Jim Messina, Ph.D., CCMHC, NCC, DCMHS Assistant Professor Troy University, Tampa Bay Site Learning Objectives PART 1 1. Status of the new DSM-5 2. Categories and changes in DSM-5 3. Impact of DSM-5 for Clinical Mental Health Counselors 1. 2. 3. Openings for Integrated Behavioral Medicine Specialty Openings for Co-Occurring Disorders Treatment Specialty Opening for Trauma Specialty 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 5. Integrated Behavioral Medicine Diagnosis and Treatment Planning using the ICD Codes for Common Medical Conditions resulting in Mental Health Disorders PART 2 1. Using DSM-5 for Improved Clinical Assessment, Diagnosis and Treatment Planning 4. Websites on DSM-5 Official APA DSM-5 site: www.dsm5.org DSM-5 on: www.coping.us Timeline of DSM-5 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 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 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 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 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 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, 2015 to alphanumeric ICD-10-CM codes on October 1, 2015 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 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 “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 The provisional diagnoses are often found in the “differential diagnosis” section within each disorders section of the DSM-5 3. Other Condition 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 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 1. 1A. Categories of: Relational Problems in Other Conditions That May Be a Focus of Clinical Attention 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) 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 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 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 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, 2015, ICD-10 codes are in effect! Implementation Date Change The ICD-10 is the basis for ICD-10-CM codes which according to the DSM-5 was to be required as of October 1, 2014 in the United States as the codes to be used in all clinical reports and for insurance and third party reimbursement billing. However on April 1, 2014, the Protecting Access to Medicare Act of 2014 (PAMA) (Pub. L. No. 113-93) was enacted, which said that the Secretary may not adopt ICD-10 prior to October 1, 2015. Accordingly, the U.S. Department of Health and Human Services expects to release an interim final rule in the near future that will include a new compliance date that would require the use of ICD-10 beginning October 1, 2015. The rule will also require HIPAA covered entities to continue to use ICD-9-CM through September 30, 2015. 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 Organization of IDC-10-CM Codes 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 Specific Changes Per Diagnostic Category in DSM-5 Neurodevelopmental Disorders 1. Intellectual Disability (Intellectual Developmental Disorder) no longer relies on IQ used as specifier because it is the adaptive functioning that determines levels of support required. IQ measures are less valid in the lower end of the IQ range Still accepted that people with intellectual disability have scores two standard deviations or more below the population mean, including a margin for error which is generally +5 points. Thus on tests with standard deviations of 15 and mean of 100 the score for mild would involve 65-75 (70+5). 2. Asperger's Syndrome is lumped into Autism Spectrum since it is at the milder end of the Spectrum 3. Childhood disintegrative disorder, Rett's disorder and Pervasive developmental disorder not otherwise specified are also now incorporated into the Autism Spectrum Disorder 4. Autism Spectrum Disorder is now characterized by deficits in two domains: 1. Deficits in social communication and social interaction 2. Restricted repetitive patterns of verbal and nonverbal communication. Schizophrenia and Other Psychotic Disorders 1.Changes for Criteria A for Schizophrenia were made: 1) elimination of the special attribution of bizarre delusions and Schneiderian first-rank auditory hallucinations (two or more voices conversing), leading to the requirement of at least two Criterion A symptoms for any diagnosis of schizophrenia 2) the addition of the requirement that at least one of the Criterion A symptoms must be delusions, hallucinations, or disorganized speech. 2. DSM-IV-TR subtypes of schizophrenia were eliminated 3. Schizoaffective disorder is reconceptualized as a longitudinal rather than a cross sectional diagnosis and requires that a major mood episode be present for a majority of the total disorder's duration after Criterion A has been met 4. Schizotypal Personality Disorder is now listed in this category Bipolar and related disorders 1. Bipolar is now a free standing category 2. Bipolar was taken out of the mood disorder category 3. Diagnostic criteria now include both changes in mood and changes in activity or energy Depressive Disorders 1. Dysthymia is now called Persistent Depressive Disorder 2. Disruptive Mood Dysregulation Disorder has been added for children up to age 18 years who exhibit persistent irritability and frequent episodes of extreme behaviors 3. Premenstrual Dysphoric Disorder has been added Anxiety Disorders 1. No longer has PTSD in this category 2. No longer has OCD in this category 3. Social Phobia is now called Social Anxiety Disorder 4. Panic Disorder and Agoraphobia are unlinked and each now have their own separate criteria 5. Separation anxiety disorder and selective mutism are now classified as anxiety disorders Obsessive-Compulsive and Related Disorders 1. OCD is now a stand alone category 2. Body Dysmorphic Disorder is now listed under OCD 3. Hoarding has been added under the category of OCD 3. Trichotillomania (Hair-Pulling Disorder) is listed under OCD 4. Excoriation (Skin Picking Disorder) is listed under OCD Trauma and Stressor Related Disorders 1 Trauma related disorders are now a stand alone category 2. Reactive Attachment Disorder is now listed here 3. Disinhibited Social Engagement Disorder has been added 4. PTSD is listed here 5. PTSD in Preschool Children has been added 6. Acute Stress Disorder is listed here and requires qualifying traumatic events as explicit as to whether they were experienced directly, witnessed or experienced indirectly 7. Adjustment Disorders are now listed here and conceptualize as a heterogeneous array of stress-response syndromes that occur after exposure to a distressing (traumatic or nontraumatic) event. Dissociative Disorders 1. Dissociative Fugue has been removed from this category and is now a specifier of dissociative amnesia 2. Derealization is included in the name and symptom structure of the former depersonalization disorder to become: Depersonalization/Derealization disorder. Somatic Symptom Disorder 1. Replaced Somatiform Disorders category with this category 2. Somatization Disorder; Pain Disorder; Hypochondriasis and undifferentiated somatoform disorder were eliminated 3. Complex Somatic Symptom Disorder was added 4. Simple Somatic Symptom Disorder was added 5. Illness Anxiety Disorder was added and replaces Hypochondriasis 6. Conversion Disorders (Functional Neurological Disorder) have modified criteria to emphasize essential importance of neurological examination, in recognition that relevant psychological factors may not be demonstrable at time of diagnosis 7. Psychological factors affecting other medical conditions has been added to this category and along with Factitious disorder both have been placed among the somatic symptom and related disorders because somatic symptoms are predominant in both disorders Feeding and Eating Disorders 1. Pica was moved to this category 2. Rumination Disorder was moved to this category 3. The "feeding disorder of infancy or early childhood” has been renamed: Avoidant/Restrictive Food Intake Disorder 4. Binge Eating Disorder was added Elimination Disorders 1. This category was created as freestanding category 2. Enuresis was moved to this category 3. Encopresis was move to this category Sleep-Wake Disorders 1. Primary Insomnia renamed Insomnia Disorder 2. Primary Hypersomnia joined with Narcolepsy without Cataplexy 3. Cheyne-Stokes Breathing added 4. Obstructive Sleep Apnea Hypopnea added 5. Idiopathic Central Sleep Apnea added 6. Congenital Central Alveolar Hypoventilation added 7. Rapid Eye Movement Behavior Disorder added 8. Restless Leg Syndrome added Sexual Dysfunctions 1. Male orgasmic disorder renamed Delayed Ejaculation 2. Premature (Early) Ejaculation renamed 3. Dyspareunia and Vaginismus were combined into Genito-Pelvic Pain/Penetration Disorder 4. Sexual Aversion Disorder combined in other categories 5. For females-sexual desire and arousal disorders have been combined into one disorder: Female sexual interest/arousal disorder Gender Dysphoria 1 This is a new diagnostic class 2. It emphasizes the phenomenon of "gender incongruence" rather than cross-gender identification per se. 3. Posttransition specifier has been added to identify individuals who have undergone at least one medical procedure or treatment to support new gender assignment Disruptive, Impulse Control, and Conduct Disorders 1. This is a new diagnostic class and combines "Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence" and the "Impulsecontrol Disorders Not Elsewhere Classified" 2. Oppositional Defiant Disorder was added here 3. Trichotillomania removed from this category 4. Conduct Disorder now in this freestanding category 5. Antisocial Personality Disorder added to this category as well as in Personality Disorders Category Substance Abuse and Addictive Disorders 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 Neurocognitive Disorders 1. Category replaces “Delirium, Dementia, and Amnestic and Other Cognitive Disorders” Category 2. Now distinguishes between Minor and Major Disorders 3. Replace wording of Dementia "due to" with Neurocognitive Disorder "Associated with" for all the conditions listed 4. Added new Neurocognitive Disorders: 1. Fronto-Temporal Lobar Degeneration 2. Traumatic Brain Injury 3. Lewy Body Disease 5. Renamed Head Trauma to Traumatic Brain Injury 6. Renamed Creutzfeldt-Jakob Disease to Prion Disease Personality Disorders Cluster A Personality Disorders 301.0 (F60.0) Paranoid Personality Disorder 301.20 (F60.1) Schizoid Personality Disorder 301.22 (F21) Schizotypal Personality Disorder Cluster B Personality Disorders 301.7 (F60.2) Antisocial Personality Disorder 301.83 (F60.3) Borderline Personality Disorder 301.50 (F60.4) Histrionic Personality Disorder 301.81 (F60.81) Narcissistic Personality Disorder Cluster C Personality Disorders 301.82 (F60.6) Avoidant Personality Disorder 301.6 (F60.7) Dependent Personality Disorder 301.4 (F60.5) Obsessive-Compulsive Personality Disorder Other Personality Disorders 310.1 (F07.0) Personality Change Due to Another Medical Condition Specify whether Labile type; Disinhibited Type; Aggressive Type; Apathetic Type; Paranoid Type; Other Type; Combined Type; Unspecified Type 301.89 (F60.89) Other Specified Personality Disorder 301.9 (F60.9) Unspecified Personality Disorder Paraphilic Disorders 1. They all carried over to DSM-5 2. New names for them all but the category remains the same 3. Overarching change is the addition of course specifiers in a controlled environment in remission 4. Distinction between paraphilias and paraphilic disorder was made: Paraphilic disorder is a paraphilia that is currently causing distress or impairment to the individual or a paraphilia whose satisfaction has entailed personal harm, or risk of harm, to others. Paraphilia is a necessary but not a sufficient condition for having a paraphilic disorder, and a paraphilia by itself does not automatically justify or require clinical intervention Conditions Designated for Further Study in DSM-5 in Section III Attenuated Psychosis Syndrome Depressive Episodes with Short-Duration Hypomania Persistent Complex Bereavement Disorder Caffeine Use Disorder Internet Gaming Disorder Neurobehavioral Disorder Associated with Prenatal Alcohol Exposure Suicidal Behavior Disorder Nonsuicidal Self-Injury Possible Disorders Discussed But Not Included in Section III of DSM-5 Dissociative Trance Disorder Anxious Depression Factitious disorder imposed on another Hypersexual Disorder Olfactory Reference Syndrome Paraphilic Coercive Disorder Behavioral Medicine Specialization Based on the DSM-5 Definition of Behavioral Medicine Behavioral Medicine is the interdisciplinary field concerned with the development and the integration of behavioral, psychosocial, and biomedical science knowledge and techniques relevant to the understanding of health and illness, and the application of this knowledge and these techniques to prevention, diagnosis, treatment and rehabilitation. (Definition is provided by Society of Behavioral Medicine on their website at: http://www.sbm.org/about ) 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 Rule of Thumb in Diagnosing Medically Related Conditions First: Put in the ICD code for the Medical Condition Second: Put in the mental health disorder related to the Medical Condition Schizophrenia & Psychotic Disorder Co-occurring with Medical Condition 293.81 (F06.2) Psychotic Disorder due to Another Medical Condition with delusions 293.82 (F06.0) Psychotic Disorder due to Another Medical Condition with hallucinations 293.89 (F06.1) Catatonic Disorder Associated with Another Medical Condition 293.89 (F06.1) Catatonic Disorder Due to Another Medical Condition Bipolar Co-occurring with Medical Condition 293.83 (F06.33) Bipolar and Related Disorder due to Another Medical Condition with manic features 293.83 (F06.33) Bipolar and Related Disorder due to Another Medical Condition with manic-or hypomanic-like episode 293.83 (F06.34) Bipolar and Related Disorder due to Another Medical Condition with mixed features Depressive Disorder Co-occurring with Medical Condition 293.83 (F06.31) Depressive Disorder Due to Another Medical Condition with depressive features 293.83 (F06.32) Depressive Disorder Due to Another Medical Condition with major depressive-like episodes 293.83 (F06.34) Depressive Disorder Due to Another Medical Condition with mixed features Anxiety Disorder Co-occurring with Medical Condition 293.84 (F06.4) Anxiety Disorder Due to Another Medical Condition Obsessive-Compulsive Co-occurring with Medical Condition 294.8 (F06.8) Obsessive-Compulsive and Related Disorder Due to Another Medical Condition Specify if with obsessive-compulsivedisorder-like symptoms or with appearance preoccupation or with hoarding symptoms or with hair-pulling symptoms or with skin picking symptoms Somatic Symptom & Related Disorders 300.82 (F45.1) Somatic Symptom Disorder 300.7 (F45.21) Illness Anxiety Disorder Conversion Disorders (Functional Neurological Symptoms Disorder) 300.11 (F44.4) Conversion Disorder with weakness or paralysis 300.11 (F44.4) Conversion Disorder with abnormal movement 300.11 (F44.4) Conversion Disorder with swallowing symptoms 300.11 (F44.4) Conversion Disorder with speech symptoms 300.11 (F44.5) Conversion Disorder with attacks or seizures 300.11 (F44.6) Conversion Disorder with anesthesia or sensory loss 300.11 (F44.6) Conversion Disorder with special sensory symptom 300.11 (F44.7) Conversion Disorder with mixed symptoms 316 (F54) Psychological Factors Affecting Medical Condition 300.19 (F68.10) Factitious Disorder (includes Factitious Disorder Imposed on Self, Factitious Disorder imposed on Another) 300.89 (F45.8) Other Specified Somatic Symptom and Related Disorder 300.82 (F45.9) Unspecified Somatic Symptom and Related Disorder Feeding & Eating Disorders 307.52 (F98.3) Pica in Children 307.52 (F50.8) Pica in Adults 307.53 (98.21) Rumination Disorder 307.59 (50.8) Avoidant/Restrictive Food Intake Disorder 307.1 (F50.01) Anorexia Nervosa Restricting type 307.1 (F50.02) Anorexia Nervosa Binge-eating/purging type 307.51 (F50.2) Bulimia Nervosa 307.59 (F50.8) Other Specified Feeding or Eating Disorder 307.50 (F50.9) Unspecified Feeding or Eating Disorder Elimination Disorders 307.6 (F98.0) Enuresis 307.7 (F98.1) Encopresis 788.39 (N39.498) Other Specified Elimination Disorder with urinary symptoms 787.60 (R15.9) Other Specified Elimination Disorder with fecal symptoms 788.30 (R32) Unspecified Elimination Disorder with urinary symptoms 787.60 (R15.9) Unspecified Elimination Disorder with fecal symptoms Sleep-Wake Disorders 780.52 (G47.00) Insomnia Disorder 780.54 (G47.10) Hypersomnolence Disorder 347.00 (G47.419) Narcolepsy without Cataplexy but with hypocretin deficiency 347.01 (G47.411) Narcolepsy with Cataplexy but without hypocretin deficiency 347.00 (G47.419) Autosomal dominant cerebellar ataxia, deafness, and narcolepsy 347.00 (G47.419) Autosomal dominant narcolepsy, obesity and type 2 diabetes 347.10 (47.429) Narcolepsy secondary to another medical condition Breathing-Related Sleep Disorders 327.23 (G47.33) Obstructive Sleep Apnea Hypopnea Central Sleep Apnea 327.21 (G47.31) Idiopathic Sleep Apnea 786.04 (R06.3) Cheyne-Stokes Breathing 780.57 (G47.37) Central Sleep Apnea comorbid with opioid use (first code opioid use disorder if present.) Sleep-Related Hyperventilation 327.24 (G47.34) Idiopathic hypoventilation 327.25 (G47.35) Congenital central aveolar hypoventilation 327.26 (G47.36) Comorbid sleep-related hypoventilation Circadian Rhythm Sleep-Wake Disorders 307.45 (G47.21) Circadian Rhythm Sleep-Wake Disorder Delayed sleep phase type 307.45 (G47.22) Circadian Rhythm Sleep-Wake Disorder Advanced sleep phase type 307.45 (G47.23) Circadian Rhythm Sleep-Wake Disorder Irregular sleep-wake type 307.45 (G47.24) Circadian Rhythm Sleep-Wake Disorder Non24 hour sleep-wake type 307.45 (G47.26) Circadian Rhythm Sleep-Wake Disorder Shift Work type Parasomnias 307.46 (F51.3) Non-Rapid Eye Movement Sleep Arousal Disorder Sleepwalking Type Specify if: With sleep-related eating; With sleep-related sexual behavior (Sexsomnia) 307.46 (F51.4) Non-Rapid Eye Movement Sleep Arousal Disorder Sleep terror type 307.47 (F51.5) Nightmare Disorder Specify if: during sleep onset. Specify if: With associated non-sleep disorder; With associated other medical condition; With associated other sleep disorder 327.42 (G47.52) Rapid Eye Movement Sleep Behavior Disorder 333.94 (G25.81) Restless Legs Syndrome Sexual Dysfunctions 302.74 (F52.32) Delayed Ejaculation 302.72 (F52.21) Erectile Disorder 302.73 (F52.31) Female Orgasmic Disorder Specify if: Never experienced an orgasm under any situation 302.72 (F52.22) Female Sexual Interest/Arousal Disorder 302.76 (F52.6) Genito-Pelvic Pain/Penetration Disorder 302.71 (F52.0) Male Hypoactive Sexual Desire Disorder 302.75 (F52.4) Premature (Early) Ejaculation Focus of Behavioral Medicine Life-span approach to health & health care for: Children Teens Adults Seniors In racially and ethnically diverse communities Desired Impact of Behavioral Medicine Changes in behavior and lifestyle can: Improve health Prevent illness Reduce symptoms of illness Behavioral changes can help people: Feel better physically and emotionally Improve their health status Increase their self-care skills Improve their ability to live with chronic illness. Behavioral interventions can: Improve effectiveness of medical interventions Help reduce overutilization of the health care system Reduce the overall costs of care Key Strategies of Behavioral Medicine Lifestyle Change Training Social Support Examples of Goals of Lifestyle Change Improve nutrition Increase physical activity Stop smoking Use medications appropriately Practice safer sex Prevent and reduce alcohol & drug abuse Examples of Training in Behavioral Medicine Coping skills training Relaxation training Self-monitoring personal health Stress management Time management Pain management Problem-solving Communication skills Priority-setting Examples of Social Support Group education Caretaker support and training Health counseling Community-based sports events Trauma Focused Therapeutic Diagnosis & Treatment Planning Trauma and Stressor Related Disorders 1. 2. 3. 4. 5. PTSD for Adults, Teens, Children & Preschool Children Acute Stress Disorder Adjustment Disorders Reactive Attachment Disorder Disinhibited Social Engagement Disorder 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 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 Identify Diagnosis based on Traumatic Events &/or ACE Factors Principal Provisional Other Conditions that May Be a Focus of Clinical Attention 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 Substance Use Disorder and Mental Health Disorder Co-occurring Substance Use Disorders & Mental Health Disorder Treatment Specialty Focus Substance /Medication – Induced Disorders Schizophrenia Bipolar Disorder Depressive Disorders Anxiety Disorders Obsessive Compulsive Disorder Sleep-Wake Disorders Sexual Dysfunctions Neurocognitive Disorders Co-occurring Substance Disorder with Schizophrenic Induced Psychotic Disorder Alcohol Cannabis Phencyclidine Hallucinogens Inhalants Sedatives Amphetamines Cocaine Co-occurring Substance Disorder with Bipolar & Related Disorders Alcohol Phencyclidine Hallucinogens Sedatives Amphetamines Cocaine Co-occurring Substance Disorder with Depressive Disorders Alcohol Phencyclidine Hallucinogens Inhalants Opioid Sedatives Amphetamines Cocaine Co-occurring Substance Disorder with Anxiety Disorders Alcohol Caffeine Cannabis Phencyclidine Hallucinogens Inhalant Opioid Sedative Amphetamine Cocaine Co-occurring Substance Disorder with Obsessive-Compulsive Disorder Amphetamines Cocaine Co-occurring Substance Disorder with Sleep-Wake Disorders Alcohol Caffeine Cannabis Sedative Amphetamine Cocaine Tobacco Co-occurring Substance Disorder with Sexual Dysfunctions Alcohol Opioid Sedative Amphetamine Cocaine Co-occurring Substance Disorder with Delirium & Neurocognitive Disorders Alcohol Cannabis Phencyclidine Hallucinogens Inhalant Opioid Sedative Amphetamine Cocaine Likelihood of SUDs in people with psychiatric diagnoses Diagnosis Odds Ratio Bipolar Disorder 6.6 Schizophrenia 4.6 Panic Disorder 2.9 Major Depression 1.9 Anxiety Disorder 1.7 Weiss, R.D. & Smith-Connery, H. (2011). Integrated Group Therapy for Bipolar Disorder and Substance Abuse. New York: Guilford Press. Substance abuse in patients with psychiatric illness Enhanced reinforcement Mood Change Escape Hopelessness Poor Judgment Inability to appreciate consequences Results of SUD with Psychiatric Disorder especially Bipolar Disorder Lower medication adherence Greater chance relapses Increased hospitalizations Homelessness Suicide Models of Dual Diagnosis Treatment Sequential – Treat SUD first then Psychiatric disorder Parallel – Treat both at same time but within different treatment modalities Integrated – Treat both at same time within the same treatment modality Integrated Treatment Model of Treatment of Comorbid Disorders Cognitive‐behavioral model focuses on parallels between the disorders in recovery/relapse thoughts and behaviors Explores the interaction between the two disorders Utilizes a single disorder paradigm: “bipolar substance abuse” Uses a “Central Recovery Rule” Focus of Integrated Model Dealing with the Psychiatric disorder without use of Alcohol &/or Drugs Confronting denial, ambivalence, acceptance Monitoring overall mood during each week Emphasis on compliance in taking psychiatric medications Identifying and fighting triggers Emphasis on “wellness” model of good night’s sleep, balance nutritional intake & exercise Parallels in Recovery & Relapse thinking between Disorders “May as well thinking” vs. “It matters what you do” Abstinence violation effect vs. stopping taking psychiatric meds when anxious or depressed Recovery thinking vs. relapse thinking and acting out Remember: you’re always on the road to getting better or getting worse: “It matters what you do!” The Central Recovery Rule No matter what Don’t drink Don’t use drugs Take your medication as prescribed No matter what Weiss, R.D. & Smith-Connery, H. (2011). Integrated Group Therapy for Bipolar Disorder and Substance Abuse. New York: Guilford Press. Completing a Thorough Clinical Assessment using the new DSM-5 System Steps to formulate an initial Tentative Diagnosis and Treatment Plan Do a thorough Psychosocial History 2. Do a Mental Status Examination 3. Develop a Diagnosis using DSM-5 4. Develop Treatment Plan 1. 1. 2. 3. 3 Goals 3 Objectives per Goal (total of 9) 1 Intervention per Objectives (total of 9) STEP 1: Complete Psychosocial History First: Establish - WHY NOW? You must be able to describe the presenting problem Listing specific symptoms and complaints which would justify diagnosis You must be able to list the duration of the symptoms or at least estimate the duration Second: Review client’s mental health history Previous treatment for mental health problems? Hospitalization for psychiatric conditions? As child involved in family therapy? Treatment for substance abuse problemsoutpatient or inpatient? Third: Determine if client is on any psychotropic medications What medications? Level of prescription? Who prescribed medications? For what are the medications prescribed? Fourth: Review client’s relevant medical history What is current overall physical health of client? When was last physical? Is there anything currently or in the past medically accounting for this current mental health complaint? Fifth: Review client’s family history Do a genogram of the family Identify psychosocial stressors within the family structure Mental health and/or substance abuse history with in the family and if successfully treated Sixth: Review client’s social history School history: Failed grades? Academic success? Social interaction with peers? Highest academic level attained? Community history: Peer group? Current network of social support? Activities and interests: sports, hobbies, social functioning? Seventh: Review client’s vocational history Level of current employment and commitment to current job? Relevant past employment history: length of tenure on past jobs, job hopping, relationships with work peers? Level of satisfaction with current employment? Eighth: List client’s strengths Identify those strengths which make the client a good candidate for successful therapy to address the “here and now” mental health problem How motivated for therapy is client? How insightful to symptoms? How psychologically minded is client? How verbal and intelligent? Ninth: List liabilities client brings to therapy Level of present social support system? Mandated for freely coming to therapy? Perceptual problems which could interfere e.g. hearing, vision, etc. Risk of decompensating (relapsing) if not treated Tenth: Rate Client on ACE Scale Identify Relevant ACE (Adverse Childhood Experiences) Abuse http://www.cdc.gov/ace/index.htm 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 Eleventh (Optional): Use & Report on Assessments 1. DSM-5 Self-Rated Level 1 Cross-Cutting Symptom Measure—Adult, 11-17, Parent Report for Children 2. DSM-5 Level 2: Adult Scale by PROMIS: anger, depression, mania, repetitive thoughts, sleep disturbance, substance use 3. DSM-5 Level 2: Children Scale by PROMIS (Parent Report) & 11-17: anger, anxiety, depression, inattention, irritability, mania, sleep disturbance, substance use http://www.psychiatry.org/practice/dsm/dsm5/online-assessment-measures 4. DSM-5 Disorder-Specific Severity Measures Agoraphobia, Generalized Anxiety, Panic Disorder, Separation Anxiety, Specific Phobia, Acute Stress, PTSD 5. WHO Disability Measure World Health Organization Disability Assessment Schedule 6. DSM-5 Personality Inventories The Personality Inventory for DSM-5 - Adult & Children 7. DSM-5 Early Development & Home Background Clinician and Parent/Guardian 8. DSM-5 Cultural Formulation Interviews Patient Health Questionnaire (PHQ) forms at http://www.phqscreeners.com/ PHQ: assesses Depression, Anxiety, Eating Disorders and Alcohol Abuse 2. PHQ-9: Depressive Scale from PHQ 3. GAD-7: Anxiety Screener from PHQ 4. PHQ-15: Somatic Symptom Scale from PHQ 5. PHQ-SADS: Includes PHQ-9, GAD-7, PHQ-15 plus panic measure 6. Brief PHQ: PHQ-9 and panic measures plus items on stressors & women’s health 1. Step 2: Mental Status Examination Mental Health Status Exam Mental Health Status Exam Rates Client’s: Appearance Consciousness Orientation to person, place & time Speech Affect Mood Concentration Activity level Thoughts Memory Judgment Step 3: Formulate Tentative Diagnosis Formulate Tentative Diagnosis You are ready to make a tentative Diagnosis using DSM-5 Including: 1. Principal Diagnosis 2. Provisional Diagnosis 3. Other Conditions That May Be a Focus of Clinical Attention DSM-5 Diagnosis Model Use DSM-5 Most Appropriate Classification Compare client’s symptoms lists with those contained in DSM-5 to get to most appropriate tentative Principal diagnosis Then list any and all secondary Principal diagnoses if the client’s symptoms match up for them Also list Provisional Diagnoses if the client’s presentation allows for these additional diagnoses List all relevant ICD Codes for Other Conditions That May Be a Focus of Clinical Attention Each must be listed with number & description just like the principal diagnosis It is important to remember The Diagnosis given a client is tentative dependent on gathering more data in future anticipated treatment Diagnoses can ALWAYS be changed to address changes with the individual’s presentation & functioning Impact of DSM-5 for Mental Health Clinicians Openings for Integrated Behavioral Medicine Specialty 2. Openings for Trauma Specialty 3. Openings for Co-Occurring Disorders Treatment Specialty 1. Application with Real Cases You will now break into groups of 4 or 5 members to work on the following five cases and be prepared to give your complete DSM-5 Model Diagnosis for each case Best of Luck in Using the DSM-5 My hope is that this helped to get you ready to use the DSM-5 to show your competency and clinical expertise in ways you have never been able to do given the limitation of the deficiencies of the previous DSM models.