Transcript DSM-5 - Wiley

DSM-5 in Action:
™
Diagnostic and Treatment Implications
Section 2, Chapters 5–13
PART 1 of Section 2
Chapters 1–7
by Sophia F. Dziegielewski, PhD, LCSW
© 2014 S. Dziegielewski
After completion of this section, participants will be
able to:



Identify the major diagnostic categories and the
criteria needed for proper diagnostic assessment.
Utilize the dimensional assessment strategy
outlined in DSM-5 for two disorders.
Utilize this information to complete the diagnostic
assessment.
© 2014 S. Dziegielewski
DSM-5 Chapters
20 Disorder Categories
Neurodevelopmental Disorders
Sleep-Wake Disorders
Schizophrenia Spectrum and the Other
Psychotic Disorders
Sexual Dysfunctions
Bipolar and the Related Disorders
Gender Dysphoria
Depressive Disorders
Disruptive, Impulse Control, and Conduct Disorders
Anxiety Disorders
Substance-Related and Addictive Disorders
Obsessive-Compulsive and the Related
Disorders
Neurocognitive Disorders
Trauma and Stressor-Related Disorders
Personality Disorders
Dissociative Disorders
Paraphilic Disorders
Somatic Symptom and Related Disorders
Other Mental Disorders
Feeding and Eating Disorders
Medication-Induced Movement Disorders and Other
Adverse Effects of Medication
Elimination Disorders
Other Conditions That May Be a Focus of Clinical
Attention
© 2014 S. Dziegielewski
(2 additional categories)
© 2014 S. Dziegielewski

Somatic, cognitive, and emotional concerns
identified in the DSM-5 are the predominant
features linking the disorders.
© 2014 S. Dziegielewski

When depressed clients experience a loss of
interest or pleasure in activities and difficulty
concentrating, these symptoms can lead to
problems with performing activities of daily
living (ADLs) and making decisions.
© 2014 S. Dziegielewski


Although some types of mixed presentations
in depression exist, the DSM-5 focuses
primarily on the depressive ones.
For a diagnosis, problems must be severe
enough to affect occupational and social
functioning.
© 2014 S. Dziegielewski

When suffering from depressive disorders, all
individuals experience some degree of
depressive symptoms, although the duration,
time frame, and etiology may vary (APA,
2013)
© 2014 S. Dziegielewski

These disorders all share depressed mood
with subsequent changes in eating, sleeping,
and energy levels; impairments in executive
function and attention; and changes in selfawareness and perception.
© 2014 S. Dziegielewski


Exogenous – “outside the body”
Endogenous – “inside the body”
© 2014 S. Dziegielewski
296.2x Major Depressive Disorder,
Single Episode
 296.3x Major Depressive Disorder,
Recurrent
 300.4 Dysthymic Disorder
 311.00 Depressive Disorder Not
Otherwise Specified

© 2014 S. Dziegielewski
© 2014 S. Dziegielewski
New Depressive Disorder in
Children/Adolescents.
 DMDD has 11 specific criteria (ranging
from A to K) that must be met.
 Core feature is persistent irritability
for at least a year, severe and
continuous course not related to a
developmental phase.

© 2014 S. Dziegielewski
Behaviors not consistent with
precipitating event.
 Involve either verbal or behavioral
manifestations toward people or
property.
 Temper outbursts are continuous,
occurring at least 3 or more times
over a 7-day period.

© 2014 S. Dziegielewski

Severe Mood Dysregulation: used to
distinguish children who have recurrent
severe/inappropriate behavioral outbursts.
© 2014 S. Dziegielewski


ADHD— DMDD is more aggressive.
Bipolar— DMDD is more continuous and not
cyclic.
© 2013 S. Dziegielewski
 An
episodic disorder (a period of
time when someone is distinctly
different from the baseline).
 BD in children is different from BD
in adults, and presents as severe
continuous irritability.
© 2014 S. Dziegielewski
 Children
with DMDD do not
meet the adult criteria for
BD.
 DMDD does NOT develop
clear manic symptoms.
© 2014 S. Dziegielewski
 More
likely to have anxiety
disorders and depression but not
BD.
 No genetic component with
DMDD.
 More anxiety and depression.
© 2014 S. Dziegielewski
© 2014 S. Dziegielewski




Nine primary symptoms, must have at least 5.
Symptoms occur during a 2-week period.
Must have either depressed mood or a loss of
interest or pleasure in daily activities
consistently for the 2-week period.
Of the nine symptoms, at least one must be
depressed mood or loss of interest or
pleasure.
© 2014 S. Dziegielewski
1. Depressed mood: Depressed mood most of
the day, nearly every day.
2. Markedly diminished interest or pleasure: In
almost all activities most of the day, nearly
every day.
© 2014 S. Dziegielewski
3. Appetite changes: Appetite and weight loss
or gain may occur.




To be considered significant, a clear change in weight is
expected while the individual is not actively dieting or trying
to gain weight.
Over a month’s time, a change of more than 5% of body
weight should be noted to be considered significant.
Eating behaviors and appetite change need to be examined
over a 1-month time frame as opposed to the 2 weeks
relevant to the condition;
Therefore, counting this criterion for the diagnosis requires
extending the evaluation beyond the 2-week period.
© 2014 S. Dziegielewski
4. Sleep disturbance: Symptoms related to
either insomnia or hypersomnia are noted
every day.
5. Psychomotor agitation: Psychomotor
agitation often exhibits as extreme
restlessness, and the individual feels he or she
cannot calm the self internally.
© 2014 S. Dziegielewski
6. Feeling fatigued or reports feelings of no
energy.
7. Feelings of worthlessness and guilt. The
guilt is so overwhelming, it preoccupies the
individual’s thoughts and can have a
delusional quality.
© 2013 S. Dziegielewski
8. Diminished concentration and indecisive
thoughts: Thoughts and the resultant
behaviors are linked.
Impaired thinking and functioning when
compared with what the individual was able to
do before and what he or she is capable of
doing now.
© 2014 S. Dziegielewski
9. Recurrent thoughts of death:



The depressed individual may often express
the idea of self-harm that may or may not be
related to a specific plan.
If an attempt is noted in the client’s past, the
circumstances surrounding it, if known,
should be documented.
In treatment, knowing this information may
assist with predicting future risk.
© 2013 S. Dziegielewski



Disturbs social, occupational, educational,
important functioning, and individual reports
distress and mood changes.
For children and adolescents, mood may be
reported as irritable. Presentation may differ from
what is seen in an adult. May be confused with
DMDD where the mood is consistently agitated for
at least a year and does not take on a cyclic pattern
in which the individual seems better, as is the case
in major depressive disorder.
Should not be diagnosed in young adults older
than age 18.
© 2013 S. Dziegielewski

Depressed mood in this disorder cannot be
caused by substances such as drugs, alcohol,
or medications.
© 2014 S. Dziegielewski
Cannot be caused by another mental health
disorder, such as:
 Schizophrenia spectrum and other psychotic
disorders such as schizoaffective disorder,
schizophreniform disorder, delusional
disorder, or other specified or unspecified
disorder in this category.
© 2014 S. Dziegielewski

There cannot be a documented history of
manic or hypomanic episodes.
© 2014 S. Dziegielewski
1. In major depressive disorder (single episode
or recurrent), this coding scheme is used:
For the diagnosis of major depressive disorder,
the first three digits using:
ICD-9-CM are always 296.xx,
ICD-10, it starts with F3x.x.
Major Depressive Disorder
296.xx (ICD-9-CM) or F3x.x (ICD-10-CM)
© 2014 S. Dziegielewski
2. The fourth digit denotes whether it is a
single (denoted with the number 2) or
recurrent (denoted with a 3) major depressive
episode in ICD-9-CM.
It is the second digit in ICD-10-CM.
ICD-9-CM 296.2x single, 296.3x recurrent for
ICD-10, F32.x. single, F33.X recurrent
(To be recurrent, there must be at least 2 months from the end
of one episode to the beginning of another. When the period
between episodes is less than this, the symptoms of the major
depressive episode are not met. )
© 2014 S. Dziegielewski
3.
The fifth digit indicates the severity, presence
of psychotic features, and remission status.
 There are three levels of severity: mild, moderate,
and severe.
 When identifying mild severity, the criteria for the
disorder are met, but the impairment to social and
occupational functioning that results is considered
minimal.
 When the severity specifier severe is used, the
criteria for the disorder have been met, and many
more symptoms than required cause significant
impairment and often require immediate attention.
© 2014 S. Dziegielewski



The severity course specifier can also be used
to denote whether there are psychotic
features (hallucinations, delusions, and
formal thought disorder) present.
This specifier would be added and simply
written “with psychotic features” when the
level of severity is also utilized.
Remember in coding that when the symptoms
of psychosis are present, always document
with psychotic features.
© 2014 S. Dziegielewski


This diagnosis also allows the coding of
partial, full, or unspecified remission.
Keep in mind, however, that remission
specifiers can be used only when the full
criteria for the major depressive episode are
no longer met.
© 2014 S. Dziegielewski







296.x1 Mild severity [ICD-9-CM] or F3x.0 [ICD-10-CM]
296.x2 Moderate severity [ICD-9-CM] or F3x.1 [ICD-10-CM]
296.x3 Severe severity [ICD-9-CM] or F3x.2 [ICD-10-CM]
296.x4 With psychotic features [ICD-9-CM] or F3x.3 [ICD10-CM]
296.x5 In partial remission [ICD-9-CM] or F3x.4 [ICD-10CM]
296.x6 In full remission [ICD-9-CM] or F3x.5 [ICD-10-CM]
296.x0 Unspecified [ICD-9-CM] or F3x.9 [ICD-10-CM]
© 2014 S. Dziegielewski


This is a milder yet more chronic form of the
disorder, requiring a 2-year history of
depressed mood.
The individual suffering from this disorder is
not without the symptoms for more than 2
months at a time. The disorder is considered
less severe than major depressive disorder
but is constant for a period of 2 years, during
which the individual experiences some
symptoms related to the disorder almost
every day.

© 2014 S. Dziegielewski

This new condition to the DSM-5 occurs in
women who have severe depressive
symptoms, irritability, and tension that occur
before menstruation.
© 2014 S. Dziegielewski



Meet the criteria for major depressive
disorder and document the
substance/medication taken, confirmed by
history, physical exam, or lab result.
Need to experience the symptoms soon after
ingestion or with resultant intoxication or
withdrawal from the substance.
That the substance taken is capable of
displaying the side effects that resulted has
to be confirmed.
© 2014 S. Dziegielewski


Similar to the criteria for
substance/medication-induced disorder, the
individual is expected to suffer from a
persistent depressed mood, accompanied by
diminished interest and pleasure in activities
that once were pleasurable.
Needs to be direct evidence from an adequate
history, physical exam, or lab result that
makes the connection to the medical
condition causing it.
© 2014 S. Dziegielewski



The diagnosis of either of these disorders
requires the symptoms characteristic of the
depressive disorders.
The three specifiers are recurrent brief
depression, short-duration depressive
episode, and depressive episode with
insufficient symptoms.
Difference between the specified and
unspecified disorder is that in the specified
disorder, the practitioner documents the
reason that it does not meet the criteria.
© 2014 S. Dziegielewski


Premenstrual Dysphonic Disorder
Mixed Features Specifier
© 2014 S. Dziegielewski



Symptoms having to come 2 months after the
death of a loved one has been removed.
Replaced with: Criteria that helps to
distinguish between grief and depression.
Recognizes bereavement can be a severe
psychosocial stressor that can precipitate a
major depressive episode soon after the
death of a loved one.
© 2014 S. Dziegielewski
 Each
diagnosis in this category
allows for ranking of anxiety.
 Each diagnostic category needs to
be addressed for suicide.
 May include a substance use
dimension.
© 2014 S. Dziegielewski



Each diagnosis in this area (Depressive
Disorders, Bipolar Disorders) can have an
anxiety component.
Each mood disorder diagnosis is
accompanied by some type of anxiety
dimension.
A rating of anxiety should be included from 0
(no anxiety) to 4 (severely anxious with five
symptoms and motor agitation).
© 2014 S. Dziegielewski

Mixed Episode (was replaced with mixed
features specifier)

Bipolar I Disorder— Single Manic Episode

Mood Disorder Not Otherwise Specified
© 2014 S. Dziegielewski
DSM-5— Ranking Anxiety Levels


Each mood disorder diagnosis is
accompanied by some type of anxiety
dimension.
A rating of anxiety should be included from
0 (no anxiety) to 4 (severely anxious with
five symptoms and motor agitation).
© 2014 S. Dziegielewski
*
© 2014 S. Dziegielewski

How to document in DSM-5
© 2014 S. Dziegielewski




Type of most current episode (Mild, Moderate,
Severe): Does it meet the criteria for the episode?
Does it meet more than the criteria?
With Psychotic Features (mood congruent [matches
manic episode] or mood incongruent [delusions
don’t match manic episode)
Partial Remission (less than 2 months without
symptoms of that presenting episode)
Full Remission (during the last 2 months without
symptoms of the presenting episode)
© 2014 S. Dziegielewski
Bipolar I Disorder (principal diagnosis)
Current Episode Manic 296.41 (F31.11) Mild
With psychotic features 296.54 (F31.5) Mood
Congruent
In Full Remission 296.56 (F31.76) (e.g., 2
months)
© 2014 S. Dziegielewski
Differentiating depression from simple
sadness.
 Is it situational?
Feeling down because of a specific event, such
as losing a job or the breakup of a relationship.
Reports feeling sad, despair, teary, or "empty"
every day for more than 2 weeks
Interferes with other aspects of life
© 2014 S. Dziegielewski




Avoids leaving the house.
Avoids conversation— too much effort.
Retreats to bed, and family/others cannot
draw out.
Losing pleasure in activities.
When they have this in treatment plan, work to
build a support network.
Work with family and support group.
© 2014 S. Dziegielewski

Remember REM sleep.
Does the individual report:
Lies awake at night with the mind racing.
Sleeps too much to avoid getting out of bed.
Speak to your doctor.

(Possible light snack before bed)
© 2014 S. Dziegielewski




Change in attitude with more difficulty
handling everyday stresses.
Small things make them ‘snap.’
Bicker with friends and family.
Easygoing before, agitated or angry outbursts
now.
© 2014 S. Dziegielewski
BEFORE AND AFTER





Were they pleasurable before?
How long (2 weeks?) has this change been
occurring?
What is the age of the person?
Relationship status?
Medications, etc.?
© 2014 S. Dziegielewski




Chronic headaches and stomachaches
Unexplained chest pain or achy legs and arms
Aches and pains don't get better with
treatment
Get physical
© 2014 S. Dziegielewski

Losing or gaining weight without a change in
diet or exercise
© 2014 S. Dziegielewski
© 2014 S. Dziegielewski


© 2014 S. Dziegielewski
Complete a
comprehensive safety
plan with clear
documentation.
Preventing Harm and
Risk—Safety Planning as
Standard of Practice
© 2014 S. Dziegielewski
© 2014 S. Dziegielewski




Can you list the primary disorders that
constitute the depressive disorders?
Can you identify at least two commonalities
that disorders in this category share?
Can you identify the types of depression
and how depression can manifest
differently in children?
Review PowerPoint slides for the answers!
© 2014 S. Dziegielewski


What is the bereavement exclusion in DSMIV and DSM-IV-TR?
Why did they delete the bereavement
exclusion of 2 months from DSM-5?
© 2014 S. Dziegielewski


Can you convert a DSM-IV-TR diagnosis to a
DSM-5?
What major factors would you need to take
into account?
© 2014 S. Dziegielewski