypoventilation
• G47.35 Congenital central aveolar hypoventilation
• G47.36 Comorbid sleep-related hypoventilation
• Circadian Rhythm Sleep-Wake Disorders
• G47.21 Circadian Rhythm Sleep-Wake Disorder
  Delayed sleep phase type
• G47.22 Circadian Rhythm Sleep-Wake Disorder
  Advanced sleep phase type
• G47.23 Circadian Rhythm Sleep-Wake Disorder
  Irregular sleep-wake type
• G47.24 Circadian Rhythm Sleep-Wake Disorder
  Non-24 hour sleep-wake type
• G47.26 Circadian Rhythm Sleep-Wake Disorder Shift
  Work type

64

• Parasomnias
• F51.3 Non-Rapid Eye Movement Sleep Arousal
  Disorder Sleepwalking Type Specify if With
  sleep-related eating With sleep-related sexual
  behavior (Sexsomnia)
• F51.4 Non-Rapid Eye Movement Sleep Arousal
  Disorder Sleep terror type
• F51.5 Nightmare Disorder Specify if during sleep
  onset. Specify if With associated non-sleep
  disorder With associated other medical
  condition With associated other sleep disorder
• G47.52 Rapid Eye Movement Sleep Behavior Disorder
• G25.81 Restless Legs Syndrome

65
Sexual Dysfunctions

• F52.32 Delayed Ejaculation
• F52.21 Erectile Disorder
• F52.31 Female Orgasmic Disorder Specify if Never
  experienced an orgasm under any situation
• F52.22 Female Sexual Interest/Arousal Disorder
• F52.6 Genito-Pelvic Pain/Penetration Disorder
• F52.0 Male Hypoactive Sexual Desire Disorder
• F52.4 Premature (Early) Ejaculation

66
Focus of Behavioral Medicine

• Life-span approach to health health care for
• Children
• Teens
• Adults
• Seniors
• In racially and ethnically diverse communities

67
Desired Impact of Behavioral Medicine

• Changes in behavior and lifestyle can
• Improve health
• Prevent illness
• Reduce symptoms of illness
• Behavioral changes can help people
• Feel better physically and emotionally
• Improve their health status
• Increase their self-care skills
• Improve their ability to live with chronic
  illness.
• Behavioral interventions can
• Improve effectiveness of medical interventions
• Help reduce overutilization of the health care
  system
• Reduce the overall costs of care

68
Key Strategies of Behavioral Medicine

• Lifestyle Change
• Training
• Social Support

69
Examples of Goalsof Lifestyle Change

• Improve nutrition
• Increase physical activity
• Stop smoking
• Use medications appropriately
• Practice safer sex
• Prevent and reduce alcohol drug abuse

70
Examples of Training in Behavioral Medicine

• Coping skills training
• Relaxation training
• Self-monitoring personal health
• Stress management
• Time management
• Pain management
• Problem-solving
• Communication skills
• Priority-setting

71
Examples of Social Support

• Group education
• Caretaker support and training
• Health counseling
• Community-based sports events

72

• Trauma Focused Therapeutic Diagnosis
• Treatment Planning

73
Trauma and Stressor Related Disorders

1. PTSD for Adults, Teens, Children Preschool
   Children
2. Acute Stress Disorder
3. Adjustment Disorders
4. Reactive Attachment Disorder
5. Disinhibited Social Engagement Disorder

74
Trauma Focused Therapeutic Diagnosis Treatment
Planning

• Adverse Childhood Experience (ACE Factors)
  Screening
• DSM-5 for Principal and Provisional Diagnoses
• Identifying Other Condition That May be a Focus
  of Clinical Attention

75
Adverse Childhood Experiences (ACE Factors)

• ABUSE
• 1. Emotional Abuse
• 2. Physical Abuse
• 3. Sexual Abuse
• Neglect
• 4. Emotional Neglect
• 5. Physical Neglect
• Household Dysfunction
• 6. Mother was treated violently
• 7. Household substance abuse
• 8. Household mental illness
• 9. Parental separation or divorce
• 10. Incarcerated household member

76
Identify Diagnosis based on Traumatic Events /or
ACE Factors

• Principal
• Provisional
• Other Conditions that May Be a Focus of Clinical
  Attention

77
Utilize Trauma Focused Evidenced Based Practices

• Prolonged Exposure Therapy
• Cognitive Processing Therapy
• EMDR or ART Therapy
• In addition to Therapeutic Plan to address
  Principal Diagnosis

78

• Co-occurring Substance Use Disorder and
• Mental Health Disorder

79
Co-occurring Substance Use Disorders Mental
Health Disorder Treatment Specialty Focus

• Substance /Medication Induced Disorders
• Schizophrenia
• Bipolar Disorder
• Depressive Disorders
• Anxiety Disorders
• Obsessive Compulsive Disorder
• Sleep-Wake Disorders
• Sexual Dysfunctions
• Neurocognitive Disorders

80
Co-occurring Substance Disorder with
Schizophrenic Induced Psychotic Disorder

• Alcohol
• Cannabis
• Phencyclidine
• Hallucinogens
• Inhalants
• Sedatives
• Amphetamines
• Cocaine

81
Co-occurring Substance Disorder with Bipolar
Related Disorders

• Alcohol
• Phencyclidine
• Hallucinogens
• Sedatives
• Amphetamines
• Cocaine

82
Co-occurring Substance Disorder with Depressive
Disorders

• Alcohol
• Phencyclidine
• Hallucinogens
• Inhalants
• Opioid
• Sedatives
• Amphetamines
• Cocaine

83
Co-occurring Substance Disorder with Anxiety
Disorders

• Alcohol
• Caffeine
• Cannabis
• Phencyclidine
• Hallucinogens
• Inhalant
• Opioid
• Sedative
• Amphetamine
• Cocaine

84
Co-occurring Substance Disorder with
Obsessive-Compulsive Disorder

• Amphetamines
• Cocaine

85
Co-occurring Substance Disorder with Sleep-Wake
Disorders

• Alcohol
• Caffeine
• Cannabis
• Sedative
• Amphetamine
• Cocaine
• Tobacco

86
Co-occurring Substance Disorder with Sexual
Dysfunctions

• Alcohol
• Opioid
• Sedative
• Amphetamine
• Cocaine

87
Co-occurring Substance Disorder with Delirium
Neurocognitive Disorders

• Alcohol
• Cannabis
• Phencyclidine
• Hallucinogens
• Inhalant
• Opioid
• Sedative
• Amphetamine
• Cocaine

88
Likelihood of SUDs in people with psychiatric
diagnoses
Diagnosis Odds Ratio
Bipolar Disorder 6.6
Schizophrenia 4.6
Panic Disorder 2.9
Major Depression 1.9
Anxiety Disorder 1.7
Weiss, R.D. Smith-Connery, H. (2011).
Integrated Group Therapy for Bipolar Disorder and
Substance Abuse. New York Guilford Press.
89
Substance abuse in patients with psychiatric
illness

• Enhanced reinforcement
• Mood Change
• Escape
• Hopelessness
• Poor Judgment
• Inability to appreciate consequences

90
Results of SUD with Psychiatric Disorder
especially Bipolar Disorder

• Lower medication adherence
• Greater chance relapses
• Increased hospitalizations
• Homelessness
• Suicide

91
Models of Dual Diagnosis Treatment

• Sequential Treat SUD first then Psychiatric
  disorder
• Parallel Treat both at same time but within
  different treatment modalities
• Integrated Treat both at same time within the
  same treatment modality

92
Integrated Treatment Model of Treatment of
Comorbid Disorders

• Cognitive-behavioral model focuses on parallels
  between the disorders in recovery/relapse
  thoughts and behaviors
• Explores the interaction between the two
  disorders
• Utilizes a single disorder paradigm bipolar
  substance abuse
• Uses a Central Recovery Rule

93
Focus of Integrated Model

• Dealing with the Psychiatric disorder without use
  of Alcohol /or Drugs
• Confronting denial, ambivalence, acceptance
• Monitoring overall mood during each week
• Emphasis on compliance in taking psychiatric
  medications
• Identifying and fighting triggers
• Emphasis on wellness model of good nights
  sleep, balance nutritional intake exercise

94
Parallels in Recovery Relapse thinking between
Disorders

• May as well thinking vs. It matters what you
  do
• Abstinence violation effect vs. stopping taking
  psychiatric meds when anxious or depressed
• Recovery thinking vs. relapse thinking and acting
  out
• Remember youre always on the road to getting
  better or getting worse It matters what you do!

95
The Central Recovery Rule

• No matter what
• Dont drink
• Dont use drugs
• Take your medication as prescribed
• No matter what
• Weiss, R.D. Smith-Connery, H. (2011).
  Integrated Group Therapy for Bipolar Disorder and
  Substance Abuse. New York Guilford Press.

96
Part 2 Use of DSm-5 in Clinical Assessment
97

• Completing a Thorough Clinical Assessment using
  the new
• DSM-5 System

98
Steps to formulate an initial Tentative Diagnosis
and Treatment Plan

1. Do a thorough Psychosocial History
2. Do a Mental Status Examination
3. Develop a Diagnosis using DSM-5
4. Develop Treatment Plan
5. 3 Goals
6. 3 Objectives per Goal (total of 9)
7. 1 Intervention per Objectives (total of 9)

99

• STEP 1
• Complete Psychosocial History

100
First Establish - WHY NOW?

• You must be able to describe the presenting
  problem
• Listing specific symptoms and complaints which
  would justify diagnosis
• You must be able to list the duration of the
  symptoms or at least estimate the duration

101
Second Review clients mental health history

• Previous treatment for mental health problems?
• Hospitalization for psychiatric conditions?
• As child involved in family therapy?
• Treatment for substance abuse problems-outpatient
  or inpatient?

102
Third Determine if client is on any
psychotropic medications

• What medications?
• Level of prescription?
• Who prescribed medications?
• For what are the medications prescribed?

103
Fourth Review clients relevant medical history

• What is current overall physical health of
  client?
• When was last physical?
• Is there anything currently or in the past
  medically accounting for this current mental
  health complaint?

104
Fifth Review clients family history

• Do a genogram of the family
• Identify psychosocial stressors within the family
  structure
• Identify if there are racial/cultural issues
  relevant in the family
• Mental health and/or substance abuse history with
  in the family and if successfully treated

105
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106
Sixth Review clients social history

• School history Failed grades? Academic success?
  Social interaction with peers? Highest academic
  level attained?
• Community history Peer group? Current network of
  social support? Activities and interests sports,
  hobbies, social functioning?
• Racial/Cultural Identify Development If
  needed-Elements of culturally adapted treatments
  language client attributes metaphors content
  concepts goals methods and context

107
Seventh Review clients vocational history

• Level of current employment and commitment to
  current job?
• Relevant past employment history length of
  tenure on past jobs, job hopping, relationships
  with work peers?
• Level of satisfaction with current employment?

108
Eighth List clients strengths

• Identify those strengths which make the client a
  good candidate for successful therapy to address
  the here and now mental health problem
• How motivated for therapy is client?
• How insightful to symptoms?
• How psychologically minded is client?
• How verbal and intelligent?

109
Ninth List liabilities client bringsto therapy

• Level of present social support system?
• Mandated for freely coming to therapy?
• Perceptual problems which could interfere e.g.
  hearing, vision, etc.
• Risk of decompensating (relapsing) if not treated

110
Tenth Rate Client on ACE Scale

• Identify Relevant ACE (Adverse Childhood
  Experiences)
• Abuse http//www.cdc.gov/ace/index.htm
• 1. Emotional Abuse
• 2. Physical Abuse
• 3. Sexual Abuse
• Neglect
• 4. Emotional Neglect
• 5. Physical Neglect
• Household Dysfunction
• 6. Mother was treated violently
• 7. Household substance abuse
• 8. Household mental illness
• 9. Parental separation or divorce
• 10. Incarcerated household member

111
Eleventh (Optional) Use Report on Assessments

• 1. DSM-5 Self-Rated Level 1 Cross-Cutting Symptom
  MeasureAdult, 11-17, Parent Report for Children
• 2. DSM-5 Level 2 Adult Scale by PROMIS anger,
  depression, mania, repetitive thoughts, sleep
  disturbance, substance use
• 3. DSM-5 Level 2 Children Scale by PROMIS
  (Parent Report) 11-17 anger, anxiety,
  depression, inattention, irritability, mania,
  sleep disturbance, substance use
• http//www.psychiatry.org/practice/dsm/dsm5/online
  -assessment-measures

112

• 4. DSM-5 Disorder-Specific Severity Measures
• Agoraphobia, Generalized Anxiety, Panic Disorder,
  Separation Anxiety, Specific Phobia, Acute
  Stress, PTSD
• 5. WHO Disability Measure
• World Health Organization Disability Assessment
  Schedule
• 6. DSM-5 Personality Inventories
• The Personality Inventory for DSM-5 - Adult
  Children
• 7. DSM-5 Early Development Home Background
• Clinician and Parent/Guardian
• 8. DSM-5 Cultural Formulation Interviews 

113
Patient Health Questionnaire (PHQ) forms at
http//www.phqscreeners.com/

1. PHQ assesses Depression, Anxiety, Eating
   Disorders and Alcohol Abuse
2. PHQ-9 Depressive Scale from PHQ
3. GAD-7 Anxiety Screener from PHQ
4. PHQ-15 Somatic Symptom Scale from PHQ
5. PHQ-SADS Includes PHQ-9, GAD-7, PHQ-15 plus
   panic measure
6. Brief PHQ PHQ-9 and panic measures plus items on
   stressors womens health

114

• Step 2
• Mental Status Examination

115
Mental Health Status ExamMental Health Status
Exam Rates Clients

• Mood
• Concentration
• Activity level
• Thoughts
• Memory
• Judgment

• Appearance
• Consciousness
• Orientation to person, place time
• Speech
• Affect

116

• Step 3
• Formulate Tentative Diagnosis

117
Formulate Tentative Diagnosis

• You are ready to make a tentative Diagnosis using
  DSM-5 Including
• Principal Diagnosis
• Provisional Diagnosis
• Other Conditions That May Be a Focus of Clinical
  Attention

118
DSM-5 Diagnosis Model

• Use DSM-5 Most Appropriate Classification
• Compare clients symptoms lists with those
  contained in DSM-5 to get to most appropriate
  tentative Principal diagnosis
• Then list any and all secondary Principal
  diagnoses if the clients symptoms match up for
  them
• Also list Provisional Diagnoses if the clients
  presentation allows for these additional
  diagnoses
• List all relevant ICD Codes for Other Conditions
  That May Be a Focus of Clinical Attention
• Each must be listed with number description
  just like the principal diagnosis

119
It is important to remember

• The Diagnosis given a client is tentative
  dependent on gathering more data in future
  anticipated treatment
• Diagnoses can ALWAYS be changed to address
  changes with the individuals presentation
  functioning

120
Impact of DSM-5 for Mental Health Clinicians

• Openings for Integrated Behavioral Medicine
  Specialty
• Openings for Trauma Specialty
• Openings for Co-Occurring Disorders Treatment
  Specialty

121
Application with Real Cases

• You will now break into groups of 4 or 5 members
  to work on the following five cases and be
  prepared to give your complete DSM-5 Model
  Diagnosis for each case

122
Best of Luck in Using the DSM-5

• My hope is that this helped to get you ready to
  use the DSM-5 to show your competency and
  clinical expertise in ways you have never been
  able to do given the limitation of the
  deficiencies of the previous DSM models.