Download Becoming familiar with the DSM 5

Becoming Familiar with
the DSM 5
Amy McCortney, Ph.D., LPC-S, NCC
Multiaxial evaluation review:
Making the transition
• Axis = Domain of information
• Introduced in DSM-III
• Ensures attention to
–
–
–
–
Biological
Psychological
Social
Impairment/severity
• Common language
Multiaxial evaluation review:
Making the transition
• 5 axes:
– I: Clinical dx, Other conditions
– II: Personality dx, Mental Retardation
– III: General Medical Conditions (GMC)
– IV: Psychosocial and environmental
conditions
– V (Global Assessment of Functioning):
scale of 0 to 100
Axis I
Clinical disorders
Other conditions that may be focus of clinical attn
• Includes all current disorders except
– Personality disorders
– Mental retardation
•
•
•
•
List principal diagnosis first
List all Axis I
Include major stressors if focus
Ok to defer or assign no diagnosis
Axis II
Personality disorders
Mental Retardation
• Includes
– Personality disorders
– Mental retardation
– Personality traits
– Defense mechanisms
• Note if principal reason
• List all Axis II
• OK to defer to assign no diagnosis
Axis III
General Medical Conditions
• Relevant to understanding or management
–
–
–
–
–
–
Directly causes disorder (xx due to yy)
Causes d/o to worsen
D/o is a reaction to medical dx
Choice of meds is influenced
Management or safety is issue
Incidental
• Specify
– “None” if none
– “Deferred” if in progress
– “By patient history” if not formal
Axis IV
Psychosocial and environmental problems
• May include problems that…
– affect dx, tx, prognosis
– Put one at risk for mental d/o
– are a result of mental d/o
• Include
– Relevant in past year
– Very salient context/history
• If focus, also gets coded on Axis I
• Often include “mild” “moderate” “severe”
Axis IV
Psychosocial and environmental problems
• Primary support
group
• Housing
• Social environment
• Health care
• Educational
• Legal system
• Occupational
• Others
• Economic
Axis V
Global Assessment of Functioning (GAF)
• Level of psych, soc, and occ functioning
• 100-point scale includes attention to
– Severity
– Functioning
• Rate
– current period (lowest past week)
– past year
– discharge/termination
Axis V
Global Assessment of Functioning (GAF)
• Often used to determine level of care
• Generally…
– 50-70 Outpatient
– 30-50 Intensive outpatient/partial hosp
– 1-30 Inpatient
Axis V
Determining a GAF Score
• Start at top and use “EITHER OR” logic
Is either severity OR level of functioning worse?
• Move down until range matches severity OR
functioning (WHICHEVER WORSE)
• Go one lower to make sure both are TOO SEVERE
• Determine SPECIFIC number within 10-point range
GAF scores (for ex.)
• 91-100 Superior functioning in a wide range of
activities, life’s problems never seem to get out of
hand, is sought out by others because of his or her
many positive qualities. No symptoms.
• 81-90 Absent or minimal symptoms (e.g., mild
anxiety before an exam), good functioning in all
areas, interested and involved in a wide range of
activities, socially effective, generally satisfied with
life, no more than everyday problems and concerns
(e.g. an occasional argument with family members).
GAF Example 1
A 35 year old advertising executive with
Borderline Personality Disorder cuts her
wrists deeply with a piece of glass after the
married man with whom she spent the
weekend informs her that he does not want to
see her again. On admission, she states she
is sorry she did this and no longer feels
acutely suicidal.
GAF Example 2
A 27 year old man with Schizophrenia,
working nights sorting mail at the post office,
is seen at a Community MHC for his monthly
appointment to manage his antipsychotic
meds. He has not had delusions or
hallucinations for the past five years, but is
tangential, has few friends, and spends most
of his free time watching television. He lives
at home with his parents.
GAF Example 3
A 28 year old graduate student presented for
a practice counseling session within a
counseling program where she maintained a
3.75 GPA. She discussed feeling
overwhelmed with responsibilities from time
to time throughout the semester. She
reported a recent disagreement with a
significant other and attributes this to time
spent at school and work. She admits that
she has not prepared this week’s assignment
because she was focused on this interaction.
GAF changing to… WHODAS
• A 36-item measure measuring
compromised functioning in 18 y.o.+
• 6 domains:
–
–
–
–
–
–
Understanding/communicating
Getting around
Self-care
Getting along with others
Life activities (ADLEs)
Participation in society
p.
745
In a nutshell…
Communicating severity and impairment
• DSM-IV severity specifiers (Axis I)
• Co-morbid personality disorders (Axis II)
• Co-morbid medical conditions (Axis III)
• Listing all stressors (Axis IV)
• Overall quality of functioning: GAF (Axis
V)
And here’s why:
Making the transition…
DSM IV TR
• I: 296.23 Major Depressive
Disorder, Single Episode,
Severe Without Psychotic
Features
• II: V71.09 No diagnosis
• III: 401.9 Hypertension,
Unspecified (per client report)
• IV: V62.2 Occupational
problems
• V (GAF): 35 (current)
DSM 5
• 296.23 Major Depressive
Disorder, Single Episode
401.9 Hypertension,
Unspecified (per client report)
V62.29 Other Problem Related
to Employment
WHODAS: 15, Moderate
Subtypes
pp.
21,
271272
• When the Manual reads “specify
whether”, this is a subtype of the
disorder itself.
• Ex.: 309.81 Posttraumatic Stress
Disorder, With dissociative symptoms,
Depersonalization
Severity & Course Specifiers
• When the Manual reads “specify if”, this is a
subtype of the disorder itself.
• Ex.: 309.81 Posttraumatic Stress Disorder,
With dissociative symptoms,
Depersonalization, With delayed onset
• Mild (Few symptoms in excess of min; minor impair);
Moderate; Severe (Many symptoms in excess, several
particularly severe symptoms, marked impairment)
• Partial remission; Full remission; Prior history
Don’t forget…
• Proceed to “Cultural considerations”
lessons.
• For next week:
• Do your readings
• Tab your DSMs