DSM-5 Essentials: The Savvy Clinician's Guide to the Changes in Criteria

By Lourie W. Reichenberg

Everything you need to know about the DSM-5 in an organized and concise presentation

Providing you with a quick and easy way to get up-to-speed on recent changes to the two main classification systemsDSM-5 Essentials highlights these changes in a logical and systematic manner so that you can easily make the transition from DSM-IV to DSM-5.

Author Lourie Reichenberg offers health care providers, instructors, clinicians in practice settings, and office staff who do coding for insurance reimbursement the information they need to do their jobs smoothly and efficiently with coverage of:

• The twenty classifications of disorders
• Emerging measures and models
• The future of diagnosis and treatment planning
• Matching clients' needs with the best evidence-based treatment
• Major changes to the DSM-5 such as the replacement of the multiaxial system, the developmental and lifespan approach, and cultural and gender considerations

Arranged in the same sequence as the DSM-5, DSM-5 Essentials covers what has changed from the DSM-IV, what these changes mean for diagnosis, and the implication of these changes on the selection of effective, evidence-based treatment.

• Language: English
• Publisher: Wiley
• Release date: Nov 18, 2013
• ISBN: 9781118846094

Book preview

Chapter 1

INTRODUCTION

In May 2013, the fifth edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders was published. The DSM, along with the International Classification of Diseases (ICD), are the two classification systems that mental health professionals turn to for the assessment, diagnosis, and coding of mental disorders. Both classification systems are important for clinicians, because the code numbers that the DSM uses are those listed for similar disorders in the ICD. Both sets of codes (ICD-9 and ICD-10, which takes effect in 2014) are included in DSM-5 and in this book. Following a discussion of the major changes to DSM-5, a brief history and explanation of how to use the World Health Organization's ICD codes will be provided.

INTRODUCTION TO DSM-5

Over the past 60 years, the Diagnostic and Statistical Manual of Mental Disorders (DSM), published by the American Psychiatric Association (APA), has become the standard reference for mental health professionals in the United States. With the publication of the fifth edition earlier this year, DSM-5 (APA, 2013a) has become more consistent with WHO's International Classification of Diseases Clinical Modifications (ICD-CM, the coding system used in the United States).

DSM-5 incorporates years of research about the brain, human behavior, and genetics. Thousands of experts participated in more than 160 task forces, work groups, and study groups over a 12-year period to research, measure, and conduct field trials of diagnostic criteria for the mental health disorders. In December 2012, the Board of Trustees of the APA approved the final changes that now constitute DSM-5.

All of the additions or substantive changes to DSM-5 were supported by research and planned with the intent to improve diagnosis and treatment, and to be able to be incorporated into routine clinical practice. According to the APA, all changes were intended to more clearly and accurately define the criteria for that mental disorder. Doing so helps to ensure that the diagnosis is accurate as well as consistent from one clinician to another—benefiting patients and the care they receive (APA, 2013b).

These and other enhancements to DSM-5, such as changes in the organizational structure, use of dimensional and cross-cutting measures, and consistency with ICD codes were planned to increase the manual's clinical utility and enhance its value for clinicians and researchers alike.

To help clinicians conceptualize and diagnose disorders, DSM-5 is divided into three sections:

Section I provides a basic introduction on how to use the new manual, how to diagnose using a nonaxial system, and a new definition of a mental disorder as a syndrome that causes clinically significant problems with cognitions, emotion regulation, or behavior that results in dysfunctional mental functioning and is associated with significant distress or disability in social, occupational, or other important activities (APA, 2013a, p. 20).

Section II provides 20 classifications of disorders that focus on diagnostic criteria and codes.

Section III, Emerging Measures and Models, includes assessment measures, cultural formulation, an alternative model for personality disorders, and conditions for further study.

The Appendix of DSM-5 features highlights of the changes made from DSM-IV to DSM-5, glossaries of terms and cultural concepts of distress, and ICD-9 and ICD-10 codes.

We turn now to a more detailed look at several important changes in DSM-5 that will impact how clinicians conceptualize the diagnosis of mental disorders: the elimination of the multiaxial system of diagnosis, the adoption of a dimensional approach to diagnosis, developmental and lifespan considerations, and the expansion of gender-related and cultural considerations.

Using a Nonaxial System

The multiaxial system in DSM-5 has been replaced with a nonaxial system that combines Axis I, Axis II, and Axis III with all mental and other medical diagnoses listed together. This is consistent with how the WHO's International Classification of Diseases records diagnoses—listing as many diagnoses as necessary to provide the clinical picture. The principal diagnosis is the one listed first and reflects either the reason for the visit or the focus of treatment.

For example, a person who makes an appointment for treatment of mild depression related to bipolar disorder and who also meets the criteria for borderline personality disorder would be coded as follows:

296.51 Bipolar I disorder, mild, most recent episode depressed

301.83 Borderline Personality Disorder

This indicates that the focus of treatment will be the bipolar disorder.

In keeping with the established WHO guidelines, other conditions that may be the focus of clinical attention will continue to be listed along with the diagnosis to highlight relevant factors that affect the client's diagnosis, prognosis, or treatment, or if they best represent the client's presenting problem. This list of psychosocial and environmental problems has been expanded in DSM-5 with additional V codes (from ICD-9) and Z codes (from ICD-10). If the same person in the previous example discusses exacerbation of his bipolar depression as a result of separation from his wife, the coding would look like this:

296.51 Bipolar I disorder, mild, most recent episode depressed

301.83 Borderline Personality Disorder

V61.03 Disruption of Family by Separation or Divorce

The Global Assessment of Functioning scale (Axis V) has also been eliminated in DSM-5. In its place, WHO's Disability Assessment Schedule (WHODAS) is included as a measurement of functioning. This useful tool can be found in DSM-5's Section III. Additional assessment measures are included in the print version of DSM-5 and online at www.psychiatry.org/dsm5

DSM-5 reassures us that a multiaxial system is not required to diagnose a mental disorder, although that system has been adopted by many insurance companies and governmental agencies. The elimination of the multiaxial system brings DSM-5 more closely inline with WHO's nonaxial system of diagnosis.

Dimensional Approach to Diagnosis

DSM-IV was based on a categorical system of classifying disorders that assessed the presence or absence of a symptom. This system of categorization had many shortcomings, as many diagnoses are not discrete entities that fit neatly into categories. The result was excessive comorbidity, fuzzy boundaries between disorders, and excessive reliance by clinicians on the NOS (not otherwise specified) category (Jones, 2012).

DSM-5 takes a dimensional approach to diagnosis, providing dimensional and cross-cutting assessments to increase clinical utility and enhance diagnostic specificity on the part of clinicians.

In many instances, separate disorders are not really separate at all but are actually related conditions on a continuum of behavior, with some conditions reflecting mild symptoms, whereas other conditions are much more severe. Consider, for example, bipolar disorders as a spectrum. Individuals can present with a range of symptoms from mild (cyclothymia), to moderate (bipolar II), or more severe (bipolar I). DSM-5 adopts the spectrum concept for many disorders, including substance abuse, autism, and schizophrenia. Using a spectrum approach allows clinicians to consider disorders on a continuum of severity.

In DSM-5, specifiers have also been added to many of the disorders to enhance diagnosis and increase clinical utility. When provided in DSM-5, specifiers apply to the client's current presentation, and only when the full criteria for a disorder have been met. Various types of specifiers in DSM-5 include:

Course (e.g., in partial remission)

Severity (e.g., mild, moderate, severe)

Frequency (e.g., two times per week)

Duration (e.g., minimum duration of 6 months)

Descriptive features (e.g., with poor insight)

In DSM-5, a number of cross-cutting measures and assessments are provided to measure symptoms frequently observed in clients regardless of their presenting concern. These assessments can be used in the initial assessment interview to measure other symptoms the client may be experiencing (e.g., anxiety, depression, substance abuse), and readministered at a later date to monitor treatment progress. Two levels of cross-cutting measures are available. Level 1 measures provide a screening tool for the presence of 18 different symptom areas. If symptoms indicate, a Level 2 screening can be conducted. Turn to Chapter 3 for a complete list of assessment tools provided by the APA in the print version of the DSM-5 and online.

Use of Other Specified and Unspecified Disorders

In DSM-5, clinicians are given two alternatives to the catchall Not Otherwise Specified category. Other Specified Disorder and Unspecified Disorder can be used when full criteria have not been met for a disorder, according to the following restrictions:

1. Other specified disorder. This category enables the clinician to identify presentations in which the symptoms are clinically significant, but do not meet the full criteria for a disorder, and to state the specific reason why the diagnostic criteria for any given disorder has not been met. For example, other specified bipolar and related disorder can be diagnosed in the following four distinct ways: (1) persons with a history of a major depressive disorder who now meet all but the duration criterion for hypomania (i.e., at least 4 consecutive days); (2) persons who meet the duration criterion but have too few symptoms of hypomania to meet the overall criteria for bipolar II; (3) the presence of a hypomanic episode without any history of major depressive disorder; and (4) short duration cyclothymia (less than 24 months) in which hypomania and depressive symptoms are present for most days but do not meet the full criteria for MDD, mania, hypomania, or a psychotic disorder. (The duration criterion is reduced to less than 12 months for children and adolescents.) In the presence of this constellation of symptoms, other specified bipolar and related disorder would be the