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Using DSM-5 for DUAL Diagnosis Assessment , Diagnosis & Treatment Plans

Jim Messina, Ph.D., CCMHC, NCC, DCMHS Assistant Professor Troy University, Tampa Bay Site. Using DSM-5 for DUAL Diagnosis Assessment , Diagnosis & Treatment Plans. Objectives Workshop. Status of the new DSM-5 Categories and changes in DSM-5

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Using DSM-5 for DUAL Diagnosis Assessment , Diagnosis & Treatment Plans

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  1. Jim Messina, Ph.D., CCMHC, NCC, DCMHS Assistant Professor Troy University, Tampa Bay Site Using DSM-5 for DUAL Diagnosis Assessment, Diagnosis & Treatment Plans

  2. Objectives Workshop • Status of the new DSM-5 • Categories and changes in DSM-5 • Impact of DSM-5 for treating Co-Occuring Disorders • 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 • Integrated Behavioral Medicine Diagnosis and Treatment Planning using the ICD Codes for Common Medical Conditions resulting in Mental Health Disorders • Using DSM-5 for Improved Clinical Assessment, Diagnosis and Treatment Planning

  3. Websites on DSM-5 • Official APA DSM-5 site: www.dsm5.org • DSM-5 on: www.coping.us

  4. 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

  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

  6. 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.

  7. 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.)

  8. 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

  9. DSM-5 Diagnostic Categories • 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

  10. 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

  11. 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, 2014 to alphanumeric ICD-10-CM codes on October 1, 2014 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 

  12. 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.

  13. 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

  14. 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-substance-related 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 

  15. 2. Provisional Diagnosis Specifier "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

  16. 3. Other Conditions 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

  17. Categories of: Other Conditions that May Be a Focus of Clinical Attention • Relational • Educational and Occupational Problems • Housing and Economic Problems • Other Problems Related to the Social Environment • Problems Related to Crime or Interaction with the Legal System • Other Health Service Encounters for Counseling and Medical Advice • Problems Related to Other Psychosocial, Personal and Environmental Circumstances • Other Circumstances of Personal History

  18. 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

  19. 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

  20. 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

  21. So a DSM-5 based Diagnosis must include: • One or More principal Diagnoses • One or More Provisional Diagnoses • One or More Other Conditions That May Be a Focus of Clinical Attention • You need all three to have a complete diagnosis using the DSM-5 Model

  22. 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, 2014, ICD-10 codes are in effect!

  23. 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

  24. 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

  25. 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

  26. Changes for Substance Abuse and Addictive Disorders in DSM-5 Only 3 qualifiers are used in the category:  • Use - replaces both abuse and dependence • 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

  27. Impact of DSM-5 for Clinicians • Openings for Integrated Behavioral Medicine Specialty • Openings for Co-Occurring Disorders Treatment Specialty • Openings for Trauma Specialty

  28. 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

  29. 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

  30. 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

  31. Then Identify Diagnosis based on ACE • Principal • Provisional • Other Conditions that May Be a Focus of Clinical Attention (V codes until October 2014 and TZ code beginning October 2014)

  32. 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

  33. Co-Occurring Disorders Treatment Specialty Focus • Substance /Medication – Induced Disorders • Schizophrenia • Bipolar Disorder • Depressive Disorders • Anxiety Disorders • Obsessive Compulsive Disorder • Sleep-Wake Disorders • Sexual Dysfunctions • Neurocognitive Disorders

  34. Co-Occurring Substance Disorder with Schizophrenic Induced Psychotic Disorder • Alcohol • Cannabis • Phencyclidine • Hallucinogens • Inhalants • Sedatives • Amphetamines • Cocaine

  35. Co-Occurring Substance Disorder with Bipolar & Related Disorders • Alcohol • Phencyclidine • Hallucinogens • Sedatives • Amphetamines • Cocaine

  36. Co-occurring Substance Disorder with Depressive Disorders • Alcohol • Phencyclidine • Hallucinogens • Inhalants • Opioid • Sedatives • Amphetamines • Cocaine

  37. Co-occurring Substance Disorder with Anxiety Disorders • Alcohol • Caffeine • Cannabis • Phencyclidine • Hallucinogens • Inhalant • Opioid • Sedative • Amphetamine • Cocaine

  38. Co-occurring Substance Disorder with Obsessive-Compulsive Disorder • Amphetamines • Cocaine

  39. Co-occurring Substance Disorder with Sleep-Wake Disorders • Alcohol • Caffeine • Cannabis • Sedative • Amphetamine • Cocaine • Tobacco

  40. Co-occurring Substance Disorder with Sexual Dysfunctions • Alcohol • Opioid • Sedative • Amphetamine • Cocaine

  41. Co-occurring Substance Disorder with Delirium & Neurocognitive Disorders • Alcohol • Cannabis • Phencyclidine • Hallucinogens • Inhalant • Opioid • Sedative • Amphetamine • Cocaine

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