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Master DSM-5 's Key Changes: Implement Its Assessment Tools, & Make It Your Path to ICD-10-CM Compliance Written and Presented by: Beth Eckerd PhD, JD DSM, DSM-IV-TR, and DSM-5 are registered trademarks of the American Psychiatric Association. The American Psychiatric Association is not affiliated with nor endorses this seminar. Any opinions, findings, recommendations or conclusions expressed by the author(s)or speaker(s) do not necessarily reflect the views of Cross Country Education, LLC. This publication is designed to provide accurate and authoritative information in regard to the subject matter covered. It is sold with the understanding that the publisher is not engaged in rendering legal, accounting or other professional service. If legal advise or other expert assistance is required, the services of a competent professional person should be sought. Copyright 2015 Beth Eckerd & Cross Country Education, LLC. No part of this workbook may be reproduced in any manner without the expressed written consent of Beth Eckerd & Cross Country Education, LLC. From a Declaration of Principles jointly adopted by a Committee of the American Bar Association and a committee of Publishers. 6891
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Master DSM 5 s Key Changes Implement Its Assessment Tools, and Make It Your Path to ICD 10 Compliance Beth Eckerd, Ph.D. DSM and DSM 5 are registered trademarks of the American Psychiatric Association. The American Psychiatric Association is not affiliated with nor endorses this seminar. For further information, please visit www.dsm5.org. Today s Main Objectives Review DSM 5 s major restructuring and how it affects practice Gain the working knowledge you need of DSM 5 s new disorders and revised diagnostic criteria Provide guidelines for the transition to ICD 10 billing codes in October Learn about DSM 5 s free standardized assessment tools Know how to use DSM 5 to your and your clients advantage! Class Overview DSM 5 structural changes DSM 5 mood and anxiety disorders Case #1 ICD coding and relation to the DSM Case #2 More DSM 5 disorders Lunch Finish DSM 5 disorders Cases #3 and #4 New DSM 5 assessment tools (Conditions for further study) 1
DSM 5 : Structural Changes Major Structural Changes No more 5 axis diagnosis Increased dimensionality 1, 2, 3 combined CMS 1500 (HCFA) revision 4: more V (and Z ) codes Why, and must you use them? 5: many new assessment tools (next slide) While still using categorical approach to dx Severity ratings required much more often (~50%) Optional DSM 5 assessment measures GAF is gone Major Structural Changes: Encouraging Use of Standardized Assessment Measures Encouraging use of standardized assessments Cross cutting symptom ratings Level 1 a screening tool Level 2 several measures, assess these Level 1 sxs in more depth Diagnostic severity ratings For several common diagnoses Disability rating Cultural formulation interview, personality inventories, early development and home background measures 2
Major Structural Changes Increased specificity More diagnostic specifiers No more NOS diagnoses Other specified Unspecified Some new dx s Many more V codes Z codes in ICD 10 CM Difficult to indicate diagnostic uncertainty; no more Provisional Rule out Principal diagnosis/reason for visit V71.09 no diagnosis 799.9 ( diagnosis deferred ) might not be available to you Major Structural Changes Organization of manual Developmental: Overarching and within chapters Criteria for closely related disorders placed near each other in manual Child disorders not in own chapter any more DSM 5 (not DSM V) a living document DSM 5.1 process When Must I Start Using DSM 5? October 1, 2015 Had probably been OK to be using DSM IV Even though DSM 5 released in May, 2013 https://questions.cms.gov/faq.php?id=5005&faqid=1817 DSM 5 contains the standard criteria and definitions of mental disorders now approved by the American Psychiatric Association (APA), and it also contains both ICD 9 CM and ICD 10 CM codes (in parentheses) selected by APA. Since DSM IV only contains ICD 9 CM codes, it will cease to be recognized for criteria or coding for services with dates of service of October 1, 2015 or later. 3
Mood Disorders in DSM 5 Now 2 chapters: Bipolar Disorders and Depressive Disorders Changes Affecting Both Bipolar Disorders and Depressive Disorders As in DSM IV, first diagnose mood episodes Depressive, manic, hypomanic, mixed Mixed mood episode is gone; instead New: Mixed features specifier When applied to bipolar disorders Full criteria met for a manic or hypomanic episode, plus at least 3 of 6 depressive sxs during current/most recent episode When applied to depressive disorders Full criteria met for a major depressive episode, plus at least 3 of 7 manic/hypomanic sxs during current/most recent episode Changes Affecting Both Bipolar Disorders and Depressive Disorders Importance of change to mixed presentation diagnosis Captures the more typical subsyndromal presentations In DSM IV, a mixed episode = meeting criteria for both manic episode + depressive episode Not necessarily bipolar any more when mixed features Client could conceivably retain a dx of Major Depressive Disorder if never met criteria for a manic or hypomanic episode If client DOES meet criteria simultaneously for a depressive and a manic episode, in DSM 5 Diagnosis = manic episode, with mixed features 4
Changes Affecting Both Bipolar Disorders and Depressive Disorders Another new specifier: with anxious distress Rationale Need 2 or more of: Keyed up/tense Unusually restless Difficulty concentrating because of worry Fear that something awful may happen Feeling that might lose control Rate severity of anxious distress Applies only to diagnosis of depressive and bipolar disorders Note: other specifiers from DSM IV are still included in DSM 5 Bipolar and Related Disorders To diagnose manic or hypomanic episode, now need change in mood AND increase in goal directed activity or energy Avoid false positives Each DSM chapter includes specified and unspecified diagnoses now Instead of NOS Other Specified Bipolar and Related Disorder; examples: Short duration hypomanic episodes and major depressive episodes Hypomanic episodes with insufficient symptoms and major depressive episodes Hypomanic episode without prior major depressive episode Short duration cyclothymia Depressive Disorders: Major Changes Disruptive Mood Dysregulation Disorder Children; to address concern about over diagnosis of bipolar disorder in children Dysthymic Disorder Is now Persistent Depressive Disorder This diagnosis also subsumes DSM IV TR MDD, chronic Premenstrual Dysphoric Disorder An official disorder, no longer in Appendix Removal of the bereavement exclusion 5
Disruptive Mood Dysregulation Disorder A. Severe recurrent temper outbursts (verbal and/or behavioral); very disproportionate B. Developmentally inappropriate C. Frequency: average at least 3x/week D. Mood between outbursts = irritable or angry most of the time; observable by others E. For at least 12 mos.; never 3 or more mos. without all symptoms F. Symptoms present in at least 2 settings; severe in at least 1 Disruptive Mood Dysregulation Disorder Diagnose for 1 st time between ages 6 18; age of onset <10 years Other rule outs Rationale A top down new diagnosis Concern re: over dx/false dx of Bipolar Disorder in children Bipolar criteria are meant to apply only to episodic presentations of bipolar sxs Premenstrual Dysphoric Disorder (PMDD) A. In majority of cycles, at least 5 sxs in final week before menses onset; sxs improve after onset B. 1 or more of (a) Marked affective lability (b) Marked irritability/anger/inter personal conflicts (c) Marked depressed mood, hopelessness, self deprecating thoughts (d) Marked anxiety, tension 6
Premenstrual Dysphoric Disorder (PMDD) C. 1 or more of (but B + C must = at least 5) (a) Anhedonia (b) Concentration difficulty (c) Lethargy/fatigability (d) Appetite change/cravings (e) Hypersomnia or insomnia (f) Feeling overwhelmed/out of control (g) Physical sxs [e.g., breast tenderness, bloating, etc.] D, E, G: the usual rule outs F: Criterion A should be confirmed by prospective daily ratings during at least 2 symptomatic cycles (provisional dx OK before confirmation) Persistent Depressive Disorder (PDD) A consolidation of Dysthymia and Major Depressive Disorder (MDD), Chronic Rationale Same sx list as DSM IV Dysthymia; same 2 year duration required, need 2 of: Poor appetite/overeating Insomnia/hypersomnia Low energy or fatigue Low self esteem Poor concentration or difficulty making decisions Feelings of hopelessness Persistent Depressive Disorder: Differential Diagnosis If client meets criteria for Major Depressive Episode (MDE; 5 of 9 sxs) for >2 years AND PDD (2 of 6 sxs), diagnose PDD (300.4, F34.1) And specify with persistent major depressive episode If client meets criteria for MDE (5 of 9 sxs) for > 2 years but does not meet criteria for PDD (2 of 6 sxs), diagnose Major Depressive Disorder (various ICD codes) Highly unusual! (4 MDE sxs do not appear on PDD sx list so it could happen) 7
Persistent Depressive Disorder: Specifiers Old specifiers remain (early/late onset; atypical features) Now, must also rate severity Mild, moderate, severe As we ve done for MDD in DSM IV Must also rate most recent 2 years course: With pure dysthymic syndrome With persistent MDE With intermittent MDEs, with current episode With intermittent MDEs, without current episode Several other new possible specifiers, similar to MDD dx E.g., with anxious distress; with peripartum onset; in partial remission; etc. Removal of Bereavement Exclusion from Major Depressive Disorder Diagnosis Highly controversial change What was the bereavement exclusion? Don t diagnose Major Depressive Disorder criteria are otherwise met, but symptoms occur within 1 st 2 months of bereavement Unless certain additional conditions are met Had been part of DSM since DSM became based on empirically supported criteria DSM III (1980) How Will It Work Now? If person meets criteria for MDD, diagnose if appropriate The DSM 5 offers an explanatory note (p. 161) Leaves much to clinical judgment Followed by a footnote on how to distinguish grief from MDE DSM 5 : errs on side of diagnosing false positives rather than missing true MDD cases, when bereavement precedes sx onset 8
(1) Other Specified Depressive Disorder (2)Unspecified Depressive Disorder Each DSM chapter includes specified and unspecified diagnoses now Instead of NOS In Specified, as in NOS in DSM IV, client does not meet full criteria for any disorders in the diagnostic class, and clinician chooses to communicate the specific reason Examples of Other Specified Depressive Disorder Recurrent brief depression Short duration depressive episode Depressive episode with insufficient symptoms In Unspecified, as in NOS in DSM IV, client does not meet full criteria for any disorder in the diagnostic class, and reason is not specified No More Mood Disorder NOS What do you diagnose when a client presents with depression and you haven t been able to assess for past (hypo)mania? Unspecified Depressive Disorder (311; F32.9) Other specified depressive disorders can t be diagnosed if ever met criteria for a bipolar disorder Practical Implications of Other Specified Disorders Usually the same ICD code applies to all other specified disorders But, specifying the presentation in this way IS part of a complete DSM 5 diagnosis Probably most useful in research settings 9
Anxiety Disorders Anxiety Disorders: DSM 5 Major Revisions Panic Disorder and Agoraphobia are unlinked Panic attack specifier Can be a specifier for any disorder in ANY DSM 5 category (except Panic Disorder) Rationale Types of panic attacks: simplified Expected vs. unexpected No more generalized subtype of Social Phobia Anxiety Disorders: DSM 5 Major Revisions Deletion of requirement that client recognizes fear is unreasonable Had applied to Specific Phobia, Social Phobia (now called Social Anxiety Disorder), Agoraphobia Instead, fear is out of proportion, taking cultural factors into account 6 month duration for adults too More specificity when coding specific phobia 10
How Anxiety Disorder Placement Differs from DSM IV to DSM 5 2 disorders moved here Separation Anxiety Disorder And can now be diagnosed in adults Selective Mutism OCD, PTSD, and Acute Stress Disorder moved to different chapters No longer considered anxiety disorders The anxiety component is still recognized, however DSM 5 Anxiety Disorders Separation Anxiety Disorder Generalized Anxiety Disorder Selective Mutism Specific Phobia Social Anxiety Disorder (Social Phobia) Panic Disorder Substance/Medication Induced Anxiety Disorder Anxiety Disorder Due to Another Medical Condition Other Specified Anxiety Disorder Panic Attack (specifier) Unspecified Anxiety Disorder Agoraphobia ICD = International Classification of Diseases; World Health Organization http://www.psychiatry.org/practice/dsm/transition to icd 10 DSM 5 and Transition to ICD 10 CM October 1, 2015 11
DSM /ICD Timeline Two Parallel Diagnostic Systems 1994 05/2013, DSM IV 05/2013, DSM 5 published ICD 9 CM ICD 10 widely used since 1994 (except in US) ICD 10 CM codes required in U.S., 10/1/2015 ICD 11 proposed publication, 2018 Diagnosis and Coding Diagnostic codes used for billing through 9/30/15 were ICD 9 CM codes (the why ) You were using ICD 9 CM! Even if it looked like you d been using DSM codes HIPAA law CPT code for the service (the what ) 2013 saw changes to these We were still using ICD 9 CM codes, with DSM 5 But now we ve switched to ICD 10 CM, 10/1/15 Very different organization, many more codes Mental health codes chapter Diagnosis and Coding ICD 10 vs. ICD 10 CM CM = Clinical Modification, for use in the U.S. You can download; google CDC and ICD10CM, but don t need to Codes you need are in DSM 5 Expected that you ll diagnose using DSM 5, then apply ICD 10 CM codes for billing Coding updates See http://dsm.psychiatryonline.org Click on coding update; last was March, 2014 Register (free) to receive e mail when new update is published 12
Finding the Appropriate ICD Codes There are online conversion tools, e.g. https://www.aapc.com/icd 10/codes/ But you still probably should use the DSM 5 for correct diagnosis, so DSM 5 has several ways DSM 5 Classification, pp. xiii xl In disorder criteria/text 3 indexes at end (alpha & numerical listings) For 90%+ of us 90%+ of the time, converting to ICD 10 CM is very easy! Issues To Be Aware Of: DSM 5 and ICD 10 Your software might provide ICD 10 codes automatically, but is your software as smart as you d like it to be? DSM and ICD similarities DSM IV and ICD 9 CM DSM 5 and ICD 9 CM (where we are now) DSM 5 and ICD 10 CM (where we go on Oct. 1) Less overlap, because some disorders re conceptualized in DSM 5 New disorders; some disorders deleted DSM 5 & ICD 11 will be closer than DSM 5 and ICD 10! Be sure to provide both full DSM 5 name AND ICD code Examples of ICD/DSM 5 Incompatibilities New DSM 5 disorders, not in ICD 9 CM or ICD 10 CM Hoarding Disorder: gets OCD code (300.3; ICD 10 F42) Binge Eating Disorder Same code as Bulimia Nervosa code (307.51) in ICD 9 CM ICD 10 CM: code = F50.8 (which is NOT the code for bulimia) Disruptive Mood Dysregulation Disorder: coded as Other specified mood disorder (296.99; F34.8) ICD 10 CM has conditions that DSM 5 does not include Social phobia, generalized Mixed anxiety depression 13
Examples of ICD/DSM 5 Incompatibilities DSM 5 reconceptualization partial, not complete, overlap DSM 5 Substance Use Disorder: mild = ICD abuse ; moderatesevere = ICD dependence Practice later Sometimes we are required to be more specific; several codes for presentations that formerly fell under just one code Or, opposite: sometimes 1 code covers what used to require 2 codes However, this is not common! Summary: Working with DSM 5 and ICD Coding Utilize your DSM 5 knowledge when diagnosing clients Make use of DSM 5 provided crosswalk to ICD 10 CM Review basic structure of ICD 10 CM ~1 hour free, online Be especially aware of incompatibilities between DSM 5 and ICD 10 CM that impact your practice areas Use complete DSM 5 diagnostic label, including specifiers, along with ICD 10 CM code Thorough, accurate, less chance of questioning from 3 rd party payer Ethical; complete diagnosis Obsessive Compulsive and Related Disorders A new chapter in DSM 5 14
Disorders in New Chapter Obsessive Compulsive Disorder Body Dysmorphic Disorder Trichotillomania (Hair Pulling Disorder) Hoarding Disorder Excoriation (Skin Picking) Disorder Substance/Medication Induced Obsessive Compulsive and Related Disorder Obsessive Compulsive and Related Disorder Due to Another Medical Condition Other Specified Obsessive Compulsive and Related Disorder Unspecified Obsessive Compulsive and Related Disorder Two New Disorders Hoarding Disorder Persistent difficulty discarding or parting with possessions, regardless of their actual value; perceived need to save Compromises intended use of living areas Can still be dx d if someone else intervenes to reduce clutter! Rationale Excoriation Disorder Skin picking; recurrent; resulting in lesions Repeated attempts at stopping or decreasing Not due to another mental disorder, substance use, etc. Body Dysmorphic Disorder Previously conceptualized as Somatoform Disorder DSM 5 adds new compulsivity criterion At some point during disorder, the person has engaged in repetitive behaviors or mental acts related to her/his concerns about appearance Examples Comparing one s appearance to others Excessive grooming Checking body part in the mirror Seeking reassurance from others Muscle dysmorphia specifier 15
Other Revisions to Disorders in OCD and Related Disorders Insight specifiers OCD, Body Dysmorphic Disorder, Hoarding Disorder Insight can range from good to absent/delusional Don t also diagnose Delusional Disorder OCD: tic related specifier Other Specified O C and Related Disorders: Body Dysmorphic like disorder with actual flaws Body Dysmorphic like disorder without repetitive behaviors Body focused repetitive behavior disorder Obsessional jealousy Cultural variants Dx is etiologically based more than symptom based A divergence from typical DSM conceptualization Trauma and Stressor Related Disorders Another new chapter in DSM 5 Trauma and Stressor Related Disorders List Reactive Attachment Disorder Disinhibited Social Engagement Disorder Posttraumatic Stress Disorder Acute Stress Disorder Adjustment Disorders Other Specified Trauma and Stressor Related Disorder Unspecified Trauma and Stressor Related Disorder 16
Rationale for New Chapter New chapter reflects updated conceptualization of these disorders Groups disorders sharing requirement that a specific stressful event preceded the symptomatology Stressor necessary (but not sufficient) Different than typical approach to DSM diagnosis Rationale for New Chapter Typical reactions to stressors (traumatic and non traumatic) involve more than anxiety symptoms (Much of the research and discussion here has focused on PTSD) PTSD is different than/more than an anxiety disorder Often fear and anxiety symptoms occur But much heterogeneity in posttraumatic symptomatology Depression/dysphoria, anger, dissociation, guilt, shame, changed cognitive schemas about self and world, risk taking behaviors Therefore, thought more useful to group by common etiology rather than by symptom presentation DSM 5 Changes to PTSD diagnosis Changes to Criterion A Traumatic stressor must involve actual or threatened death, sexual violence, or serious injury; or direct witnessing Not confronted with (DSM IV ) See next slide Removal of need to experience intense fear, helplessness, or horror 4 symptom clusters, not 3 Still have intrusion and arousal But arousal includes irritable or self destructive behavior too Avoidance/numbing split into 2 avoidance and persistent negative alteration in mood The latter includes most of the numbing symptoms as well as persistent negative emotional states 17
PTSD DSM 5 Criterion A Exposure to actual or threatened death, serious injury, or sexual violence in one (or more) of the following ways: 1. Direct (it happened to you) 2. You witnessed it as it occurred to others 3. You learned that a traumatic event(s) occurred to a close family member or close friend. If actual or threatened death, the traumatic event must have been violent or accidental. 4. Repeated or extreme exposure, as in first responders But #4 specifically does not apply to video/electronic exposure (unless work related) PTSD: 4 Symptom Clusters B. At least 1 intrusion sx: Memories; dreams; flashbacks; distress at exposure to cues; physiological reactions C. At least 1 avoidance sx: Memories/thoughts/feelings or external reminders D. Negative alteration in cognitions and mood, at least 2: Inability to remember; negative beliefs; distorted cognitions; negative emotional state; diminished interest; detachment; can t experience positive emotions PTSD: 4 Symptom Clusters E. Arousal/reactivity, at least 2: Irritability/angry outbursts; reckless or self destructive behavior; hypervigilance; startle response; concentration difficulties; sleep disturbance Note the heterogeneity of possible presentations! 636,000 possible combinations of symptoms DSM IV : 79,000 18
Misc. Points about Trauma Related Diagnoses Similar changes for Acute Stress Disorder Definition of traumatic event Also, dissociative symptoms no longer required for ASD dx PTSD new specifiers With dissociative symptoms With delayed expression Instead of delayed onset Adjustment Disorders in DSM 5 Criteria are the same as in DSM IV Error in DSM 5 text (see coding update) DSM 5 maintains other specifiers with depressed mood ; with disturbance of conduct ; etc. No attempt to limit the conditions under which Adjustment Disorder can be diagnosed Children and the Trauma and Stressor Related Diagnoses PTSD One criteria set for 6 years and younger, another for 7 years+ E.g., notes that intrusive memories may emerge in play reenactment Avoidance OR negative alteration in cognition/mood Not both, as is required for 7 years & up DSM IV Reactive Attachment Disorder is now 2 distinct diagnoses Reactive Attachment Disorder Disinhibited Social Engagement Disorder 19
Other Specified Trauma and Stressor Related Disorders Adjustment like disorders with delayed onset of sxs (>3 mos.) Adjustment like disorders w/prolonged duration (>6 mos.) without prolonged duration of stressor Cultural syndromes (e.g., ataque de nervios) Persistent complex bereavement disorder Dissociative Disorders; Somatic Symptom and Related Disorders (each is a distinct chapter) DSM IV to DSM 5 : Dissociative Disorders Dissociative identity disorder Dissociative fugue Dissociative amnesia Depersonalization disorder NOS 20
DSM IV Somatoform/Factitious DSM 5 Somatic Symptom and Related DSM IV Somatoform Disorders Somatization Disorder Undifferentiated Somatoform Disorder Conversion Disorder Pain Disorder Hypochondriasis Body Dysmorphic Disorder DSM IV Factitious Disorders DSM 5 Somatic Symptom and Related Disorders Somatic Symptom Disorder Illness Anxiety Disorder Conversion Disorder (functional neurological sx disorder) Psychological Factors Affecting Other Medical Conditions Factitious Disorder Other Specified Unspecified New: Somatic Symptom Disorder One diagnosis, instead of several that are poorly differentiated Less emphasis on medically unexplained sxs For all disorders in this category One or more somatic sxs causing distress or disruption Excessive thoughts, feelings, or behaviors related to the somatic sxs or associated health concerns Although any 1 sx may not be continuously present, the state of being symptomatic is persistent (typically >6 mos.) Illness Anxiety Disorder Preoccupation with having or acquiring a serious illness No or mild somatic sxs Excessive health related behaviors Compare to Somatic Symptom Disorder Preoccupation is prominent issue, rather than the sxs Less somatic symptomatology in Illness Anxiety Disorder In both, there can be excessive concern/anxiety/energy Note: Medical condition still relevant in DSM 5 diagnosis 21
Feeding and Eating Disorders Feeding and Eating Disorders Chapter includes feeding disorders from childhood/adolescence chapter of DSM IV Pica, rumination disorder, avoidant/restrictive food intake disorder Anorexia nervosa Amenorrhea requirement gone Rewording of weight criterion Bulimia nervosa Bingeing/purging 1x/week minimum (used to be 2x) for 3 mos. Severity ratings based on weight (anorexia) or frequency (bulimia; binge eating disorder) Feeding and Eating Disorders: New Binge Eating Disorder Binge eating without inappropriate compensation Binge eating defined by (1) definitely larger amount in discrete time period, AND (2) sense of lack of control At least 1x/week for 3 months Marked distress re: binge eating 3 or more of: (a) rapid eating; (b) uncomfortably full; (c) eat alone due to embarrassment; (d) disgusted/depressed/guilty after binge; (e) not physically hungry Don t dx if anorexia or bulimia dx s apply 22
Substance Related and Addictive Disorders Substance Related and Addictive Disorders DSM IV TR Substance use disorders Abuse Dependence Other substance disorders E.g., Delirium, Intoxication, Withdrawal E.g., substance induced mood disorder, anxiety disorder, sexual dysfunction Major DSM 5 Changes Abuse and dependence combined into Substance Use Disorder New diagnoses Cannabis Withdrawal Caffeine Withdrawal Tobacco criteria Expansion of category Gambling disorder How DSM 5 Substance Use Disorder Differs from DSM IV TR DSM IV Dependence* Tolerance Withdrawal Larger amounts/longer than intended Desire/effort to cut down Lots of time spent Important activities given up/ eliminated Use despite knowledge of physical/psych. problem worsened by use DSM IV Abuse* (maladaptive pattern of use impairment or distress as defined by ) Failure to fulfill role obligations Physically hazardous situations Substance related legal problems Use despite recurrent social/ interpersonal problems caused or exacerbated by use New: craving (strong desire or urge) Removed: legal problems * DSM IV criteria are abbreviated 23
DSM 5 Substance Use Disorders 7 DSM IV dependence criteria + 4 abuse criteria 1 new criterion ( craving ); 1 deleted ( legal difficulties ) 2 criteria = diagnosis Dimensional rating 2 3 = mild 4 5 = moderate 6+ = severe Affects coding Misc. Points about Substance Diagnoses No more polysubstance dependence diagnosis Withdrawal syndromes identified for 8 of the 10 substance categories Cannabis and caffeine new to DSM 5 No identified withdrawal syndrome for hallucinogens or inhalants DSM 5 Cannabis Withdrawal Criteria Stopping heavy and prolonged cannabis use 3 or more of 7 sxs below, onset within one week: Irritability, anger, or aggression Nervousness or anxiety Sleep difficulty (e.g., insomnia, disturbing dreams) Decreased appetite or weight loss Restlessness Depressed mood At least 1 physical sx, e.g.,: shakiness, sweating, headache, abdominal pain, etc. Distress/impairment Not due to another condition 24
Schizophrenia Spectrum and Other Psychotic Disorders DSM IV to DSM 5 Schizophrenia Schizophreniform Disorder Schizoaffective Disorder Delusional Disorder Brief Psychotic Disorder Shared Psychotic Disorder NOS Medical Condition Substance Induced Schizophrenia Spectrum and Other Psychotic Disorders Schizophrenia: change to Criterion A 2 sxs required At least one = delusions, hallucinations, or disorganized speech Schizophrenia subtypes are gone Schizoaffective Disorder DSM 5 requires that a major mood episode be present for a majority of the disorder s total duration after Criterion A has been met Delusional Disorder Delusions can be bizarre now; use specifier New exclusion criterion (OCD, BDD) 25
Schizophrenia Spectrum and Other Psychotic Disorders Catatonia Can be a specifier Or a diagnosis, associated with another medical condition Or unspecified Other specified schizophrenia spectrum and other psychotic disorders Schizotypal Personality Disorder found here (and in PD section) Neurodevelopmental Disorders First DSM 5 chapter; new Autism Spectrum Disorder Combines several DSM IV TR diagnoses into one Asperger s, PDD NOS, Childhood Disintegrative Disorder, Autistic Disorder Reorganizes criteria Categorize by need for support Many specifiers Those who had a well established DSM IV diagnosis of Asperger s, PDD NOS, or Autistic Disorder should be given the diagnosis of Autism Spectrum Disorder A grandfather clause! How is this really working? 26
Autism Spectrum Disorder: Summary of Criteria Restricted, repetitive patterns of behavior, interests, or activities 2 of 4 required (DSM IV TR required only one) Stereotyped/repetitive motor movements Insistence on sameness, routines, etc. Highly restricted fixated interests Hyper or hyporeactivity to sensory input or unusual interest in sensory aspects of environment Autism Spectrum Disorder: Summary of Criteria Persistent deficits in social communication and social interaction in multiple contexts Social emotional reciprocity; nonverbal communicative behaviors; deficits in developing, understanding, maintaining relationships All are required Sxs present in early developmental period Etc. (distress, impairment; not better explained ) Other Neurodevelopmental Disorders Communication disorders Includes, among others: Social (Pragmatic) Communication Disorder Social communication and interaction impairment, without restricted/repetitive interests/behavior Motor disorders E.g., Tourette s, other tic disorders Other specified neurodevelopmental disorders 27
Neurodevelopmental Disorders: Other Selected Changes ADHD Onset of sxs by age 12 (not age 7) Changes will make adulthood diagnosis easier dx threshold lowered for those 17+ Only 5 sxs required, not 6 Specific Learning Disorder De emphasis of IQ test score All learning disorders within one diagnosis Specifiers Intellectual Disability Adaptive functioning Intellectual deficit, but confirmed by clinical assessment too (not just IQ test score) Other Disorders Often (Not Always) Diagnosed in Childhood NOT a separate DSM 5 chapter New Chapter: Disruptive, Impulse Control, and Conduct Disorders Oppositional Defiant Disorder 3 types of sxs Guidance re: normal vs. ODD; severity ratings Differential diagnosis Conduct Disorder New with limited prosocial emotions specifier Intermittent Explosive Disorder Aggression can be verbal or nondestructive physical Antisocial Personality Disorder listed here And in PD section 28
Elimination Disorders No significant changes Their own chapter Were in childhood chapter of DSM IV Disorders Enuresis Encopresis Other specified elimination disorder Unspecified elimination disorder Overview of Other DSM 5 Revisions Personality Disorders MUCH work and discussion of changing the entire diagnostic scheme Would have been dimensional Would have eliminated some personality disorders DSM 5 kept EVERYthing the same in spite of poor reliability and validity of PD diagnoses The proposed revision to this chapter is in DSM 5 Section III, Emerging Measures and Models Assess personality functioning AND pathological personality traits 29
Neurocognitive Disorders: DSM IV to DSM 5 Delirium Dementia Amnestic Disorders Cognitive Disorder NOS Neurocognitive Disorders Modest decline in 1 or more cognitive domains Do not interfere with capacity for independence in everyday activity Decline requires use of compensatory strategy Delirium Major and Mild Neurocognitive Disorders Combines DSM IV Dementia and Amnestic Disorder Major vs. Mild : Capacity for independence Degree of decline Then code based on etiological subtype DSM IV to DSM 5 : Sleep Disorders Primary sleep disorders Dyssomnias Parasomnias Sleep disorders related to another mental disorder Other sleep disorders 30
Sleep Wake Disorders Provides links to Int l Classification of Sleep Disorders Sleep wake disorder due to (a) another mental disorder or (b) a general medical condition are deleted Because DSM 5 requires concurrent specification of coexisting conditions Removes causal attribution Primary Insomnia Insomnia Disorder in DSM 5 New disorders Restless Legs Syndrome Rapid Eye Movement Sleep Behavior Disorder Sexual Dysfunctions The DSM 5 disorders Delayed Ejaculation Erectile Disorder Female Orgasmic Disorder Female Sexual Interest/Arousal Disorder Genito Pelvic Pain/ Penetration Disorder Male Hypoactive Sexual Desire Disorder Premature (early) Ejaculation Substance induced; other; unspecified No longer follows Masters & Johnson sexual response cycle More gender specific disorders Vaginismus and Dyspareunia merged Psychological vs. combined factors subtyping gone Minimum 6 month duration Gender Dysphoria Previously, Gender Identity Disorder Remove possibly stigmatizing label of Disorder but keep as a reimbursable condition in DSM Criteria changes Emphasis on gender incongruence rather than cross gender identification 2 criteria sets: kids vs. adolescents/adults New specifiers With a disorder of sex development Posttransition 31
Paraphilic Disorder DSM 5 makes distinction between Paraphilia and Paraphilic Disorder Paraphilia is necessary, but not sufficient, for Paraphilic Disorder For disorder, must have distress or impairment, or harm (or risk of harm) to other Why do this? Try not to label nonnormative sexual interests as disordered But have a nomenclature for these interests for research purposes DSM 5 Standardized Assessment Measures Online, free to you, easy to use! DSM 5 Assessment Tools Recommended, not required, for DSM 5 diagnosis Third party payers might eventually require some or all of these All can be freely used by clinicians with clients But copyright protected for formal presentation such as this All are available at: http://www.psychiatry.org/practice/dsm/dsm5/onlineassessment measures Shorter: google DSM online assessment 32
Basic DSM 5 Assessment Procedure (Optional) 1. Symptomatology assessment A. Client completes Level 1 cross cutting symptom measure (parent or informant can complete) Clinician reviews for areas of concern B. Client can then complete Level 2 measure for area(s) of concern Some are completed by clinician, e.g., psychotic sx severity C. Additional disorder specific symptomatology measures 2. Disability (impairment) WHODAS 2.0 3. Other types of measures Personality, cultural formulation, early development and home background Why Use Written Assessment Tools? Research evidence (Formal) assessment can be therapeutic Good practice to monitor client symptomatology and progress over time; empirical support Reimbursement issues Increase chances of reimbursement for particular tests and/or treatments Further evidence (beyond clinical interview) for severity rating Why use DSM 5 tools? Easily available, free Norms, cutoff scores available Empirical support (some) Fairly brief, easy to administer Example: Adult (possible) PTSD Client 1A) Client completes Level 1 cross cutting sx assessment 23 questions, 0 4 scale, 13 domains, past 2 weeks Example domains: suicidal ideation, sleep, anger, anxiety Clinician reviews for areas of concern Suggest follow up if any question within domain is endorsed at 2 (mild; experienced on several days) or above Lower threshold for 3 of the 13 domains We ll assume client meets or exceeds threshold in 3 domains: Anger, anxiety, substance use 33
Example: Adult PTSD Client 1B) Client could then complete Level 2 measures for these 3 domains Measures have 5 10 questions, 5 point scale; past 1 2 weeks Most indicate cutoff scores for mild, severe, etc. 1C) If you want a client completed measure for symptomatology of a particular DSM 5 disorder i.e., not cross cutting symptoms There s a severity measure for posttraumatic stress symptoms 9 questions covering major sx clusters E.g., hypervigilance, negative emotional state, flashbacks, avoidance 0 4 scale, past 7 days These are not one to one matches with criteria list! Example: Adult PTSD Client 2. Client completes measure of disability (impairment) World Health Organization Disability Assessment Schedule (WHODAS 2.0) Applies to patients with any health condition Ease of comparability 36 items, past 30 days, 1 5 scale 6 domains, including Getting along with people, getting around, life activities (housework, school, work) Example: Adult PTSD Client 3. Other tools you might want to use Personality inventory (maladaptive traits only) Cultural formulation interview Child clients: Early development and home background form 34
DSM 5 Personality Assessment Personality inventories included in online assessments ; clinicians may freely use http://www.psychiatry.org/practice/dsm/dsm5/onlineassessment measures Personality Only maladaptive traits are assessed (can be useful to assess normal personality as well; this is not part of DSM, however) Cultural Formulation Interview Person centered, collaborative Focus on 5 main areas Individual s cultural identity Cultural conceptualizations of distress Psychosocial stressors and cultural features of vulnerability and resilience Cultural features of the relationship between the individual and clinician Overall cultural assessment Can use some or all questions Supplementary modules, available at DSM 5 website www.psychiatry.org/dsm5 Practical Considerations When to use written standardized assessment inventories? Complete level 1 cross cutting sx measure and disability measure (WHODAS 2.0) at first session, before meeting clinician Assessing specific symptoms Cross cutting domain, or Sxs of a particular disorder Initial assessment should be very early (1 st 2 nd session) Track regularly As often as weekly, at first Rationale Approximately monthly for longer term clients 35
Rest of Section III: Emerging Measures and Models Alternative personality disorder model; Conditions for Further Study Summary of Alternative Personality Disorder Model General PD criteria Moderate or greater impairment in personality functioning 1 or more pathological personality traits Criteria (in DSM IV too) such as: Pervasive, stable, not better explained by other disorder, substance, etc., not a developmental stage 6 personality disorders (currently there are 10, + NOS) Antisocial, Avoidant, Borderline, Narcissistic, Obsessive Compulsive, Schizotypal Brief Summary of Alternative Model Rate level of personality functioning in 4 areas Self (identity; self direction) Other (empathy, intimacy) Rate each on 0 4 scale At least 2 must be moderate (rated 2 or higher) These manifest differently for the different PDs Specified number of pathological personality traits 5 trait domains; 25 facets (traits) Domains = negative affectivity, detachment, antagonism, disinhibition, psychoticism A different way to diagnose what we ve known as PD NOS: Personality Disorder Trait Specified 36
Borderline PD Example Moderate or greater difficulty in at least 2 of the 4 personality functioning areas 4 or more of 7 enumerated pathological personality traits Emotional lability Anxiousness Separation insecurity Depressivity Impulsivity Risk taking Hostility Compare to DSM IV Conditions for Further Study Not official DSM 5 disorders Insufficient evidene for inclusion But criteria sets provide operational definitions for research Some of these conditions appear in the other specified section of relevant chapter Attenuated Psychosis Syndrome Depressive Episodes with Short Duration Hypomania Persistent Complex Bereavement Disorder Conditions for Further Study Caffeine Use Disorder Internet Gaming Disorder Neurobehavioral Disorder Associated with Prenatal Alcohol Exposure Suicidal Behavior Disorder Nonsuicidal Self Injury 37
Remember October 1 deadline! Must begin using ICD 10 CM codes for services on that date or after (Must use ICD 9 CM codes for services occurring on 9/30/15 or before) Must use DSM 5 for diagnosis; DSM IV diagnosis no longer acceptable as of 10/1/15 My contact information Beth Eckerd, Ph.D. Private practice, Medford, Oregon Humboldt State University, Psychology Department Associate Professor Emeritus Email addresses: beth.eckerd@humboldt.edu betheckerd@yahoo.com References Angst, J. (2013). Bipolar disorders in DSM 5: Strengths, problems, and perspectives. International Journal of Bipolar Disorders, 1, 12. Blazer, D. (2013). Neurocognitive disorders in DSM 5. American Journal of Psychiatry, 170, 585 587. Bryant, R. A. (2014). Prolonged grief: Where to after Diagnostic and Statistical Manual of Mental Disorders, 5 th edition? Current Opinion in Psychiatry, 27, 21 26. Finn, S. E. (2007). In our clients shoes: Theory and techniques of therapeutic assessment. New York: Routledge. First, M. B., Pincus, H. A., & Schoenbaum, M. (2009). Issues for DSM V: Adding problem codes to facilitate assessment of quality of care. American Journal of Psychiatry, 166, 11 13. Frances, A. (2013). Saving normal: An insider s revolt against out of control psychiatric diagnosis, DSM 5, big pharma, and the medicalization of ordinary life. New York: HarperCollins. 38
References Frances, A. J., & Widiger, T. (2012). Psychiatric diagnosis: Lessons from the DSM IV past and cautions for the DSM 5 future. Annual Review of Clinical Psychology, 8, 109 130. Friedman, M. J., Resick, P. A., Bryant, R. A., Strain, J., Horowitz, M., & Spiegel, D. (2011). Classification of trauma and stressor related disorders in DSM 5. Depression and Anxiety, 28, 737 749. Goodheart, C. D. (2014). A primer for ICD 10 CM users: Psychological and behavioral conditions. Washington, DC: American Psychological Association. Hasin, D. S., O Brien, C. P., Auriacombe, M., Grant, B. F. (2013). DSM 5 criteria for substance use disorders: Recommendations and rationale. American Journal of Psychiatry, 170, 834 851. Lambert, M. J., & Hawkins, E. J. (2004). Measuring outcome in professional practice: Considerations in selecting and using brief outcome instruments. Professional Psychology: Research and Practice, 35, 492 499. Margulies, D. M., Weintraub, S., Basile, J., Grover, P. J., & Carlson, G. A. (2012). Will disruptive mood dysregulation disorder reduce false diagnosis of bipolar disorder in children? Bipolar Disorders, 14, 488 496. References Mataix Cols, D., & Pertusa, A. (2011). Annual research review: Hoarding disorder potential benefits and pitfalls of a new mental disorder. The Journal of Child Psychology and Psychiatry, 53, 608 618. Newnham, E. A., Hooke, G. R., & Page, A. C. (2010). Monitoring treatment response and outcomes using the World Health Organization s Wellbeing Index in psychiatric care. Journal of Affective Disorders, 122, 133 138. Parker, G. (2013). Opening Pandora s box: How DSM 5 is coming to grief. Acta Psychiatrica Scandinavica, 128, 88 91. Poston, J. M., & Hanson, W. E. (2010). Meta analysis of psychological assessment as a therapeutic intervention. Psychological Assessment, 22, 203 212. Reed, G. M., Roberts, M. C., Keeley, J., Hooppell, C., Matsumoto, C., Sharan, P.,... Medina Mora, M. E. (2013). Mental health professionals natural taxonomies of mental disorders: Implications for the clinical utility of the ICD 11 and the DSM 5. Journal of Clinical Psychology, 69, 1191 1212. Regier, D. A., Kuhl, E. A., & Kupfer, D. J. (2013). The DSM 5: Classification and criteria changes. World Psychiatry, 12, 92 98. References Regier, D. A., Narrow, W. E., Clarke, D. E., Kraemer, H. C., Kuramoto, S. J., Kuhl, E. A., & Kupfer, D. J. (2013). DSM 5 field trials in the United States and Canada, Part II: Test retest reliability of selected categorical diagnoses. American Journal of Psychiatry, 170, 59 70. Spiegel, D., Lewis Fernandez, R., Lanius, R., Vermetten, E., Simeon, D., & Friedman, M. (2013). Dissociative disorders in DSM 5. Annual Review of Clinical Psychology, 9, 299 326. Stein, D. J., Craske, M. G., Friedman, M. J., & Phillips, K. A. (2011). Meta structure issues for the DSM 5: How do anxiety disorders, obsessive compulsive and related disorders, post traumatic disorders, and dissociative disorders fit together? Current Psychiatry Reports, 13, 248 250. Stein, D. J., Lund, C., & Nesse, R. M. (2013). Classification systems in psychiatry: Diagnosis and global mental health in the era of DSM 5 and ICD 11. Current Opinion in Psychiatry, 26, 493 497. Tanofsky Kraff, M., Bulik, C. M., Marcus, M. D., Striegel, R. H., Wiffley, D. E., Wonderlich, S. A., & Hudson, J. I. (2013). Binge eating disorder: The next generation of research. International Journal of Eating Disorders, 46, 193 207. Wakefield, J. C. (2013). DSM 5: An overview of changes and controversies. Clinical Social Work Journal, 41, 139 154. 39
References Whipple, J. L., & Lambert, M. J. (2011). Outcome measures for practice. Annual Review of Clinical Psychology, 7, 87 111. Wilson, C. E., Gillan, N., Spain, D., Robertson, D., Roberts, G., Murphy, C. M.,... Murphy, D. G. M. (2013). Comparison of ICD 10R, DSM IV TR and DSM 5 in an adult Autism Spectrum Disorder diagnostic clinic. Journal of Autism and Developmental Disorders, 43, 2515 2525. Zisook, S., Corruble, E., Duan, N., & Young, I. T. (2012). The bereavement exclusion and DSM 5. Depression and Anxiety, 29, 425 443. Wolf, E. J., Lunney, C. A., Miller, M. W., Resick, P. A., Friedman, M. J., & Schnurr, P. P. (2012). The dissociative subtype of PTSD: A replication and extension. Depression and Anxiety, 29, 679 688. World Health Organization. (2013). International Classification of Diseases (ICD). Retrieved from http://www.who.int/classifications/icd/en/ Zoellner, L. A., Rothbaum, B. O., & Feeny, N. C. (2011). PTSD not an anxiety disorder? DSM committee proposal turns back the hands of time. Depression and Anxiety, 28, 853 856. Internet Sites of Interest http://www.psychiatry.org/dsm5 http://www.apapracticecentral.org/update/2013/05 16/frequent questions.aspx http://www.psychiatry.org/practice/dsm/dsm5/onlineassessment measures http://cms.hhs.gov/medicare/quality Initiatives Patient Assessment Instruments/PQRS/index.html?redirect=/pqri/ https://www.aapc.com/icd 10/codes/ 40
CASE #1: CHARLIE Charlie is a 57-year-old man who is seeking counseling for the first time in his life. At your first meeting with him last week, he told you that his life has gone to hell since he lost his job as a security guard in June, 2012. He and his wife survived on his unemployment payments for over a year, and when he started looking for jobs in early 2014, he didn t have any luck. Now he says he doesn t think he can do security work any more because my knees have gotten so bad from an old injury, and he feels like I m out of options. Charlie tells you that he feels like he s in a vicious circle he hasn t felt good about himself since losing his job, so he just sits around the house and ends up snacking all day. He keeps gaining weight, making his knees feel even worse, and then his weight gain and laziness make him feel even worse about himself which leads him back to eating and sleeping as an escape. Charlie says he gained about 40 pounds in the first two years of unemployment, and has added about another 35 pounds in the past year. He also says he s been sleeping more than he ever had before since not working, he s been sleeping 8-9 hours a night, plus napping for 1-2 hours during the day. When he worked, Charlie said he slept more like 6.5-7 hours a night and felt good. Charlie said that when he first lost his job but was bringing in money from his unemployment check, he didn t feel nearly as bad as he feels now. He had down days, and days that were OK; he says maybe half the days or a little more were bad days. But he said he still enjoyed camping and hunting and the outdoor activities he s always loved. He enjoyed his kids and grandkids, and looked forward to spending the holidays with family. He also looked forward to the day when he d be employed again and things would be better. Now, Charlie says, for probably almost a year he just hasn t been interested in anything and he feels basically hopeless. He said his wife is concerned and is encouraging him to seek help. He reluctantly admitted that he s thinking about death, wondering if it might not be better if he just went to sleep and never woke up ; that way his wife could collect on his life insurance policy. In addition, Charlie says he s noticed that he can t pay attention to the TV documentaries he d always enjoyed; he turns them on but he can t follow the show because he s so worried about what might happen as he and his wife continue to deplete their savings. Sleep, he says, is his only escape from worry. He goes to bed as early as he can without worrying his wife too much usually around 9 p.m., and gets up at around 8-9 a.m. the next day. Charlie says he still feels tired, though, during the day, and usually still takes his nap. When Charlie isn t sleeping or eating, he says he s restless and tense and keeps wondering when the next terrible thing is going to happen. He says every day now is a bad day where he feels down almost all the time. He doesn t think anything can change for him, but comes to see you because he doesn t know what else to do. How would you have diagnosed Charlie under DSM-IV? How would you diagnose Charlie under DSM-5? Be as specific as time allows include severity and specifiers, if any. 41
CASE #2: ALICE Alice is a 23-year-old recent college graduate, and has been your client for several months. You ve diagnosed her with Specific Phobia. (For this exercise, we ll assume she meets both DSM-IV and DSM-5 criteria for Specific Phobia.) Alice has a few phobias that you ve discussed. Right now, you two are doing some exposure therapy for her currently most disabling phobia, her fear of dogs. Alice has been phobically afraid of dogs since the age of six. This phobia is impacting her life because she s been dating a woman for 6 months who she feels quite serious about ( I think she could be the one ), but her girlfriend has had a dog for 8 years to whom she (the girlfriend) feels quite attached. As Alice and her girlfriend contemplate spending more time together at each other s homes, Alice would like to feel comfortable around her girlfriend s dog. Alice has also told you about other objects or situations that make her feel so anxious that she avoids them if at all possible. She is highly anxious in enclosed spaces, like closets and elevators. (She takes the stairs to your 6 th floor office.) She has also not sought any medical care, since she was 18 and no longer forced by her parents to go to the doctor. Alice tells you it just makes me very uncomfortable to go to a doctor s office. She is afraid of perhaps having to receive a shot; she usually had panic attacks when she had to receive shots as a child. But Alice says that even when she knows she would not be getting a shot, she still is very anxious about seeing a doctor or nurse anyway. Let s practice ICD coding. How would you code Alice s situation now (while we re still using ICD-9)? How will you code Alice s situation when we switch to ICD-10? 42
CASE #3: PENELOPE Penelope is a 36-year-old woman who was primarily raised by her grandmother, Melanie. Melanie became Penelope s legal guardian after Penelope s parents lost parental rights due to neglect of their children related to drug addiction. Melanie was diagnosed with terminal cancer last year, and as her condition worsened and she neared the end of life, Penelope took time off from work so she could care for Melanie full-time. She did so for the last 6 weeks of Melanie s life, and was at her side when Melanie passed away. Unfortunately, Melanie s death could not be described as peaceful, and it was a difficult and painful few weeks before she died. But Penelope was glad to have been there to come to her aid, as Melanie had done for her 30 years ago. Melanie died in March of this year, and Penelope has recently come to see you for therapy because she wonders if she should be feeling the way she is. She says that she finds herself having disturbing thoughts during the day, for no apparent reason, about the invasive medical procedures that Melanie endured, and about Melanie s death. She often feels cold and sweaty and sick to her stomach when she has these thoughts. At times, Melanie said she wonders if she s had a panic attack she s been tempted to go to the ER a couple times recently when she s noticed her heart pounding very quickly, her breathing being shallow, feeling dizzy, like the world is closing in on her, and feeling like she s maybe going to die. Her husband insists that the next time it happens, he s going to take her there, like it or not. Penelope said it feels strange to her that she just can t bring herself to help other relatives go through Melanie s belongings she avoids going to Melanie s house whenever possible. She s even asked her sister to bring boxes of belongings over to her own (Penleope s) house because that just doesn t seem quite as difficult. Penelope said she just doesn t feel normal. Although my life is good by all accounts I love my husband and kids, my job is good, we re doing ok financially, she said she just feels off since Melanie s death. Penelope said she somehow can t really feel happy any more, even though there s a lot to be happy about, and feels cut off from others. She s stopped going to her regular Friday lunches with work friends, and turns down social engagements with her husband whenever she feels she can. She said she finds herself getting irritable much more often with her family, which feels so unlike her normal self. Penelope also said she is probably continuously stressed out because her sleep is so poor she often wakes up in the middle of the night from nightmares about Melanie s death, and she also has trouble falling asleep. She said she sometimes actually feels as if the whole world around her is dreamlike, like she s watching it behind a glass or through water. Penelope said she s never had anyone die that she was close to, and she s wondering if this is just normal grief or if something is really wrong with her. What do you think? Is there a mental disorder here? If so, how would you diagnose it under DSM-5? 43
CASE #4: JASON Jason is a 43-year-old man who has been using alcohol regularly and heavily for years. So we can get right to the diagnostic and coding issues, let s assume the following about your client Jason: 1) You ve identified from previous sessions that Jason meets criteria for the following symptoms regarding his alcohol use: a. Using alcohol in larger amounts than was intended b. Unsuccessful efforts to quit or cut down on alcohol use c. A great deal of time spent using alcohol and recovering from its effects d. Recurrent alcohol use in situations where it is physically hazardous (e.g., driving) e. Recurrent alcohol use resulting in failure to fulfill major role obligations at school (Jason was going to school at night to get his MBA and improve his job prospects, but failed the program due to his daily drinking) 2) He s seeing you for sexual dysfunction. Specifically, about a year ago, he and his partner were making love after a party where Jason had been drinking heavily, but no more than usual. Jason found that he lost his erection even though he felt very eager to engage in sexual activity. Jason was a little anxious the next time he and his partner started to engage in sexual activity, and even though he d had a bit less to drink, he still was unable to maintain his erection. Jason tells you that this is what happens now about half the time. Sometimes he is able to engage in intercourse, but sometimes he isn t, and he isn t able to predict when this will happen. Jason said he finds all this very distressing. He says he came to see you after talking to his physician about this problem, and the physician found nothing physically wrong. First, let s diagnose him using DSM-5. What s the diagnosis/es? How would Jason s situation be coded under ICD-9? How would Jason s situation be coded under ICD-10? 44
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Seminar Evaluation Objectives Master DSM -5 s Key Changes: Implement Its Assessment Tools, & Make It Your Path to ICD-10-CM Compliance Speaker: BETH ECKERD, PhD, JD The purpose/goal of this activity is to master key DSM-5 changes, smoothly integrate new assessment tools, ease the transition to ICD-10-CM compliance and learn how to utilize DSM-5 s increased specificity to maximize reimbursement and improve treatment effectiveness. Objectives: 1. Describe primary differences in DSM-5 that impact how mood and anxiety disorders are diagnosed. 2. Summarize changes made to the conceptualization and diagnosis of grief and trauma-related symptoms. 3. Define three psychological disorders appearing for the first time in DSM-5. 4. Explain three ways in which the DSM has been restructured. 5. Apply two DSM-5 assessment measures into your clinical work. 6. Support the transition to ICD-10-CM with knowledge of DSM-5 diagnostic coding.
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