Introduction to the DSM-5 for APRNs Continuing Education Subcommittee APNA Education Council Presenters Co-Chairs of CE subcommittee: Barbara J. Limandri, PhD, PMHCNS-BC Joyce M. Shea, DNSc, APRN, BC Presenters: Julie A. Cambray, PhD, APN, BC Sattaria Dilks, DNP, APRN, PMHNP-BC Mary Moller, DNP, PMHCNS-BC, FAAN Barbara Warren, PhD, PMHCNS-BC, FAAN Disclosures The faculty and planners have no conflict of interest to disclose 1
Objectives At the completion of all the modules the participant will: 1.Describe the major differences between DSM-IV and DSM-5 format and categories. 2.Describe specific changes in each of the diagnostic categories. 3.Apply knowledge of the changes through case studies and diagnostic formulation. 4.Use measurement tools to increase accuracy in screening and diagnosing of mental disorders. Process of the Course Have available the full DSM-5 book and review the categories relevant to each module. Review the module PowerPoint slides. Review the case study for the module. Participate in a discussion about the case studies (onsite at annual conference). Submit a diagnostic write up using the template for each module. Module 1: How Is DSM-5 Different? Barbara J Limandri, PhD, PMHCNS-BS 2
Definition of Mental Disorder Syndrome characterized by clinically significant disturbance in cognition, emotion regulation, or behavior Reflection dysfunction in psychological, biological, or developmental processes Associated with significant distress or disability in social, occupational, or other activities Approach to Diagnosis Purpose of diagnosis is to determine Prognosis Treatment plan Potential treatment outcomes Diagnosis not equivalent to need for treatment. Need for treatment involves weighing symptom severity and salience, distress, disability, risks & benefits of available treatments, and involvement of client Organizational Scheme Diagnostic classifications in life span/developmental order Diagnostic criteria Criteria A: Symptom sets required for dx Timing & impairment of the disorder Exclusions Differential and possible co-morbidity 3
Major Changes No longer use 5-Axes Insufficient evidence to support as part of the diagnosis Instead include principle diagnosis for the clinical encounter and related or consequential diagnoses (e.g., Primary dx is major depressive episode secondary to PTSD), provisional diagnosis Medical illness included in the history GAF replaced by the World Health Organization Disability Assessment Scale, Version 2 (WHODAS) Major Changes Continued No longer use Not Otherwise Specified (NOS) because it became a catch-all Instead use specifiers in the written diagnosis (e.g., Major depressive disorder, single episode, moderate with anxious distress Unspecified: indicating significant distress or impairment of function without meeting full criteria, often related to insufficient information Other specified: indicating symptoms are characteristic of the disorder but don t meet full criteria. Clinician then provides specific reason Measurement Section Level 1 Cross-Cutting Symptom Measures for child and adult provide screening tools Level 2 Symptom Specific Severity Rating Scales for adults provide measurement beyond screening (e.g., anger, anxiety, sleep disturbance) Personality Inventory Brief and Detailed for Adult Cultural Formulation Interview 4
Case Formulation Involves careful clinical history gathered from multiple sources (client, family, previous treatment encounters) Identification of symptoms within the diagnostic criteria that client demonstrates and timing of those symptoms within client s life line Case Formulation Continued Concise summary of social, psychological, and biological factors contributing to development of the disorder Consideration of the predisposing, precipitating, perpetuating, and protective factors resulting in the development of the disorder Diagnostic Categories Renamed Neurodevelopmental Disorders Schizophrenia Spectrum and other Psychotic Disorders Bipolar and Related Disorders Depressive Disorders Anxiety Disorders 5
Diagnostic Categories Renamed Obsessive-Compulsive and Related Disorders Trauma- and Stressor-Related Disorders Dissociative Disorders Somatic Symptom and Related Disorders Feeding and Eating Disorders Sleep-Wake Disorders Diagnostic Categories Renamed Sexual Dysfunctions Gender Dysphoria Disruptive, Impulse-Control, and Conduct Disorders Substance-Related and Addictive Disorders Neurocognitive Disorders Diagnostic Categories Renamed Personality Disorders Paraphillic Disorders Our course modules will focus on the most common diagnostic categories as exemplars for learning to use the DSM-5 6
The Diagnostic Interview Introduction and alliance building History of present illness or help-seeking request Psychiatric history Risk assessment Review of systems (the diagnostic categories, e.g., mood, psychosis, etc) The Diagnostic Interview Substance use (alcohol, drugs, nicotine, caffeine) Medical history Social and relationship history including family history Mental Status Exam Summary Case formulation and plan Diagnostic Coding Coding numbers for diagnoses used to identify the diagnosis in relation to the visit DSM-5 codes relatively unchanged ICD-9-CM codes listed with the DSM-5 codes for billing purposes ICD-10-CM codes also included but not yet officially adopted. 7
References American Psychiatric Association (2013). Diagnostic and Statistical Manual of Mental Disorders, 5 th Ed. Arlington, Va: American Psychiatric Press. Nussbaum, A.M. (2013). The Pocket Guide to the DSM-5 Diagnostic Exam. Arlington, Va: American Psychiatric Press. 8