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Making Friends with the DSM:
Practicing Per DSM5
A Workshop Taught by Christina G. Watlington, Ph.D.
Corporate University of Providence, Providence Service Corporation
Disclaimer
DSM and DSM 5 are registered trademarks of the American Psychiatric
Association (APA). The APA has not endorsed this training or its content.
Material under APA Copyright in this presentation is used according to
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through 118 of the copyright law title 17, U. S. Code). You should only
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distribution of the information is not allowed.
Visit the official APA DSM-5 website at www.dsm5.org.
What do you think of DSM-5?
Warm-up! Bumper cars
Part I
Brief DSM History Lesson
Why Do We Have A DSM
…To assist trained clinicians in the diagnosis of their patients’ mental
disorders as part of case formulation assessment that leads to a fully
integrated treatment plan for each individual
We have a new DSM to assist with:
1. Accurate diagnosis
2. Case Formulation
3. Treatment Planning
A Short History of the DSM
1952: DSM-I (106)
1968: DSM-II (182)
1980: DSM-III (265)
1987: DSM-III-R (292)
1994: DSM-IV
2000: DSM-IV-TR
2013: DSM-5
Major Changes of the DSM5
• ICD/DSM harmony
• Discontinuation of
multiaxial system
• Spectrum disorders and
dimensional ratings
• Greater recognition of the influence of age, gender and culture
• New organization of chapters
Online Enhancements
• The 5 is correct. No more roman numerals!
• Available online at PsychiatryOnline.org
DSM5 Concerns
• Disruptive Mood Dysregulation Disorder for tantrums?
• Major depressive disorder includes normal grief?
• Minor neurocognitive disorder for normal forgetting in old age?
-Francis (2012)
Welcome DSM5
Part II
Getting Acquainted with the DSM5
DSM5 Sections
Section I: DSM-5 Basics
Section II: Diagnostic Criteria and Codes
Major Changes
Section III: Emerging Models end Measures
What is the ICD-9 & ICD-10?
• ICD-International Classification of Diseases
• Standard diagnostic tool for epidemiology, health
management
& clinical purposes
• Medical diagnoses
• Codes are used for reimbursement
Diagnostic Codes
• Changed diagnostic codes from numeric to alphanumeric
• Codes in DSM-IV-TR were ICD-9CM codes
• Examples
ICD-9
ICD-10
OCD
300.3
F42
PTSD
309.81
F43.1
The DSM5 Paradigm Shift
Removed NOS and replaced with:
1. Other specified ___________ disorder
Specific reason given for choosing this category.
Example: Other specified depressive episode with insufficient
symptoms.
2. Unspecified _________ disorder.
Use of Other Specified & Unspecified
An individual with clinically significant depressive symptoms, lasting 4
weeks but whose symptomatology falls short of the dx threshold for a
MDE = “other specified depressive disorder, depressive episode with
insufficient sxs.”
Use unspecified when the clinician is not able to further specify and
describe the clinical presentation
Multiaxial System
1. New nonaxial documentation of diagnosis
2. Combined former axis I, II, and III
3. Eliminated Axis 4: use V codes (Z codes)
Example: Parent-Child relational problem V.61.20 (Z62.820)
4. Eliminated Axis V: Proposed use of WHODAS
Other Changes
 Replace the categorical approach to diagnosis with a dimensional
approach
 Greater emphasis on comorbidity
 Removal of developmental trajectory in organizing classification of
disorders
 Cultural Issues
Definition of a Mental Disorder
• 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.
What is NOT a mental disorder
• 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 dysfunction in
the individual as described.
Writing a Diagnosis I
Locate the disorder that meets criteria
Write out the name of the disorder:
–Ex.: Posttraumatic Stress Disorder
Now add any subtype or specifiers that fit the presentation:
–Ex.: Posttraumatic Stress Disorder, with dissociative symptoms, with delayed expression
Add the code number
(located either at the top of the criteria set or within the
subtypes or specifiers):
–Two code numbers are listed, one in bold (ICD-9) and one in parentheses (ICD-10), for
example, 309.81 (F43.10) DSM 5 Criteria Sets\PTSD.docx
Writing a Diagnosis II
Before October 1, 2015, use the bolded ICD-9 code:
• 309.81 Posttraumatic Stress Disorder, with dissociative symptoms,
with delayed expression
Starting October 1, 2015 use the ICD-10 code that is in parentheses:
• F43.10 Posttraumatic Stress Disorder, with dissociative symptoms,
with delayed expression
Order of multiple diagnoses: The focus of treatment or reason for visit is listed
first (principal diagnosis), followed by the other diagnoses in descending order of clinical
importance
Table of Contents
1.
Neurodevelopmental D/Os
10. Feeding & Eating D/Os
2.
Schizophrenia Spectrum & Other Psychotic D/Os
11. Elimination D/Os
3.
Bipolar & Related D/Os
12.Sleep-Wake D/Os
4.
Depressive D/Os
13. Sexual Dysfunctions
5.
Anxiety D/Os
14. Gender Dysphoria
6.
Obsessive- Compulsive & Related D/Os
15. Disruptive, Impulse-Control & Conduct D/Os
7.
Trauma & Stressor-Related Disorders
16. Substance-Related & Addictive D/Os
8.
Dissociative D/Os
17. Neurocognitive D/Os
9.
Somatic Symptom & Related D/Os
18. Personality D/Os
19. Paraphilia D/Os
20. Other Mental D/Os
Organization Within Chapters
Diagnostic Criteria for particular
disorder
Explanatory text information for that
disorder
– Subtypes and Specifiers
– Diagnostic features
– Coding and Recording Procedures
– Associated features
– Prevalence
– Development and course
– Risk and prognostic factors
– Culture-related diagnostic issues
– Gender-related diagnostic issues
– Suicide risk
– Functional consequences
– Differential diagnosis
– Comorbidity
Connection:
Open up to any
chapter of the
DSM5 and identify
the dx criteria and
explanatory text
information for that
disorder!
Section II: Chapter Comparison DSM-IVTR to DSM5
DSM-IV-TR
DSM5
Disorders first diagnosed in infancy,
childhood and development
DELETED disorders reorganized under
other chapters
Delirium, Dementia and Amnestic and
Other Cognitive Disorders
RENAMED
Neurocognitive Disorders
Mental Disorder due to a general medical
condition nos
DELETED
Substance related disorders
RENAMED
Substance use and addictive disorders
Section II: Chapter Comparison DSM-IVTR to DSM5 (cont)
DSM-IV-TR
DSM5
Schizophrenia and other psychotic
disorders
RENAMED Schizophrenia spectrum and
other psychotic disorders
Mood Disorders
SPLIT INTO 2 CHAPTERS
Bipolar and related Disorders
Depressive Disorders
Somataform Disorders
RENAMED Somatic symptom and related
disorders
Sexual and Gender Identity Disorders
BROKEN INTO 3 SECTIONS
Sexual dysfunction
Gender Dysphoria
Paraphillic Disorders
Section II: Chapter Comparison DSM-IVTR to DSM5 (cont.)
DSM-IV-TR
DSM5
Adjustment Disorder
CHAPTER ELIMINATED Moved to trauma
and stress related disorders
Other conditions that may be a focus of
clinical attention
SEVERAL DISORDERS SHIFTED TO
“Other Mental Disorders”
BREAK
Review of Some DSM5 Diagnoses
See Website
Name That Diagnosis
Anthony is a 6 year old male referred for evaluation due to difficulties adjusting to kindergarten. His
mother reports that Anthony dislikes going to school and will often cry or say that he is sick in order
to avoid going to school. Anthony’s mother did not report any pregnancy or delivery complications
and reported that Anthony met all developmental milestones at an average or faster than average
rate. She reported that he has always been a picky eater and is also fussy about this clothing (e.g.,
doesn’t like to have tags on his clothes, won’t wear shirts that aren’t soft cotton.) She noted that
Anthony began speaking at an early age (1.5) and that he is very verbal and likes to talk about his
interest in cars and car engines.
Anthony Case Example Cont
She noted with pride that Anthony can talk for hours about different types of cars and car engines.
She noted that his favorite activity is to play with matchbox cars at home and that he spends hours
lining up his cars and building small cities and gets upset if his play is disrupted (i.e., his younger
brother picks up a car without permission). Anthony’s teacher has noted that Anthony tends to play
by himself, seldom engages with other children, and gets agitated if other children attempt to
engage in play with him. She noted that he is doing well academically but seems disinterested in
participating in class activities. For example, when asked a question in class he will either remain
silent or respond with a comment that is minimally related to the question. Anthony’s mother
reports that she feels he is bored at school since he is already starting to read and other children are
still learning their numbers and colors.
Investigation of Changes
• Break up in groups of 3
• Review packet on changes and review DSM5.
• Bullet point 3-5 changes to share with the group and how it might
impact your work.
•
•
•
•
Group 1: Neurodevelopmental disorders
Group 2: Depressive disorders
Group 3: Anxiety disorders
Group 4: Trauma- and Stressor Related disorders
Presentations
Lunch & Case Presentations
Quick Energizer
Assessment Practice
• WHODAS 2.0
• Cross-Cutting Symptom Measure: Adult
• CFI
Can we find treasure in this experience?
Continue Learning
Use the resources in the virtual
classroom at www.corpUprov.com
Take the 2 DSM-5 courses in the
Relias/Essential learning LMS.
Explore http://www.dsm5.org
Read the DSM-5.
For tech help, email
[email protected]
CE Credit for Workshop
Be sure you have signed your
attendance in and out!
You will receive email with
directions to access course
evaluation & print certificate on the
Relias learning LMS.
Save your certificate. Save a copy of
the course flier for your records.
References
American Psychiatric Association (2013). Diagnostic and statistical Manual of Mental Disorders, Fifth Edition (DSM-5 ™). Arlington, VA,
American Psychiatric Association.
American Psychiatric Association (2013). Multiple materials from www.dsm5.org/ retrieved 6-2013.
Frances, A. (2012, Dec). “The ten worst diagnoses in the DSM-5,” Psychology Today.
Ginter, G. (2014). DSM-5: What Counselors Need to Know. Powerpoint from Louisana State University. Retrieved: June 2, 2014 from:
http://www.lacounseling.org/images/lca/DSM-5%20LCA%20Preconf.pdf
Greenberg, G. (2013). The Book of Woe: The DSM-5 and the Unmaking of Psychiatry. New York: Oxford Press.
Klott, J. (2013). Revolutionizing Diagnosis & Treatment Using the DSM-5. CMI educational institute.
Munson, C. (2013). Using DSM-5: A brief summary. Handout packet #1, retrieved
http://csmh.umaryland.edu/Conferences/ship/SHIPArchives/1.DSM5.%20SHIP%20CarltonMunson.pdf
12-2-2013
from
Munson, C. (2013). Using DSM-5: A brief summary. Handout packet
http://csmh.umaryland.edu/Conferences/ship/SHIPArchives/2.DSM5.SHIPCarltonMunson.pdf
12-2-2013
from
Paris, J. (2013). The Intelligent Clinician’s Guide to the DSM-5. New York: Oxford University press.
Practice Cases. Retrieved June 2, 2014 from:
http://www.indstate.edu/socwork/docs/conferences/handouts/dsm-v/case-examples.pdf
#2,
retrieved