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DSM-5 in Action: ™ Diagnostic and Treatment Implications Section 2, Chapters 5–13 PART 1 of Section 2 Chapters 1–7 by Sophia F. Dziegielewski, PhD, LCSW © 2014 S. Dziegielewski After completion of this section, participants will be able to: Identify the major diagnostic categories and the criteria needed for proper diagnostic assessment. Utilize the dimensional assessment strategy outlined in DSM-5 for two disorders. Utilize this information to complete the diagnostic assessment. © 2014 S. Dziegielewski DSM-5 Chapters 20 Disorder Categories Neurodevelopmental Disorders Sleep-Wake Disorders Schizophrenia Spectrum and the Other Psychotic Disorders Sexual Dysfunctions Bipolar and the Related Disorders Gender Dysphoria Depressive Disorders Disruptive, Impulse Control, and Conduct Disorders Anxiety Disorders Substance-Related and Addictive Disorders Obsessive-Compulsive and the Related Disorders Neurocognitive Disorders Trauma and Stressor-Related Disorders Personality Disorders Dissociative Disorders Paraphilic Disorders Somatic Symptom and Related Disorders Other Mental Disorders Feeding and Eating Disorders Medication-Induced Movement Disorders and Other Adverse Effects of Medication Elimination Disorders Other Conditions That May Be a Focus of Clinical Attention © 2014 S. Dziegielewski (2 additional categories) © 2014 S. Dziegielewski © 2014 S. Dziegielewski Mood disorders no longer a combined chapter. Bipolar disorders now in the middle as a bridge between: schizophrenia spectrum disorders and depressive disorders © 2014 S. Dziegielewski Bipolar I disorder, Bipolar II disorder, Cyclothymic disorder, Substance/medication-induced bipolar and related disorder, Bipolar disorder due to another medical condition, Other specified bipolar and the related disorders, and Unspecified bipolar and the related disorders. © 2013 S. Dziegielewski Bipolar disorder due to another medical condition When listing this as a principal diagnosis, according to the ICD, which should be listed first—the medical or the mental health condition? © 2014 S. Dziegielewski Manic episode Hypomanic episode Depressive episode © 2014 S. Dziegielewski Present mood is persistently elevated, irritable, and expansive, with severe mood disturbance, leading to impaired functioning. At least THREE symptoms: pressured speech, increased psychomotor agitation, flight of ideas, decreased need for sleep, increased involvement in goal-oriented activities, distractibility, and inflated self-esteem or grandiosity. © 2014 S. Dziegielewski Excessive involvement in pleasurable activities that have the potential for high risk and negative consequences. The time frame for the episode is at least 1 week. When hospitalized to control or address behaviors occurs, the 1-week time frame is NOT NEEDED. © 20134 S. Dziegielewski Similar to manic, LESS SEVERE features and symptoms Interfere with functioning. Criteria for hypomanic includes a distinct period of: persistently expansive, irritable, elevated mood that Lasts at least 4 days but less than 1 week. © 2014 S. Dziegielewski At least THREE symptoms (four symptoms required if predominantly irritable mood): Pressured speech Increased involvement in goal-oriented activities Psychomotor agitation Distractibility Decreased need for sleep Inflated self-esteem or grandiosity © 2014 S. Dziegielewski Similar to MANIC May be excessive involvement in pleasurable activities that have the potential for high risk and negative consequences. © 2014 S. Dziegielewski Depressed mood LASTS at least 2 weeks OR a loss of interest or pleasure in nearly all activities Plus at least 5 additional symptoms Experienced almost daily for the same 2-week period © 2014 S. Dziegielewski Sleeping Appetite disturbances Fatigue or decreased energy Changes in sleep Changes in psychomotor activity Reduced ability to think, concentrate, or make decisions Feelings of worthlessness or guilt Morbid ideation or suicidal ideation, plans, or attempts Irritable mood © 2014 S. Dziegielewski Gather information from collateral sources such as family and friends. In the bipolar and related disorders, similar to most of the other disorders, in the DSM-5, a disorder may not clearly fit into distinct diagnostic categories. A course specifier may be warranted. © 2014 S. Dziegielewski No subtypes No subtypes to clarify a diagnosis as mutually exclusive and exhaustive. A subtype is used for schizoaffective disorder © 2014 S. Dziegielewski Allows the crosscutting of core anxiety-related symptoms characteristic of the episode of mania, hypomania, or depression. Requires 2 or more of the symptoms—feeling keyed up, unusually restless, difficulty concentrating because of worry, fearing something awful might happen, and feeling the loss of control. Occurs most days during the mood episode. © 2014 S. Dziegielewski Mixed features can be further divided into two types: manic or hypomanic episode with mixed features depressive episode with mixed features. © 2014 S. Dziegielewski Can be used with both bipolar I and bipolar II disorder Rapid cycling is the switch to an opposite episode (e.g., major depressive episode to a manic episode) Only difference between rapid cycling and other episodes is the frequency of the episodes © 2013 S. Dziegielewski There needs to have been at least four mood episodes within the past 12 months. Same duration criteria/symptom numbers for a major depressive, manic, or hypomanic episode. Can have a period of remission or a switch to an opposite episode. © 2014 S. Dziegielewski To distinguish rapid cycling from episodes caused by a substance, consider: Medical history, Laboratory tests, Medical physical © 2014 S. Dziegielewski Characterized by a loss of pleasure in activities previously considered pleasurable. The loss or lack of pleasure needs to be present during the most severe period of the episode. In addition, three or more of the following six symptoms must be present: a distinct depressed mood or empty mood, depression that is worse in the mornings, early-morning awakening (at least 2 hours earlier than usual), psychomotor retardation or agitation, significant weight loss or anorexia, and excessive guilt. Melancholic features are noted at the most severe stage of the episode, where there is almost a complete absence of pleasure, and even in positive circumstances, the mood does not improve. These features are seen most frequently in the inpatient setting because of the severe loss of pleasure in almost all activities. The numbness often experienced is more characteristic of the most severe stages of the disorder and is more likely in individuals with psychotic features. © 2014 S. Dziegielewski Atypical features are more common than the name implies. The mood is brightened with the occurrence of positive events and may stay that way for an extended period of time. Characteristic of at least two of the following symptoms: significant weight gain or increase in appetite, hypersomnia (increase in sleep), leaden paralysis (heavy feelings in arms or legs), and sensitivity to interpersonal rejection that affects social or occupational functioning. There can be an increase in food intake that leads to weight gain. There may also be leaden paralysis, which is characterized by a heavy sensation in the arms or legs. Sensitivity to rejection from others is present even when the client is not in a depressed episode. © 2014 S. Dziegielewski The specifier with psychotic features is characterized by delusions or hallucinations during the episode. There are two types: mood-congruent and mood-incongruent features. With mood-congruent features, the content of the delusions and hallucinations is consistent with the manic episode of grandiosity and invulnerability and may also include paranoia. With mood-incongruent features, the content of the delusions and hallucinations is inconsistent with the themes of the episode, or there is a mixture of mood-congruent and moodincongruent features. © 2014 S. Dziegielewski With Catatonic Features The specifier with catatonic features can be present in either a manic or a depressive episode. With Peripartum Features The specifier with peripartum onset is applied if symptoms occur during pregnancy or 4 weeks postdelivery. This specifier is used for manic, hypomanic, or major depressive episodes in both bipolar I and bipolar II disorders. © 2014 S. Dziegielewski Involves depressive, hypomanic, or manic episodes and the criteria for each. The expected course results in a clearly defined manic episode that comes as the first episode, and it can be followed by hypomanic or depressive episodes (APA, 2013). To diagnose bipolar 1 disorder, however, according to DSM-5 there are two criteria that must be met (A-B). REMEMBER— MUST MEET THE CRITERIA FOR THE EPISODE ! © 2013 S. Dziegielewski Criterion A requires that at least one manic episode be present. Criterion B— the potential for hypomanic and depressive episodes exists, but the full criteria for the manic and major depressive episodes must be met and are not better explained by another mental disorder such as selected schizophrenia spectrum and the psychotic disorders. Time frame: Has lasted least one week, and is present almost every day. The exact time frame is not given in DSM-5 as to what constitutes almost all day, every day but approximately 75% to 100% of the time appears to be a safe estimate. © 20134 S. Dziegielewski Characterized by one or more depressive episodes with at least one hypomanic episode. Hypomanic episode involves a period of elevated or irritable mood with increased activity, lasting at least 4 consecutive days and present throughout each day most of the time. © 2014 S. Dziegielewski This disorder is characterized by a persistent mood disturbance lasting at least 2 years (1 year in children and adolescents), and the individual must not be without the symptoms for 2 months. This disorder, although considered more chronic because of the duration of the symptoms, is less severe because the symptoms experienced do not meet the criteria for either the full hypomanic or depressive episodes. © 2014 S. Dziegielewski Characterized by a disturbance in mood, including symptoms of elevated or irritable mood, occurring with or without depressed mood, or diminished interest or pleasure in all or most activities. A physical exam and laboratory tests are needed to confirm that the symptoms developed during or soon after substance intoxication or withdrawal or after taking a medication as evidence that the substance/medication produces the mood symptoms. © 2014 S. Dziegielewski Not better explained by a bipolar or related disorder that is not induced by substances/medications, does not occur only during a delirium. Causes significant impairment in social, occupational, or other areas of functioning. Categories of the substances include alcohol, phencyclidine, other hallucinogen, sedative, hypnotic or anxiolytic, amphetamine or other stimulant, cocaine, other, or unknown substance. © 2014 S. Dziegielewski Characterized by a period of elevated or irritable mood with extreme increased activity or energy. Results from laboratory tests and physical exams show evidence of another medical disorder. The disturbance is not explained by another mental disorder and does not occur exclusively during a delirium. Causes significant impairment in social, occupational, or other areas of functioning. Specify with manic features, with manic or hypomanic features, or with mixed features. © 2014 S. Dziegielewski Characterized by impairment in social, occupational, or other significant areas of functioning but does not meet full criteria for any of the other categories of bipolar and related disorders. Can apply to the following four clinical presentations: short-duration hypomanic episodes (2–3 days) and major episodes, hypomanic episodes with insufficient symptoms and major depressive episodes, hypomanic episode without prior major depressive episode, and short-duration cyclothymia (less than 24 months). © 2014 S. Dziegielewski Characteristic of bipolar and related disorder. Does not meet the full criteria for any of the BP and related disorders. Used with insufficient information to place a more formal diagnosis and used in settings such as emergency rooms. © 2014 S. Dziegielewski Bipolar I: Anxiety disorders, ADHD and disruptive impulse control disorders Bipolar I: Alcohol use disorder (half have symptoms of both) Medical Conditions: Bipolar I: Metabolic syndrome and migraines; Bipolar II: Eating disorders—BED binge eating disorder Cyclothymic substance and sleep-related disorders © 2014 S. Dziegielewski How to document in DSM-5 © 2014 S. Dziegielewski AXIS I: 296.6 Bipolar I Disorder, Most Recent Episode Depressed AXIS II: None AXIS III: Deferred AXIS IV: Occupational Problems: Discord as Boss With Coworkers; Economic Problems: Overspending and Impulsive Buying Resulting in Large Debt AXIS V: GAF (current/highest in past year) = 30/70 © 2014 S. Dziegielewski Type of most current episode (Mild, Moderate, Severe): Does it meet the criteria for the episode? Does it meet more than the criteria? With Psychotic Features (mood congruent [matches manic episode] or mood incongruent [delusions don’t match manic episode) Partial Remission (less than 2 months without symptoms of that presenting episode) Full Remission (during the last 2 months without symptoms of the presenting episode) © 2014 S. Dziegielewski Bipolar I Disorder (principal diagnosis) Current Episode Manic 296.41 (F31.11) Mild With Psychotic Features 296.54 (F31.5) Mood Congruent In Full Remission 296.56 (F31.76) (e.g., 2 months) © 2014 S. Dziegielewski