DSM-IV-TR in Action : DSM-5 E-Chapter Update.

46 Pages·2013·6.82 MB·English

by  Dziegielewski, Sophia F.

C01 07/15/2010 11:54:23 Page2
3GFFIRS 08/22/2013 11:50:50 Pagei
DSM-5
TM
E-Chapter Update
to DSM-IV-TR
TM
in Action
Second Edition
SOPHIA F. DZIEGIELEWSKI
3GFFIRS 08/22/2013 11:50:50 Page ii
Cover image: top image: © iStockphoto.com/blackred, bottom image: © iStockphoto.com/DNY59
Cover design: Wiley
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3GCHAPTER 08/23/2013 8:22:12 Page1
DSM-5™ Update to DSM-IV-TR™
in Action, Second Edition
INTRODUCTION concepts of the diagnostic assessment applying
the DSM-5 as the primary means for mental
Formulating and completing a diagnostic assess- health assessment. This book, supported by
mentisembeddedintheuseofsupportingtexts, this last chapter with the DSM-5 updates, is to
oftenreferredtoasthe“bibles”ofmentalhealth, continuetobeusedasthefoundationtosupport
such as the Diagnostic and Statistical Manual of behavior-based practice strategy and treatment
Mental Disorders, Fourth Edition, Text Revision planning. It is also expected to identify and
(DSM-IV-TR™) and the International Classifica- provideupdatesrelativetoAPA’snewestversion
tionofDiseases,NinthEdition(ICD-9).Thesetwo of the DSM and explain how these changes will
versionsoutliningdiagnosticstandardsformental relate to the diagnostic assessment and subse-
health practice have represented state-of-the-art quent treatment efforts.
assessments for over a decade. Therefore, it
should come as no surprise to mental health
professionalsthatpresentationofthenewedition THEDSMANDTHEICD:THEBIBLES
of the Diagnostic and Statistical Manual of Mental OFMENTALHEALTH
Disorders, Fifth Edition (DSM-5™) and expected
utilization for insurance billing of International The DSM-IV-TR (2000) was the standard for
Classification of Diseases, Tenth Edition (ICD-10) assessment until the revision to this edition
withitslatestmandatoryrequirementforusagein (DSM-5) was released in May, 2013. The
October 2014, will bring forth what some con- DSM-IV-TR and DSM-5 state clearly that these
sider earth-shaking changes. For example, the booksaredesignedtobeusedinawidevarietyof
committee responsible for the DSM-5 made the settings, including inpatient and outpatient set-
decisionearlyontoeliminatetheromannumeral tings as well as consultation and liaison work.
from the title, changing it from the expected Furthermore, the latest versions of the DSM
DSM-V to DSM-5. It is also expected that the remain designed to be used by professionals
revisions will follow a similar pattern with the and are not to be used as self-help books for
first edition titled DSM-5 and each subsequent the lay public. Paris (2013) questions this, how-
revisionfollowedbyaDSM-5.1,DSM-5.2,and ever, stating that clients have a right to know
so on. theirowndiagnosisandthemoretheyknowthe
Thepurposeofthischapteristoupdate,and moretheycanbecomeempoweredtoparticipate
insomecasesreintroduce,thereadertothecore in self-help strategy. Also, with the Internet and
1
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2 DSM-5™ E-CHAPTER UPDATE TO DSM-IV-TR™ IN ACTION
other forms of information so readily accessible, policydecisions.Whatremainsconsistentamong
clients become active in gathering information allversionsoftheDSMisthatitdoesnotsuggest
related to their own mental health. Clients treatmentapproaches.Therefore,othersupport-
shouldnotbekept inisolationoftheirdiagnosis ivebooks,aswellasthepreviouschaptersofthis
andthecriteriathatcontributestoit,asdoingso textthatsuggesttreatmentstrategy,remainrele-
createsadisservicethatforcesthemtobepassive vant for achieving comprehensive, efficient, and
consumers of their own health care. Arguments effective care.
that the DSM is very complex and could over- The International Classification of Diseases
whelm a client unfamiliar with the technical (ICD) is said to have its origins in the 1850s.
jargon have been questioned and active partici- When completing diagnostic assessment, the
pation on the part of the client has become importance of the ICD cannot be underesti-
expected (Paris, 2013). mated. The World Health Organization
Similar to previous versions of the DSM, (WHO), after assuming responsibility for the
DSM-5 suggests the book is for use by profes- ICD,wascreditedasthefirstofficialinternational
sionalpractitionerssuchaspsychiatristsandother classification system for mental disorders. This
physicians, psychologists, social workers, occu- beganwiththefirstedition(ICD-6)publishedin
pational and rehabilitation therapists, and other 1948, under the auspices of WHO. Following
health and mental health professionals (APA, this early publication of the ICD, the APA
2000, 2013). Because these professionals can all published its first edition of the DSM in 1952.
have very different training and expertise, par- Originally, the APA developed the DSM for
ticular attention to following the diagnostic statistical, epidemiological, and reporting pur-
criteria is expected, coupling this with clinical poses,whereastheICDwasdevelopedtoreflect
skill and judgment designed to achieve similar clinical approaches to diagnosis and training
determinations. Before putting the DSM-5 into (Sorensen, Mors, & Thomsen, 2005). This is
practice, professionals will need to be trained in probably why the ICD remains the global stan-
how to use categorical and dimensional dard for diagnostic classification and why it is
approaches,aswellasbeingawareofthepoten- recognized for service reimbursement. After the
tial for misuse. When using any diagnostic sys- WorldHealthAssemblyadoptedthenomencla-
tem, care and consideration should always be ture outlined by WHO, use of the ICD for
given to protect the rights of the patients being mortality and morbidity statistics was adopted
served. by all member states in 1967. The ICD is a
In the United States, the DSM is often used classification system that creates a global linkage
to classify mental health disorders. True to its and allows for disorders across the world to be
historical roots, the most current version of the viewedatonepointintime;therefore,scientific
DSMsupportsthispurposebystatingthatitisto progressultimatelyrequiresrevisionandupdates
be used for statistical and assessment purposes as (Sartorios, 1992). Similar to the DSM, the ICD
wellaseducationalsupport.ThismakestheDSM has gone through many changes and updates.
an important reference for students, researchers, The latest version of the ICD is ICD-10, which
and clinicians. For clinicians, it provides the replaced ICD-9-CM (WHO, 1979, 1990). Sub-
starting point for determining the nature of a sequently, it is expected that ICD-11 will be
client’s problem. It also provides supportive released in 2015.
informationonprevalencerateswithinthelarger The ICD-10 was originally released in 1990
population that have been gathered to inform andreceivedfullendorsementbyWHOin1994.
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DSM-5™UpdatetoDSM-IV-TR™inAction,SecondEdition 3
QUICKREFERENCE1
WEBSITES FOR GENERAL ICD-10 INFORMATION
ICD-10-CM files, information related to diseases, functioning, and disability
http://www.cdc.gov/nchs/icd/icd10.htm
ICD-9-CM files related to diseases, functioning and disability
http://www.cdc.gov/nchs/icd/icd9cm.htm
In 2002, it was published in 42 languages and in APA states clearly that the categories are general
1999, the United States implemented it for mor- enough to match the categories in the ICD,
tality (death certificates). Currently, it consists of ensuring clarity and uniformity between the
three volumes. Volume 1 has tabular lists that two texts may once again become a concern.
contain cause of death titles and the codes that This will be most evident to those trained on
accompany the cause of death titles; Volume 2 has DSM-IV and DSM-IV-TR as these texts closely
description guidelines and coding resources; and match the ICD-9-CM. For billing purposes,
Volume 3 provides an alphabetical index to dis- there were few discrepancies between the cate-
eases and the nature of injury, external causes of gories listed and both books DSM-IV and DSM-
injury, and table of drugs and chemicals (see Quick IV-TR could be used interchangeably. In the
Reference 1). ICD-10 hosts more than 141,000 application to treatment, however, all versions of
codes with many different diagnostic categories the book should remain helpful as the classifi ca-
compared to the 17,000 codes present in the ICD- tion systems cross all theoretical orientations but
9-CM (AAPC, 2013). do not suggest treatment.
The DSM-IV-TR is similar to the ICD in Since the DSM provides more comprehen-
terms of diagnostic codes and the billing catego- sive diagnostic support than the ICD, it has gained
ries. Concern has been voiced that although the its greatest popularity in the United States. This
codes are listed for both the ICD 9-CM followed recognition has made it the resource tool most
by the codes for ICD-10-CM, the criteria needed often used by psychiatrists, psychologists, psychi-
for the diagnosis may not match what has been atric nurses, social workers, and other mental
updated in DSM-5. Similar to what happened in health professionals. Similar to what has been
the late 1980s with DSM-III , some professionals suggested in the past, related to the close relation-
fear that once again the diagnostic and billing ship between placing the diagnosis and reimburse-
categories won’t match. Since these two books mentandbillingrequirements,cliniciansneedto
need to go hand-in-hand, categories with criteria remain knowledgeable of both books.
listed in one book that are not listed in the other
can be extremely problematic for proper coding
and reimbursement. These two books have to SOWHATABOUTBILLING?
work together and when clinicians use the ICD
for billing while referring to the DSM for clarity For diagnostic classification and billing, ICD is
of the diagnostic criteria, both books need to consideredtheglobalstandard.InOctober2014,
have similar matching criteria. Although the the ICD-10 codes for service will replace the
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4 DSM-5™ E-CHAPTER UPDATE TO DSM-IV-TR™ IN ACTION
ICD-9-CM codes currently in use across the reimbursement leaders all agreed to wait until
United States (CMS, 2013). The reason for October 2014. To date, some agencies and
adopting the new version is three-fold: (1) It is organizations moved forward to utilize the sys-
expected to provide improved data for measur- tem conversions as originally mandated. For
ing health care and service quality; (2) it will help those agencies that already made billing system
information technology systems to record more changes as originally posted, either the ICD-9-
specific and comprehensive diagnostic informa- CM or ICD-10 codes can be used temporarily.
tion; and (3) it can improve documentation and Regardless,allagenciesthatdoelectronicbilling
billing information by helping to better identify will need to complete the transition by the due
specific health conditions (UnitedHealthcare date,whichwaslastscheduledforOctober2014.
Online, 2013). ICD conforms to the Health Insu- In summary, for the most part DSM-IV and
rance Portability Accountability Act (HIPAA) of DSM-IV-TRparalleltheICD-9-CMbutDSM-5
1996 that seeks to protect consumers, among does not directly parallel ICD-10 in quite the
other things, by creating standardized mecha- sameway.NordoesitparallelICD-11,whichis
nisms for electronic data exchanges involving the expected to be released in 2015. It is highly
transfer and subsequent usage of consumer pri- recommendedthattrainingbeprovidedforbill-
vate health-care related data. In 2000, ICD-9- ing staff and practitioners who intend to use the
CM, inclusive of its three volumes, was adopted billing categories outlined in ICD-10-CM. For
for reporting of diagnoses, other health prob- practitioners in private practice without billing
lems, causes of injury, diseases, and impairments staff, training on ICD-10-CM is also recom-
in all standard billing transactions. Furthermore, mended, as well as the suggestion that practi-
according to the Secretary of the Department of tioners become familiar with both books, the
Health and Human Services, a ruling was ICD and the DSM.
released and published in the Federal Register
on January 16, 2009, to adopt the ICD-10-CM
standards and the Procedural Coding System DSM-5:SUPPORTINGTHECHANGES
(PCS). The final rule is posted on: http://
www.gpo.gov/fdsys/pkg/FR-2009–01–16/pdf/ According to the DSM-5 task force, all changes
E9–743.pdf. This means that everyone covered madeinthisversionchartedthefollowingprem-
by HIPAA must be ICD-10 compliant. ises. First, the priority was always given to
Some professionals may question why it increasing clinical utility by making the book
took so long to adopt the ICD-10 and there is as relevant and helpful to clinicians as possible.
nosimpleanswer.Forthemostpart,theoriginal This would allow clinicians to make the transi-
push was to make ICD-10 the standard back in tion from the previous edition and see how the
2003.Thepushback wasso great, however, and changes support improved diagnostic acumen.
filled with concerns about it being too big a Second, changes were based on research
change to adopt while also trying to work with evidence. The DSM-IV and the DSM-IV-TR
newly designated HIPAA regulations. There- were no strangers to research as many of the
fore, the implementation date has been pushed sweeping diagnostic changes made in the previ-
backseveraltimes.Whentheyoriginallytriedto ous version were also research supported. Since
makeithappenin2013,theinpatientversionof this was one of the major weaknesses in earlier
the ICD-10-PCS was so complicated and diffi- editionsoftheDSM,DSM-IVandDSM-IV-TR
cult to incorporate into the Content Manage- addressed this shortfall by basing the diagnostic
ment Systems (CMS), administrative and changes on: (1) literature reviews, (2) data
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DSM-5™UpdatetoDSM-IV-TR™inAction,SecondEdition 5
analysis and reanalysis, and (3) field trials. Fur- Lastly,DSM-5seekstoclarifytheboundaries
thermore,researchincludedsystematicandcom- between what constitutes normal human func-
puterized reviews, to support the suggestions tioning and what constitutes a mental disorder.
made by the individual work groups as well as This is an important distinction, especially when
data analysis and reanalysis. DSM-IV-TR also workingwithchildrenandadolescents.Forexam-
included12fieldtrialseachwith5to10different ple, when does the agitated teenager represent
sites and over 1,000 participants (APA, 2000). whatcouldbeconsideredatypicalimpulsiveactin
Thus, the two most recent editions of the responsetoaproblemandwhenisitassessedtobe
DSM, unlike their predecessors, have made something more? When looking at depressive
efforts to incorporate the best mix of practice symptomsintheadult,theysimplymaynotpre-
wisdomandresearchfordeterminingthecriteria sentthesameasinadolescents.Inthe30-year-old
and characteristics of categories presented. This male, for example, the mood may be depressed
trendwasexemplifiedinDSM-5,comprisingnot andthecongruentaffectissadorblunted,whereas
only clinical field trials but also including large intheadolescentthemoodmaystillbedepressed
academicfieldtrials.Inaddition,specialattention butmaypresentasangryandagitated.Thisangry
was given to establishing reliability information andimpulsivebehaviorcouldinturnresultinone
related to the criteria included and the modifi- ormorerepeatedactsthatareinterpretedasmood
cations made. Similar to DSM-IV, the literature swings similar to bipolar disorder.
reviews were conducted to elicit clinical utility,
reliability (i.e., did the same criteria continue to
present from case to case), as well as testing new DSM-5:THREESECTIONS
measurement instruments and criteria related to
psychometric performance. The DSM-5 has had major changes to the struc-
Third, there were also periods during the ture and the format of the book, resulting in all
development that provided open windows of chapters being organized in the lifespan order.
opportunity for practicing clinicians to provide Within this new organizational structure, the
clinical feedback related to the diagnostic cate- mental disorders that can occur in infants, chil-
gories and changes proposed. This allowed all dren,andadolescentsarelistedfirstineachrespec-
clinicians to comment and make suggestions for tive chapter. This leads to the elimination of the
criteria changes. These suggestions were viewed ChildDisorderssectionoutlinedinDSM-IVand
without the expectation of predetermined con- DSM-IV-TR.Terminologythatmaybehelpfulto
straints on changing structure and format, espe- note in DSM-5 involves the terms neurodevelop-
cially if it was noted to be problematic. mentalandneurocognitive(seeQuickReference2).
QUICKREFERENCE2
DEFINITIONS AND THE LIFESPAN APPROACH
Neurodevelopmental: Examinesdiagnosesacrossthelifespanandthedisordersmostfrequently
diagnosed in childhood.
Neurocognitive: Examines diagnoses most frequently diagnosed in adulthood.
Source:SummarizedinformationfromtheDiagnosticandStatisticalManualofMentalDisorders,FifthEdition.
Copyright2013bytheAmericanPsychiatricAssociation.
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6 DSM-5™ E-CHAPTER UPDATE TO DSM-IV-TR™ IN ACTION
QUICKREFERENCE3
DSM-5—THREE SECTIONS
Section I: Introduction and Directions on How to Use the Updated Manual
Section II: Outline the Categorical Diagnoses That Eliminated the Multiaxial System (20 Disorder
Chapters and 2 Additional Categories)
Section III: Conditions That Require Future Research, Cultural Formulations, and Other Information
The DSM-5 manual has been restructured This is followed by 20 chapters that outline the
andbrokendownintothreesections(seeQuick documentedmentaldisordersfoundinSectionII
Reference3).SectionIprovidesanintroduction (seeQuickReference4).SectionIIIoutlinesthe
to the manual, some rationale for the changes, conditions that require future research, cultural
and instructions for using the updated manual. formulations, and other information.
QUICKREFERENCE4
SECTION II—CATEGORICAL SECTIONS: 20 DISORDERS
AND 2 ADDITIONAL CATEGORIES
DSM-5Chapters
NeurodevelopmentalDisorders EliminationDisorders
SchizophreniaSpectrumandtheOther Sleep-WakeDisorders
PsychoticDisorders
BipolarandtheRelatedDisorders SexualDysfunctions
DepressiveDisorders GenderDysphoria
AnxietyDisorders Disruptive,ImpulseControl,andConductDisorders
Obsessive-CompulsiveandtheRelatedDisorders SubstanceUseandAddictiveDisorders
TraumaandStressor-RelatedDisorders NeurocognitiveDisorders
DissociativeDisorders PersonalityDisorders
SomaticSymptomDisorders ParaphilicDisorders
FeedingandEatingDisorders OtherDisorders
*OtherConditionsThatMayBeaFocusof *Medication-InducedMovementDisordersand
ClinicalAttention OtherAdverseEffectsofMedication
*Includesotherconditionsandproblemsthatrequire *Notconsideredmentaldisorders.
clinicalattentionbutnotmentaldisorders.