Transcript Signs and Symptoms of Mental Illness

Jim Messina, Ph.D., CCMHC, NCC, DCMHS
Assistant Professor
Troy University, Tampa Bay Site
Objectives Workshop
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Status of the new DSM-5
Categories and changes in DSM-5
Impact of DSM-5 for treating Co-Occuring Disorders
Trauma Focused Therapeutic Diagnosis and Treatment Planning using the
Adverse Childhood Experience (ACE Factors) Screening, the DSM-5 for
principal and Provisional Diagnoses along with Identifying Other Condition That
May be a Focus of Clinical Attention
Integrated Behavioral Medicine Diagnosis and Treatment Planning using the
ICD Codes for Common Medical Conditions resulting in Mental Health
Disorders
Using DSM-5 for Improved Clinical Assessment, Diagnosis and Treatment
Planning
Websites on DSM-5
Official APA DSM-5 site: www.dsm5.org
 DSM-5 on: www.coping.us
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Timeline of DSM-5
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1999-2001 Development of Research Agenda
2002-2007 APA/WHO/NIMH DSM-5/ICD-11
Research Planning conferences
2006
Appointment of DSM-5 Taskforce
2007
Appointment of Workgroups
2007-2011 Literature Review and Data Re-analysis
2010-2011 1st phase Field Trials ended July 2011
2011-2012 2nd phase Field Trials began Fall 2011
July 2012
Final Draft of DSM-5 for APA review
May 2013
Publication Date of DSM-5
Revision Guidelines for DSM-5
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Recommendations to be grounded in empirical evidence
Any changes to the DSM-5 in the future must be made in
light of maintaining continuity with previous editions for
this reason the DSM-5 is not using Roman numeral V but
rather 5 since later editions or revision would be DSM-5.1,
DSM-5.2 etc.
There are no preset limitations on the number of changes
that may occur over time with the new DSM-5
The DSM-5 will continue to exist as a living, evolving
document that can be updated and reinterpreted over
time
Focus of DSM-5 Changes
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DSM-5 is striving to be more etiological-however disorders are
caused by a complex interaction of multiple factors and various
etiological factors can present with the same symptom pattern
The diagnostic groups have been reshuffled
There is a dimensional component to the categories to be further
researched and covered in Section III of the DSM-5
Emphasis was on developmental adjustment criteria
New disorders were considered and older disorders were to be
deleted
Special emphasis was made for Substance/Medication Induced
Disorders and specific classifications for them are listed for
Schizophrenia; Bipolar; Depressive, Anxiety, Obsessive
Compulsive; Sleep-Wake; Sexual Dysfunctions; and
Neurocognitive Disorders.
Definition of Mental Disorder
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
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 a dysfunction in the individual, as
described above.
(American Psychiatric Association (2013). Diagnostic and Statistical Manual of
Mental Disorders-Fifth Edition DSM-5. Arlington VA: Author, p. 20.)
Why identify a mental disorder
diagnosis?
The diagnosis of a mental disorder should have clinical utility:
 Helps to determine prognosis
 Helps in development of treatment plans
 Helps to give an indication of potential treatment outcomes
A diagnosis of a mental disorder is not equivalent to a need for treatment.
Need for treatment is a complex clinical decision that takes into
consideration:
 Symptom severity
 Symptom salience (presence of relevant symptom e.g., presence of
suicidal ideation)
 The client's distress (mental pain) associated with the symptom(s)
 Disability related to the client's symptoms, risks, and benefits of
available treatment
 Other factors such as mental symptoms complicating other illness
DSM-5 Diagnostic Categories
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Neurodevelopmental disorders
Schizophrenia Spectrum and Other Psychotic Disorders
Bipolar and Related Disorders
Depressive Disorders
Anxiety Disorders
Obsessive Compulsive and Related Disorders
Trauma- and Stressor-Related Disorders
Dissociative Disorders
Somatic Symptom and Related Disorders
Feeding and Eating Disorder
Elimination Disorders
Sleep-Wake Disorders
Sexual Dysfunctions
Gender Dysphoria
Disruptive, Impulse-Control, and Conduct Disorders
Substance-Related and Addictive Disorders
Neurocognitive Disorders
Personality Disorders
Paraphilic Disorders
Other Mental Disorders
Obvious Changes in DSM-5 (1)
The DSM-5 will discontinue the Multiaxial
Diagnosis, No more Axis I,II, III, IV & V-which
means that Personality Disorders will now
appear as diagnostic categories and there will
be no more GAF score or listing of psychosocial
stressor or contributing medical conditions
 The Multi-axial model will be replaced by
Dimensional component to diagnostic
categories
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Obvious Changes in DSM-5 (2)
Developmental adjustments will be added to criteria
 The goal has been to have the categories more sensitive to
gender and cultural differences
 Diagnostic codes will change from numeric to
alphanumeric e.g., Obsessive Compulsive Disorder will
change from 300.3 to F42
 Diagnostic codes will change from numeric ICD-9-CM
codes on September 30, 2014 to alphanumeric ICD-10-CM
codes on October 1, 2014 e.g., Obsessive Compulsive
Disorder will change from 300.3 to F42
 They have done away with the NOS labeling and replaced
it with Other Specified... or Unspecified
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What Replaces NOS?
NOS is replace by either:
Other specified disorder or Unspecified disorder type are to be
used if the diagnosis of a client is too uncertain because of:
1. Behaviors which are associated with a classification are seen but
there is uncertainty regarding the diagnostic category due to the fact
that
 The client presents some symptoms of the category but a complete
clinical impression is not clear
 The client responds to external stimuli with symptoms of psychosis,
schizophrenia etc. but does not present with a full range of the
symptoms need for a complete diagnosis
2. The client has been unwilling to provide information due to an
unwillingness to be with the clinician or angry about being brought in to
be seen or the there is too brief a period of time in which the client has
been seen or the clinician is untrained in the classification
Rules for use of Other Specific or Unspecified
This designation can last only six months and after that a specific
diagnostic category has to be determined for the diagnosis of the
client.
Respect for Age, Gender & Culture in DSM-5
Each diagnostic definition, where appropriate
will incorporate:
1. Developmental symptom manifestation –
regarding the age of client
2. Gender specific disorders
3. Cultural sensitivity in regards to certain
behaviors
1. Principal Diagnosis
Principal Diagnosis is to be used when more than one diagnosis for an
individual is given in most cases as the main focus of attention or treatment:
 In an inpatient setting, the principal diagnosis is the condition established
to be chiefly responsible for the admission of the individual
 In an outpatient setting, the principal diagnosis is the condition
established as reason for visit responsible for care to be received
The principal diagnosis is often harder to identify when a
substance/medication related disorder is accompanied by a non-substancerelated diagnosis such as major depression since both may have contributed
equally to the need for admission or treatment.
 Principal diagnosis is listed first and the term "principal diagnosis" follows
the diagnosis name
 Remaining disorders are listed in order of focus of attention and
treatment
2. Provisional Diagnosis
Specifier "provisional" can be used when
there is strong presumption that the full
criteria will be met for a disorder but not
enough information is available for a firm
diagnosis. It must be recorded "provisional"
following the diagnosis given
3. Other Conditions that May Be a
Focus of Clinical Attention
Replaces the Psychosocial Stressors (Axis 4)
and GAF Score (Axis 5)
 Other Conditions that May Be a focus of
Clinical Attention ARE NOT mental disorders
 They are meant to draw attention to additional
issues which may be encountered in clinical
practice (p.715)
 Should be documented to help identify factors
which could impact the treatment planned
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Categories of: Other Conditions that
May Be a Focus of Clinical Attention
Relational
2. Educational and Occupational Problems
3. Housing and Economic Problems
4. Other Problems Related to the Social Environment
5. Problems Related to Crime or Interaction with the Legal
System
6. Other Health Service Encounters for Counseling and
Medical Advice
7. Problems Related to Other Psychosocial, Personal and
Environmental Circumstances
8. Other Circumstances of Personal History
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1A. Categories of: Relational Problems in Other
Conditions that May Be a Focus of Clinical Attention
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Problems Related to Family Upbringing
Other Problems Related to Primary Support Group
Child Maltreatment and Neglect Problems
 Child Physical Abuse (Confirmed or Suspected)
 Child Sexual Abuse (Confirmed or Suspected)
 Child Neglect (Confirmed or Suspected)
 Child Psychological Abuse (Confirmed or Suspected)
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Other Circumstance Related to Child Maltreatment
 Encounter for MH Services for being a victim
 Personal history (past history) as a child
 Encounter for MH Services as a perpetrator
1B. Categories of: Relational Problems in Other
Conditions that May Be a Focus of Clinical Attention
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Adult Maltreatment and Neglect Problems
 Spouse or Partner Violence, Physical(Confirmed or Suspected)
 Spouse or Partner Violence, Sexual(Confirmed or Suspected)
 (Confirmed or Suspected)
 Spouse or Partner Neglect (Confirmed or Suspected)
 Spouse or Partner Abuse, Psychological (Confirmed or
Suspected)
 Adult Physical Abuse by Nonspouse
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Other Circumstance Related to Adult Maltreatment
 Encounter for MH Services for being a victim
 Personal history (past history) as a victim
 Encounter for MH Services as a perpetrator
What does a DSM-5 Diagnosis look like?
Principal Diagnosis:
 303.90 (F10.20) Alcohol Use Disorder Moderate
 304.30 (F12.20) Cannabis Use Disorder Severe
Provisional Diagnosis:
 291.89 (F10.14) Substance/Medication-Induced
Depressive Disorder with Moderate Alcohol Use Disorder
Other Condition That May Be a Focus of Clinical Attention
 V61.10 (Z63.0) Relationship Distress with Spouse or
Intimate Partner
 V61.8 (Z63.8) High Expressed Emotion Level within
Family
 V62.5 (Z65.3) Problem Related to Other Legal
Circumstances
So a DSM-5 based Diagnosis
must include:
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One or More principal Diagnoses
One or More Provisional Diagnoses
One or More Other Conditions That
May Be a Focus of Clinical Attention
You need all three to have a complete
diagnosis using the DSM-5 Model
ICD Codes
Relationship to DSM-5
The World Health Organization (WHO) is
revising International Classification of
Diseases and Related Health Problems
(ICD-10) so that by 2015, ICD-11 will come
out
 DSM-5’s Codes are only the ICD-CM codes
(CM=Clinically Modified to fit a Nation’s
cultural makeup)
 October 1, 2014, ICD-10 codes are in
effect!
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Which codes do we use?
Codes used in clinical reports &
insurance or 3rd party billing are the ICD
codes
 ICD codes are the only HIPAA approved
codes in the USA
 The DSM system is simply a diagnostic
aid to help us sort out what ICD-CM
code that is applicable for our clients
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Organization of IDC-10-CM Codes
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F01-F09 Mental disorders due to known physiological
conditions
F10-F19 Mental and behavioral disorders due to
psychoactive substance use
F20-F29 Schizophrenia, schizotypal, delusional, and other
non-mood psychotic disorders
F30-F39 Mood (affective) disorders
F40-F48 Anxiety, dissociative, stress-related, somatoform
and other nonpsychotic mental disorders
F50-F59 Behavioral syndromes associated with
physiological disturbances and physical factors
F60-F69 Disorders of adult personality and behavior
F70-F79 Intellectual disabilities
F80-F89 Pervasive and specific developmental disorders
F90-F98 Behavioral and emotional disorders with onset
usually occurring in childhood and adolescence
F99
Unspecified mental disorder
Descriptive Manual for ICD
The WHO publishes what is called “the
Blue Book” with descriptive explanations
of their Mental, Behavioral Disorders. It
is free from WHO and is available on
their website
 The difference between the APA DSM
system and the WHO ICD model is that
the WHO model is free which make no
one money
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Changes for Substance Abuse and
Addictive Disorders in DSM-5
Only 3 qualifiers are used in the category:
1. Use - replaces both abuse and dependence
2. Intoxication and Withdrawal remain the same
2. Nicotine Related renamed Tobacco Use Disorder
3. Caffeine Withdrawal added
4. Cannabis Withdrawal added
5. Polysubstance Abuse categories discontinued
6. Gambling added to this category
Impact of DSM-5 for Clinicians
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Openings for Integrated Behavioral
Medicine Specialty
Openings for Co-Occurring Disorders
Treatment Specialty
Openings for Trauma Specialty
Integrated Behavioral
Medicine Specialty Focus
Neurocognitive Disorders
 Hormonal Imbalances
 Cardiovascular Health Conditions
 Respiratory Difficulties
 Chronic Health Conditions
 Cancers: Bladder, Breast, Colon, Rectal,
Uterine-Ovarian, Kidney, Leukemia, Lung,
Melanoma, Non-Hodgkin Lymphoma,
Pancreatic, Prostate, Thyroid
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Trauma Focused Therapeutic
Diagnosis &Treatment Planning
Adverse Childhood Experience (ACE
Factors) Screening
 DSM-5 for principal and Provisional
Diagnoses
 Identifying Other Condition That May be
a Focus of Clinical Attention
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Adverse Childhood
Experiences (ACE Factors)
ABUSE
1. Emotional Abuse
2. Physical Abuse
3. Sexual Abuse
Neglect
4. Emotional Neglect
5. Physical Neglect
Household Dysfunction
6. Mother was treated violently
7. Household substance abuse
8. Household mental illness
9. Parental separation or divorce
10. Incarcerated household member
Then Identify Diagnosis
based on ACE
Principal
 Provisional
 Other Conditions that May Be a Focus
of Clinical Attention (V codes until
October 2014 and TZ code beginning
October 2014)
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Utilize Trauma Focused
Evidenced Based Practices
Prolonged Exposure Therapy
Cognitive Processing Therapy
EMDR or ART Therapy
In addition to Therapeutic Plan to address
Principal Diagnosis
Co-Occurring Disorders
Treatment Specialty Focus
Substance /Medication – Induced Disorders
 Schizophrenia
 Bipolar Disorder
 Depressive Disorders
 Anxiety Disorders
 Obsessive Compulsive Disorder
 Sleep-Wake Disorders
 Sexual Dysfunctions
 Neurocognitive Disorders
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Co-Occurring Substance Disorder with
Schizophrenic Induced Psychotic
Disorder
Alcohol
 Cannabis
 Phencyclidine
 Hallucinogens
 Inhalants
 Sedatives
 Amphetamines
 Cocaine
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Co-Occurring Substance Disorder
with Bipolar & Related Disorders
Alcohol
 Phencyclidine
 Hallucinogens
 Sedatives
 Amphetamines
 Cocaine
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Co-occurring Substance Disorder
with Depressive Disorders
Alcohol
 Phencyclidine
 Hallucinogens
 Inhalants
 Opioid
 Sedatives
 Amphetamines
 Cocaine
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Co-occurring Substance Disorder
with Anxiety Disorders
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Alcohol
Caffeine
Cannabis
Phencyclidine
Hallucinogens
Inhalant
Opioid
Sedative
Amphetamine
Cocaine
Co-occurring Substance Disorder
with Obsessive-Compulsive Disorder
Amphetamines
 Cocaine
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Co-occurring Substance Disorder
with Sleep-Wake Disorders
Alcohol
 Caffeine
 Cannabis
 Sedative
 Amphetamine
 Cocaine
 Tobacco
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Co-occurring Substance Disorder
with Sexual Dysfunctions
Alcohol
 Opioid
 Sedative
 Amphetamine
 Cocaine
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Co-occurring Substance Disorder
with Delirium & Neurocognitive Disorders
Alcohol
 Cannabis
 Phencyclidine
 Hallucinogens
 Inhalant
 Opioid
 Sedative
 Amphetamine
 Cocaine
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