DSM-5:
Just the Basics
(Excerpt from 6 hr CEU training)
Debbie Spaeth, LMFT, LPC, LADC
Quest MHSA, LLC
Diagnostic & Statistical Manual of
Mental Disorders - 5
Purpose: Assist trained clinicians in Dx of Mental
Dis’ as part of case formulation assessment that
leads to a fully informed (cultural/social) Tx Plan for
each individual. Manual makes NO
recommendations for Tx or ForensicsCompentency/Criminal Resp./Disability
Dx Criteria Sets: Summarize characteristic
syndromes of signs/symptoms that point to
underlying disorder, follows developmental path
Published by American Psychiatric Association
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. MD's 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 the death of a loved one, is not a MD. Socially deviant behavior
(political/religious/sexual) and conflicts that are primarily between the individual and society are not MD unless
the deviance/conflict results from a dysfunction in the individual, as described above.
DSM-5: Diagnostic Elements
Assessment
Dx Criteria and Descriptors
Subtypes and Specifiers
Course
Severity
Principal Diagnosis
Hierarchy determined by order of the Focus of Tx
Primary Dx - reason for appointment or admission
Secondary Dx - lesser focus
Tertiary Dx - least focus
Comorbidity = MH Dx first and Medical 2nd
No Multi-Axial
Consider patient’s functional status separately from Dx
or symptoms
Axis I, II, & III are combined
IV is now displayed in V and ICD Z codes
V/GAF is now WHODAS - World Health Org Disability
Assess Schedule, 36 item self admin w/domains
Diagnostic Criteria
Diagnostic features
Associated features
Prevalence
Gender-related
diagnostic issues
Suicide risk
Development and course
Functional
consequences
Risk and prognostic factors
Differential diagnosis
Culture-related diagnostic
issues
Comorbidity
Dx Criteria - Cont
Culture/Gender Related Issues
Suicide Risk
Functional Consequences
Differential Diagnosing
Comorbidity
Provisional & Differential Dxs
#1: Does not meet full criteria
Strong presumption that full criteria will be met
“provisional” is written after Dx on record
#2: Differential Dx = similar but distinct
“Other Specified”- title, w/insufficient symptoms
“Unspecified”- clinician does not reveal specifics
Course
Usual Dx is the current presentation of Patient
Can be full presentation
Recurrent presentation
Previous Dx noted by partial or full remission
Severity
Intensity
Frequency
Duration
Symptom Count
Indicated “Specify Current Severity” criteria set
Descriptive Features Specifiers
Additional
Information that can
inform Tx Planning
“with poor insight”
International Coding
WHO, CMS, CDC, Prevention’s Nat Cent Health Stat
Purpose: Data Collection, Billing, Mortality/Effect
Official Date: October 14, 2014
Oklahoma Date: Can begin January 1, 2014
ICD-9 and ICD-10 are included in the Manual
DSM and ICD-11 plan towards unity
4, 5, & 6th digit coding
Digits 1-3 relate to the diagnostic category
Allows increased specificity of Dx
Subtypes: mutually exclusive phenominological
subgroupings w/in a Dx, indicated by “Specify
whether” instruction in the criteria set.
Specifiers: not mutually exclusive, so multiple
spcifiers may be listed, indicated by “Specify” or
“Specify if” instruction in the criteria set.
Subtype/Specifiers and
ICD-9 & 10
International Statistical Classification of Diseases
and Related Health Problems - World Health Org.
Majority of the Subtypes and Specifiers cannot be
coded in ICD-9 or 10 systems (Medicaid/MCR), but
some 4 & 5th codes covered in ICD
Use S&S in the Dx Title on documentation if not
supported in ICD coding
Diagnosis & Format, examples
1) 312.81 (F91.1) Conduct Disorder, child onset,
w/ limited prosocial emotions, severe
V61.03 (Z63.5) Disruption of Fmaily by Divorce;
995.54 (T74.12XD) Subsequent encounter;
V60.2 (Z59.5) Extreme Poverty
2) 314.01 (F90.2) Attention-deficit hyperactivity disorder, combined
presentation; Other factors: V62.3 (Z55.9) Academic underachievement
3) Case #2: 301.81 (F60.81) Narcissistic Personality Disorder; V62.29
(Z56.9) Other Problem Rltd to Employment
4) 300.01 (F41.0) Panic Disorder; Other factors: 995.81 (T74.11XD)
Spouse/Partner Violence, subsequent encounter; V61.03 (Z63.5
Disruption of family by divorce (recent); V60.2 (Z59.7) Low income;.
Measures and Models
Cross-Cutting
Symptom Measure
Adult Self-rated Level 1 CCSM - pg 738/9
13 domains: Depression, Anger, Mania, Anxiety,
Somatic Symptoms, Suicidal Ideation, Psychosis,
Sleep, Memory, Repetitive Thoughts/Behaviors,
Dissociation, Personality Functioning, and
Substance Use
Mild or Greater = Further Inquiry for Level 2
All Level 2 tools - www.psychiatry.org/dsm5
CCSM contd.
Parent/Guar rated Level 1 for 6-17 yoa, pg 740/1
12 domains: Somatic Symptoms, Sleep, Inattention,
Depression, Anger, Irritabiity, Mania, Anxiety,
Psychosis, Retetitive Thoughts/Behaviors,
Substance Use, and Suicidal Ideation/Attempts
Mild or Greater = Further Inquiry for Level 2
All Level 2 tools - www.psychiatry.org/dsm5
Other Assessment Tools
Clinician-Rated Dimensions
of Psychosis Symptom
Severity
World Health Organization
Disability Assessment
Schedule 2.0 (WHODAS 2.0)
Cultural Formulation
Cultural Formulation Interview (CFI) pgs. 752-7
Definition of Problem
Perceptions of Cause/Context/Support
Self-Coping and Past/Current Help Seeking
Patient or Informant
Alternative Personality Disorders Model
Level of Personality Functioning Scale
Self - Identity & Self Direction
Level of Impairment Scale: 0 none - 4 extreme
Interpersonal - Empathy & Intimacy
Definitions of Personality Dis Trait Domains/Facets
Study Conditions
Attenuated Psychosis Syndrome
Depressive Episodes w/Short-Duration Hypomania
Persistent Complex Bereavement Disorder
Caffeine Use Disorder
Internet Gaming Disorder
Neurobehavioral Dis Assoc w/Prenatal Alcohol Exp
Suicidal Behavior Disorder/Nonsuicidal Self Injury
Appendix
DSM-IV to DSM-5 changes
Glossary of Terms
Glossary of Cultural Concepts of Distress
Alphabetical/Numerical Listings
ICD 9 and 10 Listings
Index
Debbie Spaeth, LMFT, LPC, LADC
DSpaeth@questmhsa.com