The use of DSM-IV-TR and ICD-9-CM/ICD-10 in School Settings

1. The use of DSM-IV-TR and ICD-9-CM/ICD-10 in School Settings Alvin E. House, Ph.D. Department of Psychology Illinois State University

2. Goals of presentation • Familiarity with basic components of DSM

3. Goals of presentation • Familiarity with basic components of DSM • Understanding the structure of DSM

4. Goals of presentation • Familiarity with basic components of DSM • Understanding the structure of DSM • Introduction to the use of DSM

5. Goals of presentation • Familiarity with basic components of DSM • Understanding the structure of DSM • Introduction to the use of DSM • What’s not covered: • Concerns about medical model • Problems with categorical assessment • Everything that is wrong with DSM

6. Goals of presentation • What’s not covered: • When do you play at a crooked card game?

7. Goals of presentation • What’s not covered: • When do you play at a crooked card game? • When it’s the only game in town.

8. Goals of presentation • What’s not covered: • When do you play at a crooked card game? • When it’s the only game in town. • DSM-IV-TR/ICD-9-CM is the only game in town with regard to most potential sources of “recovered funds”, “third party carriers”, “reimbursement”, “funding”

9. Two metaphors for DSM-IV-TR • A house

10. Two metaphors for DSM-IV-TR • A house Oh, isn’t that a clever play on words. What, they’re both made from trees? I had to take the morning off for this?

11. Two metaphors for DSM-IV-TR • A house • “Constructed”, not “found”

12. Two metaphors for DSM-IV-TR • A house • Constructed, not “found” • Constrained by nature of phenomenon

13. Two metaphors for DSM-IV-TR • A house • Constructed, not “found” • Constrained by nature of phenomenon • Utility rather than truth criterion for success

14. Two metaphors for DSM-IV-TR • A house • A language

15. Two metaphors for DSM-IV-TR • A house • A language used to communicate

16. Two metaphors for DSM-IV-TR • A house • A language used to communicate used to capture as much information about the case as possible

17. Two metaphors for DSM-IV-TR • A house • A language used to communicate used to capture as much information about the case as possible It’s less about getting the “right answer” than getting the clearest message across

18. The central role played by the examiner in DSM • You are the most important element of a DSM-IV-TR diagnosis

19. The central role played by the examiner in DSM • DSM is at heart a tool prepared by (mostly) physicians for the use of (mostly) other physicians

20. The central role played by the examiner in DSM • You are the standard by which almost all judgments are made

21. The central role played by the examiner in DSM • You are the standard by which almost all judgments are made • Clinical judgment and responsibility are critical factors in DSM

22. The central role played by the examiner in DSM • Sign/symptom • Syndrome • Disorder • Disease

23. The central role played by the examiner in DSM • Sign/symptom

24. The central role played by the examiner in DSM • Sign/symptom • Sign: objective manifestation of pathological condition observed by examiner (p. 827) • Symptom: subjective manifestation of pathological condition reported by affected individual (p. 828)

25. Sources of confusion • The complexity of the subject/task

26. Sources of confusion • The complexity of the subject/task • Errors in the references • Very first case in DSM-IV-TR Case Studies shows a diagnosis of Mental Retardation on Axis I (p. 4)

27. Sources of confusion • The complexity of the subject/task • Errors in the references • Ambiguities in the document • What counts for a “setting” (besides “school” and “home”) for ADHD?

28. Sources of confusion • The complexity of the subject/task • Errors in the references • Ambiguities in the document • What counts for a “setting” (besides “school” and “home”) for ADHD? • Does an Adjustment Disorder diagnosis take precedence over a thematic NOS diagnosis?

29. DSM-IV-TR Multiaxial Assessment

30. DSM-IV-TR Multiaxial Assessment Continued

31. _ _ _ . _ _ Number The 3-5 digit number is the ICD-9-CM code for the condition or disorder being recorded ________ Disorder Title The condition or disorder being recorded (title, criterion set, other features) is an entry from DSM-IV-TR All DSM-IV-TR diagnoses are legitimate ICD-9-CM and ICD-10 diagnoses “DSM-IV-TR diagnosis”

32. DSM-IV Conceptualization of Mental Disorder • “In DSM-IV, each of the mental disorders is conceptualized as a clinically significant behavioral or psychological syndrome or pattern that occurs in an individual and that is associated with present distress (e.g., a painful symptom) or disability (i.e., impairment in one or more important areas of functioning) or with a significantly increased risk of suffering death, pain, disability, or an important loss of freedom.” DMS-IV-TR, 2000, p. xxxi

33. DSM-IV Conceptualization of Mental Disorder Continued • Clinically significant • Syndrome/pattern • Occurs in an individual • Not expectable & culturally sanctioned response to a particular event • Conflicts between individual and society are not mental disorders, unless the deviance or conflict is a symptom of a dysfunction in the individual • Classified disorders that people have, not people

34. Clinical significance • Distress

35. Clinical significance • Distress • Impairment

36. Clinical significance • Distress • Impairment • In order to reduce false positive diagnoses almost all DSM-IV-TR diagnoses reiterate the distress/impairment criteria for a mental disorder

37. Clinical significance • Distress • Impairment • In order to reduce false positive diagnoses almost all DSM-IV-TR diagnoses reiterate the distress/impairment criteria for a mental disorder • An interesting exception is one of the few criterion changes made in the TR revision: • Tourette’s Disorder

38. Use of DSM: multiple diagnoses • DSM-IV-TR allows/encourages multiple diagnoses when the criteria for more than one diagnosis are met

39. Use of DSM: multiple diagnoses • DSM-IV-TR allows/encourages multiple diagnoses when the criteria for more than one diagnosis are met; however, there are three general exceptions to control unbridled comorbidity

40. Use of DSM: multiple diagnoses • Three general exceptions to multiple diagnoses: • General Medical Condition/Substance Use

41. Use of DSM: multiple diagnoses • Three general exceptions to multiple diagnoses: • General Medical Condition/Substance Use “not due to the direct effects of a substance (e.g., drugs of abuse or medication) or a general medical condition.”

42. Use of DSM: multiple diagnoses • Three general exceptions to multiple diagnoses: • General Medical Condition/Substance Use • Associated feature of a more pervasive disorder

43. Use of DSM: multiple diagnoses • Three general exceptions to multiple diagnoses: • General Medical Condition/Substance Use • Associated feature of a more pervasive disorder “has never met the criteria for . . . .” “does not meet the criteria for . . . .” “does not occur exclusively during the course of . . . .”

44. Use of DSM: multiple diagnoses • Three general exceptions to multiple diagnoses: • Associated feature of a more pervasive disorder more pervasive diagnoses usually take precedence over more focal or narrow diagnoses

45. Importance of Associated Symptoms • Associated symptoms are not part of a disorder’s definition or criterion set, but are common observed in the clinical presentation • Associated symptoms tell you what else a given diagnosis will “account for” • Associated symptoms help you decide if a single diagnosis is sufficient to explain the features of your case or if other diagnoses are needed

46. Course and Associated Symptoms • An concurrent diagnosis of a pattern that normally would be as associated symptom of a more pervasive disorder, would suggest that you had established a history of the independent occurrence of that set of problems

47. Course and Associated Symptoms • An concurrent diagnosis of a pattern that normally would be as associated symptom of a more pervasive disorder, would suggest that you had established a history of the independent occurrence of that set of problems For example, diagnosing • Major Depressive Disorder, Single Episode • and • Generalized Anxiety Disorder Would suggest you had established a history of GAD when the Major Depressive Disorder wasn’t present

48. Course and Associated Symptoms • An concurrent diagnosis of a pattern that normally would be as associated symptom of a more pervasive disorder, would suggest that you had established a history of the independent occurrence of that set of problems For example, diagnosing • Major Depressive Disorder, Single Episode • and • Generalized Anxiety Disorder Or that you had made a mistake

49. Use of DSM: multiple diagnoses • Three general exceptions to multiple diagnoses: • Associated feature of a more pervasive disorder more pervasive diagnoses usually take precedence over more focal or narrow diagnoses Conduct Disorder has precedence over ODD

50. Use of DSM: multiple diagnoses • Three general exceptions to multiple diagnoses: • Associated feature of a more pervasive disorder more pervasive diagnoses usually take precedence over more focal or narrow diagnoses Conduct Disorder has precedence over ODD Mood Disorders have precedence over Anxiety Disorders