Download DSM-5 - Center for School Mental Health (CSMH)

Using DSM-5
SHIP Conference 8/1/2014
Handout Packet 1
DISTRIBUTION OF THIS HANDOUT PACKET VIA THE
INTERNET IS PROHIBITED
Carlton Munson, PhD, LCSW-C
Professor
University of Maryland Baltimore
School of Social Work
8/14/2014
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.
8/14/2014
Copyright © 2013 Dr. Carlton Munson
2
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
–
8/14/2014
Copyright © 2013 Dr. Carlton Munson
3
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
8/14/2014
Copyright © 2013 Dr. Carlton Munson
4
SLIDE KEY
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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
This symbol indicates copyrighted material that cannot be copied 
Some slides in the presentation are not in the handouts due to
copyright restrictions
8/14/2014
Copyright © 2013 Dr. Carlton Munson
5
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
8/14/2014
Copyright
© 2013 Dr.
Carlton
Pages missing
apparent
rush
toMunson
publication
without thorough proof reading
Philip
Muskin
DSM-5 app for iPhone, iPad, Samsung, android, &
Hemorrhoid Devices
8/14/2014
Copyright © 2013 Dr. Carlton Munson
7
DSM-5: Online
DSM-5 ON-LINE AVAILABLE
DSM-IV-TR version was $490 annually now $420 and site
licenses available
“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
8/14/2014
Copyright © 2013 Dr. Carlton Munson
8
Question?
I guess I should throw away my DSM-IV-TR since DSM-5 comes out?
No!
-Some payers will take 9 months to transition computer billing codes
-You will need to look up reports you receive prepared under DSM-IV
-You will need the “DSM-4” to review disorders eliminated from “DSM-5
-Because of the opposition some organizations may not adopt DSM-5
-You will need to use DSM-IV to upgrade ongoing clients to DSM-5
-Needed for clients referred come with DSM-IV Dx.
-New clients Dx. Years ago
if you do retain your copy of DSM-4
you are at risk of being diagnosed
with Hoarding Disorder (See DSM-5)
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Copyright © 2013 Dr. Carlton Munson
9
Highlights of DSM-5 Changes
8/14/2014
Copyright © 2013 Dr. Carlton Munson
10
Where have all the flowers gone?
First and foremost, where has the multiaxial format gone?
AXIS I
Combined and presented in
vaguely defined narrative format
Axis II
AXIS III
Axis IV
Primary Support group
Social Environment
Sent to Other
Educational Problem
Occupational Problems
Be a Focus of
Housing
section
Economic Problems
Access to healthcare
Problems with the legal system
Other P/S Problems
Axis V
Conditions That May
Clinical Attention
Converted to severity
measures
in individual disorders
8/14/2014 8:59:20 AM
Copyright © 2003 Dr. Carlton Munson
11
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
8/14/2014 8:59:20 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
12
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
8/14/2014
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
Copyright © 2013 Dr. Carlton Munson
13
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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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
14
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
Personality disorders
Ends
Paraphilic disorders
with
Other mental disorders
Medication-Induced Movement Disorders and Other Adverse Effects of Medication
Other Conditions That May be a Focus of Clinical Attention
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Copyright © 2013 Dr. Carlton Munson
15
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
8/14/2014
Detailed
Descriptive
Text
p. 183
See following slide
p. 169-171
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
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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
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Copyright © 2013 Dr. Carlton Munson
17
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
8/14/2014
Glossary of Cultural Concepts of Distress
pp. 833-837
Blue text indicates new to DSM-5
Each concept has two sub sections:
-Related conditions in other cultural contexts
-Related conditions in DSM-5
Ataque de nervios
Dhat syndrome
Khyal cap
Kufugisisa
Maladi noun
Nervios
Shenjing Shuairuo
Susto
Taijin Kyofusho
Copyright © 2013 Dr. Carlton Munson
18
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
What
Nonsuicidal Self-Injury
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Copyright © 2013 Dr. Carlton Munson
19
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
8/14/2014
Copyright © 2013 Dr. Carlton Munson
changes
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Diagnostic Formulation
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Copyright © 2013 Dr. Carlton Munson
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Nonaxial assessment diagnosis good news! It provides latitude
P. 16

Elements of Dx. Formulation
Diagnosis
Medical Conditions
Notations
Disability Severity
Diagnosis
Psychosocial &
Contextual Factors
“Notations”
Disability Severity
Medical Conditions

Categories of Munson
Diagnostic Formulation
2,4,5 ...Has moved to a nonaxial documentation
of
(formerly Axis I, II, & III) with
separate
for important psychosocial and
contextual factors (formerly Axis IV) and
(formerly Axis 5) (p. 16)
3. Clinicians should continue
important to
understanding or management of an
individual’s mental disorder (s). (p. 16)
1. A case formulation involves a careful
of social, psychological, and biological
factors that may have
(p. 19)
1. Clinical History and Concise
summary
2. Diagnosis
3. Medical Conditions
4. Notations
5. Disability Severity
6. Treatment Plan
Considerations
6. Primary purpose of DSM 5 is to assist trained clinicians in the diagnosis of their patients’ mental
disorders as part of a case formulation assessment that leads to
individual. (p. 19)
Use of word plan fails to recognize many Dx interviews do not involve Tx planning
8/14/2014
Copyright © 2013 Dr. Carlton Munson
for each
23
ADOLESCENT
CHILD
ADULT
0
NEEDS Tx –
THREAT
TO SELF OR
OTHERS
CONCERN
-Child removed from 3
daycare centers b/o
-Aggression toward
other children with
sharp objects
-Child causes parent
Conflict about how to
manage behavior
-Child placed in
specialized daycare
-Failing all subjects
-School suspension 3t for
gang fights
-Committed date rape
-Truancy
-Disappears for 3 days
-Probation theft
-Refuses to get out of bed
-Will not go out of house
-Frequently expresses
hopelessness
-Talks of “walking into
traffic”
-Writes a new will
-Picked up by police for
vandalism of teachers
Car
-Obsessed with
Internet porn
-Sleep disturbance
-Loss of appetite
-Has stopped looking for
work
10
20
30
40
50
60
70
SYMPTOMS/BEHAVIORS MUST BE CONSIDERED IN COMBINATION
OCCASIONAL
PROBLEMS
ACCEPTABLE
BEHAVIOR
Clinical
Sig.
Criteria
-Fussy child who has
uneasy temperament
-Frequent timeouts at
daycare & refuses naps
-Cusses adults
-Failing science
-Masturbates
excessively
Prolonged sadness b/o
fathers death
-Sleep disturbance about job
loss
Examples of Clinical Significance
80
90
100
Doing Any Diagnosis
Assign Disorder
Differentiation 5.
Confirmation 4.
Distress 3.
Duration 2.
Symptom Count 1.
8/14/2014
5. Differential Dx.
4. Observable by others by others, noticeable
change from usual behavior
3. Mild, moderate, severe, marked impairment, sig.
Degree, persistent (different, difficult,
dysfunctional, dangerous)
2. 1 week, 3 months , distinct period, most of the
day, nearly every day, same 2-week period, for
more days than not, recurrent
1. 3 or more of.....
Copyright © 2013 Dr. Carlton Munson
27
Doing Any Diagnosis Interview Questions
Assign Disorder
Differentiation 5.
Confirmation 4.
Distress 3.
Duration 2.
Symptom Count 1.
8/14/2014
5. Have you ever had this before or anything like it?
Have you been treated before? Is there anything
else you have not mentioned?
4. What has your wife, children, coworkers said
about?
3. How has your life change since...?
2. How long have you had...? When did you first
notice...?
1. Tell me what has been happening...? List for me
the things you have noticed...
Copyright © 2013 Dr. Carlton Munson
28
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
8/14/2014
Copyright © 2013 Dr. Carlton Munson
29
DSM-IV ICA Disorders & DSM-5 Neurodevelopmental Disorders
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Mental Retardation
Learning Disorders
Motor Skills Disorder
Communication Disorders
PDDs
ADHD & Disruptive Behavior
Disorders
Feeding & Eating Disorders
Tic Disorders
Elimination Disorders
Other Disorders of ICA
• 10 Categories
• Intellectual Disabilities
• Communication Disorders
• Autism Spectrum Disorder
•
ADHD
• Specific Learning Disorder
• Motor Disorders
• Tic Disorders
• Other Neurodevelopmental Disorders
• 8 Categories
•
All disorders in NDD section except for Feeding
and Eating Disorders and Elimination Disorders
that are in stand alone sections
DSM-IV ICA Disorders in DSM-5 (page numbers are for the Desk Reference)
•
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ADHD and Disruptive Behavior Disorders
DSM-IV-TR
Now 1 disorder w
– ADHD “presentation” specifiers
Mental Retardation Intellectual Disability (pp.)
– ADHD NOS
Learning Disorders Specific Learning Disorder (pp.)
Moved to Disruptive,
–
Conduct
Disorder
Specifiers
Impulsive control ...section
– Reading Disorder
“with impairment in“
(pp. 219-224)
– ODD
– Mathematics Disorder (pp.)
– Disruptive Behavior Disorder NOS
– Disorder Od Written Expression
•
Feeding/Eating Disorder of Infancy or Early
– Learning Disorder NOS
Childhood
Motor Skills Disorder
Moved to Feeding & Eating Disorders
–
Pica
(pp.169)
– Developmental Coordination Disorder
– Rumination Disorder
Communication Disorders
– Feeding/Eating Disorder of Infancy or Early
– Expressive Language Disorder
Childhood
– Mixed Receptive Expressive Language
•
Tic Disorders Moved to ND Motor Disorders (p. 41)
Disorder
• Tourette’s Disorder
– Phonological Disorder
• Chronic Motor or Vocal Tic Disorder
– Stuttering Now Childhood-Onset Disorder (p. 25)“Persistent” added
• Transient Tic Disorder Transient changed
– Communication Disorder NOS
to provisional
•
Tic
Disorder
NOS
Pervasive Developmental Disorders
Now Other/Unspecified
•
Elimination Disorders
– Autistic Disorder
Tic Disorder
Now Autism Spectrum
–
Encopresis
– Rett’s Disorder
Disorder (p. 27)
Now in stand alone section (p.177)
–
Enuresis
– Childhood Disintegrative Disorder
•
More disorders on next page
– Asperger’s Disorder
– PDD NOS
DSM-IV ICA Disorders in DSM-5
•
DSM-IV-TR
•
Other Disorders of ICA
•
Separation Anxiety Disorder
•
Selective Mutism
•
Reactive Attachment Disorder
•
Stereotypic Movement Disorder
•
Disorder of ICA NOS
Moved to Anxiety Disorders (p.115)
Moved to Anxiety Disorders (p.116)
Moved to Trauma/stress Disorders
Subtypes split into 2 disorders of RAD & DSED
Moved to Motor Disorders
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: Intellectual functioning typically measured by IQ scores of 65-75 (70 + 5)
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)
C: Onset of intellectual and adaptive deficits during the developmental period
(childhood or adolescence)
Coding note: ICD-9-CM code for ID is 317, which is assigned regardless of severity
specifier
Specify current severity (see Table 1):
Notice coding absent because it is found
(F70) Mild
within the criteria specifiers
9F71 )Moderate
(F72) Severe
(F73) Profound

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
ID Testing KBIT-2 & KFAST
Kaufman
Brief
Intelligence
Test
2nd Edition
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
8/14/2014
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
37
Neurodevelopmental Disorders
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
8/14/2014
Copyright © 2013 Dr. Carlton Munson
38
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
8/14/2014
Copyright © 2013 Dr. Carlton Munson
39
DSM-5: Autism Spectrum Disorder
pp. 50-59
Severity of impairment in areas of development:
Level 1
Reciprocal
social
interaction
skills
c
A
Level 1
Communication
skills
Level 1
Restricted: Behavior
cB “RRBs”
Interests
Activities
Level 3
Reciprocal
social
interaction
skills
Level 2
Reciprocal
social
interaction
skills
Level 3
Level 2
Communication
skills
Level 2
SLIDER
BUTTON
Restricted: Behavior
“RRBs” Interests
Activities
Communication
skills
Level 3
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
8/14/2014
Copyright © 2013 Dr. Carlton Munson
41
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
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
.
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Copyright © 2013 Dr. Carlton Munson
43
DSM-5: Schizophrenia Spectrum and Other Psychotic Disorders
cA eliminated bizarre delusion & it is now a specifier
Schizotypal Personality Disorder (New Strategy of dual listing)
Delusional Disorder
DSM-1 to DSM-IV subtypes eliminated
Brief Psychotic Disorder
cA eliminated bizarre delusions & Schneiderian 1st rank audirory
Schizophreniform Disorder
hallucinations Sx.
Added 1 cA Sx. must be delusions, hallucinations, or disorganized
Schizophrenia
speech
Schizoaffective Disorder
Substance/Medication-Induced Psychotic Disorder
Psychotic Disorder Due to Another Medical Condition
Catatonia
Catatonia Associated With Another Mental Disorder (Catatonia Specifier)
Catatonic Disorder Due to Another Medical Condition
Shared Psychotic
Unspecified Catatonia
Disorder deleted
Other Specified Schizophrenia Spectrum and Other Psychotic Disorder and now “other
Unspecified Schizophrenia Spectrum and Other Psychotic Disorder
specified....Disorder
Specifier added for catatonia in
context of other medical condition
8/14/2014
Copyright © 2013 Dr. Carlton Munson
”
(see p. 122)
44
DSM-5 Schizophrenia Spectrum and Other Psychotic Disorders pp. 87-122
Delusional Disorder 297.1 (F22)
A. Delusions for 1+ months
B. cA for Schizophrenia never met
C. Marked impairment & behavior not bizarre or odd
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
Schizophrenia 295.90
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
4. Grossly disorganized or catatonic behavior
Eliminated
5. Negative symptoms
b/o low
B. Episode 1 m but less than 6 m
reliability
C. Not other psychotic disorder
poor
D. Not due to substance or other medical condition validity
Suicide risk in all
Schizophrenia phases
Prodromal refers to
early
Cochrane Schizophrenia Group at UK’s
Nottingham University reported intermittent
antipsychotic therapy is less effective than
long-term therapy in preventing episodic
recurrences in individuals with schizophrenia.
Psychiatric Times. 8/28/13
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
1+ 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
Change to DSM-IV
schizophrenia
Criterion A : Elimination of
special attribution of bizarre
delusions and Schneiderian
first-rank auditory
hallucinations (e.g., two or
more voices conversing)
Key Terms (pp.-87-88)
Delusions: Persistent fixed belief self, other, or objects that is maintained despite indisputable
evidence to the contrary.
Types: Persecutory: Belief that one is going to be harmed or harassed by an individual
organization or group.
Referential: Belief gestures, comments, cues are directed at oneself
Grandiose: Believe one has exceptional abilities, wealth, or fame.
Erotomanic: False belief that another person loves the individual.
Nihilistic: Conviction a major catastrophe will occur.
Somatic: Preoccupation with with health and organ function.
Severity: Nonbizarre: The delusion has a possibility of being plausible.
Bizarre: Delusion nonplausible and not understandable to same culture
peers and are not part of ordinary life experiences.
Hallucinations : Perception like experiences that occur without an external stimulus. (Also,
experience involving apparent perception of something not present / synonyms, delusion,
illusion, figment of imagination, vision, apparition, mirage, chimera, fantasy)
Types: Auditory: Usually hearing voices perceived distinct form the person’s thoughts.
Visual: Persons or events that are seen vividly and clearly and experienced as
perceptions.
Hypnagogic: Clear sensorium occurring while falling asleep. These experiences are normal.
Hypnopompic: clear sensorium occurring while waking up. These experiences are normal.
Note: “Hallucinations may be a part of religious experiences in certain cultural contexts.”
8/14/2014
Copyright © 2013 Dr. Carlton Munson
47
NEW SECTION
DSM-5: Bipolar and Related Disorders
Bipolar I Disorder
Bipolar II Disorder
cA for manic and hypomanic episodes changes in activity and energy and mood.
Mixed episodes replaced with specifier “with mixed features”
Added anxious distress specifier
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
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Copyright © 2013 Dr. Carlton Munson
48
Bipolar I and Bipolar II Disorders (pp. 123-132)
cA. At least 1 week most of the day (or hospitalization needed) of elevated expansive or irritable mood or
increased & energy or goal directed activity w 3+ of (4 if mood only irritable): (1) inflated self esteem/grandiosity
(2) decreased sleep (3) pressured talking (4) flight of ideas/racing thoughts (5) distractibility (6) increased goal
activity (7) excessive activities that have painful consequences (sexual/financial acting out)
cB. 3 / 4 Sx. To sig. degree and is noticeable change from usual behavior
cC. Sx. severe enough to cause marked impairment in SOF or to cause hospitalization is noticeable change
of usual behavior
Manic Episodes
Differentiation
cA. Same as manic episode except symptoms for 4 days
By degree &
cC. Associated with change in functioning
duration of Sx.
cD. Observable by others
cE. NOT severity to cause marked impairment in SOF / if psychotic Dx as BP-1 mania
Hypomanic
Episodes
Baseline Stable Mood
Depressive Episodes
cA: For 2 weeks changed functioning w 5+ of: (1) depressed mood (2) diminished interest (3)
Weight loss (4) insomnia/hypersomnia (5) psychomotor agitation (6) fatigue (7) Feeling
worthless (8) diminished ability to think (9) thoughts of death
US prevalence 0.6%/ international 0.0% to 0.6% lifetime m/f ratio 1.1:1 / late life manic Sx. onset may indicate medical
condition (neurocognitive disorder) or substance use or withdrawal / 90% with single manic episode go on to have
recurrent mood episodes 60% of manic episodes occur just before a depressive episode (p. 130). 15 times more likely to
suicide &accounts fr 25% of all suicides. Mixed episodes now a specifier.
Bipolar I Bipolar II & Cyclothymia Disorder Differentiation
pp. 123-41
(cA)Manic episode 7 days (occurring before or after hypomanic or depressive episode)
(cA) Depressive episode 2 weeks (any duration if hospitalization required)
(cC) With mood severity causing marked impairment in functioning
(cA) Current or past episode hypomania for 4 days
(cA) Depressive episode 2 weeks
(cE) No marked impairment in functioning. If psychosis present automatically Dx. is manic
(cA) 2+ years ( children & adolescents 1 year) of numerous hypomanic and depressive
episode that do not meet the full criteria for H/D episodes
(cB) Sx. Present 50% of time and person not w/o Sx. for more than 2 months
(cF) Sx. Cause clinically significant distress in SOOAF
DSM-5: Depressive Disorders
In DSM-4 Mood Disorders section
Disruptive Mood Dysregulation Disorder
Added & can be Dx. until age 18
Major Depressive Disorder, Single and Recurrent Episodes
Persistent Depressive Disorder (Dysthymia)
Premenstrual Dysphoric Disorder
-Specifier added for anxious
distress for anxiety Sx. not part
of depressive Dsrd criteria
-Bereavement exclusion
eliminated
Includes chronic depression
& DSM-IV Dsythymic Dsrd.
Substance/Medication-Induced Depressive Disorder
Depressive Disorder Due to Another Medical Condition
Other Specified Depressive Disorder
Unspecified Depressive Disorder
8/14/2014
Copyright © 2013 Dr. Carlton Munson
Moved up from DSM-IV
Appendix B
Depression &
Affective
Disorders
Association
DRADA
51
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
8/14/2014
“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
52
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
8/14/2014
•
•
•
•
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
53
DSM-5 Other Conditions That May Be A Focus Of Clinical Attention
(pp.716-717)
• V62.82 Uncomplicated bereavement: ...normal reaction to
death of loved one... Some grieving individuals present with
Sx. of a major depressive episode... Duration and expression
of “normal” bereavement vary considerably in different
cultural groups.
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Copyright © 2013 Dr. Carlton Munson
54
CRITERIA
TIME FRAMES
Most of day for more days than not
At least 2y for adults and 1y for C/A
Childhood onset w chronic course
CRITERIA
A. Depressed mood 2y or 1y
B. While depressed 2+ of:
1. Poor appetite or over eating
2. Insomnia or hypersomnia
3. Low energy or fatigue
4. Low self esteem
5. Poor concentration difficulty making
decisions
6. Feelings of hopelessness
C. No more than 2m remission in 2y / 1y
D. Major Depressive disorder may be
present ...
•
•
Persistent Depressive Disorder pp. 168-171
FEATURES
– Prevalence .5%
– risk when neuroticism (negative affectivity),
anxiety disorder, conduct disorder, parental
loss, present & family Hx of PDD & MDD
– Brain regions involved prefrontal cortex,
anterior cingulate, amygdala, & hippocampus
– risk of PD and A/S Disorders
• Specifiers
– Features (anxiety, mixed, melancholic,
atypical, psychotic, peripartum
– Remission (Partial / full)
– Onset (Early / Late)
– Episodes (pure dysthymic / depressive
– Severity (M-M-S)