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
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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
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
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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, 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
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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
“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
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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
1.
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
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!
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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
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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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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
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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
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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
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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
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Somatic Symptom & Related Disorders
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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
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307.50 (F50.9) Unspecified Feeding or Eating Disorder
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Elimination Disorders
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

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.
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Other Personality Disorders