Download Other Problems Related to the Social Environment

DSM-5 in Action:
™
Chapter 3
Understanding What’s New and
Applying It in Clinical Practice
by Sophia F. Dziegielewski, PhD, LCSW
© 2014 S. Dziegielewski
After completion of the workshop, participants will be
able to:
 Describe the rationale and resulting
changes between DSM-IV-TR and DSM-5.
 Identify when to use the principal and the
provisional diagnosis.
© 2014 S. Dziegielewski
Starts with gathering information:
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Biomedical
Psychological
Social
Cultural
Spiritual
© 2013 S. Dziegielewski
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Making the Diagnostic Assessment
Removal of the Multiaxial System
© 2014 S. Dziegielewski
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Limited usage.
Address stigma and misperceptions related to
use of Axis I and Axis II.
Better utilize the “other conditions that may
be the focus of clinical attention” already in
the coding system.
© 2014 S. Dziegielewski
Axis I
Axis II
Axis III
Axis IV
Axis V
© 2014 S. Dziegielewski
DSM-IV-TR Major Clinical Syndromes,
Pervasive Developmental Disorders,
Learning Disorders, Motor Skills Disorders,
Communication Disorders, and Other
Conditions That May Be the Focus of Clinical
Attention
Clinical Syndromes (e.g., Mood Disorders,
Schizophrenia, Dementia, Anxiety Disorders,
Substance Disorders, Disruptive Behavior Disorders,
etc.)
© 2014 S. Dziegielewski
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Academic Problem: underachievers
Childhood or Adolescent Antisocial Behavior: isolated acts
Adult Antisocial Behavior: e.g., professional thieves, dealers
Borderline Intellectual Functioning: IQ between 71 and 84
Malingering: voluntary mental or exaggerated physical
symptoms, with an obvious recognizable goal
Bereavement
Medication-Induced Movement Disorders:
 Neuroleptic Malignant Syndrome and Tardive Dyskinesia
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Acculturation Problem: exposure to living in a new culture
Aging-Associated Cognitive Decline: normal aging causes
stress or impairment
© 2014 S. Dziegielewski
Personality Disorders
Mental Retardation
(Intellectual Disability in DSM-5)
Borderline
Intellectual Functioning (IQ 71-84)
© 2014 S. Dziegielewski
Nonaxial documentation of a diagnosis
and eliminate Axes I, II, and III
Replace
with criteria and severity
specifiers
Utilize
© 2014 S. Dziegielewski
dimensional assessments
© 2014 S. Dziegielewski
This is generally the reason for the
visit and is generally listed first.
 If there are multiple diagnoses, the
reason for the visit should always be
listed first.
 Use phrase (principal diagnosis) or
(reason for visit)
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© 2014 S. Dziegielewski
 If
the principal diagnosis is a
mental disorder that is attributed
to a medical disorder, the medical
disorder (according to the ICD) is
listed first.
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Examples to follow.
© 2014 S. Dziegielewski
Alzheimer’s Disease 331.0 (G30.9)
(List this medical diagnosis first)
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Major Neurocognitive Disorder
Specify whether: Due to Alzheimer’s disease
(principal diagnosis) or (reason for visit)
© 2014 S. Dziegielewski
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Malignant Lung Neoplasm 293.81 [F06.2]
Psychotic Disorder Due to Another Medical
Condition (principal diagnosis)
Specify whether: With delusions
293.81 (F06.2)
Specify whether: With hallucination 293.82
(F06.0)
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© 2014 S. Dziegielewski
 Inpatient:
The reason for
admission.
 Outpatient:
The reason that any
types of outpatient services are
provided.
© 2014 S. Dziegielewski
Provisional means:
 It is believed the criteria will be met but at
the time do not have enough information.
 Or time frame has not been met.
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Generally list (provisional) AFTER the
principal diagnosis.
© 2014 S. Dziegielewski
Two reasons it can be used:
1. Criteria are not met but believe they will be.
Ex: major depressive episode could also have
bipolar, inadequate history.
2. Time frame criteria are not met yet.
Ex: Schizophreniform if one month but six
months not met, and the professional cannot
wait for possible recovery, so this is used.
© 2013 S. Dziegielewski
List the principal diagnosis first.
(If criteria are met, can have more than one;
take into account comorbidity and list them
all.)
 List the provisional diagnosis (after the
principal one) if relevant.
 Provide supportive information.
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© 2014 S. Dziegielewski
Post-Traumatic Stress Disorder (Principal
Diagnosis)
Specify whether with dissociative symptoms
Specify if delayed expression
ICD-9 code: 309.81. ICD-10 code: F43.10
© 2014 S. Dziegielewski
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General Medical Conditions
Hearing Impairment
Vision Impairment
Mixing Medical and Mental
Physical (medical) conditions relevant to the
condition being treated are listed here.
© 2014 S. Dziegielewski
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The phrase “general medical
condition” is replaced with “another
medical condition” where relevant
across all disorders.
© 2014 S. Dziegielewski
index with the ICD
medical codes that used to be
placed on Axis III
 Removed
© 2014 S. Dziegielewski
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DSM-IV-TR Psychosocial and Environmental
Problems/Stressors
The stressors can be clarified with specifics:
problems with primary support
problems related to social environment
educational problems— occupational problems
housing problems— economic problems
problems with access to health care services
problems related to interaction with the legal system
and other psychosocial problems
© 2014 S. Dziegielewski
No more formal listing.
 The stressors can be listed in the
descriptions if desired.
 Consider using V or Z codes
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(Other Conditions That May Be the Focus of
Clinical Attention)
© 2014 S. Dziegielewski
 ICD-9-CM
usually termed V codes
 ICD-10
CM (usually Z codes)
Divided into areas: 8 categories
(see next slide)
© 2014 S. Dziegielewski
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Relational Problems e.g., Problems related to family upbringing
Abuse and Neglect e.g., Child maltreatment and neglect problems
Educational and Occupational Problems
Housing and Economic Problems
Problems Related to Crime or Interaction With
the Legal System
Other Health Service Encounters for
Counseling and Medical Advice
Problems Related to Other Psychosocial,
Personal, and Environmental Circumstances
Other Circumstances of Personal History
© 2014 S. Dziegielewski
Relational Problems
 Problems Related to Family Upbringing
1. Parent–Child Relational Problem
(V61.20 ICD-9-CM or Z62.820 ICD-10-CM)
2. Sibling Relationship Problem
3. Upbringing Away From Parents
4. Child Affected by Parental Relationship
Distress
© 2014 S. Dziegielewski
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Other Problems Related to the Primary
Support Group
Disruption of the Family by Separation or
Divorce
High Expressed Emotion Level Within the
Family
Uncomplicated Bereavement (a normal
reaction to the death of a loved one)
© 2014 S. Dziegielewski
Abuse and Neglect
Child Maltreatment and Neglect Problems
Child Physical Abuse (Physical Abuse,
Confirmed; Physical Abuse, Suspected)
Other Circumstances Related to Child Physical
Abuse
Child Sexual Abuse
Child Neglect
Child Psychological Abuse
© 2014 S. Dziegielewski
Educational and Occupational Problems
Educational Problems; Occupational Problems
Housing and Economic Problems
Other Problems Related to the Social
Environment
Phase of Life Problem; Problem Related to Living
Alone; Acculturation Difficulty; Social Exclusion or
Rejection; Target of (Perceived) Adverse
Discrimination or Persecution; Unspecified Problem
Related to the Social Environment
© 2014 S. Dziegielewski
Adult Maltreatment and Neglect
 Spouse or Partner Violence, Physical
 Spouse or Partner Violence, Sexual
 Spouse or Partner Violence, Neglect
 Spouse or Partner Violence, Psychological
 Adult Abuse by Nonspouse or Nonpartner
© 2014 S. Dziegielewski
Educational and Occupational Problems
Educational Problems; Occupational Problems;
Housing Problems, Economic Problems
Other Problems Related to the Social
Environment
Phase of Life Problem; Problem Related to
Living Alone; Acculturation Difficulty; Social
Exclusion or Rejection; Target of (Perceived)
Adverse Discrimination or Persecution;
Unspecified Problem Related to the Social
Environment
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© 2014 S. Dziegielewski
Problems Related to Crime or
Interaction With the Legal Environment
 Other Health Service Encounters for
Counseling or Medical Advice
 Problems Related to Other
Psychosocial, Personal, and
Environmental Circumstances (Selfharm, military deployment, etc.)
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© 2014 S. Dziegielewski
Other Circumstances of Personal
History
 Problems Related to Medical or Other
Health Care
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© 2014 S. Dziegielewski
Examples
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Overweight or Obesity: This condition is the
focus of clinical intervention.
Malingering (see next slide)
Wandering Associated with a Mental
Disorder
Borderline Intellectual Functioning: Does
not qualify as mild intellectual disability
© 2014 S. Dziegielewski
Intentional production of false or grossly
exaggerated symptoms (i.e., avoiding military duty,
work, obtaining drugs, etc.)
Four areas to strongly suspect malingering:
1. Attorney refers or self-referred during litigation or
while criminal charges are pending.
2. Marked discrepancy with what individual claims
and what are the objective findings.
3. Lack of cooperation during the diagnostic
evaluation and following treatment regime.
4. The presence of antisocial personality disorder.
© 2014 S. Dziegielewski
Global Assessment of Functioning (GAF)
 GAF is a scale of 100 points.
 The higher the number, the higher the level
of functioning.
 Covers both symptomology and level of
functioning.
 The highest level of functioning is
determined and rated.
© 2014 S. Dziegielewski
WHODAS
Disability
(was Axis V, no more GAF)
© 2014 S. Dziegielewski
Adult self-administered version
(age 18 and older)
 Assesses disability across 6 domains
(36-item measure)
 Measure over the past 30 days
 Online there is a caregiver version (e.g., with
dementia)
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© 2014 S. Dziegielewski
Comparable to GAF
 0 = None (GAF score greater than 70)
 1 = Mild
 2 = Moderate
 3 = Severe
 4 = Very Severe (GAF score under 31)
© 2014 S. Dziegielewski
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Clinicians started reporting that as of July
2013 the GAF was no longer being required
to support Social Security Disability claims.
What do you think it will be replaced with and
when?
© 2014 S. Dziegielewski
Subtypes “Specify whether”
Mutually exclusive and exhaustive
Homogeneous subgroupings within a diagnosis
 Specifiers “Specify if”
Not mutually exclusive and exhaustive
Can have more than one; better explains the
particular diagnosis
 Specify current severity: Mild, moderate, or
severe
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© 2014 S. Dziegielewski
Specify whether:
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Combined presentation
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Predominantly inattentive presentation
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Predominately hyperactive/impulsive
presentation
© 2014 S. Dziegielewski
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Depressive Disorders and Bipolar Disorders
Allow for feelings of anxiety, do not need a
separate diagnosis
Use specify if:
With anxious distress
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© 2014 S. Dziegielewski
Not on diagnostic listing in the front table but
in the text, typo?
 High levels of anxiety related to:
1. High probability of suicide risk
2. Longer duration of the illness
3. Greater likelihood of treatment
NONRESPONSE
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Information taken from APA (2013) p. 184
© 2014 S. Dziegielewski
Need at least two of the following, most days
1. Feeling keyed up and tense
2. Feeling unusually restless
3. Difficulty concentrating (worry)
4. Fearing something awful will happen
5. Feeling individual might lose control
Specify current severity:
Mild–2 symptoms, Moderate=3 symptoms
Moderate-Severe=4-5, Severe=4-5 WITH
motor agitation
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© 2014 S. Dziegielewski
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Know your scope of practice!
Identify the problem(s) and how it interferes
with functioning.
Problem behavior recognition
Problem behavior identification
Treatment plan
© 2013 S. Dziegielewski
© 2014 S. Dziegielewski
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Identify two major changes that
occurred in DSM-5 in Section One .
Elimination of the multiaxial system
and application of its replacements.
 Principal and provisional diagnoses.
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© 2014 S. Dziegielewski
© 2014 S. Dziegielewski