Download DSM-5: Handout Packet # 1 Carlton Munson, PhD

Using DSM-5: A Brief Summary
Handout Packet # 1
Carlton Munson, PhD
Professor
University of Maryland Baltimore
School of Social Work
8/16/2013
Copyright © 2013 Dr. Carlton Munson
1
Disclaimer
DSM and DSM 5 are registered trademarks of the American Psychiatric
Association (APA). The APA is not affiliated with this training and does not
endorses this seminar or its content. Material under APA Copyright in this
presentation is used according to U.S. Copyright Office regulations regarding fair
use (sections 107 through 118 of the copyright law (title 17, U. S. Code. Permission is
NOT granted to participants in this training to copy and distribute the paper copy
handouts used in the presentation.
For further information about APA and the DSM-5 visit the official APA DSM-5
website at www.dsm5.org.
8/16/2013
Copyright © 2013 Dr. Carlton Munson
2
Donald Black & Jon Grant
Name will officially be
DSM-5 Not DSM-V
DSM-5
Collection
August
September
2013
Laura Weiss Alan K.
Roberts
Louie
&
John
Barnhill
Michael
First
8/16/2013
Copyright
© 2013
Dr. Carlton rush
Munsonto publication
Pages
missing
apparent
without thorough proof reading
Philip
Muskin
DSM-5: Online
DSM-5 ON-LINE AVAILABLE FALL September 2013
There will be an on-line DSM-5
DSM-IV-TR version was $490 annually
DSM-5 version $420 annually
“There will be price restructuring related to the product options”
This resource can be helpful for students and others adjusting to
the DSM-5 changes
8/16/2013
Copyright © 2013 Dr. Carlton Munson
4
Licensing Exam Conversion to DSM-5
• Social Work
– LCSW Exam Does not apply to this exam no questions on
DSM there are questions on assessment
– LCSW-C Examination January 2015
– NOTE: In Maryland in October 2013 LGSWs can diagnose
when under supervision of LCSW-C
• Psychologists
– Conversion August 2014
• CPC, CPC-MFT, CAC-AD, & CSC-AD
– No information posted at the ACA or MD BOPC website
–
8/16/2013
Copyright © 2013 Dr. Carlton Munson
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Changes in Social Work Licensing Statute
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OCTOBER 1, 2013 CHANGES IN THE SOCIAL WORK STATUTE § 19-101 Definitions Section
Deleted from the general definition of social work practice:
FORMULATING DIAGNOSTIC IMPRESSIONS
Added to the definition of graduate and certified social work:
FORMULATING A DIAGNOSIS, UNDER THE DIRECT SUPERVISION OF A LICENSED CERTIFIED SOCIAL
WORKER-CLINICAL
Treatment of BIOPSYCHOSOCIAL CONDITIONS
TREATMENT OF mental disorders..............
Added to the definition of clinical social work:
PETITIONING FOR EMERGENCY EVALUATIONS UNDER TITLE 10, SUBTITLE 6 OF THE HEALTHGENERAL ARTICLE
§ 19-307 Scope of license A licensed Bachelor social worker may not ENGAGE IN PRIVATE
PRACTICE
Changed
A licensed Graduate social worker may not diagnose a mental disorder WITHOUT THE DIRECT
SUPERVISION OF A LICENSED CERTIFIED SOCIAL WORKER- CLINICAL
A licensed Graduate social worker may not ENGAGE IN PRIVATE PRACTICE WITHOUT THE DIRECT
SUPERVISION OF A LICENSED CERTIFIED SOCIAL WORKER-CLINICAL
A licensed Certified social worker may not diagnose a mental disorder WITHOUT THE DIRECT
SUPERVISION OF A LICENSED CERTIFIED SOCIAL WORKER- CLINICAL
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Copyright © 2013 Dr. Carlton Munson
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SLIDE KEY
Some material in this presentation is keyed to color and symbols
Text in blue indicates a change for DSM-5
Green indicates my interpretation or a relevant study or information
This symbol represents a change with questionable rationale or
outcome (i.e., no empirical basis)
• This symbol indicates disorder or section new to DSM-5
• Indicates a reading assignment slide
• Most slides have DSM-5 page references and participants who have
DSMs can follow the presentation of the new material and make
notes in the manual
• Some slides in the presentation are not in the handouts due to
copyright restrictions
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Copyright © 2013 Dr. Carlton Munson
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20-365-1,000+
DSM History
16-365-889
Diagnostic
Inflation ?
16-365-886
15-297-482
15-26-482
11-185-92
3-106-132
Coding:
Categories-Disorders-Pages
Research Domain Criteria – RDoC
Thomas Insel on March 06, 2012
-Most genes associated with risk for schizophrenia also contribute to risk for bipolar
disorder and autism.
-RDoC primary focus is neural circuits. Accumulating findings on neural circuitry that
generates behavior is making it possible to use this approach.
-Genes cut across current diagnostic labels and neuroimaging often helps sub-divide
current groups.
-By studying patterns of brain activity either at rest or with activation the brain tell us
different forms of mood, anxiety, or psychotic disorders.
-This is the diagnostic approach in neurology, where imaging is used routinely for
localizing lesions, rather than relying exclusively on motor or sensory changes.
-Current systems see disorders as present or absent. RDoC approach is dimensionalRDoC incorporates magnitude or severity measures, analogous to tests of blood
pressure or cholesterol.
-RDoC will develop administered tests of dimensional information in reliable and valid
ways.
-RDoC framework is a heuristic to facilitate incorporation of behavioral neuroscience in
the study of psychopathology.
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Copyright © 2013 Dr. Carlton Munson
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Mental Illness Context
-In US 50% will have lifetime incidence of a mental disorder
-20-25% met criteria for a mental disorder during any
12-month period
-78% of cases are mild to moderate severity
-22% have significant impairment severity
-75% of all lifetime disorders have onset by age 24
-Conclusion: Interventions should be aimed at young people, but
mental illness increasing in the elderly
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Copyright © 2013 Dr. Carlton Munson
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My General Principles of DSM-5 Diagnostic Criteria
• Clinical Relevance
– Is it necessary or appropriate to assign a DSM-5
diagnosis? (E.g., Avoidant PD)
• Clinical Significance
– Are symptoms/behaviors/problems at a level that
warrants a DSM-5 diagnosis? E.g., (PTSD
diagnosis)
• Clinical Judgment
– Among competing or cross-cutting symptoms
what diagnosis (es) appropriate? (E.g., MDD
and/or Anx. Disorder)
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DSM-5: Definition of a Mental Disorder
See p. 20 for details
DSM-5: A mental disorder is 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. An expectable or culturally approved response
to a common stressor or loss, such as the 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 the dysfunction in the individual, as
described above.
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Copyright © 2013 Dr. Carlton Munson
12
Where have all the flowers gone?
First and foremost, where has the multiaxial format gone?
AXIS I
Axis II
AXIS III
Combined and presented in
Continue to list code, diagnosis
vaguely defined narrative format and medical Conditions
Axis IV Primary Support group
Social Environment
Educational Problem
Occupational Problems
Housing
Economic Problems
Access to healthcare
Problems with the legal system
Other P/S Problems
Axis V
Sent to Other Conditions That May
Be a Focus of Clinical Attention
Listed as “Notations”
section
Converted to severity
Measures in individual
disorders
8/16/2013 11:19:43 AM
3 Basic Types of Specifiers
Specify if:
With anxious distress
Specify current severity
mild, moderate, severe
Specify whether:
314.01 (F90 0.2) Combined presentation:
Copyright © 2013 Dr. Carlton Munson
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P. 16
Nonaxial Assessment
Diagnosis
Good news! It provides
latitude
2
Psychosocia
l
factors now
“notations”
3
Axis 5 now
“disability”
Meaning
severity
4
Medical
Conditions
I now report Dx.
formulation
categories of:
1. Diagnosis
2. Notations
3. Disability Severity
4. Medical conditions
DSM-5:Sections
Section III
Emerging Measures and Models
-Assessment Measures
-Cross-Cutting Symptom Measures
-Clinician-Rated...Psychosis ...Severity
-Cultural Formulation
-Alternative ...Model...for personality
-Conditions for further Study
DSM-5 Classification
-AKA Table of Contents
-Codes & page #s for 20
Categories of disorders
Preface
Section I
DSM-5 Basics
-Introduction
-Use of the Manual
-...Forensic Use of DSM-5
Section II
-Diagnostic Criteria and Codes
-HEART OF THE MANUAL
Note: This information
In a different
format in handout
8/16/2013
Appendices
-Highlights of Changes
-Glossary of Technical Term
-Glossary of Cultural concepts of Distress
-Alphabetic Listings of Diagnoses/Codes
-Numeric Listing of Codes (ICD-9-CM)
-Numeric Listing of Codes (ICD-10-CM)
-DSM-5 Advisors & Contributors
-Index
What is in side DSM-5?
Copyright © 2013 Dr. Carlton Munson
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DSM-5 Organizational Changes: Section II: Essential Elements:
Diagnostic Criteria and Codes
Neurodevelopmental disorders
Schizophrenia spectrum and other psychotic disorders
Begins
Bipolar and related disorders
with
Notice
Depressive disorders
Anxiety disorders
Grouping
Obsessive-compulsive and related disorders
Reordering is “sequential”
Trauma- and stressor-related disorders.
to reflect “attenuated”
Dissociative disorders
(weak) effort to suggest
Somatic symptom and related disorders
dimensional approach to
Feeding and eating disorders
entire manual based on
Elimination disorders
childhood features,
Sleep-wake disorders. Breathing-related sleep disorders. Parasomnias
adult disorders, and the
Sexual dysfunctions
5-Factor Model originally
Gender dysphoria
Disruptive, impulse-control, and conduct disorders
proposed in 2 books
Substance related and addictive disorders
published by APA
Neurocognitive disorders
Ends
Personality disorders
with
Paraphilic disorders
Other mental disorders
Medication-Induced Movement Disorders and Other Adverse Effects of Medication
Z and V Codes
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Copyright © 2013 Dr. Carlton Munson
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DSM-5 Organizational Changes: Section III: Emerging Measures and Models
Cross-cutting measures, Level 1 and Level 2
AREA TO WATCH FOR EBP
Some used in clinical field trials. I will explain them if
you want me to
Assessment Measures
Cultural Formulation
Cultural Formulation Interview (CFI) Separate formats for client
and informant
Replaces Outline for Cultural Formulation and Glossary of
Culture-Bound Syndromes
Alternative DSM-5 Model for Personality Disorders
Conditions for Further Study
I recommend
you ignore
and not use
this section
of DSM-5
Attenuated Psychosis Syndrome
Depressive Episodes With Short-Duration Hypomania
Persistent Complex Bereavement Disorder
Caffeine Use Disorder
Internet Gaming Disorder
Neurobehavioral Disorder Due to Prenatal Alcohol Exposure (ND-PAE)
Suicidal Behavior Disorder
All “Section 3” items new to DSM-5
Nonsuicidal Self-Injury
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Copyright © 2013 Dr. Carlton Munson
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DSM-5 Section: Appendix and Index [pp. 808-947]
Highlights of changes from DSM-IV to DSM-5 (p. 809)
Glossary of technical terms (75 terms in DSM-IV 183 in DSM-5) [p. 817]
Glossary of cultural concepts of distress (25 in DSM-IV 9 in DSM-5) [p. 833]
Alphabetical listing of DSM-5 diagnoses and codes(ICD-9-CM) and ICD-10-CM)
Numerical Listing of DSM-5 diagnoses and codes (ICD-9-CM) [p.863]
Numerical listing of DSM-5 diagnoses and codes (ICD-10-CM) [p.877]
DSM-5 advisors and other contributors [p. 897-916, See
Index [p. 917-947]
I worked hard for
p. 915)that small
recognition
In MH Hx!!!
Index much improved. You will need to use It to master the
8/16/2013
Copyright © 2013 Dr. Carlton Munson
changes
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Where have all the flowers gone?
Where have all disorders gone?
OUT
ICA Disorders
R/O
Rule out
By
Prior
History
Asperger's
Schizophrenia
RELD
Disorder
Subtypes
Substance
Abuse
IN
Global
DMDD Hoarding
DSED
Excoriation
Developmental
Disorder
Delay
PDD
8/16/2013 11:19:43 AM
PTSD
Binge
CHILD
Eating
Criteria Disorder
DMDD = Disruptive Mood Dysregulation Disorder
DSED = Disinhibited social engagement disorder
PDD = Premenstrual Dysphoric Disorder
Copyright © 2003 Dr. Carlton Munson
19
NOTE: In this slide persistent
depressive disorder in depressive
disorders classification used as an
example. Go to the pages indicated as
each icon is explained
Diagnostic Criteria Organization
for the 20 Categories of Disorders
Unspecified
Disorders
DSM
Fundamental
core
Diagnostic
Criteria
Summary
Brief
Introduction
Text
p. 155
8/16/2013
Detailed
Descriptive
Text
p. 183
See following slide
p. 169-171
See following slide
p. 168-169
Other
Specified
Disorders
Essentially Replace
NOS
p. 184
-Disorder capitalization eliminated
-Text section titles right justified
-Number of text sections vary
for some disorders
Copyright © 2013 Dr. Carlton Munson
Some
redundancy
In the
sections
20
Text Accompanying Each DSM-5 Disorder
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Note: Diagnostic Criteria are
At the beginning of the text
and not at the end as in DSM-I
Diagnostic Criteria
Diagnostic Features
Associated Features Supporting Diagnosis
Prevalence
Development And Course
Risk And Prognosis Factors
Culture-Related Diagnostic Issues
Gender-related Diagnostic Issues
Diagnostic Markers
Functional Consequences Of .....
Differential Diagnosis
Comorbidity
8/16/2013
Copyright © 2013 Dr. Carlton Munson
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Orienting to the DSM-5
Read the Sections Below in the Order Recommended
Experienced Users
Beginning Users
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Review Table of Contents
Read Use of the Manual (pp. 19-24)
Review Highlights of Changes From DSM-IV to DSM5 (pp.809-816)
Review Other Conditions That May be a Focus of
Clinical Attention (pp. 715-727)
Review DSM-5 Classification (pp. xiii-xI)
Review the diagnostic criteria and text for disorders
you use most
Review Cultural Formulation (pp. 749-760 &
Glossary of Cultural Concepts of Distress (pp. 833837)
Review Glossary of Technical Terms (pp. 817-831)
Review Assessment Measures (pp.733-748)
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8/16/2013
Review Table of Contents
Read Use of the Manual (pp. 19-24)
Review DSM-5 Classification (pp. xiii-xI)
Review diagnostic criteria and text for
disorders that you plan to use the most
Review closely Glossary of Technical Terms
(pp. 817-831)
Read in detail the text section of the
disorders you begin to use
Review Other Conditions That May be a
Focus of Clinical Attention (pp. 715-727)
Review Cultural Formulation (pp. 749-760 &
Glossary of Cultural Concepts of Distress (pp.
833-837)
Review Assessment Measures (pp.733-748)
Copyright © 2013 Dr. Carlton Munson
22
Persistent Depressive Disorder
pp. 168-169
Persistent Depressive Disorder
300.4 (F34.1)
This disorder is consolidation of DSM-IV chronic major depressive disorder and dysthymic disorder.
A. Depressed mood for most of the day, for more days than not, as indicated by subjective account or observation by others, for at least 2 years
B. Presence, while depressed, of 2 or more of the following:
1.
Poor appetite or overeating
2.
Insomnia or hypersomnia
3.
Low energy or fatigue
4.
Low self-esteem
5.
Poor concentration or difficulty making decisions
6.
Feelings of hopelessness.
C. During a 2-year period (1year for children /adolescents), individual has never been without the symptoms in criterion A and B for more than 2 months at a time.
D. Criteria for a major depressive disorder may be continuously present for 2 years
E. There has never been a manic episode, hypomanic episode, or criteria met for cyclothymic disorder
F. Disturbance not better explained by a persistent schizoaffective and disorder, schizophrenia, etc.
G. The symptoms are not attributable to physiological effects of a substance
H. Symptoms cause clinically significant distress…
Specify if:
With anxious distress
With mixed features
With melancholic features
With atypical features
With pericardium onset
With mood congruent psychotic features
With mood incongruent psychotic features
Specify if:
In partial remission
In full remission
Specify if
Early Onset
Late onset
Refers to separate section of depressive
disorders, Specifiers for Depressive Disorders,
that details specifiers for this class od disorders
Specify If:
With pure dysthymic syndrome
With persistent major depressive episode
With intermittent major depressive episodes with current episode
With intermittent major depressive episodes, without current episode
Specify if current severity:
Mild (p. 188)
Moderate (p. 188)
Severe (p. 188)
How to Record DSM-5 Dx.
A Holiday Dx.
DSM-5
Code
Record disorder or condition
296.23 major depressive disorder, recurrent episode, severe, with seasonal pattern
Course Specifier
Course Specifier
8/16/2013
Copyright © 2013 Dr. Carlton Munson
Specifier
24
...strong presumption full criteria
will ultimately be met for a disorder,
but not enough information available
to make a firm diagnosis...
...Clinician can indicate diagnostic
uncertainty by recording
“(provisional)” following the
diagnosis...
Provisional Diagnosis (p. 23)
Schizophreniform Disorder
295.40 (F20.81)
2+ present sig. portion of time for 1+m of at least 1 must be
1, 2, or 3:
1. Delusions
See. pp. 96-97
2. Hallucinations,
3. Disorganized speech
4. Grossly disorganized or catatonic behavior
5. Negative symptoms
B. Episode 1-m but less than 6m
C. Not other psychotic disorder
D. Not due to substance or other medical condition
Diagnosis
295.90 Schizophreniform, With good prognostic features, mild (provisional)
305.60 Phencyclidine use disorder, severe
Notations
V62.29 Other problem related to employment see p. 723
V15.59 Personal history of self harm
see p. 726
Medical Conditions
No reported medical problems
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Copyright © 2013 Dr. Carlton Munson
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...strong presumption full criteria
will ultimately be met for a disorder,
but not enough information available
to make a firm diagnosis...
...Clinician can indicate diagnostic
uncertainty by recording
“(provisional)” following the
diagnosis...
Provisional Diagnosis (p. 23)
Schizophreniform Disorder
295.40 (F20.81)
2+ present sig. portion of time for 1+m of at least 1 must be
1, 2, or 3:
1. Delusions
See. pp. 96-97
2. Hallucinations,
3. Disorganized speech
4. Grossly disorganized or catatonic behavior
5. Negative symptoms
B. Episode 1-m but less than 6m
C. Not other psychotic disorder
D. Not due to substance or other medical condition
Diagnosis
295.90 Schizophreniform, With good prognostic features, mild (provisional)
305.60 Phencyclidine use disorder, severe
Notations
V62.29 Other problem related to employment see p. 723
V15.59 Personal history of self harm
see p. 726
Medical Conditions
No reported medical problems
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Copyright © 2013 Dr. Carlton Munson
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DSM-5 Cultural Formulation and Concepts of Distress
Cultural Formulation
pp. 749-759
Outline for Cultural Formulation
-Cultural identity of the individual
-Cultural conceptualization of distress
-Psychosocial stressors & cultural features of vulnerability
& resilience
-Cultural features of relationship of individual & clinician
-Overall cultural assessment
Cultural Formulation Interview (CFI)
-16 questions may use about impact of culture in areas of:
-perceptions of cause, context, support
-Self-coping & past help seeking
-Current help seeking
-Supplement modules: www.psychiatry.org/dsm5
-Used with other received information
-Used in entirety or selective
-Client and informant versions
8/16/2013
Glossary of Cultural Concepts of Distress
pp. 833-837
Blue text indicates new to DSM-5
Ataque de nervios
Dhat syndrome
Khyal cap
Kufugisisa
Maladi noun
Nervios
Shenjing Shuairuo
Susto
Taijin Kyofusho
Copyright © 2013 Dr. Carlton Munson
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Neurodevelopmental Disorders
Intellectual Disabilities
Intellectual Disability (Intellectual Developmental Disorder)
Global Developmental Delay
Unspecified Intellectual Disability (Intellectual Developmental Disorder)
Communication Disorders
Language Disorder
Speech Sound Disorder (previously Phonological Disorder)
Childhood Onset Fluency Disorder (Stuttering)
Social (Pragmatic) Communication Disorder
Unspecified Communication Disorder
Autism Spectrum Disorder
Autism Spectrum Disorder
Attention-Deficit/Hyperactivity Disorder
Attention-Deficit/Hyperactivity Disorder
Other Specified Attention-Deficit/Hyperactivity Disorder
Unspecified Attention-Deficit/Hyperactivity Disorder
Specific Learning Disorder
Specific Learning Disorder
Motor Disorders
Developmental Coordination Disorder
Stereotypic Movement Disorder
Tic Disorders
Tourette’s Disorder
Persistent (Chronic) Motor or Vocal Tic Disorder
Provisional Tic Disorder
Other Specified Tic Disorder
Unspecified Specified Tic Disorder
Other Neurodevelopmental Disorders
Other Specified Neurodevelopmental Disorder
Unspecified Neurodevelopmental Disorder
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Copyright © 2013 Dr. Carlton Munson
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Intellectual Disabilities
Intellectual Disability
(Intellectual Developmental Disorder)
Diagnostic Criteria
Intellectual disability (intellectual developmental disorder) is a disorder with onset during
the developmental period that includes both intellectual and adaptive functioning deficits
in conceptual, social and practical domains. The following three criteria must be met :
A: Deficits in intellectual functioning confirmed by both clinical assessment and intelligence testing.
B: Deficits in adaptive functioning with failure to meet developmental & sociocultural standards
for personal independence and social responsibility.
W/O support adaptive deficits limit functioning in 1 or more areas of: Communication, social
participation, & independent living across environments (home, school, work, & Community)
* Specify current severity (see Table 1): 317 318.0 318.1 318.2
(F70) Mild (F71) Moderate (F72) Severe (F73) Profound
C: Onset of intellectual and adaptive deficits during the developmental period
(childhood or adolescence)
Coding note: ICD-9-CM code for ID is 319, which
specifier
Specify current severity (see Table 1):
(F70) Mild
(F71 )Moderate
(F72) Severe
(F73) Profound
is assigned regardless of severity
Note the layout difference
Disorder name to far right
Coding is a note and not at the head
of the disorder title
This format varies for some disorders
Sample Dx.
Necessitated by removal of
“Prior History ”specifier
(diagnosis) DSM-IV, p. 2
DIAGNOSIS
Koma Smith reportedly has had two episodes of mental health treatment and
mental health diagnosis in the past. Koma cannot remember the Dx. received and
cannot remember the physician’s name or the hospital name. Based on the clinical
interview, scales administered and collateral information, the following diagnoses
were made as part of this assessment:
317, Intellectual developmental disorder, Moderate
V61.8 high expressed emotion level within family
V15.41 Personal history (past history) of spouse violence, Physical
V61.20 Parent-child relational problem
V60.1 Inadequate housing
V60.2 Low income
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Copyright © 2013 Dr. Carlton Munson
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Another Sample DSM-5 Diagnosis
Based on my evaluation the following is my DSM-5 diagnostic
formulation:
Diagnoses
-317 Intellectual Disability (Intellectual Developmental disability), Mild
Notations
-V61.20 Parent-Child Relational Problem
-Unspecified Bipolar Disorder by prior diagnosis that may be controlled
with medication
-309.81 PTSD by prior diagnosis current symptom level not clear due to
client guarded reporting
Disability Severity
-This woman’s diagnoses are of a magnitude that impairs ability to
parent children
Medical Conditions
-Patient reported only medical condition as asthma
Neurodevelopmental Disorders
Global Developmental Delay
315.8 (F88)
...Reserved for individuals under age 5 years when clinical severity level cannot be assessed
during early childhood .Dx. when individual fails to meet expected developmental milestones
in several areas of intellectual functioning, and child is not able to undergo standardized
testing. Requires periodic reassessment
Unspecified Intellectual Disability
(Intellectual Developmental
disorder)
319 (F79)
...Reserved for individuals over age 5 when assessment of ID (IDD) by
locally available procedures or difficult or impossible due to sensory or
physical impairments, as in blindness or pre-lingual deafness; locomotor
disability; or presence of severe problem behaviors or co-occurring mental
disorder. Used only in exceptional circumstances. Requires periodic
reassessment
Other Neurodevelopmental Disorders
Global Developmental Delay
315.8 (F88)
...Reserved for individuals under age 5 years when clinical severity level cannot be assessed
during early childhood .Dx. when individual fails to meet expected developmental milestones
in several areas of intellectual functioning, and child is not able to undergo standardized
testing. Requires periodic reassessment
Note change. Coding is
under disorder heading
Unspecified Intellectual Disability
(Intellectual Developmental
disorder)
319 (F79)
...Reserved for individuals over age 5 when assessment of ID (IDD) by
locally available procedures or difficult or impossible due to sensory or
physical impairments, as in blindness or pre-lingual deafness; locomotor
disability; or presence of severe problem behaviors or co-occurring mental
disorder. Used only in exceptional circumstances. Requires periodic
reassessment
Intellectual Disability (Intellectual Developmental Disorder)
was Mental Retardation in DSM-IV
cA: Deficits in reasoning, problem-solving, planning,
abstract thinking, judgment, academic & experience
learning
Confirmed by clinical assessment & standardized testing
Severity criteria:
•
•
•
•
319
319
319
319
Mild
Moderate
Severe
Profound
(IQ 50-70)
(IQ 35-55)
(IQ 20-40)
(IQ <25)
cB: Sig. Limitations in adaptive functioning in 2 skill
areas of: Communication / Social participation /
independent living at home, school, work, & community
cC: Onset during developmental period
Note: Borderline
Intellectual
Functioning in
OCTMBFCA
p. 727
Generally IQ 70-85 but not
specified in DSM-5
Measured by
Clinical
assessment
and
standardized
measures like
Vineland
ABS & AAIDD
ABS
Intellectual Disability in Maryland DDA
2 levels of eligibility for funded services
1. Developmental Disability
• Severe, chronic disability that :
– Attributable to physical/mental
impairment, other than Dx of MI
or combo of mental/physical
impairment
– Likely to continue indefinitely
– Inability to live independently
– Intellectual Developmental
Disorder
8/16/2013
2. Support Services Only
• Eligibility for person with
severe, chronic, disability
that:
– Attributable to
physical/mental impairment
other than sole Dx. of MI, or
combo of mental/physical
impairment, and
– Is likely to continue
indefinitely
– Intellectual Disability
Copyright © 2013 Dr. Carlton Munson
36
Communication Disorders
pp. 41-49
Used to Dx. RELDs
315.39 (F80.9) Language Disorder
In DSM-IV
315.39 (F80.0) Speech Sound Disorder
315.35 (F80.81) Childhood-Onset Fluency Disorder
315.39 (F80.89) Social (Pragmatic) Communication Disorder
307.9 (F80.9) Unspecified Communication Disorder
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Copyright © 2013 Dr. Carlton Munson
37
Neurodevelopmental Disorders
pp. 50-59
Autism Spectrum Disorder
299.00 (F84.0)
A. Persistent deficits in social communication and social interaction across
multiple contexts, as manifested by the following, currently or by history
(examples are illustrative, not exhaustive see text):
1. Deficits in social emotional reciprocity
2. Deficits in nonverbal communication behaviors used for social interaction...
3. Deficits in developing, maintaining, and understanding relationships...
Specify current severity:
Severity is based on social communication impairments and restricted,
repetitive patterns of behavior (see table 2).
DSM-5 allows adult Dx. by noting symptoms may not be apparent until adolescence or
adulthood. Severity scale may substantiate need for supportive employment and
accommodations in the workplace
ASD Continued
B. Restricted, repetitive patterns of behavior, interests, or activities, as manifested
by at least 2 of the following...
1. Stereotyped or repetitive motor movements, use of objects, or speech...
2. Insistence on sameness, inflexible adherence to routines, or ritualized
patterns of verbal or nonverbal behavior...
3. Highly restricted, fixated interest that are abnormal in intensity or focus
4. Hyper-or hyporactivity to sensory input or unusual interest in sensory aspects
of the environment...
Specify current severity...(See severity specification in cA above)
C. Symptoms must be present in the early developmental period
D. symptoms cause clinically significant impairment in social occupational or other
important areas of current functioning
E. These disturbances are not better explained by intellectual disability (intellectual
developmental disorder) or global developmental delay
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Copyright © 2013 Dr. Carlton Munson
39
ASD Continued
Specify if:
With or without accompanying intellectual impairment
With or without accompanying language impairment
Associated with any known medical or genetic condition or
environmental factor (Coding note: Use additional code to identify
associated medical or genetic condition.)
Associated with another neurodevelopmental, mental, or behavioral
disorder (Coding note: Use additional codes to identify the associated
neurodevelopmental, mental, or behavioral disorder.)
With catatonia (refer to criteria for catatonia associated with another
mental disorder, pp. 119-120 for definition (Coding note: Use
additional code 293. 89 (F06.1) catatonia associated with autism
spectrum disorder to indicate presence of comorbid catatonia
8/16/2013
Copyright © 2013 Dr. Carlton Munson
40
DSM-5: “Severity scale” Descriptive of ASD ADLs.
3 point severity level:
LEVEL 3 “Requiring very substantial support”
Level 2 “Requiring substantial support”
Level 1 “Requiring support”
Note: Need for support defined separately for social communication deficits and
restricted interests and repetitive behaviors
An individual may be a Level 3 for social communication, and level 2 for
repetitive behaviors which need only a moderate level of support
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Copyright © 2013 Dr. Carlton Munson
41
DSM-5: Autism Spectrum Disorder
pp. 50-59
Severity of impairment in areas of development:
Level 1
Reciprocal
social
interaction
skills
SLIDER
BUTTON
Level 1
Level 2
Reciprocal
social
interaction
skills
Level 2
Level 3
Reciprocal
social
interaction
skills
Level 3
Communication
skills
Level 1
Communication
skills
Level 2
Communication
skills
Level 3
Restricted: Behavior
“RRBs”
Interests
Activities
Restricted: Behavior
“RRBs” Interests
Activities
Restricted: Behavior
“RRBs” Interests
Activities
DSM-5: Autism Spectrum Disorder (ASD) Alternative Diagnoses
• Some who no longer meet criteria for ASD in
DSM-5 may meet criteria for other DSM-5
diagnoses, including:
– Intellectual Disability
– Communication Disorder
– Anxiety Disorders, and/or
– Attention Deficit/Hyperactivity Disorder
– This position of APA and not this presenter
8/16/2013
Copyright © 2013 Dr. Carlton Munson
43
DSM-5 ADHD
ADHD Criteria
Fewer symptoms for adult
ADHD. Research: Symptoms<
w age, but remain- Adult 5 Sx
after age 17 Children 6 Sx
Combined
Addition of ADHD
other & Unspecified
Before
age 12
Subtypes
Become
Specifiers
24%
increase
in ADHD
Dx. from
2001
To 2010
Increase
from 3%
to 10%
of
population
“In partial
remission”
added
Attention-Deficit /Hyperactivity Disorder: Slide 1
“Sx.”= symptom (s)
“SOA”= Social, academic, occupational
pp. 59-66
Attention-Deficit /Hyperactivity Disorder
Diagnostic Criteria
A. Persistent Sx. of inattention and /or hyperactivity impulsivity interfering with functioning
or development characterized by 1 and/or 2:
1. Inattention: 6+ of following Sx. for 6+ months inconsistent with developmental level
and negatively impacts directly SAO activities:
Note: Sx. not part of oppositional behavior, defiance, hostility or failure to understand
tasks or instructions. For older adolescents and adults (age 17+), 5+ symptoms required.
a. Often lacks close attention to details or makes careless mistakes.
b. Often has difficulty sustaining attention in tasks or play activities.
c. Often does not seem to listen when spoken to directly.
d. Often does not follow through on instructions and fails to finish schoolwork, chores,
or duties in the workplace.
e. Often has difficulty organizing tasks and activities.
f. Often avoids, dislikes, reluctant to engage in tasks requiring sustained mental effort.
g. Often loses things necessary for tasks or activities.
h. Is often easily distracted by extraneous stimuli.
i. Is often forgetful in daily activities.
8/16/2013
Copyright © 2013 Dr. Carlton Munson
45
Attention-Deficit /Hyperactivity Disorder: Slide 2
pp. 59-66
Attention-Deficit /Hyperactivity Disorder
Diagnostic Criteria
2. Hyperactivity and impulsivity: 6+ of the following Sx. for 6+ months to a degree
inconsistent with the developmental level and negatively impacts SOA activities:
a. Often fidgets with or taps hands or feet or squirms in seat.
b. Often leaves seat in situations when remaining seated is expected.
c. Often runs about or climbs in situations where it is inappropriate.
(Note: Adolescence or adults, may be limited to feeling restless).
d. Is often “on the go,” acting as if “driven by a motor.”
f. Often talks excessively.
g. Often blurts out an answer before a question has been completed.
h. Often has difficulty waiting his or her turn.
i. Often interrupts or intrudes on others.
B. Several inattentive or hyperactive impulsive Sx. present prior to age 12.
C. Several inattentive or hyperactive impulsive symptoms present 2+ settings.
D. Evidence Sx. Interfere with or reduce quality of SAO functioning.
E. Sx. do not occur exclusively during schizophrenia or other psychotic disorder and not
better explained by another mental disorder.
8/16/2013
Copyright © 2013 Dr. Carlton Munson
46
Attention-Deficit /Hyperactivity Disorder: Slide 3
pp. 59-66
Attention-Deficit /Hyperactivity Disorder
Diagnostic Criteria
Specify whether:
314.01 (F90 0.2) Combined presentation: If both criteria A1 and criteria A2 are met for past
6 months.
314.00 (F90 0.0) Predominantly inattentive presentation: If criteria A1 is met, but criteria A2
is not met for the past 6 months.
314.01 (F90 0.1) Predominantly hyperactive/impulsive presentation: If criteria A2 is met
and A1 is not met for the past 6 months.
Specify if:
In partial remission: Full criteria were previously met, fewer than full criteria have been met
for the past 6 months and Sx. still resulting in impairment in SAO functioning.
Specify current severity:
Mild: Few, if, any symptoms, present and symptoms resulting in no more than minor
impairments in SAO functioning.
Moderate: Sx. or functional impairment between “mild” and “severe” are present.
Severe: Many Sx. in excess of those required to make diagnosis, or several Sx. are particularly
severe, are present or the Sx. result in marked impairment in SAO functioning.
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Copyright © 2013 Dr. Carlton Munson
47
Attention-Deficit /Hyperactivity Disorder: Slide 4
pp. 59-66
Attention-Deficit /Hyperactivity Disorder
Sample diagnoses:
314.01 Attention-Deficit /Hyperactivity Disorder, Combined presentation,
moderate.
314.00 Attention-Deficit /Hyperactivity Disorder, Predominantly
inattentive presentation, mild, in partial remission.
314.01 Predominantly hyperactive/impulsive presentation, severe.
48
314.01 Attention-Deficit
/Hyperactivity Disorder, Combined presentation,
Severe, in partial remission.
Also note possible use of:
314.01 Other Specified Attention-Deficit/hyperactivity Disorder, child has
symptoms in one setting, home, but no other settings. (See cC)
314.01 Unspecified Attention-Deficit/hyperactivity Disorder due to lack of
information from the school and parent reluctance to have child
medicated.
8/16/2013
Copyright © 2013 Dr. Carlton Munson
Neurodevelopmental Disorders
Specific Learning Disorder
314.01 (F90.9)
A. Difficulties Learning and using academic skills, indicated by presence of 1+ of
the following symptoms that have persisted for 6 months despite intervention:
1. Inaccurate or slow and effortful word reading...
RECEPTIVE EXPRESSIVE LANGUAGE
(RELD)
2. Difficulty understanding the meaning of what is read... DISORDER
76% OF CHILDREN WHO HAVE
EXPERIENCED TRAUMA MEET RELD
3. Difficulties with spelling...
DX. CRITERIA
4. Difficulties with written expression...
5. Difficulties mastering number sense, number facts, or calculation...
6. Difficulty with mathematical reasoning
B. Affected academic skills are substantially below those expected for the
individual’s chronological age
C. Learning difficulties begin in during school age years....
See DSM-5 for specifier categories (p.67)
DSM-5: Motor Disorders & Tic Disorder pp. 74-86
The following motor disorders are included in DSM-5
neurodevelopmental disorders chapter:
Motor Disorders
Developmental Coordination Disorder
Stereotypic Movement Disorder
Tic Disorders
Tourette’s Disorder
Persistent (Chronic) Motor Or Vocal Tic Disorder
Provisional Tic Disorder
Other Specified Tic Disorder
Unspecified Tic Disorder
.
8/16/2013
Copyright © 2013 Dr. Carlton Munson
50
DSM-5: Schizophrenia Spectrum and Other Psychotic Disorders
Schizotypal Personality Disorder (New Strategy of dual listing)
Delusional Disorder
DSM-4
Brief Psychotic Disorder
subtypes
Schizophreniform Disorder
eliminated
Schizophrenia
Schizoaffective Disorder
Substance/Medication-Induced Psychotic Disorder
Psychotic Disorder Due to Another Medical Condition
Catatonia Associated With Another Mental Disorder (Catatonia Specifier)
Shared Psychotic Disorder deleted?
Catatonic Disorder Due to Another Medical Condition Unspecified Catatonia
Other Specified Schizophrenia Spectrum and Other Psychotic Disorder
Unspecified Schizophrenia Spectrum and Other Psychotic Disorder
8/16/2013
Copyright © 2013 Dr. Carlton Munson
51
DSM-5 Schizophrenia Spectrum and Other Psychotic Disorders pp. 87-122
Delusional Disorder
297.1 (F22)
A.
B.
Schizophrenia
295.90
Delusions for 1+ months
cA for Schizophrenia never met
Brief Psychotic Disorder
298.8 (F23)
cA. 1+ of 1 must 1, 2, or 3:
1. Delusions,
2. Hallucinations
3. Disorganized speech & behavior
B. For 1 day but less than 1 month
4. Grossly disorganized or catatonic behavior
A. Same as Schizophreniform Disorder
B. Failure to achieve expected levels of
functioning
C. 6m+ duration...
Schizophreniform Disorder
295.40 (F20.81)
2+ present sig. portion of time for 1+m of at least 1 must be
1, 2, or 3:
1. Delusions
2. Hallucinations,
3. Disorganized speech
Eliminated
4. Grossly disorganized or catatonic behavior
b/o low
5. Negative symptoms
reliability
B. Episode 1 m but less than 6 m
poor
C. Not other psychotic disorder
validity
D. Not due to substance or other medical condition
Suicide risk in all
Schizophrenia phases
Prodromal refers to
early
Psychotic Ds rare in children. Onset in early
20’s for males late 20a for females. Prev
DSM-5 Schizophrenia Spectrum and Other Psychotic Disorders pp. 87-122
Delusional Disorder
297.1 (F22)
A.
B.
Schizophrenia
295.90
Delusions for 1+ months
cA for Schizophrenia never met
Brief Psychotic Disorder
298.8 (F23)
A. 1+ of 1 must 1, 2, or 3:
1. Delusions,
2. Hallucinations
3. Disorganized speech & behavior
B. For 1 day but less than 1 month
4. Grossly disorganized or catatonic behavior
A. Same as Schizophreniform Disorder
B. Failure to achieve expected levels of
functioning
C. 6m+ duration...
Attenuated Psychosis Syndrome
Proposed criteria
A. 1+ present in attenuated form with relatively intact reality
testing and is of severity to warrant clinical attention:
1. Delusions
2. Hallucinations,
3. Disorganized speech
B. Symptoms present 1+ week for past month
C. Symptoms begum or worsened in past year
D. Symptoms distressing at level requiring clinical attention
E. Not due to another mental disorder
See pp. 783-786
F. Criteria for psychotic never met
Schizophrenia & Other Psychotic Disorders
• 295.70 Schizoaffective Disorder
• 297.1 Delusional Disorder
– Delusions for 1 month
Change to a
longitudinal
diagnosis
Removed
nonbizarre
distinction
• 297.3 Shared Psychotic Disorder (Folie a Deux)
•
Deleted as separate
diagnosis and and
making it as specifier
for delusional dsrd
293.xx Psychotic Disorder Due to GMC
–
293.81 With Delusions
– 293.82 With Hallucinations
• Substance-Induced Psychotic Disorder (Use specific substance
coding, see p. 343)
– Clarifies distinction of substance-induced psychotic Dsrd and other psychotic w
Dsrd comorbid substance use
• 298.9.9 Psychotic Disorder NOS
NEC
Diagnostic Recording Example
See pp. 743-745
Schizoaffective Disorder (pp. 105-106)
Nutshell Criteria
cA. Schizophrenia cA
2+ 1m delusions, hallucinations
Disorganized speech
Gross disorganized or catatonic
Behavior
Negative Sx.
With mood episode cA1
(Major depressive or manic)
Present
cB. Delusion or hallucinations 2+
Weeks absent mood episode
cC. Mood Sx. present in active &
residual phase
cD. Not due to substances
Clinician-Rated Dimensions
of Psychosis Symptoms Survey
Necessitated by
removal of
Axis 5 GAF <20
8/16/2013
295.70 Schizoaffective disorder, depressive type,
multiple episodes, currently in acute episode,
delusions present & severe (4), negative symptoms
present & moderate (3), depression, present & severe
(4). IP has at least three prior episodes of illness
with OP Tx and 3 hospitalizations. IP is not
currently threat to others, but is threat to self with
suicidal thoughts including consideration of
suicide methods V62.4 Social exclusion & rejection.
Rx. = Hospitalization
p. 106, “Dx. can be made w/o using this specifier”
so the alternative Dx recording is:
295.70 Schizoaffective disorder, depressive type,
multiple episodes, currently in acute episode
IP has at least three prior episodes of illness with OP
Tx and 3 hospitalizations. IP is not currently threat
to others, but is threat to self with suicidal thoughts
including consideration of suicide methods. V62.4
Social exclusion & rejection. Rx. = Hospitalization
Copyright © 2013 Dr. Carlton Munson
See pp. 724
55
DSM-5: Bipolar and Related Disorders
Bipolar I Disorder
Bipolar II Disorder
cA for manic and hypomanic episodes now includes
emphasis on changes in activity and energy as well as mood.
NEW
SECTION
A specifier added for anxious distress identifies
anxiety symptoms not part of bipolar diagnostic
criteria
Cyclothymic Disorder
Substance/Medication-Induced Bipolar and Related Disorder
Bipolar and Related Disorder Due to Another Medical Condition
Other Specified Bipolar and Related Disorder
Unspecified Bipolar and Related Disorder
Bipolar I Dsrd, mixed episode requiring individual meeting full criteria for both
mania & depressive episode removed & specifier, “with mixed features,” added
& can be applied to episodes of mania or hypomania when depressive features
present
8/16/2013
Copyright © 2013 Dr. Carlton Munson
56
Bipolar I Disorder
pp. 123-127
Bipolar I Disorder
Coding in text section
For diagnosis of bipolar I disorder, it is necessary to meet the following criteria for a manic episode. The manic episode
may have been preceded by and may be followed by hypomanic or major depressive episodes.
Manic Episode
A. A distinct period of abnormality and persistently elevated, expansive, or irritable mood and abnormally and
persistently increased goal directed activity or energy lasting at least 1 week and present most of the day…(or any
duration if hospitalization is necessary).
B. During the period of mood disturbance and increased energy activity 3 or more of the following symptoms (4 if the
mood is only irritable) are present to a significant degree and represent and noticeable change from usual behavior:
See list of 7 symptoms in DSM 5
C. Mood disturbance is sufficiently severe to cause marked impairment in social or occupational functioning or to
necessitate hospitalization to prevent harm to self or others, or there are or psychotic features.
D. the episode is not attributable to the physiological effects of a substance
Major Depressive Episode
A. 5 (or more) of the following symptoms have been present during the same 2-week period and represent a change
from previously functioning; at least 1of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure:
See list of 9 symptoms in DSM-5
Specify; With anxious distress
With Mixed Features
With rapid cycling 4 mood episodes in 12 months
With melancholic features
With peripartum onset
With catatonia
With atypical features
With catatonia
With seasonal pattern
With mood congruent psychotic features
With mood incongruent psychotic features
Bipolar II Disorder
pp. 132-135
Bipolar I Disorder
296.89 (F31.81)
For diagnosis of bipolar II disorder, it is necessary to meet the following criteria for a current or past hypomanic
episode and the following criteria for a current or past major depressive episode:
Hypomanic Episode
A. A distinct period of abnormality and persistently elevated, expansive, or irritable mood and abnormally and
persistently increased goal directed activity or energy lasting at least 4 consecutive days and present most of the
day, nearly every day.
B. During the period of mood disturbance and increased energy activity 3 or more of the following symptoms (4 if the
mood is only irritable), represent and noticeable change from usual behavior and have been present to a noticeable
degree:
See list of 7 symptoms in DSM 5
C. The episode is associated with an unequivocal change in functioning that is uncharacteristic of the individual when
not symptomatic
D. The disturbance in mood and the change in functioning are observable by others.
E. The episode is not severe enough to cause marked impairment in social or occupational functioning or to necessitate
hospitalization. If there are psychotic features, the episode is by definition manic.
F. The episode is not attributable to the physiological effects of a substance
Major Depressive Episode
A. 5 (or more) of the following symptoms have been present during the same 2-week period and represent a change
from previously functioning; at least 1of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure:
See list of 9 symptoms in DSM-5
See specifiers on pp. 134-135 they are slightly different than specifiers for BPI
DSM-5: Depressive Disorders
In DSM-4 Mood Disorders section
Disruptive Mood Dysregulation Disorder
Most likely extensive
specifiers survived
Major Depressive Disorder, Single and Recurrent Episodes
Persistent Depressive Disorder (Dysthymia)
A specifier added for anxious distress
identifies anxiety symptoms not part of
depressive Dsrd diagnostic criteria
Premenstrual Dysphoric Disorder
Substance/Medication-Induced Depressive Disorder
Depressive Disorder Due to Another Medical Condition
Other Specified Depressive Disorder
Unspecified Depressive Disorder
8/16/2013
Copyright © 2013 Dr. Carlton Munson
Depression &
Affective
Disorders
Association
DRADA
59
Disruptive Mood Dysregulation Disorder
pp. 156-160
Disruptive Mood Dysregulation Disorder
296.99 (F34.8)
A. Severe recurrent temper outbursts manifested verbally and or behaviorally toward people or property
that are grossly out of proportion in intensity or duration to the situation or provocation.
B. The temper outburst are inconsistent with developmental level.
C. The temper outbursts occur, on average, 3 or more times per week
D. Mood between temper outburst is persistently irritable or angry most of the day nearly every day, and is
observable by others.
E. Criteria A-D present for 12+ months with no more than 3 consecutive months without the symptoms
F. Criteria A. and D. are present in at least 2 of 3 settings
G. The diagnosis should not be made for the first time before age 6 or after age 18
H. By history or observation, the age at onset of criterion A-E is before age 10
I. Never been a distinct period lasting more than 1day during which the full symptom criteria, except
duration, for a manic or hypomanic episodes have been met. See not in DSM-5 p. 156.
J. Behaviors do not occur exclusively during an episode of major depressive disorder and not explained by
another disorder.
K. Symptoms not attributable to physiological effects of substance or other medical/neurological condition
Doing a Major Depressive Disorder Diagnosis
3
Select
Coding
Recording
Procedures
p. 162
2
Review
Diagnostic
Criteria
pp. 160-161
1
Review
Descriptive
Text
pp. 162-168
8/16/2013
“In recording the name of a Dx. , terms should be listed in
following order: major depressive disorder, single or
recurrent episode, severity /psychotic/remission specifiers,
followed by as many of specifiers w/o codes that apply.”
Select Code
From
Coding
Table
Diagnostic
Criteria
p. 162
4
5
Select
Specifier
From
Specifier
List
p. 162
6
Consult
Specifiers for
Depressive
Disorders
pp. 184-188
Captured from
text coding
table
296.31 major depressive disorder, recurrent episode, Mild, with
anxious distress, mild
Copyright © 2013 Dr. Carlton Munson
61
Major Depressive Disorder
pp. 160-162
Major Depressive Disorder
Coding in text section
A. 5+ of following symptoms present during the same 2-week period and represent change from previous
functioning. At least 1 of the symptoms is either (1) depressed mood or (2) loss of interest in pleasure.
1. Depressed mood most of the day, nearly everyday, as he indicated by subjective report or observation
made by others (Note: In children and adolescents can be irritable mood).
2. Markedly diminished interest or pleasure in all or almost all, activities most of the day, nearly every day.
3. Significant weight loss when not dieting or weight gain (note: In children,… failure expected weight gain)
4. Insomnia or hypersomnia nearly every day.
5. Psychomotor agitation or retardation nearly every day.
6. Fatigue or loss of energy nearly every day.
7. Feelings of worthlessness or excessive or inappropriate guilt.
8. Diminished ability to think or concentrate, or indecisiveness, nearly every day.
9. Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or
a suicide attempt or a specific plan for committing suicide.
B. Symptoms cause clinically significant distress or impairment in social occupational or other important
areas of functioning.
C. Episode is not attributable to the physiological effects of the substance or to another medical condition.
D. … not better explained by schizoaffective disorder, schizophrenia, schizophreniform disorder ….
E. There is never been a manic episode or hypomanic episode
Major Depressive Disorder
pp. 160-162
Major Depressive Disorder
Coding and Recording Procedures
The diagnostic codes for major depressive disorder is based on whether this is a single or recurrent episode, current
severity, presence of psychotic features, and remission status. Current severity and psychotic features are only
indicated if full criteria are currently met for a major depressive episode. Remission specifiers are only indicated if the
full criteria Are not currently met for a major depressive episode. Codes are as follows:
Severity/course specifiers
Single episode
Recurrent episode*
Mild (p. 188)
Moderate (p. 188)
Severe (p.188)
With psychotic features** (p. 186)
In partial remission (p.188)
In full remission (PA. 188)
Unspecified
296.21 (F32.0)
296.22 (F32.1)
296.23 (F32.2)
296.24 (F32.3)
296.25 (F32.4)
296.26 (F32.5)
296.20 (F32.9)
296.31 (F. 33.0)
296.32 (F33.1)
296.33 (F33.2)
296.34 (F33.3)
296.35 (F33.41)
296.36 (F33.42)
296.30. (F33.9)
See
Explanatory
section,
Specifiers
for Depressive
Disorders, for
depressive
disorders
*For an episode to be considered recurrent, there must be an interval of at least 2 consecutive months between
separate episodes in which criteria are not met for a major depressive episode. The definitions of the specifiers are
found on the indicated pages.
**If psychotic features are present code the “with psychotic features” specifier irrespective of episode severity.
In recording the name of a diagnosis, terms should be listed in the following order major depressive disorder, single or
recurrent episode, severity/psychotic/remission specifier, followed by as many of the following specifiers or without
codes that apply to the current episode.( see p.162 for the specifiers list).
Sample Dx.
DIAGNOSIS
Mr. Jones reported he has never received a mental health diagnosis in the past.
Based on the clinical interview, scales administered and collateral information, the
following diagnoses were made as part of this evaluation.
296.31 major depressive disorder, recurrent episode, Mild, with anxious distress,
mild
312.31Gambling Disorder, episodic, mild
V61.8 high expressed emotion level within family
V60.2 insufficient social insurance or welfare support
Back injury with significant pain associated with ATV accident in 2009.
8/16/2013
Copyright © 2013 Dr. Carlton Munson
64
Major Depressive Disorder Bereavement Note
pp. 160-162
Major Depressive Disorder
Note: In distinguishing grief from a major depressive episode (MDE) it is useful to consider
that in grief the predominant affect is feelings of emptiness and loss, while in MDE it is
persistent depressed mood and the inability to anticipate happiness or pleasure. The
dysphoria and grief is likely to decrease in intensity over days to weeks and occurs in waves,
the so-called pains of grief. These waves tend to be associated with lots or reminders of the
deceased. The depressed mood of MDE is more persistent and not tied to specific thoughts
or preoccupations. The pain of grief may be accompanied by positive emotions and humor
that are uncharacteristic of the pervasive unhappiness and misery characteristic of MDE. The
thought content associated with grief generally features a preoccupation with thoughts and
self esteem is generally preserved whereas in MDE feelings of worthlessness and self loathing
are common. If self derogatory ideation is present in grief, it typically involves perceived
failings vis-a-vis the deceased (e.g., not visiting frequently enough, not telling the deceased
how much he or she was loved). If a bereaved individual thinks about death and dying, such
thoughts are generally focused on the deceased and possibly about “mourning” the
deceased, whereas in MDE such thoughts are focused on ending one's own life because of
feeling worthless, undeserving of life, or unable to cope with the pain of depression.
:
Bereavement and Major Depressive Episode Symptoms Compared
p.161
• BEREAVEMENT
• MAJOR DEPRESSIVE EPISODE (MDE)
•
•
•
•
•
•
•
•
1.Feelings of emptiness and loss
2.Dysphoria gradual decrease with waves
of grief about the loved one
3. Grief accompanied by positive
emotions and humor about loved one
4. Preoccupied thoughts & self-esteem
preserved
5. Self derogatory of failing deceased
while alive
6. Death/dying thoughts focused on the
deceased and possibly about “mourning”
the deceased, whereas in MDE such
8/16/2013
•
•
•
•
1. Inability to anticipate happiness & pleasure
2. Pain persistent and not tied to specific
thoughts or preoccupations
3. Unfocused and pervasive unhappiness and
misery
4. Feelings of worthlessness in general w/o
self esteem
5. General self loathing of self w/o cause or
explanation
6. thoughts are focused on ending one's own
life b/o of worthless, undeserving of life, or
pain of depression
Copyright © 2013 Dr. Carlton Munson
66
Persistent Depressive Disorder
pp. 168-169
Persistent Depressive Disorder
300.4 (F34.1)
This disorder is consolidation of DSM-IV chronic major depressive disorder and dysthymic disorder.
A. Depressed mood for most of the day, for more days than not, as indicated by subjective account or
observation by others, for at least 2 years
B. Presence, while depressed, of 2 or more of the following:
1. Poor appetite or overeating
2. Insomnia or hypersomnia
3. Low energy or fatigue
4. Low self-esteem
5. Poor concentration or difficulty making decisions
6. Feelings of hopelessness.
C. During a 2-year period (1year for children /adolescents), individual has never been without the
symptoms in criterion A and B for more than 2 months at a time.
D. Criteria for a major depressive disorder may be continuously present for 2 years
E. There has never been a manic episode, hypomanic episode, or criteria met for cyclothymic disorder
F. Disturbance not better explained by a persistent schizoaffective and disorder, schizophrenia, etc.
G. The symptoms are not attributable to physiological effects of a substance
H. Symptoms cause clinically significant distress…
See specifiers on next slide…
Persistent Depressive Disorder Specifiers
pp. 168-169
Persistent Depressive Disorder
300.4 (F34.1)
Specify if:
With anxious distress
With mixed features
With atypical features
With pericardium onset
With mood incongruent psychotic features
Specify if:
In partial remission
In full remission
Specify if:
Early Onset
Late onset
With melancholic features
With mood congruent psychotic features
Specify If:
With pure dysthymic syndrome
With persistent major depressive episode
With intermittent major depressive episodes with current episode
With intermittent major depressive episodes, without current episode
Specify if: current severity:
Mild (p. 188)
Moderate (p. 188)
Severe (p. 188)
Consult
Specifiers for
Depressive
Disorders
pp. 184-188