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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 Somatic, cognitive, and emotional concerns identified in the DSM-5 are the predominant features linking the disorders. © 2014 S. Dziegielewski When depressed clients experience a loss of interest or pleasure in activities and difficulty concentrating, these symptoms can lead to problems with performing activities of daily living (ADLs) and making decisions. © 2014 S. Dziegielewski Although some types of mixed presentations in depression exist, the DSM-5 focuses primarily on the depressive ones. For a diagnosis, problems must be severe enough to affect occupational and social functioning. © 2014 S. Dziegielewski When suffering from depressive disorders, all individuals experience some degree of depressive symptoms, although the duration, time frame, and etiology may vary (APA, 2013) © 2014 S. Dziegielewski These disorders all share depressed mood with subsequent changes in eating, sleeping, and energy levels; impairments in executive function and attention; and changes in selfawareness and perception. © 2014 S. Dziegielewski Exogenous – “outside the body” Endogenous – “inside the body” © 2014 S. Dziegielewski 296.2x Major Depressive Disorder, Single Episode 296.3x Major Depressive Disorder, Recurrent 300.4 Dysthymic Disorder 311.00 Depressive Disorder Not Otherwise Specified © 2014 S. Dziegielewski © 2014 S. Dziegielewski New Depressive Disorder in Children/Adolescents. DMDD has 11 specific criteria (ranging from A to K) that must be met. Core feature is persistent irritability for at least a year, severe and continuous course not related to a developmental phase. © 2014 S. Dziegielewski Behaviors not consistent with precipitating event. Involve either verbal or behavioral manifestations toward people or property. Temper outbursts are continuous, occurring at least 3 or more times over a 7-day period. © 2014 S. Dziegielewski Severe Mood Dysregulation: used to distinguish children who have recurrent severe/inappropriate behavioral outbursts. © 2014 S. Dziegielewski ADHD— DMDD is more aggressive. Bipolar— DMDD is more continuous and not cyclic. © 2013 S. Dziegielewski An episodic disorder (a period of time when someone is distinctly different from the baseline). BD in children is different from BD in adults, and presents as severe continuous irritability. © 2014 S. Dziegielewski Children with DMDD do not meet the adult criteria for BD. DMDD does NOT develop clear manic symptoms. © 2014 S. Dziegielewski More likely to have anxiety disorders and depression but not BD. No genetic component with DMDD. More anxiety and depression. © 2014 S. Dziegielewski © 2014 S. Dziegielewski Nine primary symptoms, must have at least 5. Symptoms occur during a 2-week period. Must have either depressed mood or a loss of interest or pleasure in daily activities consistently for the 2-week period. Of the nine symptoms, at least one must be depressed mood or loss of interest or pleasure. © 2014 S. Dziegielewski 1. Depressed mood: Depressed mood most of the day, nearly every day. 2. Markedly diminished interest or pleasure: In almost all activities most of the day, nearly every day. © 2014 S. Dziegielewski 3. Appetite changes: Appetite and weight loss or gain may occur. To be considered significant, a clear change in weight is expected while the individual is not actively dieting or trying to gain weight. Over a month’s time, a change of more than 5% of body weight should be noted to be considered significant. Eating behaviors and appetite change need to be examined over a 1-month time frame as opposed to the 2 weeks relevant to the condition; Therefore, counting this criterion for the diagnosis requires extending the evaluation beyond the 2-week period. © 2014 S. Dziegielewski 4. Sleep disturbance: Symptoms related to either insomnia or hypersomnia are noted every day. 5. Psychomotor agitation: Psychomotor agitation often exhibits as extreme restlessness, and the individual feels he or she cannot calm the self internally. © 2014 S. Dziegielewski 6. Feeling fatigued or reports feelings of no energy. 7. Feelings of worthlessness and guilt. The guilt is so overwhelming, it preoccupies the individual’s thoughts and can have a delusional quality. © 2013 S. Dziegielewski 8. Diminished concentration and indecisive thoughts: Thoughts and the resultant behaviors are linked. Impaired thinking and functioning when compared with what the individual was able to do before and what he or she is capable of doing now. © 2014 S. Dziegielewski 9. Recurrent thoughts of death: The depressed individual may often express the idea of self-harm that may or may not be related to a specific plan. If an attempt is noted in the client’s past, the circumstances surrounding it, if known, should be documented. In treatment, knowing this information may assist with predicting future risk. © 2013 S. Dziegielewski Disturbs social, occupational, educational, important functioning, and individual reports distress and mood changes. For children and adolescents, mood may be reported as irritable. Presentation may differ from what is seen in an adult. May be confused with DMDD where the mood is consistently agitated for at least a year and does not take on a cyclic pattern in which the individual seems better, as is the case in major depressive disorder. Should not be diagnosed in young adults older than age 18. © 2013 S. Dziegielewski Depressed mood in this disorder cannot be caused by substances such as drugs, alcohol, or medications. © 2014 S. Dziegielewski Cannot be caused by another mental health disorder, such as: Schizophrenia spectrum and other psychotic disorders such as schizoaffective disorder, schizophreniform disorder, delusional disorder, or other specified or unspecified disorder in this category. © 2014 S. Dziegielewski There cannot be a documented history of manic or hypomanic episodes. © 2014 S. Dziegielewski 1. In major depressive disorder (single episode or recurrent), this coding scheme is used: For the diagnosis of major depressive disorder, the first three digits using: ICD-9-CM are always 296.xx, ICD-10, it starts with F3x.x. Major Depressive Disorder 296.xx (ICD-9-CM) or F3x.x (ICD-10-CM) © 2014 S. Dziegielewski 2. The fourth digit denotes whether it is a single (denoted with the number 2) or recurrent (denoted with a 3) major depressive episode in ICD-9-CM. It is the second digit in ICD-10-CM. ICD-9-CM 296.2x single, 296.3x recurrent for ICD-10, F32.x. single, F33.X recurrent (To be recurrent, there must be at least 2 months from the end of one episode to the beginning of another. When the period between episodes is less than this, the symptoms of the major depressive episode are not met. ) © 2014 S. Dziegielewski 3. The fifth digit indicates the severity, presence of psychotic features, and remission status. There are three levels of severity: mild, moderate, and severe. When identifying mild severity, the criteria for the disorder are met, but the impairment to social and occupational functioning that results is considered minimal. When the severity specifier severe is used, the criteria for the disorder have been met, and many more symptoms than required cause significant impairment and often require immediate attention. © 2014 S. Dziegielewski The severity course specifier can also be used to denote whether there are psychotic features (hallucinations, delusions, and formal thought disorder) present. This specifier would be added and simply written “with psychotic features” when the level of severity is also utilized. Remember in coding that when the symptoms of psychosis are present, always document with psychotic features. © 2014 S. Dziegielewski This diagnosis also allows the coding of partial, full, or unspecified remission. Keep in mind, however, that remission specifiers can be used only when the full criteria for the major depressive episode are no longer met. © 2014 S. Dziegielewski 296.x1 Mild severity [ICD-9-CM] or F3x.0 [ICD-10-CM] 296.x2 Moderate severity [ICD-9-CM] or F3x.1 [ICD-10-CM] 296.x3 Severe severity [ICD-9-CM] or F3x.2 [ICD-10-CM] 296.x4 With psychotic features [ICD-9-CM] or F3x.3 [ICD10-CM] 296.x5 In partial remission [ICD-9-CM] or F3x.4 [ICD-10CM] 296.x6 In full remission [ICD-9-CM] or F3x.5 [ICD-10-CM] 296.x0 Unspecified [ICD-9-CM] or F3x.9 [ICD-10-CM] © 2014 S. Dziegielewski This is a milder yet more chronic form of the disorder, requiring a 2-year history of depressed mood. The individual suffering from this disorder is not without the symptoms for more than 2 months at a time. The disorder is considered less severe than major depressive disorder but is constant for a period of 2 years, during which the individual experiences some symptoms related to the disorder almost every day. © 2014 S. Dziegielewski This new condition to the DSM-5 occurs in women who have severe depressive symptoms, irritability, and tension that occur before menstruation. © 2014 S. Dziegielewski Meet the criteria for major depressive disorder and document the substance/medication taken, confirmed by history, physical exam, or lab result. Need to experience the symptoms soon after ingestion or with resultant intoxication or withdrawal from the substance. That the substance taken is capable of displaying the side effects that resulted has to be confirmed. © 2014 S. Dziegielewski Similar to the criteria for substance/medication-induced disorder, the individual is expected to suffer from a persistent depressed mood, accompanied by diminished interest and pleasure in activities that once were pleasurable. Needs to be direct evidence from an adequate history, physical exam, or lab result that makes the connection to the medical condition causing it. © 2014 S. Dziegielewski The diagnosis of either of these disorders requires the symptoms characteristic of the depressive disorders. The three specifiers are recurrent brief depression, short-duration depressive episode, and depressive episode with insufficient symptoms. Difference between the specified and unspecified disorder is that in the specified disorder, the practitioner documents the reason that it does not meet the criteria. © 2014 S. Dziegielewski Premenstrual Dysphonic Disorder Mixed Features Specifier © 2014 S. Dziegielewski Symptoms having to come 2 months after the death of a loved one has been removed. Replaced with: Criteria that helps to distinguish between grief and depression. Recognizes bereavement can be a severe psychosocial stressor that can precipitate a major depressive episode soon after the death of a loved one. © 2014 S. Dziegielewski Each diagnosis in this category allows for ranking of anxiety. Each diagnostic category needs to be addressed for suicide. May include a substance use dimension. © 2014 S. Dziegielewski Each diagnosis in this area (Depressive Disorders, Bipolar Disorders) can have an anxiety component. Each mood disorder diagnosis is accompanied by some type of anxiety dimension. A rating of anxiety should be included from 0 (no anxiety) to 4 (severely anxious with five symptoms and motor agitation). © 2014 S. Dziegielewski Mixed Episode (was replaced with mixed features specifier) Bipolar I Disorder— Single Manic Episode Mood Disorder Not Otherwise Specified © 2014 S. Dziegielewski DSM-5— Ranking Anxiety Levels Each mood disorder diagnosis is accompanied by some type of anxiety dimension. A rating of anxiety should be included from 0 (no anxiety) to 4 (severely anxious with five symptoms and motor agitation). © 2014 S. Dziegielewski * © 2014 S. Dziegielewski How to document in DSM-5 © 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 Differentiating depression from simple sadness. Is it situational? Feeling down because of a specific event, such as losing a job or the breakup of a relationship. Reports feeling sad, despair, teary, or "empty" every day for more than 2 weeks Interferes with other aspects of life © 2014 S. Dziegielewski Avoids leaving the house. Avoids conversation— too much effort. Retreats to bed, and family/others cannot draw out. Losing pleasure in activities. When they have this in treatment plan, work to build a support network. Work with family and support group. © 2014 S. Dziegielewski Remember REM sleep. Does the individual report: Lies awake at night with the mind racing. Sleeps too much to avoid getting out of bed. Speak to your doctor. (Possible light snack before bed) © 2014 S. Dziegielewski Change in attitude with more difficulty handling everyday stresses. Small things make them ‘snap.’ Bicker with friends and family. Easygoing before, agitated or angry outbursts now. © 2014 S. Dziegielewski BEFORE AND AFTER Were they pleasurable before? How long (2 weeks?) has this change been occurring? What is the age of the person? Relationship status? Medications, etc.? © 2014 S. Dziegielewski Chronic headaches and stomachaches Unexplained chest pain or achy legs and arms Aches and pains don't get better with treatment Get physical © 2014 S. Dziegielewski Losing or gaining weight without a change in diet or exercise © 2014 S. Dziegielewski © 2014 S. Dziegielewski © 2014 S. Dziegielewski Complete a comprehensive safety plan with clear documentation. Preventing Harm and Risk—Safety Planning as Standard of Practice © 2014 S. Dziegielewski © 2014 S. Dziegielewski Can you list the primary disorders that constitute the depressive disorders? Can you identify at least two commonalities that disorders in this category share? Can you identify the types of depression and how depression can manifest differently in children? Review PowerPoint slides for the answers! © 2014 S. Dziegielewski What is the bereavement exclusion in DSMIV and DSM-IV-TR? Why did they delete the bereavement exclusion of 2 months from DSM-5? © 2014 S. Dziegielewski Can you convert a DSM-IV-TR diagnosis to a DSM-5? What major factors would you need to take into account? © 2014 S. Dziegielewski