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Overview of the DSM-5

DSM-5 Official Websites

The DSM-5 website is at:

 

DSM-5 Patient Assessment Measures to be researched are avaibable at:   http://www.psychiatry.org/practice/dsm/dsm5/online-assessment-measures 


DSM-5 Diagnostic Criteria Mobile App is available for both iOS and Android Devices


Subscribe to DSM-5 online by going to: PsychiatryOnline.org


NOTE: The DSM-5 was published in May of 2013. Unfortunately there were approximately 70 diagnostic code errors in all DSM-5s printed and purchased before March of 2014. To correct for this an addendum was published by the APA for those books published prior to March 2014. To obtain this addendum go to:  http://dsm.psychiatryonline.org/pb/assets/raw/dsm/pdf/DSM-5%20Coding%20Update_Final.pdf

Background on DSM-5

Timeline:

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     First phase Field Trials ended July 2011

2011-2012     Second 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

1. Recommendations were to be grounded in emprical evidence

2. 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 edtions or revision would be DSM-5.1, DSM-5.2 etc.

3. There are no preset limitations on the number of changes that may occur over time with the new DSM-5

4. The DSM-5 will continue to exist as a living, evolving document that can be updated and reinterpreted over time


Focus of Changes being made in DSM-5

1. 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

2. The diagnositic groups have been reshuffled

3. There are dimensional component to the categories to be further researched and covered in Section III of the DSM-5

4. Emphasis was on developmental adjustment criteria

5. New disorders were considered and older disorders were to be deleted

6. 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.


DSM-5 Definition of a 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.)


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


The DSM-5 Diagnostic Categories are:

  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
  20. 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 however in the V-Codes more factors are presented which can be utilized by clinicians to give a broader understanding of the relevant contributing factors in a patient's life which contribute to or exacerbate the current mental health disorder.

2. Developmental adjustments were added to criteria

3. The goal has been to have the categories more sensitive to gender and cultural differences

4. 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

5. They have done away with the NOS labeling and replaced it with Other Specified... or  Unspecified 

No More NOS, so what replaces it?

NOS is replace by either:

  • Other specified disorder
   or
  • Unspecifed disorder type

Use of Other Specified Disorder or Unspecified Disorder

They 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

a) The client presents some symptoms of the category but a complete clinical impression is not clear

b) 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.

Principal Diagnosis and Provisional 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 principle diagnosis is the condition established to be chiefly responsible for the admission of the individual
  • In an outpatient setting, the principle diagnosis is the condition established as the reason for the visit responsible for the 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 

Provisional Diagnosis: specifier "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. 
Other Conditions That May Be a Focus of Clinical Attention
  • These Descriptors replace 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)
  • These descriptors should be documented to help identify factors which could impact the treatment planned

ICD Codes Drove the DSM-5 Changes

The World Health Organization (WHO) in in the process of revising International Classification of Diseases and Related Health Problems (ICD-10) and by 2017 is hoping to come out with its new ICD-11. 


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. 


 It is the ICD-CM codes which have always been the codes used for billing, and interestingly enough the DSM codes used were always ICD codes. It may be surprising to most mental health professionals that the codes they use when diagnosing their mental health clients are ICD codes established by WHO. WHO’s ICD codes are an international classification system and when the ICD-11 codes come out, based on an agreement between the American Psychiatric Association (authors of the DSM) and WHO, the ICD-11 will be the sole coding system to be used in the United States and there will be no discrepancies between the ICD-11 codes and the DSM-5 codes which will be modified at that time. 

WHO views the current revision from ICD-10 to ICD-11 as an important opportunity to improve the clinical utility of the classification system for mental disorders. Serious problems with the clinical utility of both the ICD and the DSM are widely acknowledged (Reed, 2010). Clinical utility affects the daily lives of practitioners and is also a global public health issue. Most people with mental disorders worldwide receive no treatment. A diagnostic system with greater clinical utility can be a tool to improve identification and treatment, helping WHO member countries to reduce the disease burden of mental disorders. Consistent with this goal, WHO’s revision process is global, multilingual, and multidisciplinary and will produce different versions of the classification for clinical use, research, and primary care. 

The ICD-10-CM

The CM stands for Clinical Modification to adjust to the cultural and ethnicity in WHO member countries which the WHO allows as long as the resulting Codes are in sync with the WHO ICD codes. The purpose of the ICD-10-CM codes are that it is a classification system which assist the mental health clinician to make the bridge between the client’s clinical presentation and the clinicians conceptualization of the client’s mental health condition.

 

ICD-10-CM will be replacing the ICD-9-CM codes which are currently in use and have been in use in the United States since 1994. The ICD-9-CM and ICD-10-CM codes are HIPAA code sets recognized by the Department of Health and Human Services. It is important to not confuse ICD codes with CPT codes which are procedure codes. 

How the IDC-10-CM Codes are organized

The Mental, Behavioral and Neurocognitive Disorders are Chapter 5 of the WHO’s ICD-10 Codes.

 

These codes are set up in blocks of disorders:

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 the ICD-10-CM Codes

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 here.

When will the ICD-11-CM be available?
Up until January 2014 it was expected that the ICD-11 codes would be ready by 2015, but then the WHO published its new timeline for the ICD-1 on their website at: 

http://www.who.int/classifications/icd/revision/timeline/en/


On that site here is the timeline they are now giving. (It sounds familiar given the USA was to begin use of the ICD-10-CM Oct 1, 2014 and it got moved back to Oct 1, 3015).


ICD Revision Timelines

May 2011

  • Open ICD-11 Alpha Browser to the public for viewing

July 2011

  • Open ICD-11 Alpha Browser to the public for commenting

May 2012

  • Open ICD-11 Beta to the public
  • ICD-11 Beta Information
WHO will engage with interested stakeholders to participate in the ICD revision process.
Individuals will be able to:
  • Make comments
  • Make proposals to change ICD categories
  • Participate in field trials
  • Assist in translating

May 2017

  • Present the ICD-11 to the World Health Assembly (This is the major change of date which most were not expecting)


So what does this mean?

  • The US Centers for Medicare & Medicaid Services (CMS) anticipates that it will take at least 6 years to develop & implement a clinical modification of ICD-11 for U.S. specific use
  • An ICD-11-PCS will also need to be developed for procedural codes.
  • CMS says that work cannot begin on adapting a CM from ICD-11 until the ICD-11 code sets have been ratified by WHA (current ETA 2017)
  • Resulting in the U.S. could be looking at least 2023 for ICD-11-CM rule making. So relax and get used to using the ICD-10-CM codes beginning October 1, 2015 until such time this new proposed set of codes comes out.

Specific Changes Per Diagnostic Category in DSM-5

 

Neurodevelopmental

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. Moveover IQ measures are less valid in the lower end of the IQ range. It is 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. Also childhood disintegrative disorder, Rett's disorder and pervasive developmental disorder not otherwise specified are also now incorporated into the Autism Spectrum Disorder. 

3. Autism Spectrum Disorder is now characterized by deficits in two domains: 1. deficits in social communication and social interaction and 2. 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. PSTD 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.

8. Complex Bereavement is covered by 309.89 (F43.8) Other Specified Trauma- and Stressor-Related Disorder with Persistent Complex Bereavement Disorder (p. 289)

 

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 and Related Disorders

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 replace Hypochondriasis

6. Conversion Disorders (Functional Neurological Disorder) have modified criteria to emphasize the essential importance of the neurological examination, and in recognition that relevant psychological factors may not be demonstrable at the 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 to this category

 

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

9. Restless Leg Syndrome added

 

Sexual Dysfunction

1. Male orgasmic disorder renamed Delayed Ejaculation

2. Premature (Early) Ejaculation renamed

3. Dyspareunia and Vaginismus were combined into Genito-Pelvic Pain/Penetraion 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. Trichotllomania 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

1. Only 3 qualifiers are used in the category: Use - replaces both abuse and dependence while 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 conditions for 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

F60.0 Paranoid Personality Disorder

F60.1 Schizoid Personality Disorder

F21 Schizotypal Personality Disorder

Cluster B Personality Disorders

F60.2 Antisocial Personality Disorder

F60.3 Borderline Personality Disorder

F60.4 Histrionic Personality Disorder

F60.81 Narcissistic Personality Disorder

Cluster C Personality Disorders

F60.6 Avoidant Personality Disorder

F60.7 Dependent Personality Disorder

F60.5 Obsessive-Compulsive Personality Disorder

Other Personality Disorders

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

F60.89 Other Specified Personality Disorder

F60.9 Unspecified Personality Disorder

 

Paraphilic Disorders

1. They all carry over to the DSM-5

2. New names for them all but the category remains the same

3. Overarching change is the addition of the course specifiers "in a controlled environment" and "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
Integrated Behavioral Medicine Specialty Focus
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 )
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

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

Specific DSM-5 Categories related to the Integrated Behavioral Medicine Model

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

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

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

Anxiety Disorder Co-occurring with Medical Condition
F06.4 Anxiety Disorder Due to Another Medical Condition

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

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

Feeding & Eating Disorders
F98.3 Pica in Children
F50.8 Pica in Adults
98.21 Rumination Disorder
50.8 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

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

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

Breathing-Related Sleep Disorders

327.23 (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.)

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

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

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
Focus of an Integrated Behavioral Medicine Approach

Life-span approach to health & health care for:

  • Children
  • Teens
  • Adults
  • Seniors
  • In racially and ethnically diverse communities

Desired Impact of an Integrated Behavioral Medicine Approach

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

Key Strategies of an Integrated Behavioral Medicine Approach
  • Lifestyle Change
  • Training
  • Social Support

Examples of Goals for Lifestyle Change within an Integrated Behavioral Medicine Model
  • Improve nutrition
  • Increase physical activity
  • Stop smoking
  • Use medications appropriately
  • Practice safer sex
  • Prevent and reduce alcohol & drug abuse

Examples of Types of Training offered by an Integrated Behavioral Medicine Approach
  • Coping skills training
  • Relaxation training
  • Self-monitoring personal health
  • Stress management
  • Time management
  • Pain management
  • Problem-solving
  • Communication skills
  • Priority-setting

Examples of Social Support in an Integrated Behavioral Medicine Approach
  • Group education
  • Caretaker support and training
  • Health counseling
  • Community-based sports events
For more information on the Integrated Behavioral Medicine Model go to: http://coping.us/introbehavioralmedicine.html

Trauma Focused Therapeutic Diagnosis and Treatment Planning Specialization

Trauma and Stressor-Related Disorders (Listed in DSM-5)

F94.1 Reactive Attachment Disorder Specify if persistent and specify current severity: Severe

F94.2 Disinhibited Social Engagement Disorder Specify if persistent and specify current severity: Severe

F43.10 Posttraumatic Stress Disorder (includes Posttraumatic Stress Disorder for Children 6 years and Younger) Specify whether with dissociative symptoms and specify if with delayed expression

F43.10 Acute Stress Disorder

F43.21 Adjustment Disorder with depressed mood

F43.22 Adjustment Disorder with anxiety

F43.23 Adjustment Disorder with mixed anxiety and depressed mood

F43.24 Adjustment Disorder with disturbance of conduct

F43.25 Adjustment Disorder with mixed disturbance of emotions and conduct

F43.20 Adjustment Disorder Unspecified

F43.8 Adjustment Disorder with Other Specified Trauma-and Stressor-Related Disorder

F43.9 Adjustment Disorder with Unspecified Trauma-and Stressor-Related Disorder


In Determining Diagnosis of a Trauma or Stressor Related Disorder one must:
  1. Rule in or rule out any Adverse Childhood Experiences (ACE Factors) by doing a thorough Psychosocial History Screening
  2. Identify the Diagnosis (es) as DSM-5 Principal and/or Provisional Diagnoses
  3. Identify Other Condition That May be a Focus of Clinical Attention which are related to the Trauma and/or Stressor related condition(s) being diagnosed

The Adverse Childhood Experiences (ACE Factors) are:

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


You can get more information on the ACE Factors at: http://www.cdc.gov/ace/index.htm


Here is a TED Talk by Nadine Burke Harris: How childhood trauma affects health across a lifetime at: https://www.ted.com/talks/nadine_burke_harris_how_childhood_trauma_affects_health_across_a_lifetime?language=en


The ACE Factors have DSM-5 Other Conditions That May Be a Focus of Clinical Attention and the  list of these codes can be downloaded here:

Utilize Trauma Informed Evidenced Based Practices in Planning Treatment
  • Cognitive Processing Therapy
  • Prolonged Exposure Therapy
  • EMDR or ACT Therapy

For more information on Evidenced Based Practices for PTSD related disorders go to: Evidenced Based Practices for PTSD - http://coping.us/evidencedbasedpractices/ptsd.html
or 
Evidenced Based Practices for Anxiety - http://coping.us/evidencedbasedpractices/anxiety.html
Co-Occurring Disorders Treatment Specialty Focus

Substance /Medication – Induced Disorders

  1. Schizophrenia
  2. Bipolar Disorder
  3. Depressive Disorders
  4. Anxiety Disorders
  5. Obsessive Compulsive Disorder
  6. Sleep-Wake Disorders
  7. Sexual Dysfunctions
  8. Neurocognitive Disorders

Co-Occurring Substance Disorder with Schizophrenic Induced Psychotic Disorder
  1. Alcohol
  2. Cannabis
  3. Phencyclidine
  4. Hallucinogens
  5. Inhalants
  6. Sedatives
  7. Amphetamines
  8. Cocaine
Co-Occurring Substance Disorder with Bipolar & Related Disorders
  1. Alcohol
  2. Phencyclidine
  3. Hallucinogens
  4. Sedatives
  5. Amphetamines
  6. Cocaine

Co-occurring Substance Disorder with Depressive Disorders
  1. Alcohol
  2. Phencyclidine
  3. Hallucinogens
  4. Inhalants
  5. Opioid
  6. Sedatives
  7. Amphetamines
  8. Cocaine

Co-occurring Substance Disorder with Anxiety Disorders
  1. Alcohol
  2. Caffeine
  3. Cannabis
  4. Phencyclidine
  5. Hallucinogens
  6. Inhalant
  7. Opioid
  8. Sedative
  9. Amphetamine
  10. Cocaine

Co-occurring Substance Disorder with Obsessive-Compulsive Disorder
  1. Amphetamines
  2. Cocaine

Co-occurring Substance Disorder with Sleep-Wake Disorders
  1. Alcohol
  2. Caffeine
  3. Cannabis
  4. Sedative
  5. Amphetamine
  6. Cocaine
  7. Tobacco

Co-occurring Substance Disorder with Sexual Dysfunctions
  1. Alcohol
  2. Opioid
  3. Sedative
  4. Amphetamine
  5. Cocaine

Co-occurring Substance Disorder with Delirium & Neurocognitive Disorders
  1. Alcohol
  2. Cannabis
  3. Phencyclidine
  4. Hallucinogens
  5. Inhalant
  6. Opioid
  7. Sedative
  8. Amphetamine
  9. Cocaine
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
Rationale behind use of Substances by patients with psychiatric illness
  • Enhanced reinforcement
  • Mood Change
  • Escape
  • Hopelessness
  • Poor Judgment
  • Inability to appreciate consequences

Results of SUD with Psychiatric Disorder especially Bipolar Disorder
  • Lower medication adherence
  • Greater chance relapses
  • Increased hospitalizations
  • Homelessness
  • Suicide

Models of Dual Diagnosis Treatment
  1. Sequential – Treat SUD first then Psychiatric disorder
  2. Parallel – Treat both at same time but within different treatment modalities
  3. Integrated – Treat both at same time within the same treatment modality

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”

Focus of the Integrated Model of Treatment of Comorbid Disorders
  • 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 night’s sleep, balance nutritional intake & exercise

Parallels in Recovery anx Relapse thinking between SUD and Psychiatric 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: you’re always on the road to getting better or getting worse: “It matters what you do!”

The Central Recovery Rule for Comorbid SUD and Psychiatric Disorders

No matter what

  • Don’t drink
  • Don’t use drugs
  • Take your medication as prescribed

No matter what


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

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
  • 3 Goals
  • 3 Objectives per Goal (total of 9)
  • 1 Intervention per each Objective (total of 9)

STEP 1: Complete a thorough Psychosocial History 

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
Second: Review the Client's 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?
Third: Determine if the Client is on any Psychotropic medications
  • What medications?
  • Level of prescription?
  • Who prescribed medications?
  • For what are the medications prescribed?
Fourth: Review Client's 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?
Fifth: Review Client's family history
  • Do a genogram of the family
  • Identify psychosocial stressors within the family structure
  • Mental health and/or substance abuse history with in the family and if successfully treated
Sixth: Review Client's 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?
Seventh: Review Client's 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?
Eighth: List Client's 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?
Ninth: List liabilities Client brings to 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
Tenth: Rate Client on the Adverse Childhood Experiences Scale

Identify Relevant ACE (Adverse Childhood Experiences) at: http://www.cdc.gov/ace/index.htm

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

OPTIONAL: Consider using one or more Clinical Assessments of Client's Functions
An overview of assessments is available at:

http://coping.us/cliniciantreatmenttools/assessmenttools.html

STEP 2: Mental Health Status Examination
Rate the client on the following characteristics:
  • Appearance
  • Consciousness
  • Orientation to person, place & time
  • Speech
  • Affect
  • Mood
  • Concentration
  • Activity level
  • Thoughts
  • Memory
  • Judgment
STEP 3: Formulate a Tentative Diagnosis Based on the DSM-5 Criteria

You are ready to make a tentative Diagnosis using DSM-5 Including:

1.Principal Diagnosis
2.Provisional Diagnosis
3.Other Conditions That May Be a Focus of Clinical Attention
Using the DSM-5 Diagnostic Model
  • Use DSM-5 Most Appropriate Classification
  • Compare client’s 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 client’s symptoms match up for them
  • Also list Provisional Diagnoses if the client’s 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
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 individual’s presentation & functioning

For more information on the Initial Clinical Mental Health Assessment go to the Initial Clinical Assessment & Treatment Plan site on www.coping.us, under Clinical Treatment Tools at: http://coping.us/cliniciantreatmenttools/clinicalassessmentplan.html