Jim Messina, Ph.D., CCMHC, NCC, DCMHS

Assistant Professor

Troy University, Tampa Bay Site

Learning ObjectivesPART 1

1.Status of the new DSM-5

2.Categories and changes in DSM-5

3.Impact of DSM-5 for Clinical Mental Health Counselors1. Openings for Integrated Behavioral Medicine Specialty

2. Openings for Co-Occurring Disorders Treatment Specialty

3. Opening for Trauma Specialty

4.Trauma Focused Therapeutic Diagnosis and Treatment Planning using the Adverse Childhood Experience (ACE Factors) Screening, the DSM-5 for Principal and Provisional Diagnoses along with Identifying Other Condition That May be a Focus of Clinical Attention

5.Integrated Behavioral Medicine Diagnosis and Treatment Planning using the ICD Codes for Common Medical Conditions resulting in Mental Health Disorders

PART 2

1.Using DSM-5 for Improved Clinical Assessment, Diagnosis and Treatment Planning

Websites on DSM-5

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

Timeline of DSM-5

1999-2001 Development of Research Agenda 2002-2007 APA/WHO/NIMH DSM-5/ICD-11

Research Planning conferences 2006 Appointment of DSM-5 Taskforce 2007 Appointment of Workgroups 2007-2011 Literature Review and Data Re-analysis 2010-2011 1st phase Field Trials ended July 2011 2011-2012 2nd phase Field Trials began Fall 2011 July 2012 Final Draft of DSM-5 for APA review May 2013 Publication Date of DSM-5

Revision Guidelines for DSM-5 Recommendations to be grounded in empirical evidence Any changes to the DSM-5 in the future must be made in

light of maintaining continuity with previous editions for this reason the DSM-5 is not using Roman numeral V but rather 5 since later editions or revision would be DSM-5.1, DSM-5.2 etc.

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

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

Focus of DSM-5 Changes DSM-5 is striving to be more etiological-however disorders are

caused by a complex interaction of multiple factors and various etiological factors can present with the same symptom pattern

The diagnostic groups have been reshuffled There is a dimensional component to the categories to be further

researched and covered in Section III of the DSM-5 Emphasis was on developmental adjustment criteria New disorders were considered and older disorders were to be

deleted Special emphasis was made for Substance/Medication Induced

Disorders and specific classifications for them are listed for Schizophrenia; Bipolar; Depressive, Anxiety, Obsessive Compulsive; Sleep-Wake; Sexual Dysfunctions; and Neurocognitive Disorders.

Definition of Mental DisorderA mental disorder is a syndrome characterized by clinically significant disturbance in an individual's cognition, emotion regulation, or behavior that reflects a dysfunction in the psychological, biological, or developmental processes underlying mental functioning. Mental disorders are usually associated with significant distress or disability in social, occupational, or other important activities. An expectable or culturally approved response to a common stressor or loss, such as death of a loved one, is not a mental disorder. Socially deviant behavior (e.g., political, religious or sexual) and conflicts that are primarily between the individual and society are not mental disorders unless the deviance or conflict results from a dysfunction in the individual, as described above. 

(American Psychiatric Association (2013). Diagnostic and Statistical Manual of Mental Disorders-Fifth Edition DSM-5. Arlington VA: Author, p. 20.)

Why identify a mental disorder diagnosis?The diagnosis of a mental disorder should have clinical utility:Helps to determine prognosisHelps in development of treatment plansHelps 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 severitySymptom 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 treatmentOther factors such as mental symptoms complicating other illness

DSM-5 Diagnostic Categories1. Neurodevelopmental disorders2. Schizophrenia Spectrum and Other Psychotic Disorders3. Bipolar and Related Disorders4. Depressive Disorders5. Anxiety Disorders6. Obsessive Compulsive and Related Disorders7. Trauma- and Stressor-Related Disorders8. Dissociative Disorders9. Somatic Symptom and Related Disorders10. Feeding and Eating Disorder11. Elimination Disorders12. Sleep-Wake Disorders13. Sexual Dysfunctions14. Gender Dysphoria15. Disruptive, Impulse-Control, and Conduct Disorders16. Substance-Related and Addictive Disorders17. Neurocognitive Disorders18. Personality Disorders19. Paraphilic Disorders20. Other Mental Disorders

Obvious Changes in DSM-5 (1) The DSM-5 will discontinue the Multiaxial

Diagnosis, No more Axis I,II, III, IV & V-which means that Personality Disorders will now appear as diagnostic categories and there will be no more GAF score or listing of psychosocial stressor or contributing medical conditions

The Multi-axial model will be replaced by Dimensional component to diagnostic categories

Obvious Changes in DSM-5 (2) Developmental adjustments will be added to criteria The goal has been to have the categories more sensitive to

gender and cultural differences Diagnostic codes will change from numeric to

alphanumeric e.g., Obsessive Compulsive Disorder will change from 300.3 to F42

Diagnostic codes will change from numeric ICD-9-CM codes on September 30, 2015 to alphanumeric ICD-10-CM codes on October 1, 2015 e.g., Obsessive Compulsive Disorder will change from 300.3 to F42

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

What Replaces NOS?NOS is replace by either:Other specified disorder or Unspecified disorder type are to be used if the diagnosis of a client is too uncertain because of:1. Behaviors which are associated with a classification are seen but there is uncertainty regarding the diagnostic category due to the fact thatThe client presents some symptoms of the category but a complete clinical impression is not clearThe 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 UnspecifiedThis designation can last only six months and after that a specific diagnostic category has to be determined for the diagnosis of the client.

Respect for Age, Gender & Culture in DSM-5

Each diagnostic definition, where appropriate will incorporate:

1. Developmental symptom manifestation – regarding the age of client

2. Gender specific disorders

3. Cultural sensitivity in regards to certain behaviors

1. Principal DiagnosisPrincipal Diagnosis is to be used when more than one diagnosis for an individual is given in most cases as the main focus of attention or treatment:In an inpatient setting, the Principal diagnosis is the condition established to be chiefly responsible for the admission of the individualIn an outpatient setting, the Principal diagnosis is the condition established as reason for visit responsible for care to be received 

The Principal diagnosis is often harder to identify when a substance/medication related disorder is accompanied by a non-substance-related diagnosis such as major depression since both may have contributed equally to the need for admission or treatment. Principal diagnosis is listed first and the term "Principal diagnosis" follows the diagnosis nameRemaining disorders are listed in order of focus of attention and treatment 

2. Provisional Diagnosis

“Provisional" can be used when there is strong presumption that the full criteria will be met for a disorder but not enough information is available for a firm diagnosis. It must be recorded "provisional" following the diagnosis given

The provisional diagnoses are often found in the “differential diagnosis” section within each disorders section of the DSM-5

3. Other Condition That May Be a Focus of Clinical Attention Replaces the Psychosocial Stressors (Axis 4)

and GAF Score (Axis 5) Other Conditions that May Be a focus of

Clinical Attention ARE NOT mental disorders They are meant to draw attention to additional

issues which may be encountered in clinical practice (p.715)

Should be documented to help identify factors which could impact the treatment planned

Categories of Other Conditions That May Be a Focus of Clinical Attention1. Relational

2. Educational and Occupational Problems

3. Housing and Economic Problems

4. Other Problems Related to the Social Environment

5. Problems Related to Crime or Interaction with the Legal System

6. Other Health Service Encounters for Counseling and Medical Advice

7. Problems Related to Other Psychosocial, Personal and Environmental Circumstances

8. Other Circumstances of Personal History

1A. Categories of: Relational Problems in Other Conditions That May Be a Focus of Clinical Attention

Problems Related to Family Upbringing Other Problems Related to Primary Support Group Child Maltreatment and Neglect Problems

Child Physical Abuse (Confirmed or Suspected) Child Sexual Abuse (Confirmed or Suspected) Child Neglect (Confirmed or Suspected) Child Psychological Abuse (Confirmed or Suspected)

Other Circumstance Related to Child Maltreatment Encounter for MH Services for being a victim Personal history (past history) as a child Encounter for MH Services as a perpetrator

1B. Categories of: Relational Problems in Other Conditions That May Be a Focus of Clinical Attention

Adult Maltreatment and Neglect Problems Spouse or Partner Violence, Physical(Confirmed or Suspected) Spouse or Partner Violence, Sexual(Confirmed or Suspected) (Confirmed or Suspected) Spouse or Partner Neglect (Confirmed or Suspected) Spouse or Partner Abuse, Psychological (Confirmed or

Suspected) Adult Physical Abuse by Nonspouse

Other Circumstance Related to Adult Maltreatment Encounter for MH Services for being a victim Personal history (past history) as a victim Encounter for MH Services as a perpetrator

What does a DSM-5 Diagnosis look like?Principal Diagnosis: 303.90 (F10.20) Alcohol Use Disorder Moderate 304.30 (F12.20) Cannabis Use Disorder Severe

Provisional Diagnosis: 291.89 (F10.14) Substance/Medication-Induced

Depressive Disorder with Moderate Alcohol Use Disorder

Other Condition That May Be a Focus of Clinical Attention V61.10 (Z63.0) Relationship Distress with Spouse or

Intimate Partner V61.8 (Z63.8) High Expressed Emotion Level within

Family V62.5 (Z65.3) Problem Related to Other Legal

Circumstances

ICD Codes Relationship to DSM-5 The World Health Organization (WHO) is

revising International Classification of Diseases and Related Health Problems (ICD-10) so that by 2015, ICD-11 will come out

DSM-5’s Codes are only the ICD-CM codes (CM = Clinically Modified to fit a Nation’s cultural makeup)

October 1, 2015, ICD-10 codes are in effect!

Implementation Date ChangeThe ICD-10 is the basis for ICD-10-CM codes which according to the DSM-5 was to be required as of October 1, 2014 in the United States as the codes to be used in all clinical reports and for insurance and third party reimbursement billing. However on April 1, 2014, the Protecting Access to Medicare Act of 2014 (PAMA) (Pub. L. No. 113-93) was enacted, which said that the Secretary may not adopt ICD-10 prior to October 1, 2015. Accordingly, the U.S. Department of Health and Human Services expects to release an interim final rule in the near future that will include a new compliance date that would require the use of ICD-10 beginning October 1, 2015. The rule will also require HIPAA covered entities to continue to use ICD-9-CM through September 30, 2015. 

Which codes do we use?

Codes used in clinical reports & insurance or 3rd party billing are the ICD codes

ICD codes are the only HIPAA approved codes in the USA

The DSM system is simply a diagnostic aid to help us sort out what ICD-CM code that is applicable for our clients

Organization of IDC-10-CM Codes F01-F09 Mental disorders due to known physiological conditions

F10-F19 Mental and behavioral disorders due to psychoactive substance use

F20-F29 Schizophrenia, schizotypal, delusional, and other non-mood psychotic disorders

F30-F39 Mood (affective) disorders F40-F48 Anxiety, dissociative, stress-related, somatoform and other

nonpsychotic mental disorders F50-F59 Behavioral syndromes associated with physiological

disturbances and physical factors F60-F69 Disorders of adult personality and behavior F70-F79 Intellectual disabilities F80-F89 Pervasive and specific developmental disorders F90-F98 Behavioral and emotional disorders with onset usually occurring

in childhood and adolescence F99 Unspecified mental disorder

Descriptive Manual for ICD The WHO publishes what is called “the

Blue Book” with descriptive explanations of their Mental, Behavioral Disorders. It is free from WHO and is available on their website

The difference between the APA DSM system and the WHO ICD model is that the WHO model is free which make no one money

Specific Changes

Per Diagnostic Category

in DSM-5

Neurodevelopmental Disorders1. Intellectual Disability (Intellectual Developmental Disorder) no longer relies on IQ used as specifier because it is the adaptive functioning that determines levels of support required. IQ measures are less valid in the lower end of the IQ rangeStill accepted that people with intellectual disability have scores two standard deviations or more below the population mean, including a margin for error which is generally +5 points. Thus on tests with standard deviations of 15 and mean of 100 the score for mild would involve 65-75 (70+5).2. Asperger's Syndrome is lumped into Autism Spectrum since it is at the milder end of the Spectrum 3. Childhood disintegrative disorder, Rett's disorder and Pervasive developmental disorder not otherwise specified are also now incorporated into the Autism Spectrum Disorder4. Autism Spectrum Disorder is now characterized by deficits in two domains: Deficits in social communication and social interactionRestricted 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 eliminated3. 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 met4. 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 Disorders1. OCD is now a stand alone category2. Body Dysmorphic Disorder is now listed under OCD3. Hoarding has been added under the category of OCD3. Trichotillomania (Hair-Pulling Disorder) is listed under OCD4. Excoriation (Skin Picking Disorder) is listed under OCD

Trauma and Stressor Related Disorders

1 Trauma related disorders are now a stand alone category2. Reactive Attachment Disorder is now listed here3. Disinhibited Social Engagement Disorder has been added4. PTSD is listed here5. PTSD in Preschool Children has been added6. Acute Stress Disorder is listed here and requires qualifying traumatic events as explicit as to whether they were experienced directly, witnessed or experienced indirectly 7. Adjustment Disorders are now listed here and conceptualize as a heterogeneous array of stress-response syndromes that occur after exposure to a distressing (traumatic or nontraumatic) event.

Dissociative Disorders

1. Dissociative Fugue has been removed from this category and is now a specifier of dissociative amnesia

2. Derealization is included in the name and symptom structure of the former depersonalization disorder to become: Depersonalization/Derealization disorder.

Somatic Symptom Disorder1. Replaced Somatiform Disorders category with this category2. Somatization Disorder; Pain Disorder; Hypochondriasis and undifferentiated somatoform disorder were eliminated3. Complex Somatic Symptom Disorder was added4. Simple Somatic Symptom Disorder was added5. Illness Anxiety Disorder was added and replaces Hypochondriasis6. Conversion Disorders (Functional Neurological Disorder) have modified criteria to emphasize essential importance of neurological examination, in recognition that relevant psychological factors may not be demonstrable at time of diagnosis7. Psychological factors affecting other medical conditions has been added to this category and along with Factitious disorder both have been placed among the somatic symptom and related disorders  because somatic symptoms are predominant in both disorders

Feeding and Eating Disorders

1. Pica was moved to this category

2. Rumination Disorder was moved to this category

3. The "feeding disorder of infancy or early childhood” has been renamed: Avoidant/Restrictive Food Intake Disorder 

4. Binge Eating Disorder was added

Elimination Disorders

1. This category was created as freestanding category

2. Enuresis was moved to this category

3. Encopresis was move to this category

Sleep-Wake Disorders

1. Primary Insomnia renamed Insomnia Disorder

2. Primary Hypersomnia joined with Narcolepsy without Cataplexy

3. Cheyne-Stokes Breathing added

4. Obstructive Sleep Apnea Hypopnea added

5. Idiopathic Central Sleep Apnea added

6. Congenital Central Alveolar Hypoventilation added

7. Rapid Eye Movement Behavior Disorder added

8. Restless Leg Syndrome added

Sexual Dysfunctions

1. Male orgasmic disorder renamed Delayed Ejaculation

2. Premature (Early) Ejaculation renamed

3. Dyspareunia and Vaginismus were combined into Genito-Pelvic Pain/Penetration Disorder

4. Sexual Aversion Disorder combined in other categories

5. For females-sexual desire and arousal disorders have been combined into one disorder: Female sexual interest/arousal disorder

Gender Dysphoria

1 This is a new diagnostic class

2. It emphasizes the phenomenon of "gender incongruence" rather than cross-gender identification per se.

3. Posttransition specifier has been added to identify individuals who have undergone at least one medical procedure or treatment to support new gender assignment

Disruptive, Impulse Control, and Conduct Disorders

1. This is a new diagnostic class and combines "Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence" and the "Impulse-control Disorders Not Elsewhere Classified"2. Oppositional Defiant Disorder was added here3. Trichotillomania removed from this category4. Conduct Disorder now in this freestanding category5. Antisocial Personality Disorder added to this category as well as in Personality Disorders Category

Substance Abuse and Addictive DisordersOnly 3 qualifiers are used in the category: 

1.Use - replaces both abuse and dependence

2.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” Category2. Now distinguishes between Minor and Major Disorders3. Replace wording of Dementia "due to"  with Neurocognitive Disorder "Associated with" for all the conditions listed4. Added new Neurocognitive Disorders: 1.Fronto-Temporal Lobar Degeneration2.Traumatic Brain Injury3.Lewy Body Disease5. Renamed Head Trauma to Traumatic Brain Injury6. Renamed Creutzfeldt-Jakob Disease to Prion Disease

Personality DisordersCluster A Personality Disorders301.0 (F60.0) Paranoid Personality Disorder301.20 (F60.1) Schizoid Personality Disorder301.22 (F21) Schizotypal Personality DisorderCluster B Personality Disorders301.7 (F60.2) Antisocial Personality Disorder301.83 (F60.3) Borderline Personality Disorder301.50 (F60.4) Histrionic Personality Disorder301.81 (F60.81) Narcissistic Personality DisorderCluster C Personality Disorders301.82 (F60.6) Avoidant Personality Disorder301.6 (F60.7) Dependent Personality Disorder301.4 (F60.5) Obsessive-Compulsive Personality DisorderOther Personality Disorders310.1 (F07.0) Personality Change Due to Another Medical Condition Specify whether Labile type; Disinhibited Type; Aggressive Type; Apathetic Type; Paranoid Type; Other Type; Combined Type; Unspecified Type301.89 (F60.89) Other Specified Personality Disorder301.9 (F60.9) Unspecified Personality Disorder

Paraphilic Disorders1. They all carried over to DSM-52. New names for them all but the category remains the same3. Overarching change is the addition of course specifiers

in a controlled environment in remission

4. Distinction between paraphilias and paraphilic disorder was made:

Paraphilic disorder is a paraphilia that is currently causing distress or impairment to the individual or a paraphilia whose satisfaction has entailed personal harm, or risk of harm, to others. 

Paraphilia is a necessary but not a sufficient condition for having a paraphilic disorder, and a paraphilia by itself does not automatically justify or require clinical intervention

Conditions Designated for Further Study in DSM-5 in Section III Attenuated Psychosis Syndrome Depressive Episodes with Short-Duration

Hypomania Persistent Complex Bereavement Disorder Caffeine Use Disorder Internet Gaming Disorder Neurobehavioral Disorder Associated with

Prenatal Alcohol Exposure Suicidal Behavior Disorder Nonsuicidal Self-Injury

Possible  Disorders Discussed But Not Included in Section III of DSM-5 Dissociative Trance Disorder Anxious Depression Factitious disorder imposed on another Hypersexual Disorder Olfactory Reference Syndrome Paraphilic Coercive Disorder

Behavioral Medicine Specialization

Based on the DSM-5

Definition of Behavioral MedicineBehavioral 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

Schizophrenia & Psychotic Disorder Co-occurring with Medical Condition 293.81 (F06.2) Psychotic Disorder due to

Another Medical Condition with delusions 293.82 (F06.0) Psychotic Disorder due to

Another Medical Condition with hallucinations 293.89 (F06.1) Catatonic Disorder Associated

with Another Medical Condition 293.89 (F06.1) Catatonic Disorder Due to

Another Medical Condition

Bipolar Co-occurring with Medical Condition 293.83 (F06.33) Bipolar and Related

Disorder due to Another Medical Condition with manic features

293.83 (F06.33) Bipolar and Related Disorder due to Another Medical Condition with manic-or hypomanic-like episode

293.83 (F06.34) Bipolar and Related Disorder due to Another Medical Condition with mixed features

Depressive Disorder Co-occurring with Medical Condition 293.83 (F06.31) Depressive Disorder Due to

Another Medical Condition with depressive features

293.83 (F06.32) Depressive Disorder Due to Another Medical Condition with major depressive-like episodes

293.83 (F06.34) Depressive Disorder Due to Another Medical Condition with mixed features

Anxiety Disorder Co-occurring with Medical Condition 293.84 (F06.4) Anxiety Disorder Due to

Another Medical Condition

Obsessive-Compulsive Co-occurring with Medical Condition 294.8 (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 300.82 (F45.1) Somatic Symptom Disorder 300.7 (F45.21) Illness Anxiety Disorder Conversion Disorders (Functional

Neurological Symptoms Disorder) 300.11 (F44.4) Conversion Disorder with weakness or paralysis 300.11 (F44.4) Conversion Disorder with abnormal movement 300.11 (F44.4) Conversion Disorder with swallowing symptoms 300.11 (F44.4) Conversion Disorder with speech symptoms 300.11 (F44.5) Conversion Disorder with attacks or seizures 300.11 (F44.6) Conversion Disorder with anesthesia or sensory loss 300.11 (F44.6) Conversion Disorder with special sensory symptom 300.11 (F44.7) Conversion Disorder with mixed symptoms 316 (F54) Psychological Factors Affecting Medical Condition 300.19 (F68.10) Factitious Disorder (includes Factitious Disorder Imposed on

Self, Factitious Disorder imposed on Another) 300.89 (F45.8) Other Specified Somatic Symptom and Related Disorder 300.82 (F45.9) Unspecified Somatic Symptom and Related Disorder

Feeding & Eating Disorders

307.52 (F98.3) Pica in Children 307.52 (F50.8) Pica in Adults 307.53 (98.21) Rumination Disorder 307.59 (50.8) Avoidant/Restrictive Food Intake Disorder 307.1 (F50.01) Anorexia Nervosa Restricting type 307.1 (F50.02) Anorexia Nervosa Binge-eating/purging type 307.51 (F50.2) Bulimia Nervosa 307.59 (F50.8) Other Specified Feeding or Eating Disorder 307.50 (F50.9) Unspecified Feeding or Eating Disorder

Elimination Disorders 307.6 (F98.0) Enuresis 307.7 (F98.1) Encopresis 788.39 (N39.498) Other Specified Elimination

Disorder with urinary symptoms 787.60 (R15.9) Other Specified Elimination

Disorder with fecal symptoms 788.30 (R32) Unspecified Elimination Disorder with

urinary symptoms 787.60 (R15.9) Unspecified Elimination Disorder

with fecal symptoms

Sleep-Wake Disorders 780.52 (G47.00) Insomnia Disorder 780.54 (G47.10) Hypersomnolence Disorder 347.00 (G47.419) Narcolepsy without Cataplexy but with

hypocretin deficiency 347.01 (G47.411) Narcolepsy with Cataplexy but without

hypocretin deficiency 347.00 (G47.419) Autosomal dominant cerebellar ataxia,

deafness, and narcolepsy 347.00 (G47.419) Autosomal dominant narcolepsy, obesity and

type 2 diabetes 347.10 (47.429) Narcolepsy secondary to another medical

condition

Breathing-Related Sleep Disorders327.23 (G47.33) Obstructive Sleep Apnea Hypopnea

Central Sleep Apnea327.21 (G47.31) Idiopathic Sleep Apnea786.04 (R06.3) Cheyne-Stokes Breathing780.57 (G47.37) Central Sleep Apnea comorbid with opioid use (first code opioid use disorder if present.)

Sleep-Related Hyperventilation327.24 (G47.34) Idiopathic hypoventilation327.25 (G47.35) Congenital central aveolar hypoventilation327.26 (G47.36) Comorbid sleep-related hypoventilation

Circadian Rhythm Sleep-Wake Disorders307.45 (G47.21) Circadian Rhythm Sleep-Wake Disorder Delayed sleep phase type 307.45 (G47.22) Circadian Rhythm Sleep-Wake Disorder Advanced sleep phase type 307.45 (G47.23) Circadian Rhythm Sleep-Wake Disorder Irregular sleep-wake type307.45 (G47.24) Circadian Rhythm Sleep-Wake Disorder Non-24 hour sleep-wake type307.45 (G47.26) Circadian Rhythm Sleep-Wake Disorder Shift Work type

Parasomnias307.46 (F51.3) Non-Rapid Eye Movement Sleep Arousal Disorder Sleepwalking Type Specify if: With sleep-related eating; With sleep-related sexual behavior (Sexsomnia)307.46 (F51.4) Non-Rapid Eye Movement Sleep Arousal Disorder Sleep terror type307.47 (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 disorder327.42 (G47.52) Rapid Eye Movement Sleep Behavior Disorder333.94 (G25.81) Restless Legs Syndrome

Sexual Dysfunctions

302.74 (F52.32) Delayed Ejaculation 302.72 (F52.21) Erectile Disorder 302.73 (F52.31) Female Orgasmic Disorder Specify if:

Never experienced an orgasm under any situation 302.72 (F52.22) Female Sexual Interest/Arousal Disorder 302.76 (F52.6) Genito-Pelvic Pain/Penetration Disorder 302.71 (F52.0) Male Hypoactive Sexual Desire Disorder 302.75 (F52.4) Premature (Early) Ejaculation

Focus of Behavioral MedicineLife-span approach to health & health care for: Children Teens Adults Seniors In racially and ethnically diverse communities

Desired Impact of Behavioral MedicineChanges in behavior and lifestyle can: Improve healthPrevent illnessReduce symptoms of illness Behavioral changes can help people:Feel better physically and emotionallyImprove their health statusIncrease their self-care skillsImprove their ability to live with chronic illness. Behavioral interventions can:Improve effectiveness of medical interventionsHelp reduce overutilization of the health care systemReduce the overall costs of care

Key Strategies of Behavioral Medicine

Lifestyle Change Training Social Support

Examples of Goalsof Lifestyle Change Improve nutrition Increase physical activity Stop smoking Use medications appropriately Practice safer sex Prevent and reduce alcohol & drug abuse

Examples of Training in Behavioral Medicine Coping skills training Relaxation training Self-monitoring personal health Stress management Time management Pain management Problem-solving Communication skills Priority-setting

Examples of Social Support Group education Caretaker support and training Health counseling Community-based sports events

Trauma Focused Therapeutic Diagnosis &

Treatment Planning

Trauma and Stressor Related Disorders

1. PTSD for Adults, Teens, Children & Preschool Children

2. Acute Stress Disorder

3. Adjustment Disorders

4. Reactive Attachment Disorder

5. Disinhibited Social Engagement Disorder

Trauma Focused Therapeutic Diagnosis &Treatment Planning Adverse Childhood Experience (ACE

Factors) Screening DSM-5 for Principal and Provisional

Diagnoses Identifying Other Condition That May be

a Focus of Clinical Attention

Adverse Childhood Experiences (ACE Factors)ABUSE

1. Emotional Abuse

2. Physical Abuse

3. Sexual Abuse

Neglect

4. Emotional Neglect

5. Physical Neglect

Household Dysfunction

6. Mother was treated violently

7. Household substance abuse

8. Household mental illness

9. Parental separation or divorce

10. Incarcerated household member

Identify Diagnosis based on Traumatic Events &/or ACE Factors

Principal Provisional Other Conditions that May Be a

Focus of Clinical Attention

Utilize Trauma Focused Evidenced Based Practices

Prolonged Exposure Therapy

Cognitive Processing Therapy

EMDR or ART Therapy

In addition to Therapeutic Plan to address Principal Diagnosis

Co-occurring Substance Use Disorder

and

Mental Health Disorder

Co-occurring Substance Use Disorders & Mental Health Disorder Treatment Specialty FocusSubstance /Medication – Induced DisordersSchizophreniaBipolar DisorderDepressive DisordersAnxiety DisordersObsessive Compulsive DisorderSleep-Wake DisordersSexual DysfunctionsNeurocognitive Disorders

Co-occurring Substance Disorder with Schizophrenic Induced Psychotic Disorder

Alcohol Cannabis Phencyclidine Hallucinogens Inhalants Sedatives Amphetamines Cocaine

Co-occurring Substance Disorder with Bipolar & Related Disorders Alcohol Phencyclidine Hallucinogens Sedatives Amphetamines Cocaine

Co-occurring Substance Disorder with Depressive Disorders Alcohol Phencyclidine Hallucinogens Inhalants Opioid Sedatives Amphetamines Cocaine

Co-occurring Substance Disorder with Anxiety Disorders Alcohol Caffeine Cannabis Phencyclidine Hallucinogens Inhalant Opioid Sedative Amphetamine Cocaine

Co-occurring Substance Disorder with Obsessive-Compulsive Disorder Amphetamines

Cocaine

Co-occurring Substance Disorder with Sleep-Wake Disorders Alcohol Caffeine Cannabis Sedative Amphetamine Cocaine Tobacco

Co-occurring Substance Disorder with Sexual Dysfunctions Alcohol Opioid Sedative Amphetamine Cocaine

Co-occurring Substance Disorder with Delirium & Neurocognitive Disorders Alcohol Cannabis Phencyclidine Hallucinogens Inhalant Opioid Sedative Amphetamine 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.

Substance abuse in 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 Sequential – Treat SUD first then

Psychiatric disorder Parallel – Treat both at same time but

within different treatment modalities Integrated – Treat both at same time

within the same treatment modality

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 Integrated Model Dealing with the Psychiatric disorder without

use of Alcohol &/or Drugs Confronting denial, ambivalence, acceptance Monitoring overall mood during each week Emphasis on compliance in taking psychiatric

medications Identifying and fighting triggers Emphasis on “wellness” model of good night’s

sleep, balance nutritional intake & exercise

Parallels in Recovery & Relapse thinking between Disorders “May as well thinking” vs. “It matters what you

do” Abstinence violation effect vs. stopping taking

psychiatric meds when anxious or depressed Recovery thinking vs. relapse thinking and

acting out Remember: you’re always on the road to

getting better or getting worse: “It matters what you do!”

The Central Recovery RuleNo matter whatDon’t drinkDon’t use drugsTake your medication as prescribed

No matter what

Weiss, R.D. & Smith-Connery, H. (2011). Integrated Group Therapy for Bipolar Disorder and Substance Abuse. New York: Guilford Press.

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 Plan1. 3 Goals

2. 3 Objectives per Goal (total of 9)

3. 1 Intervention per Objectives (total of 9)

STEP 1:

Complete 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 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 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 bringsto therapy Level of present social support system? Mandated for freely coming to therapy? Perceptual problems which could interfere

e.g. hearing, vision, etc. Risk of decompensating (relapsing) if not

treated

Tenth: Rate Client on ACE ScaleIdentify Relevant ACE (Adverse Childhood Experiences)

Abuse http://www.cdc.gov/ace/index.htm

1. Emotional Abuse

2. Physical Abuse

3. Sexual Abuse

Neglect

4. Emotional Neglect

5. Physical Neglect

Household Dysfunction

6. Mother was treated violently

7. Household substance abuse

8. Household mental illness

9. Parental separation or divorce

10. Incarcerated household member

Eleventh (Optional): Use & Report on Assessments1. DSM-5 Self-Rated Level 1 Cross-Cutting Symptom Measure—Adult, 11-17, Parent Report for Children

2. DSM-5 Level 2: Adult Scale by PROMIS: anger, depression, mania, repetitive thoughts, sleep disturbance, substance use

3. DSM-5 Level 2: Children Scale by PROMIS (Parent Report) & 11-17: anger, anxiety, depression, inattention, irritability, mania, sleep disturbance, substance use

http://www.psychiatry.org/practice/dsm/dsm5/online-assessment-measures

4. DSM-5 Disorder-Specific Severity MeasuresAgoraphobia, Generalized Anxiety, Panic Disorder, Separation Anxiety, Specific Phobia, Acute Stress, PTSD

5. WHO Disability MeasureWorld Health Organization Disability Assessment Schedule

6. DSM-5 Personality InventoriesThe Personality Inventory for DSM-5 - Adult & Children

7. DSM-5 Early Development & Home BackgroundClinician and Parent/Guardian

8. DSM-5 Cultural Formulation Interviews 

Patient Health Questionnaire (PHQ) forms at http://www.phqscreeners.com/1. PHQ: assesses Depression, Anxiety, Eating

Disorders and Alcohol Abuse

2. PHQ-9: Depressive Scale from PHQ

3. GAD-7: Anxiety Screener from PHQ

4. PHQ-15: Somatic Symptom Scale from PHQ

5. PHQ-SADS: Includes PHQ-9, GAD-7, PHQ-15 plus panic measure

6. Brief PHQ: PHQ-9 and panic measures plus items on stressors & women’s health

Step 2:

Mental Status Examination

Mental Health Status ExamMental Health Status Exam Rates Client’s:

Appearance Consciousness Orientation to person,

place & time Speech Affect

Mood Concentration Activity level Thoughts Memory Judgment

Step 3:

Formulate Tentative Diagnosis

Formulate Tentative DiagnosisYou 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

DSM-5 Diagnosis 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

Impact of DSM-5 for Mental Health Clinicians1. Openings for Integrated Behavioral

Medicine Specialty

2. Openings for Trauma Specialty

3. Openings for Co-Occurring Disorders Treatment Specialty

Application with Real Cases You will now break into groups of 4 or 5

members to work on the following five cases and be prepared to give your complete DSM-5 Model Diagnosis for each case

Best of Luck in Using the DSM-5 My hope is that this helped to get you

ready to use the DSM-5 to show your competency and clinical expertise in ways you have never been able to do given the limitation of the deficiencies of the previous DSM models.