Evolution from DSM-IV to DSM-5: Understanding Changes and Challenges
What’s in DSM-5
•
DSM 5 diagnoses and numbers xiii-xl
•
summary of changes from IV -preface
•
How the DSM 5 was developed-Intro 5-19
•
Further description of major changes-intro
5-19
•
How to use the manual 19-24
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Diagnostic codes and diagnostic criteria for
every diagnosis pp31-715
•
Dimensional assessment measures 733-748
•
Dimensional assessment of personality
disorders 761-783
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Focus on cultural assessment 749-760
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Cultural formulation interviews 749-760
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Conditions for further study 783-808
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Highlight of all changes from DSM-IV to
DSM 5 PP 809 – 816
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Glossary of mental terms 817-832
•
Glossary of cultural concepts of distress
833-838
•
DSM crosswalks for ICD-9 and ICD 10 863-
897
WHY CHANGE?
•
DSM-IV’s organizational structure failed to
reflect shared features or symptoms of related
disorders and diagnostic groups (like psychotic
disorders with bipolar disorders, or
internalizing (depressive, anxiety, somatic) and
externalizing (impulse control, conduct,
substance use) disorders.
•
DSM-IV Thin on Culture
•
Did not represent or
integrate the latest
findings from
neuroscience, genetics
and cognitive research
•
Multi axial structure
was out of line with
the rest of medicine
•
Global assessment of
functioning was an
unreliable measure
•
Decision trees did not
increase inter-rater
reliability
Other problems
•
Separates diagnoses from treatment
•
Diagnosis has become an end in itself! (billability &
pressure for scientific determinism)
•
Minimizes TIME as a major factor in making diagnoses
•
Minimizes emergent symptoms
•
Minimizes lack of symptom clarity as an issue
•
Ignores internal unobservables
•
Funnels tx focus to symptom negation rather than well-
being
•
Forces clinician to make immediate diagnoses
•
Forces clinician to more severe DX
•
There have been no no established "zones of
rarity" between diagnosis (much symptom
overlap)
•
Law-like biological markers have not yet been
found
•
Categorical measurement (depressed vs NOT
depressed) doesn’t capture clinical variance
DSM III & IV limits
Focus on only what is observable; limits diagnostic
possibilities
Limited number of observable signs & symptoms
(12 to 19 symptoms )
Because law-like biomarkers have not been found,
Elements that cannot be seen directly
are excluded. This is exactly the opposite of
medicine which strives to see below the surface.
Limited number of observable signs/symptoms
But 400 diagnoses in DSM = diagnostic confusion
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DSM III & IV – problems with measuring
Limited number of observable signs and
Symptoms, Elements that cannot be seen directly
are excluded. This is exactly the opposite of
medicine which strives to see below the surface.
Limited number of observable signs/symptoms
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- false positives
-
rise of comorbidity
- problems of differential dx
- one size fits all diagnoses
- only agreement on most severe
The relationship between Categorical Dx,
comorbidity and increased reliability
•
1. no major depression; 2. major depression
•
1. No generalized anxiety 2. generalized anxiety
Depression
1 2 3
4 5 6 7
8
None minimal mild minor moderate major severe maximal
None minimal mild minor moderate major severe maximal
1 2 3
4 5 6 7
8
General anxiety
Categorical measurement increases potential for inter-rater
reliability. 50% chance of inter-rater reliability
Fewer choices = easier= less information = more possibility of
making mistake = inflated comorbidity
Categorical measures = No clinical variance & no diagnostic threshold
Decreasing variance increases potential for inter rater reliability and
increases potential for specious comorbidity
Dimensional measure
inter-rater reliability
lower = 12%
More choices = harder=
more info
Subtle distinctions ; less
Potential for specious
comorbidity
•
DSM III & IV turned assessment into yes/no
decision trees
•
Inflated comorbidity
•
Inflated inter-rater reliability (but did not
increase it)
•
Never established true biological markers
•
Reduced the rigorousness of good assessment
in the name of
clinical utility
DSM 5
1.
Emphasizes dimensional measurement
2.
Provides World Health Organization measure
of overall well-being
3.
Does away with Axes
4.
Focuses more on culture
5.
Attempts to “Re-organize” diagnostic
categories according to what we now (think
we)know
6.
Attempts to “re-group” individual diagnoses
according to what we now (think we) know
7.
Includes crosswalks with ICD-9 and ICD 10
http://www.dsm5.org/Pages/Default.aspx
1. Dimensional measures
http://www.psychiatry.org/practice/dsm/dsm5/online-assessment-measures#Level1
•
Allows clinician opportunity to “fine tune”
diagnosis
•
Captures diagnostic complexity
•
Should reduce inflated comorbidity. By allowing
inclusion of crosscutting symptoms (such as
anxiety) within other diagnoses
•
Focuses assessment on crosscutting symptoms
•
Creates "severity specifier" for many diagnoses
•
Dimensions make diagnosis congruent with up-
to-date neurocognitive research indicating
symptoms are on a continuum
•
DSM 5 adds dimensional
measures WITHOUT
abandoning categorical
measures
•
Criteria are basically the
same as they were in the
DSM-IV
Crosscutting symptoms
(symptoms that can occur across many DXs)
•
Captures
symptom comorbidity
without diagnostic
comorbidity
•
Cross-cutting symptom measures may aid in a
comprehensive mental status assessment by drawing
attention to symptoms that are important across diagnoses.
They are intended to help identify additional areas of
inquiry that may guide treatment and prognosis. The cross-
cutting measures have two levels: Level 1 questions are a
brief survey of 13 domains for adult patients and 12
domains for child and adolescent patients, and Level 2
questions provide a more in-depth assessment of certain
domains.
http://www.psychiatry.org/practice/dsm/dsm5/online-assessment-measures#Level1
Table 1: Adult DSM-5 Self-Rated Level 1 Cross-Cutting Symptom Measure:
domains, thresholds for further inquiry, and associated Level 2 measures for
adults ages 18 and over
DSM-5 Self-Rated Level 1 Cross-Cutting Symptom Measure—Adult
THE CROSS-CUTTING SYMPTOM MEASURES CAN DO THREE THINGS
1.
POINT YOU IN THE RIGHT DIRECTION DIAGNOSTICALLY (LEVEL I)
2.
GIVE YOU A BASIC SENSE OF THE CLINICAL PROFILE OF EACH CLINET
3.
CAPTURE SYMPTOMS THAT ARE LIKELY TO OCCUR ACROSS
DIAGNOSIS, BUT NOT NECESSARILY QUALIFY FOR ITS OWN DX
DEPRESSION
ANXIETY
SOMATIC SYMPTOMS
SLEEP ISSUES ETC.
level II measures(Dimensional)
•
Level II crosscutting measures
–
Focus on one specific domain
–
Provides a more varied clinical profile within that
domain
–
Allows for follow-up exploration with more than one
domain in order to specify diagnostic boundaries. (For
example, in my dealing with major depression with a
co-occurring anxiety disorder or major depression,
with anxious features
–
Provides clinical verification before diagnosis
Level 2 measures of symptoms
•
Level 2 questions provide a more in-depth
assessment of certain domains:
http://www.psychiatry.org/practice/dsm/dsm
5/online-assessment-measures#
Level2
•
Level 2 is given as a specific follow up, once
the clinician is ‘oriented’ in a symptomatic
direction they are focused WITHIN a specific
symptom domain
Level 2 Cross-Cutting Symptom Measures
For Adults
LEVEL 2—Depression—Adult
(PROMIS Emotional Distress—Depression—Short Form)
LEVEL 2—Anger—Adult
(PROMIS Emotional Distress—Anger—Short Form)
LEVEL 2—Mania—Adult
(Altman Self-Rating Mania Scale [ASRM])
LEVEL 2—Anxiety—Adult
(PROMIS Emotional Distress—Anxiety—Short Form)
LEVEL 2—Somatic Symptom—Adult
(Patient Health Questionnaire 15 Somatic Symptom Severity Scale [PHQ-15])
LEVEL 2—Sleep Disturbance—Adult
(PROMIS—Sleep Disturbance—Short Form)
LEVEL 2—Repetitive Thoughts and Behaviors—Adult
(Adapted from the Florida Obsessive-Compulsive Inventory [FOCI]
Severity Scale [Part B])
LEVEL 2—Substance Use—Adult
(Adapted from the NIDA-Modified ASSIST)
For Parents of Children Ages 6–17
LEVEL 2—Somatic Symptom—Parent/Guardian of Child Age 6–17
(Patient Health Questionnaire 15 Somatic Symptom
Severity Scale [PHQ-15])
LEVEL 2—Sleep Disturbance—Parent/Guardian of Child Age 6–17
(PROMIS—Sleep Disturbance—Short Form)
LEVEL 2—Inattention—Parent/Guardian of Child Age 6–17
(Swanson, Nolan, and Pelham, version IV [SNAP-IV])
LEVEL 2—Depression—Parent/Guardian of Child Age 6–17
(PROMIS Emotional Distress—Depression—Parent Item Bank)
LEVEL 2—Anger—Parent/Guardian of Child Age 6–17
(PROMIS Emotional Distress—Calibrated Anger Measure—Parent)
LEVEL 2—Irritability—Parent/Guardian of Child Age 6–17
(Affective Reactivity Index [ARI])
LEVEL 2—Mania—Parent/Guardian of Child Age 6–17
(Adapted from the Altman Self-Rating Mania Scale [ASRM])
LEVEL 2—Anxiety—Parent/Guardian of Child Age 6–17
(Adapted from PROMIS Emotional Distress—Anxiety—Parent Item
Bank)
LEVEL 2—Substance Use—Parent/Guardian of Child Age 6–17
(Adapted from the NIDA-Modified ASSIST)
For Children Ages 11–17
LEVEL 2—Somatic Symptom—Child Age 11–17
(Patient Health Questionnaire 15 Somatic Symptom Severity Scale [PHQ-15])
LEVEL 2—Sleep Disturbance—Child Age 11–17
(PROMIS—Sleep Disturbance—Short Form)
LEVEL 2—Depression—Child Age 11–17
(PROMIS Emotional Distress—Depression—Pediatric Item Bank)
LEVEL 2—Anger—Child Age 11–17
(PROMIS Emotional Distress—Calibrated Anger Measure—Pediatric)
LEVEL 2—Irritability—Child Age 11–17
(Affective Reactivity Index [ARI])
LEVEL 2—Mania—Child Age 11–17
(Altman Self-Rating Mania Scale [ASRM])
LEVEL 2—Anxiety—Child Age 11–17
(PROMIS Emotional Distress—Anxiety—Pediatric Item Bank)
LEVEL 2—Repetitive Thoughts and Behaviors—Child Age 11–17
(Adapted from the Children’s Florida Obsessive Compulsive
Inventory [C-FOCI] Severity Scale)
LEVEL 2—Substance Use—Child Age 11–17
(Adapted from the NIDA-Modified ASSIST)
List of all the level 2 (disorder specific) cross-cutting symptom measures
Table 1: Adult DSM-5 Self-Rated Level 1 Cross-Cutting Symptom Measure:
domains, thresholds for further inquiry, and associated Level 2 measures for
adults ages 18 and over
Hypothetically scores on our client using level I crosscutting symptoms indicated
the following areas circled
b
b
b
b
b
LEVEL 2—Depression—Adult*
*PROMIS Emotional Distress—
Depression
—Short Form
Name:
Age:
Sex:
Male
Female Date:_
If the measure is being completed by an informant
, what is your relationship with the individual receiving care?
In a typical week, approximately how much time do you spend with the individual receiving care?
hours/week
Instructions:
On the DSM-5 Level 1 cross-cutting questionnaire that you just completed, you indicated that
during the past 2 weeks
you (the
individual receiving care) have been bothered by “no interest or pleasure in doing things” and/or “feeling down, depressed, or hopeless” at a mild
or greater level of severity. The questions below ask about these feelings in more detail and especially how often you (the individual receiving
care) have been bothered by a list of symptoms
during the past 7 days.
Please respond to each item by marking (
P
or x) one box per row.
LEVEL 2—Substance Use—Adult*
*Adapted from the
NIDA-Modified ASSIST
Name:
Age:
Sex:
q
Male
q
Female Date:
If the measure is being completed by an informant
, what is your relationship with the individual receiving care?
In a typical week, approximately how much time do you spend with the individual receiving care?
hours/week
Instructions:
On the DSM-5 Level 1 cross-cutting questionnaire that you just completed, you indicated that
during the past 2 weeks
you
(the individual receiving care) have been bothered by “using medicines on your own without a doctor’s prescription, or in greater amounts
or longer than prescribed, and/or using drugs like marijuana, cocaine or crack, and/or other drugs” at a slight or greater level of severity.
The questions below ask how often you (the individual receiving care) have used these medicines and/or substances
during the past 2
weeks.
Please respond to each item by marking (
P
or x) one box per row.
Useless for alcohol. Perhaps ADS
LEVEL 2—Somatic Symptom—Adult Patient*
*Adapted from the Patient Health Questionnaire Physical Symptoms (PHQ-15)
Name: Age
:
Sex:
q
Male
q
Female Date:
If the measure is being completed by an informant
, what is your relationship with the individual receiving care?
In a typical week, approximately how much time do you spend with the individual receiving care?
hours/week
Instructions:
On the DSM-5 Level 1 cross-cutting questionnaire that you just completed, you indicated that
during the past 2 weeks
you (the individual receiving care) have been
bothered by “unexplained aches and pains”, and/or “feeling that your illnesses are not being taken seriously enough” at a mild or greater level of severity. The questions below ask
about these feelings in more detail and especially how often you (the individual receiving care) have been bothered by a list of symptoms
during the past 7 days.
Please respond to
each item by marking (
P
or x) one box per row.
Level 2 cross-cutting scale for Somatic symptoms - Adult
LEVEL 2—Anxiety—Adult*
*
PROMIS Emotional Distress—Anxiety—Short Form
Name:
Age:
Sex:
q
Male
q
Female Date:
If the measure is being completed by an informant
, what is your relationship with the individual?
In a typical week, approximately how much time do you spend with the individual?
hours/week
Instructions to patient:
On the DSM-5 Level 1 cross-cutting questionnaire that you just completed, you indicated that
during the past 2
weeks
you (individual receiving care) have been bothered by “feeling nervous, anxious, frightened, worried, or on edge”, “feeling panic
or being frightened”, and/or “avoiding situations that make you anxious” at a mild or greater level of severity. The questions below ask
about these feelings in more detail and especially how often you (individual receiving care) have been bothered by a list of symptoms
during the past 7 days.
Please respond to each item by marking (
P
or x) one box per row.
Instructions to parent/guardian:
On the DSM-5 Level 1 cross-cutting questionnaire that you just completed, you
indicated that during the past 2 weeks your child receiving care has been bothered by “feeling nervous, anxious, or
scared”, “not being able to stop worrying”, and/or “couldn’t do things he/she wanted to or should have done because
they made him/her feel nervous” at a mild or greater level of severity. The questions below ask about these feelings in
more detail and especially how often your child receiving care has been bothered by a list of symptoms during the past
7 days. Please respond to each item by marking ( or x) one box per row.
Level 2 cross-cutting scale for anxiety in children – parent filled
LEVEL 2—Sleep Disturbance—Adult*
*
PROMIS—Sleep Disturbance—Short Form
Name:
Age:
Sex:
q
Male
q
Female Date:
If the measure is being completed by an informant
, what is your relationship with the individual receiving care?
In a typical week, approximately how much time do you spend with the individual receiving care?
hours/week
Instructions to patient:
On the DSM-5 Level 1 cross-cutting questionnaire that you just completed, you indicated that
during the past
2 weeks
you (the individual receiving care) have been bothered by “problems with sleep that affected your sleep quality over all” at a mild or
greater level of severity. The questions below ask about these feelings in more detail and especially how often you (the individual receiving
care) have been bothered by a list of symptoms
during the past 7 days.
Please respond to each item by marking (
P
or x) one box per row.
DIMENSIONAL SEVERITY MEASURES
•
In addition to a diagnosis,
DSM MEASURES
SEVERITY OF MANY DIAGNOSIS
•
SEVERITY HAS NEVER BEEN CONSISTENTLY
MEASURED IN DSM UNTIL NOW
–
ONE EITHER WAS PSYCHOTIC OR ONE WAS NOT
–
THERE WERE NO GRADATIONS
Severity -
The DSM uses 2 methods of assessing
severity, depending on the diagnosis..
Method 1 involves using a specific dimensional
measure or scale Called “disorder specific severity
measures”. These can be find on the DSM 5 website
under online assessment measures (DIMENSIONAL
SCALE )
Method 2 involves counting the number of symptoms
and rating severity based on number of symptoms.
For example, ‘mild alcohol use Disorder = 2 – 3
symptoms: moderate alcohol use disorder = 4 – 5
symptoms; severe alcohol use Disorder= presence of 6
or more symptoms (Total number of diagnostic
crtieria)
Disorder-Specific Severity Measures
For Adults
Severity Measure for Depression—Adult
(Patient Health Questionnaire [PHQ-9])
Severity Measure for Separation Anxiety Disorder—Adult
Severity Measure for Specific Phobia—Adult
Severity Measure for Social Anxiety Disorder (Social Phobia)—Adult
Severity Measure for Panic Disorder—Adult
Severity Measure for Agoraphobia—Adult
Severity Measure for Generalized Anxiety Disorder—Adult
Severity of Posttraumatic Stress Symptoms—Adult
(National Stressful Events Survey PTSD Short Scale [NSESS])
Severity of Acute Stress Symptoms—Adult
(National Stressful Events Survey Acute Stress Disorder Short Scale [NSESS])
Severity of Dissociative Symptoms—Adult
(Brief Dissociative Experiences Scale [DES-B])
For Children Ages 11–17
Severity Measure for Depression—Child Age 11–17
(PHQ-9 modified for Adolescents [PHQ-A]—Adapted)
Severity Measure for Separation Anxiety Disorder—Child Age 11–17
Severity Measure for Specific Phobia—Child Age 11–17
Severity Measure for Social Anxiety Disorder (Social Phobia)—Child Age 11–17
Severity Measure for Panic Disorder—Child Age 11–17
Severity Measure for Agoraphobia—Child Age 11–17
Severity Measure for Generalized Anxiety Disorder—Child Age 11–17
Severity of Posttraumatic Stress Symptoms—Child Age 11–17
(National Stressful Events Survey PTSD Short Scale [NSESS])
Severity of Acute Stress Symptoms—Child Age 11–17
(National Stressful Events Survey Acute Stress Disorder Short Scale
[NSESS])
Severity of Dissociative Symptoms—Child Age 11–17
(Brief Dissociative Experiences Scale [DES-B])
Clinician-Rated
Clinician-Rated Severity of Autism Spectrum and Social Communication Disorders
Clinician-Rated Dimensions of Psychosis Symptom Severity
(also available in print book)
Clinician-Rated Severity of Somatic Symptom Disorder
Clinician-Rated Severity of Oppositional Defiant Disorder
Clinician-Rated Severity of Conduct Disorder
Clinician-Rated Severity of Nonsuicidal Self-Injury
This document is
found on page
743 of the DSM.
It allows the
clinician to rate
all of the salient
dimensions
that might be
present in a
disorder on the
schizophrenia
spectrum
- IN
TERMS OF
SEVERITY
-
using Likert scale
to rate the
dimensions
A.
Five or more
of the following symptoms of been
present
during the same two-week period
and
represent a change from previous functioning; at
least one of the symptoms is
either depressed mood
or loss of interest or pleasure
1. Depressed mood most of the day, nearly every day as indicated
by subjective reporter observation.
Yes or no
2. Marked diminished interest or pleasure in all our almost all
activities. Most of the day, nearly every day.
Yes or no
3. Significant weight loss when not dieting or weight gain or
decrease in appetite, nearly every day.
Yes or no
4. Insomnia or hypersomnia nearly every day.
Yes or no
5. Psychomotor agitation or retardation nearly every day.
Yes or
no
6. Fatigue or loss of energy nearly every day.
Yes or no
7. Feelings of worthlessness or excessive or inappropriate guilt.
Yes or no
8. Diminished ability to think or concentrate or indecisiveness
nearly every day.
Yes or no
9. Recurrent thoughts of death or recurrent suicidal ideation or
suicide attempt
Yes or no
B. The symptoms cause clinically significant distress
or impairment
Yes or no
C. The episode is not attributable to the
physiological effects of a substance or another
medical condition
Yes or no
D. The occurrence of the major depressive disorder
is not better explained by schizoaffective
schizophrenia schizophreniform or anything else on
the schizophrenia spectrum
Yes or no
E. There has never been a manic episode or
hypomanic episode
Yes or no
DSM 5 criteria for major depression
1.
Lead with level I
crosscutting symptom
measures to assess all
symptom domains
2.
Follow-up with level II
crosscutting measures in
order to capture clinical
nuances and potential
comorbid
3.
Move to categories and
check off criteria
4.
Assess severity
Psycho-social HX
MSE
Adapted from the Patient Health Questionnaire–9 (PHQ-9) depression
Name:
Age:
Sex: Male
q
Female
q
Date:
Instructions:
Over the
last 7 days
, how often have you been bothered by any of the following problems?
Method #2 for severity
A.
Problematic pattern of alcohol use leading to clinically significant impairment or
distress as manifested by at least two of the following occurring within a 12
month period
1.
Alcohol taken in larger amount (need more for increased effect)
2.
Persistent desire or efforts to
quit Using alcohol
3.
Time spent to obtain, use, recover from effects Of alcohol
4.
Cravings Or urges to use Alcohol
5.
Failure to fulfill significant roles
6.
Continued use Alcohol despite persistent and recurrent problems
7.
Important social/occupational activities are reduced
8.
Recurrent use Of alcohol in physically hazardous situations
9.
Use Of alcohol continues despite knowledge of impact of the problem
10.
Tolerance, as defined by a. Increased amounts needed to achieve intoxication
or b. Diminished effect Of alcohol
11.
Withdrawal From alcohol
Alcohol use disorder
Severity
Mild = presence of 2-3 symptoms
moderate
= presence of four – five symptoms
severe
= presence of six or more symptoms
Course specifiers
early remission
= after full criteria were l
previously met none of the criteria met
for at least three months but less than 12 (with the exception of craving)
In sustained remission
= after full criteria were previously met none exists except craving
during the period of 12 months or more
2. NO MORE GAF
WHODAS
•
DSM IV-TR- HAD SOMETHING CALLED THE
GLOBAL ASSESSMENT OF FUNCTIONING
–
THE ONLY DIMENSIONAL MEASURE IN THE DSM IV
TR
–
USED BY CLINICIAN; COMPLETELY UNRELIABLE
AND NOT VALID
•
REPLACED WITH A SCALE THAT HAS
RELIABILITY AND VALIDITY DATA
–
THE WORLD HEALTH ORGANIZATION DISABLITY
ASSESSMENT SCALE (WHODAS PP 745-749)
DSM 5 recommends the following
1.
Assess symptom severity/severity of
diagnosis-use severity scales
2.
Use dimensional scales or standardized
scales whenever possible
3.
Assess suicidality, capacity for self harm
or harming others- use separate
assessment protocol
4.
Use World Health Organization disability
assessment scale to assess social and self-
care functioning
WHODAS 2.0
•
Based on the International Classification of
Functioning, Disability, and Health (ICF)
•
Applicable to any health condition
•
Reliability and clinical utility established in
DSM 5 Field trials
see pages 745 to 748 in DSM 5
WHODAS Assesses the following six areas
1.
Understanding and communicating
2.
Getting around
3.
Self-care
4.
Getting along with people
5.
Life activities
6.
Participation in society
STANDARDIZED WAY TO MEASURE HEALTH AND DISABILITY ACROSS CULTURES
DOES NOT TARGET SPECIFIC DISEASE, SO CAN BE USED TO ASSESS DISABILITY ACROSS DISEASE
WHODAS 36 ITEM ON NEXT 3 SLIDES (PP745-749 IN DSM)
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•
If WHODAS is used, place
results at the very end of
assessment, after psychosocial
stressors
3. How to chart without axes
DSM-5 has moved to a nonaxial documentation of diagnosis (formerly
Axes I, II, and III), with separate notations for important psychosocial
and contextual factors (formerly Axis IV) and disability (formerly Axis V)
Taken from Northstar behavioral health system
http://www.northstarbehavioral.com/Overview%20of%20DSM%205%20changes%20HO%20Ver
sion%20for%20Web%208-13-13.pdf
Axis IV - psychosocial and environmental factors - are now
covered through an expanded set of V codes. V codes allow
clinicians to indicate other conditions that may be a focus
of clinical attention or affect diagnosis, course, prognosis or
treatment of a mental disorder
Axis V - CGAS and GAF - are replaced by separate measures
of symptoms severity and disability for individual disorders.
Change to the World Health Organization Disability
Assessment Schedule (WHO DAS 2.0)
Taken from Northstar behavioral health system
http://www.northstarbehavioral.com/Overview%20of%20DSM%205%20changes%20HO
%20Version%20for%20Web%208-13-13.pdf
All diagnoses are considered primary
diagnosis
•
All diagnoses are listed consecutively (no distinction
between diagnosis previously listed on axis I, axis II
or axis III)
•
List diagnosis that is the reason for visit 1
st
Primary-reason for visit, 296.33, major depressive disorder, recurrent, severe.
Primary- Medical condition; Parkinson’s disease, moderate
Primary-305.00 alcohol use disorder, mild.
Primary -v15.81 non-adherence to medical treatment. (Patient continues to drink
while on antidepressants and does not take antidepressants regularly.)
•
If the principal diagnosis that is a reason for visit is a
mental disorder caused by a medical condition, the
medical condition is listed 1
st
Primary-Parkinson's disease-moderate with tremors and newly developed
postural instability (scored 3 on
Hoehn and Yahr)
Primary-Reason for visit, 296.22; major depressive disorder, single
episode, moderate
Case example – for listing of DX
John is a 65-year-old white male who is morbidly obese and has been a smoker for 40 years. He quit
smoking 5 years ago after being diagnosed with Parkinson's disease. Over the last 5 years, John's ability
to perform physical activity, has progressively deteriorated. Although John reports bouts of depression,
beginning in adolescence and continuing throughout his adult life, he was not diagnosed with major
depressive disorder until 4 years ago (one year after the diagnosis of Parkinson’s). Since that time, he has
been on several antidepressant medications, most recently Remeron. John reports that he has been a
regular drinker since his days in college. Although he denies it, his alcohol use, according to his wife, has
increased since his diagnosis of Parkinsons. However, upon evaluation both john and his wife agree that
he drinks no more than 3 times per week – usually a six pack. Although John has been advised to
discontinue drinking, he has not done so. According to both John and his wife. He misses his medication
anywhere from 1 to 3 times per week.
About 3 months ago john fell while at home. His wife at first thought it was a result of his drinking.
According to John he noticed that he was having more difficulty standing and walking while maintaining
his A recent neurological consult indicates that John does NOT have any neurological deficits that are out
of normal range for his age but has developed postural instability consistent with a progression of
Parkinson’s
Despite advice to the contrary, John has become progressively more sedentary and has discontinued all
forms of exercise. About 1 month ago, John's employers required that John start working part-time and
consider filing for early Social Security. According to them, John's ability to work has diminished. They
too noted that he was having difficulty walking. For the last 3 weeks, John has met all of the criteria for a
severe episode of major depression
.
Primary diagnosis
Primary-reason for visit, 296.33, major depressive disorder, recurrent, severe.
Primary- Medical condition; Parkinson’s disease-recently upgraded to moderate
Primary-305.00 alcohol use disorder, mild.
Primary -v15.81 non-adherence to medical treatment. Patient continues to drink while on antidepressants
take antidepressants irregularly
V codes -psychosocial stressors
Greatly expanded in the DSM 5
•
V codes (codes V01–V91) are used to describe encounters
with circumstances other than formal mental disorder
diagnoses disease or injury.
•
V codes are taken from the ICD. Their conditions and
problems that may be the focus of clinical attention or
that otherwise might affect the diagnosis, course,
prognosis or treatment of the mental disorder.
•
First Incorporated in the DSM-III
•
Will become Z codes in ICD 10 -October 2014 (these are
listed in DSM 5)
1.
Focus or need for clinical attention
(along with
the billable diagnosis) . Can be a
primary
diagnosis.
2.
Psychosocial stressors -
Conditions that affect the
mental health diagnosis and/or contribute to the
development or exacerbation of the DX
3.
Other issues, circumstances, conditions that
need attention or affect the diagnosis, course
and outcome of treatment)
Use V codes To indicate
V codes (codes V01–V91) are used to describe encounters with
circumstances other than formal mental disorder diagnoses
disease or injury
V codes are taken from the ICD. Their conditions and problems
that may be the focus of clinical attention or that otherwise
might affect the diagnosis, course, prognosis or treatment of the
mental disorder.
First Incorporated in the DSM-III
Will become Z codes in ICD 10 -October 2014 (these are listed in
DSM 5)
Code in the following ways
1.
As a Focus or need for clinical attention
=
Place code as a comorbid diagnosis
or as another primary diagnosis
2.
As a Psychosocial/ Environmental
stressor =
Place code as A stressor at
the end of all of the diagnoses
John is a 65-year-old white male who is morbidly obese and has been a smoker for 40 years. He quit 5 years ago
after being diagnosed with Parkinson's disease. Over the last 5 years, John's ability to perform physical activity,
has progressively deteriorated. Although John reports bouts of depression, beginning in adolescence and
continuing throughout his adult life, he was not diagnosed with major depressive disorder until 4 years ago (one
year after the diagnosis of Parkinson’s). Since that time, he is been on several antidepressant medications, most
recently Remeron. John reports that he has been a regular drinker since his days in college. Although he denies it,
his alcohol use, according to his wife, has increased since his diagnosis of Parkinsons. However, upon evaluation
both john and his wife agree that he drinks no more than 3 times per week – usually a six pack. Although John has
been advised to discontinue drinking, he has not done so. And according to both John and his wife. He misses his
medication anywhere from 1 to 3 times per week.
About 3 months ago john fell while at home. His wife at first thought it was a result of his drinking. According to
John he noticed that he was having more difficulty standing and walking while maintaining his A recent
neurological consult indicates that John does NOT have any neurological deficits that are out of normal range for
his age but has developed postural instability consistent with a progression of Parkinson’s
Despite advice to the contrary, John has become progressively more sedentary and has discontinued all forms of
exercise. About 1 month ago, John's employers required that John start working part-time and consider filing for
early Social Security. According to them, John's ability to work has diminished. They too noted that he was having
difficulty walking. For the last 3 weeks, John has met all of the criteria for a severe episode of major depression.
Primary diagnosis
Primary-reason for visit, 296.33, major depressive disorder, recurrent, severe.
Primary- Medical condition; Chronic Obstructive Pulmonary Disease, moderate
Primary-305.00 alcohol use disorder, mild.
Primary -v15.81 non-adherence to medical treatment. Patient continues to drink while on antidepressants
take antidepressants irregularly
Psychosocial stressors and factors that might affect treatment
v278.00 – Obesity
v69.9 - Problems related to lifestyle. John's diet and his progressive sedentary behavior, along with his
nonadherence and progressive isolation are contributing factors to his primary diagnoses
v62.29 - Other problems related to employment. John has recently had his work hours cut in half
WHODAS raw score = 98: domain
averages:
Cognition = 1none
mobility = 4 severe
self-care = 2 mild
getting along with others = 2 mild
Life activities = 2.5 mild- moderate
work activities = 3, moderate
participation = 3.5moderate- severe
4. A cultural framework:
The DSM and cultural formulation
•
DSM calls for systematic cultural assessment in these areas
1.
Cultural identity of the individual-describe reference group that
might influence his or her relationships resources, developmental,
and current challenges
2.
Cultural conceptualization of distress-describe constructs that
influence how the individual experiences understands and
communicates symptoms or problems to others
3.
Psychosocial stressors and cultural features of vulnerability and
resilience-identify key stressors and supports in the individual social
environment, role of religion, family and other social.
4.
Cultural features or influencing factors of the relationship between
the individual and clinician.-Identify differences that may cause
difficulties in communication and may influence diagnosis
5.
Overall cultural assessment-summarize the implications of the
components of the cultural formulation, identified earlier. (DSM 5,
pp749-750)
DSM and the cultural formulation
interview
•
16 questions used to obtain information about
the impact of culture on key aspects of a person's
clinical presentation
•
Assesses 4 areas
1.
Cultural definition of the problem (Q1 – 3)
2.
Cultural perceptions of cause, context and support
(Q4 – 10)
3.
Culture of factors affecting self coping and past help
seeking (Q 11 – 13
4.
Cultural factors affecting current help seeking (Q 14
– 16)
This page and the 3 following are reprinted from the DSM 5
website at psychiatry.org. Please see provisions for copying at
the bottom of the slides
5. Overall organization of disorders
Neuro
develop
mental
Bipolar
Schizophrenia
Depressive
Anxiety
Obsessive-
compulsive
and related
Trauma
related
Dissociative
Somatic
symptom
related
Feeding and
eating
disorders
Sexual
dysfunctions
Sleep wake
disorders
Elimination
disorders
Substance
related and
addictive
disorders
Disruptive
, impulse
control
disorders
Neurocognitive
disorders
Personality
disorder
Gender
dysphoria
Paraphilia
disorders
Others
Younger
Older
The progression from younger to older in the DSM is general and there are
specific disorders such as some early childhood feeding disorders that
clearly occur later
Initial occurrence
DSM categories organized over developmental lifespan
Neuro
develop
mental
Bipolar
Schizophrenia
Depressive
Anxiety
Obsessive-
compulsive
and related
Trauma
related
Dissociative
Somatic
symptom
related
Feeding and
eating
disorders
Sexual
dysfunctions
Sleep wake
disorders
Elimination
disorders
Substance
related and
addictive
disorders
Disruptive
, impulse
control
disorders
Neurocognitive
disorders
Personality
disorder
Gender
dysphoria
Paraphilia
disorders
Others
These distinctions have some strong validation from recent neuro-scientific
and genetic research
DSM categories organized using
empirically validated common factors
Neural
commonalities
Externalizing
Symptom
factors
Physiological
Symptom
factors
Internalizing
Symptom
factors
Bio-genetic
similar
factors
6
. Highlight of specific changes in diagnosis
Gone
•
Disorders usually evident in infancy, childhood and adolescence.
•
Factitious disorders and malingering
•
adjustment disorders (now included in trauma and stress-related
disorders)
•
NOS Diagnosis for all categories
Added
•
neurodevelopmental disorders
•
obsessive-compulsive and related disorders (moved out of anxiety)
•
trauma and stress-related disorders (moved out of anxiety)
•
Disruptive, impulse control, and conduct related disorders
•
"Specified" and “Unspecified" disorder for all diagnoses
•
"Suicide risk" is now specified for 25 diagnosis
Changed
•
Delirium, dementia and cognitive disorders = neurocognitive
disorders
•
psychotic disorders = schizophrenia spectrum and other psychotic
disorders
•
mood disorders = bipolar and related disorders & depressive
disorders
•
somatoform disorders = somatic symptom and related disorders
Neuro developmental disorders
1.
The term "mental retardation" has been changed to intellectual disability
2.
The term "phonological disorders" has been changed to "communication disorders".
1.
A new diagnosis of social/pragmatic communication disorder has been added here
2.
childhood onset fluency disorder new name for stuttering
3.
Speech sound disorder is new name for phonological disorder
3.
Autism spectrum disorder is the new term and DSM 5 which consolidates Aspergers
disorder, autism, and pervasive developmental disorder. Severity measures are included
4.
Several changes have been made to the diagnostic criteria for attention deficit
hyperactive disorder
5.
Specific learning disorder combines DSM-IV diagnosis of reading disorder mathematics
disorder disorder of written expression and learning disorder NOS
6.
Language disorder combines expressive and mixed receptive expressive into one
7.
Symptom onset for ADHD was extended to before age 12;
Subtypes eliminated and
replaced by specifiers; now allowed to make a comorbid diagnosis with ASD; Symptom
criteria for adults reduced to 5 instead of 6
Schizophrenia spectrum and other
psychotic disorders
1.
The spectrum seems to emphasize degrees of psychosis
2.
Change in criteria for schizophrenia now requires at least one
criteria to be either a. Delusions, b. Hallucinations or c.
Disorganized speech
3.
Subtypes of schizophrenia were eliminated
4.
Dimensional measures of symptom severity are now included
5.
Schizoaffective disorder has been reconceptualized
6.
Delusional disorder no longer requires the presence of “non-
bizarre" in delusions. There is now specifier for bizarre delusions.
7.
Schizotypal personality disorder is now considered part of the
spectrum
Bipolar and related disorders
•
Diagnosis must now include
both
changes in
mood and changes in activity/energy level
•
Some particular conditions can now be
diagnosed under "other specified bipolar and
related disorders“
•
An "anxiety" specifier has now been included
•
Attempts made to clarify definition of
'hypomania". However it was not successful
Depressive disorders
•
New diagnosis included = "disruptive mood
dysregulation disorder”-use for children up to age
18
•
New diagnosis included = "premenstrual
dysphoric disorder“
•
What used to be called dysthymic disorder is now
"persistent depressive disorder“
•
Bereavement is no longer excluded – used to be
an exclusion for 2 months
•
New specifiers such as mixed features. And
anxious distress
Obsessive-compulsive and related
disorders
•
A completely new diagnostic grouping category
•
Hoarding disorder-new diagnosis
•
Excoriation (skin picking) disorder-new diagnosis
•
Substance induced obsessive-compulsive
disorder-new diagnosis
•
Trichotillomania now called hair pulling disorder
•
Tic specifier has been added
•
Muscle dysphoria is now a specifier within body
dysmorphic disorder
Trauma and stress related disorders
•
For diagnosis of acute stress disorder, it must
be specified whether the traumatic events
were experienced directly or indirectly
•
Adjustment disorders (a separate class in the
DSM-IV) are included here as various types of
responses to stress
•
Major changes in the criteria for the diagnosis
of PTSD
Anxiety disorders
•
Obsessive-compulsive disorder has been moved out of
this category
•
PTSD has been moved out of this category
•
Acute stress disorder has been moved out of this
category
•
Changes in criteria for specific phobia and social anxiety
have been made
•
Panic attacks can now be used as a specifier within any
other disorder in the DSM
•
Separation anxiety disorder has been moved to this
group
•
Selective mutism has been moved to this group
Dissociative disorders
•
Depersonalization disorder has been relabeled
“Depersonalization/Derealization disorder“
•
Dissociative fugue is no longer a separate
diagnosis but is now specifier within the
diagnosis of "dissociative amnesia“
•
Changes in criteria for the diagnosis of
"dissociative identity disorder"
Somatic symptom and related
disorders
•
This is a new name for what was previously called
"somatoform disorders“
•
The number of diagnoses in this category has
been reduced. The diagnoses of somatization
disorder, hypochondriasis, pain disorder and
undifferentiated somatoform disorder have all
been removed
•
"Illness anxiety disorder" has been an added
diagnosis and replaces hypochondriasis
•
Factitious disorder is now included in this group
Feeding and eating disorders
•
"Binge eating disorder' is now included as a
separate diagnosis
•
also includes a number of diagnosis that were
previously included in a DSM-IV TR in the
chapter "disorders usually 1st diagnosed
during infancy childhood and adolescence“.
–
Pica and rumination disorder are 2 examples
Elimination disorders
•
Originally classified in chapters on childhood and
infancy. Now have separate classification
•
Primary insomnia renamed "insomnia disorder«
•
Narcolepsy now distinguished from other forms of
hypersomnia
•
Breathing related sleep disorders have been broken
into 3 separate diagnoses
•
Rapid eye movement disorder and restless leg
syndrome are now independent diagnoses within this
category
Sleep wake dis
orders
Sexual dysfunctions
•
Some gender related sexual dysfunctions have
been outed
•
Now only 2 subtypes-acquired versus lifelong and
generalized versus situational
•
New diagnostic class and the DSM 5
•
Include separate classifications for children
adolescents and adults
•
The construct of gender has replaced the
construct of sex
Gender dysphoria
Disruptive, impulse control and
conduct disorders
•
New diagnostic grouping and DSM 5
•
Combines a group of disorders previously included
in disorders of infancy and childhood such as
conduct disorder oppositional defiant disorder with
a group previously known as impulse control
disorders not otherwise classified
•
Oppositional defiant disorder now has 3 subtypes
•
Intermittent explosive disorder no longer requires
physical violence but can include verbal aggression
Substance related and addictive
disorders
•
The distinctions between substance abuse and
substance dependence are no longer made
–
Now includes criteria for intoxication, withdrawal
and substance induced disorders
•
Now includes gambling disorder
•
Cannabis and caffeine withdrawal are now
new disorders
Neuro-cognitive disorders
•
New diagnostic group
•
Dementia and amnestic disorder are included
in this new group
•
Mild NCD is a new diagnosis
Personality disorders
Nothing changes
DSM 5 promised major changes in
criteria
•
Promised dimensional focus
•
Promised reduction in number of personaliity
disorders to five
•
Changes did not occur
•
Dimensional focus for personality disorders
was moved to section 3
Primary Criteria in DSM 5
(Unchanged from DSM-IV TR)
A.
Enduring pattern of inner experience & behavior that
deviates markedly from expectations of the culture. This
pattern is manifested in 2 or more of the following areas
A.
Cognition;
B.
Affect;
C.
Interpersonal;
D.
Impulse control
B.
Inflexible & pervasive across situation
C.
Distress or impairment in social, occupational
interpersonal..…
D.
Long-standing (back to adolescence or early adulthood)
Dimensional classification of
personality disorders
•
Authors of DSM 5 had planned to use
dimensional measures to diagnose personality
disorders
•
They plan to reduce personality disorders
from 10 to 5
•
This changed in a closed-door meeting
•
Dimensional measures are now in section 3
Proposed changes in assessment of PDs
Two broad dimensions
Overall
personality
functioning
5 Broad
Pathological
Trait Domains
self
Interpersonal
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Psychoticism
The transition from DSM-IV to DSM-5 was driven by the need to improve diagnostic accuracy, reflect shared symptomatology, integrate new research findings, and enhance cultural considerations. DSM-5 addressed shortcomings such as the multi-axial structure, unreliable measures like GAF, and the focus on immediate diagnoses. Additionally, it aimed to incorporate advancements in neuroscience and genetics, provide dimensional assessments, and emphasize well-being over mere symptom negation.
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Presentation Transcript
Whats in DSM-5 DSM 5 diagnoses and numbers xiii-xl summary of changes from IV -preface How the DSM 5 was developed-Intro 5-19 Further description of major changes-intro 5-19 How to use the manual 19-24 Diagnostic codes and diagnostic criteria for every diagnosis pp31-715 Dimensional assessment measures 733-748 Dimensional assessment of personality disorders 761-783 Focus on cultural assessment 749-760 Cultural formulation interviews 749-760 Conditions for further study 783-808 Highlight of all changes from DSM-IV to DSM 5 PP 809 816 Glossary of mental terms 817-832 Glossary of cultural concepts of distress 833-838 DSM crosswalks for ICD-9 and ICD 10 863- 897
DSM-IVs organizational structure failed to reflect shared features or symptoms of related disorders and diagnostic groups (like psychotic disorders with bipolar disorders, or internalizing (depressive, anxiety, somatic) and externalizing (impulse control, conduct, substance use) disorders.
Did not represent or integrate the latest findings from neuroscience, genetics and cognitive research
Multi axial structure was out of line with the rest of medicine
Global assessment of functioning was an unreliable measure Decision trees did not increase inter-rater reliability
Other problems Separates diagnoses from treatment Diagnosis has become an end in itself! (billability & pressure for scientific determinism) Minimizes TIME as a major factor in making diagnoses Minimizes emergent symptoms Minimizes lack of symptom clarity as an issue Ignores internal unobservables Funnels tx focus to symptom negation rather than well- being Forces clinician to make immediate diagnoses Forces clinician to more severe DX
There have been no no established "zones of rarity" between diagnosis (much symptom overlap) Law-like biological markers have not yet been found Categorical measurement (depressed vs NOT depressed) doesn t capture clinical variance
DSM III & IV limits Focus on only what is observable; limits diagnostic possibilities Limited number of observable signs & symptoms (12 to 19 symptoms ) Because law-like biomarkers have not been found, Elements that cannot be seen directly are excluded. This is exactly the opposite of medicine which strives to see below the surface. Limited number of observable signs/symptoms But 400 diagnoses in DSM = diagnostic confusion Simple counting of the number of symptoms in Order to make a diagnosis DOES NOT WORK
DSM III & IV problems with measuring Limited number of observable signs and Symptoms, Elements that cannot be seen directly are excluded. This is exactly the opposite of medicine which strives to see below the surface. Limited number of observable signs/symptoms But 400 diagnoses in DSM # 1 Problem = under- determination of diagnosis Consequences = - boundary problems (paris) - false positives - rise of comorbidity - problems of differential dx - one size fits all diagnoses - only agreement on most severe
The relationship between Categorical Dx, comorbidity and increased reliability 1. no major depression; 2. major depression 1. No generalized anxiety 2. generalized anxiety Depression 4 1 2 3 None minimal mild minor moderate major severe maximal 5 6 7 8 General anxiety 1 2 3 4 5 6 7 8 None minimal mild minor moderate major severe maximal Categorical measurement increases potential for inter-rater reliability. 50% chance of inter-rater reliability Dimensional measure inter-rater reliability lower = 12% Fewer choices = easier= less information = more possibility of making mistake = inflated comorbidity More choices = harder= more info Subtle distinctions ; less Potential for specious comorbidity Categorical measures = No clinical variance & no diagnostic threshold Decreasing variance increases potential for inter rater reliability and increases potential for specious comorbidity
DSM III & IV turned assessment into yes/no decision trees Inflated comorbidity Inflated inter-rater reliability (but did not increase it) Never established true biological markers Reduced the rigorousness of good assessment in the name of clinical utility
DSM 5 1. Emphasizes dimensional measurement 2. Provides World Health Organization measure of overall well-being 3. Does away with Axes 4. Focuses more on culture 5. Attempts to Re-organize diagnostic categories according to what we now (think we)know 6. Attempts to re-group individual diagnoses according to what we now (think we) know 7. Includes crosswalks with ICD-9 and ICD 10 http://www.dsm5.org/Pages/Default.aspx
1. Dimensional measures http://www.psychiatry.org/practice/dsm/dsm5/online-assessment-measures#Level1 Allows clinician opportunity to fine tune diagnosis Captures diagnostic complexity Should reduce inflated comorbidity. By allowing inclusion of crosscutting symptoms (such as anxiety) within other diagnoses Focuses assessment on crosscutting symptoms Creates "severity specifier" for many diagnoses Dimensions make diagnosis congruent with up- to-date neurocognitive research indicating symptoms are on a continuum
DSM 5 adds dimensional measures WITHOUT abandoning categorical measures Criteria are basically the same as they were in the DSM-IV
Crosscutting symptoms (symptoms that can occur across many DXs) Captures symptom comorbidity without diagnostic comorbidity Cross-cutting symptom measures may aid in a comprehensive mental status assessment by drawing attention to symptoms that are important across diagnoses. They are intended to help identify additional areas of inquiry that may guide treatment and prognosis. The cross- cutting measures have two levels: Level 1 questions are a brief survey of 13 domains for adult patients and 12 domains for child and adolescent patients, and Level 2 questions provide a more in-depth assessment of certain domains. http://www.psychiatry.org/practice/dsm/dsm5/online-assessment-measures#Level1
Table 1: Adult DSM-5 Self-Rated Level 1 Cross-Cutting Symptom Measure: domains, thresholds for further inquiry, and associated Level 2 measures for adults ages 18 and over Domain Domain Name DSM-5 Level 2 Cross-Cutting Symptom Measure available online Threshold to guide further inquiry I. Depression Mild or greater LEVEL 2 Depression Adult (PROMIS Emotional Distress Depression Short Form)1 II. Anger Mild or greater LEVEL 2 Anger Adult (PROMIS Emotional Distress Anger Short Form)1 III. IV. Mania Mild or greater Mild or greater LEVEL 2 Mania Adult (Altman Self-Rating Mania Scale) LEVEL 2 Anxiety Adult (PROMIS Emotional Distress Anxiety Short Form)1 Anxiety V. Somatic Symptoms Mild or greater LEVEL 2 Somatic Symptom Adult (Patient Health Questionnaire 15 Somatic Symptom Severity [PHQ-15]) VI. VII. VIII. Suicidal Ideation Psychosis Sleep Problems Slight or greater Slight or greater Mild or greater None None LEVEL 2 Sleep Disturbance - Adult (PROMIS Sleep Disturbance Short Form)1 IX. X. Memory Mild or greater Mild or greater None LEVEL 2 Repetitive Thoughts and Behaviors Adult (adapted from the Florida Obsessive-Compulsive Inventory [FOCI] Severity Scale [Part B]) Repetitive Thoughts and Behaviors XI. XII. Dissociation Personality Functioning Substance Use Mild or greater Mild or greater None None XIII. Slight or greater LEVEL 2 Substance Abuse Adult (adapted from the NIDA-modified ASSIST)
DSM-5 Self-Rated Level 1 Cross-Cutting Symptom MeasureAdult None Slight Mild Moderate Severe Highest During the past TWO (2) WEEKS, how much (or how often) have you been bothered by the following problems? Not at all Rare, less than a day or two Several days More than half the days Nearly every day Domain Score (clinician) I. 1. Little interest or pleasure in doing things? 0 1 2 3 4 2. Feeling down, depressed, or hopeless? 0 1 2 3 4 II. 3. Feeling more irritated, grouchy, or angry than usual? 0 1 2 3 4 III. 4. Sleeping less than usual, but still have a lot of energy? 0 1 2 3 4 0 1 2 3 4 5. Starting lots more projects than usual or doing more risky things than usual? IV. 6. Feeling nervous, anxious, frightened, worried, or on edge? 0 1 2 3 4 7. Feeling panic or being frightened? 0 1 2 3 4 8. Avoiding situations that make you anxious? 0 1 2 3 4 V. 9. Unexplained aches and pains (e.g., head, back, joints, abdomen, legs)? 0 1 2 3 4 10. Feeling that your illnesses are not being taken seriously enough? 0 1 2 3 4 VI. 11. Thoughts of actually hurting yourself? 0 1 2 3 4 VII. 0 1 2 3 4 12. Hearing things other people couldn t hear, such as voices even when no one was around? 13. Feeling that someone could hear your thoughts, or that you could hear what another person was thinking? 0 1 2 3 4 VIII. 14. Problems with sleep that affected your sleep quality over all? 0 1 2 3 4 IX. 15. Problems with memory (e.g., learning new information) or with location (e.g., finding your way home)? 0 1 2 3 4 X. 16. Unpleasant thoughts, urges, or images that repeatedly enter your mind? 0 1 2 3 4 17. Feeling driven to perform certain behaviors or mental acts over and over again? 0 1 2 3 4 XI. 18. Feeling detached or distant from yourself, your body, your physical surroundings, or your memories? 0 1 2 3 4 XII. 19. Not knowing who you really are or what you want out of life? 0 1 2 3 4 20. Not feeling close to other people or enjoying your relationships with them? 0 1 2 3 4 XIII. 21. Drinking at least 4 drinks of any kind of alcohol in a single day? 0 1 2 3 4 22. Smoking any cigarettes, a cigar, or pipe, or using snuff or chewing tobacco? 0 1 2 3 4 0 1 2 3 4 23. Using any of the following medicines ON YOUR OWN, that is, without a doctor s prescription, in greater amounts or longer than prescribed [e.g., painkillers (like Vicodin), stimulants (like Ritalin or Adderall), sedatives or tranquilizers (like sleeping pills or Valium), or drugs like marijuana, cocaine or crack, club drugs (like ecstasy), hallucinogens (like LSD), heroin, inhalants or solvents (like glue), or methamphetamine (like speed)]?
THE CROSS-CUTTING SYMPTOM MEASURES CAN DO THREE THINGS 1. POINT YOU IN THE RIGHT DIRECTION DIAGNOSTICALLY (LEVEL I) 2. GIVE YOU A BASIC SENSE OF THE CLINICAL PROFILE OF EACH CLINET 3. CAPTURE SYMPTOMS THAT ARE LIKELY TO OCCUR ACROSS DIAGNOSIS, BUT NOT NECESSARILY QUALIFY FOR ITS OWN DX DEPRESSION ANXIETY SOMATIC SYMPTOMS SLEEP ISSUES ETC.
level II measures(Dimensional) Level II crosscutting measures Focus on one specific domain Provides a more varied clinical profile within that domain Allows for follow-up exploration with more than one domain in order to specify diagnostic boundaries. (For example, in my dealing with major depression with a co-occurring anxiety disorder or major depression, with anxious features Provides clinical verification before diagnosis
Level 2 measures of symptoms Level 2 questions provide a more in-depth assessment of certain domains: http://www.psychiatry.org/practice/dsm/dsm 5/online-assessment-measures# Level2 Level 2 is given as a specific follow up, once the clinician is oriented in a symptomatic direction they are focused WITHIN a specific symptom domain
List of all the level 2 (disorder specific) cross-cutting symptom measures Level 2 Cross-Cutting Symptom Measures For Adults LEVEL 2 Depression Adult (PROMIS Emotional Distress Depression Short Form) LEVEL 2 Anger Adult (PROMIS Emotional Distress Anger Short Form) LEVEL 2 Mania Adult(Altman Self-Rating Mania Scale [ASRM]) LEVEL 2 Anxiety Adult(PROMIS Emotional Distress Anxiety Short Form) LEVEL 2 Somatic Symptom Adult(Patient Health Questionnaire 15 Somatic Symptom Severity Scale [PHQ-15]) LEVEL 2 Sleep Disturbance Adult(PROMIS Sleep Disturbance Short Form) LEVEL 2 Repetitive Thoughts and Behaviors Adult(Adapted from the Florida Obsessive-Compulsive Inventory [FOCI] Severity Scale [Part B]) LEVEL 2 Substance Use Adult (Adapted from the NIDA-Modified ASSIST) For Parents of Children Ages 6 17 LEVEL 2 Somatic Symptom Parent/Guardian of Child Age 6 17 (Patient Health Questionnaire 15 Somatic Symptom Severity Scale [PHQ-15]) LEVEL 2 Sleep Disturbance Parent/Guardian of Child Age 6 17 (PROMIS Sleep Disturbance Short Form) LEVEL 2 Inattention Parent/Guardian of Child Age 6 17 (Swanson, Nolan, and Pelham, version IV [SNAP-IV]) LEVEL 2 Depression Parent/Guardian of Child Age 6 17 (PROMIS Emotional Distress Depression Parent Item Bank) LEVEL 2 Anger Parent/Guardian of Child Age 6 17 (PROMIS Emotional Distress Calibrated Anger Measure Parent) LEVEL 2 Irritability Parent/Guardian of Child Age 6 17 (Affective Reactivity Index [ARI]) LEVEL 2 Mania Parent/Guardian of Child Age 6 17 (Adapted from the Altman Self-Rating Mania Scale [ASRM]) LEVEL 2 Anxiety Parent/Guardian of Child Age 6 17 (Adapted from PROMIS Emotional Distress Anxiety Parent Item Bank) LEVEL 2 Substance Use Parent/Guardian of Child Age 6 17 (Adapted from the NIDA-Modified ASSIST) For Children Ages 11 17 LEVEL 2 Somatic Symptom Child Age 11 17 (Patient Health Questionnaire 15 Somatic Symptom Severity Scale [PHQ-15]) LEVEL 2 Sleep Disturbance Child Age 11 17 (PROMIS Sleep Disturbance Short Form) LEVEL 2 Depression Child Age 11 17 (PROMIS Emotional Distress Depression Pediatric Item Bank) LEVEL 2 Anger Child Age 11 17 (PROMIS Emotional Distress Calibrated Anger Measure Pediatric) LEVEL 2 Irritability Child Age 11 17 (Affective Reactivity Index [ARI]) LEVEL 2 Mania Child Age 11 17 (Altman Self-Rating Mania Scale [ASRM]) LEVEL 2 Anxiety Child Age 11 17 (PROMIS Emotional Distress Anxiety Pediatric Item Bank) LEVEL 2 Repetitive Thoughts and Behaviors Child Age 11 17 (Adapted from the Children s Florida Obsessive Compulsive Inventory [C-FOCI] Severity Scale) LEVEL 2 Substance Use Child Age 11 17 (Adapted from the NIDA-Modified ASSIST)
Table 1: Adult DSM-5 Self-Rated Level 1 Cross-Cutting Symptom Measure: domains, thresholds for further inquiry, and associated Level 2 measures for adults ages 18 and over Hypothetically scores on our client using level I crosscutting symptoms indicated the following areas circled Domain Domain Name DSM-5 Level 2 Cross-Cutting Symptom Measure available online Threshold to guide further inquiry b I. Depression Mild or greater LEVEL 2 Depression Adult (PROMIS Emotional Distress Depression Short Form)1 II. Anger Mild or greater LEVEL 2 Anger Adult (PROMIS Emotional Distress Anger Short Form)1 III. IV. Mania Mild or greater Mild or greater LEVEL 2 Mania Adult (Altman Self-Rating Mania Scale) LEVEL 2 Anxiety Adult (PROMIS Emotional Distress Anxiety Short Form)1 Anxiety b b V. Somatic Symptoms Mild or greater LEVEL 2 Somatic Symptom Adult (Patient Health Questionnaire 15 Somatic Symptom Severity [PHQ-15]) VI. VII. VIII. Suicidal Ideation Psychosis Sleep Problems Slight or greater Slight or greater Mild or greater b None None LEVEL 2 Sleep Disturbance - Adult (PROMIS Sleep Disturbance Short Form)1 IX. X. Memory Mild or greater Mild or greater None LEVEL 2 Repetitive Thoughts and Behaviors Adult (adapted from the Florida Obsessive-Compulsive Inventory [FOCI] Severity Scale [Part B]) Repetitive Thoughts and Behaviors XI. XII. Dissociation Personality Functioning Substance Use Mild or greater Mild or greater None None XIII. Slight or greater b LEVEL 2 Substance Abuse Adult (adapted from the NIDA-modified ASSIST)
LEVEL 2DepressionAdult* *PROMIS Emotional DistressDepressionShort Form Name: Age: Sex: MaleFemale Date:_ If the measure is being completed by an informant, what is your relationship with the individual receiving care? In a typical week, approximately how much time do you spend with the individual receiving care? hours/week Instructions: On the DSM-5 Level 1 cross-cutting questionnaire that you just completed, you indicated that during the past 2 weeks you (the individual receiving care) have been bothered by no interest or pleasure in doing things and/or feeling down, depressed, or hopeless at a mild or greater level of severity. The questions below ask about these feelings in more detail and especially how often you (the individual receiving care) have been bothered by a list of symptoms during the past 7 days. Please respond to each item by marking (P or x) one box per row. Clinician Use In the past SEVEN (7) DAYS.... Item Score Never Rarely Sometimes Often Always 1. I felt worthless. q 1 q 2 q 3 q 4 q 5 2. I felt that I had nothing to look forward to. q 1 q 2 q 3 q 4 q 5 3. I felt helpless. q 1 q 2 q 3 q 4 q 5 4. I felt sad. q 1 q 2 q 3 q 4 q 5 5. I felt like a failure. q 1 q 2 q 3 q 4 q 5 6. I felt depressed. q 1 q 2 q 3 q 4 q 5 7. I felt unhappy. q 1 q 2 q 3 q 4 q 5 8. I felt hopeless. q 1 q 2 q 3 q 4 q 5 Total/Partial Raw Score: Prorated Total Raw Score: T-Score:
LEVEL 2Substance UseAdult* *Adapted from the NIDA-Modified ASSIST Name: Age: Sex: q Male q Female Date: If the measure is being completed by an informant, what is your relationship with the individual receiving care? In a typical week, approximately how much time do you spend with the individual receiving care? Instructions: On the DSM-5 Level 1 cross-cutting questionnaire that you just completed, you indicated that during the past 2 weeks you (the individual receiving care) have been bothered by using medicines on your own without a doctor s prescription, or in greater amounts or longer than prescribed, and/or using drugs like marijuana, cocaine or crack, and/or other drugs at a slight or greater level of severity. The questions below ask how often you (the individual receiving care) have used these medicines and/or substances during the past 2 weeks. Please respond to each item by marking (P or x) one box per row. hours/week During the past TWO (2) WEEKS, about how often did you use any of the following medicines ON YOUR OWN, that is, without a doctor s prescription, in greater amounts or longer than prescribed? Clinician Use One or two days Several days More than half the days Nearly every day Item Score Not at all a. Painkillers (like Vicodin) q 0 q 1 q 2 q 3 q 4 b. Stimulants (like Ritalin, Adderall) Sedatives or tranquilizers (like sleeping pills or Valium) q 0 q 1 q 2 q 3 q 4 c. q 0 q 1 q 2 q 3 q 4 Or drugs like: d. Marijuana q 0 q 1 q 2 q 3 q 4 e. Cocaine or crack q 0 q 1 q 2 q 3 q 4 f. Club drugs (like ecstasy) q 0 q 1 q 2 q 3 q 4 g. Hallucinogens (like LSD) q 0 q 1 q 2 q 3 q 4 h. Heroin q 0 q 1 q 2 q 3 q 4 i. Inhalants or solvents (like glue) q 0 q 1 q 2 q 3 q 4 j. Methamphetamine (like speed) q 0 q 1 q 2 q 3 q 4 Total Score: Useless for alcohol. Perhaps ADS
Level 2 cross-cutting scale for Somatic symptoms - Adult LEVEL 2 Somatic Symptom Adult Patient* *Adapted from the Patient Health Questionnaire Physical Symptoms (PHQ-15) Name: Age: Sex: q Male q Female Date: If the measure is being completed by an informant, what is your relationship with the individual receiving care? In a typical week, approximately how much time do you spend with the individual receiving care? hours/week Instructions: On the DSM-5 Level 1 cross-cutting questionnaire that you just completed, you indicated that during the past 2 weeks you (the individual receiving care) have been bothered by unexplained aches and pains , and/or feeling that your illnesses are not being taken seriously enough at a mild or greater level of severity. The questions below ask about these feelings in more detail and especially how often you (the individual receiving care) have been bothered by a list of symptoms during the past 7 days. Please respond to each item by marking (P or x) one box per row. Clinician Use Item Score During the past 7 days, how much have you been bothered by any of the following problems? Not bothered at all 0 Bothered a little 1 Bothered a lot 2 1. Stomach pain 2. Back pain 3. Pain in your arms, legs, or joints (knees, hips, etc.) 4. Menstrual cramps or other problems with your periods WOMEN ONLY 5. Headaches 6. Chest pain 7. Dizziness 8. Fainting spells 9. Feeling your heart pound or race 10. Shortness of breath 11. Pain or problems during sexual intercourse 12. Constipation, loose bowels, or diarrhea 13. Nausea, gas, or indigestion 14. Feeling tired or having low energy 15. Trouble sleeping Total/Partial Raw Score: Prorated Total Raw Score: (if 1-3 items left unanswered)
LEVEL 2AnxietyAdult* *PROMIS Emotional DistressAnxietyShort Form Name: Age: Sex: q Male q Female Date: If the measure is being completed by an informant, what is your relationship with the individual? In a typical week, approximately how much time do you spend with the individual? hours/week Instructions to patient: On the DSM-5 Level 1 cross-cutting questionnaire that you just completed, you indicated that during the past 2 weeks you (individual receiving care) have been bothered by feeling nervous, anxious, frightened, worried, or on edge , feeling panic or being frightened , and/or avoiding situations that make you anxious at a mild or greater level of severity. The questions below ask about these feelings in more detail and especially how often you (individual receiving care) have been bothered by a list of symptoms during the past 7 days. Please respond to each item by marking (P or x) one box per row. Clinician Use In the past SEVEN (7) DAYS.... Item Score Never Rarely Sometimes Often Always 1. I felt fearful. q 1 q 2 q 3 q 4 q 5 2. I felt anxious. q 1 q 2 q 3 q 4 q 5 3. I felt worried. q 1 q 2 q 3 q 4 q 5 4. I found it hard to focus on anything other than my anxiety. q 1 q 2 q 3 q 4 q 5 5. I felt nervous. q 1 q 2 q 3 q 4 q 5 6. I felt uneasy. q 1 q 2 q 3 q 4 q 5 7. I felt tense. q 1 q 2 q 3 q 4 q 5 Total/Partial Raw Score: Prorated Total Raw Score: T-Score:
Level 2 cross-cutting scale for anxiety in children parent filled Instructions to parent/guardian: On the DSM-5 Level 1 cross-cutting questionnaire that you just completed, you indicated that during the past 2 weeks your child receiving care has been bothered by feeling nervous, anxious, or scared , not being able to stop worrying , and/or couldn t do things he/she wanted to or should have done because they made him/her feel nervous at a mild or greater level of severity. The questions below ask about these feelings in more detail and especially how often your child receiving care has been bothered by a list of symptoms during the past 7 days. Please respond to each item by marking ( or x) one box per row. In the past SEVEN (7) DAYS, my child said that he/she Clinician use Never 1 almost never 2 Sometimes 3 Often 4 Almost always 5 Item score 1. Felt like something awful might happen 2. Felt nervous 3. Felt scared 4. Felt worried 5. Worried about what could happen to him/her. 6. Worried when he/she went to bed at night 7. Got scared really easy. 8. Was afraid of going to school. 9 Worried when he/she was at home 10. Worried when he/she was away from home Total/partial raw score Prorated total raw score T-score
LEVEL 2Sleep DisturbanceAdult* *PROMISSleep DisturbanceShort Form Name: Age: Sex: q Male q Female Date: If the measure is being completed by an informant, what is your relationship with the individual receiving care? In a typical week, approximately how much time do you spend with the individual receiving care? hours/week Instructions to patient: On the DSM-5 Level 1 cross-cutting questionnaire that you just completed, you indicated that during the past 2 weeks you (the individual receiving care) have been bothered by problems with sleep that affected your sleep quality over all at a mild or greater level of severity. The questions below ask about these feelings in more detail and especially how often you (the individual receiving care) have been bothered by a list of symptoms during the past 7 days. Please respond to each item by marking (P or x) one box per row. Clinician Use In the past SEVEN (7) DAYS.... Not at all A little bit Somewhat Quite a bit Very much q 1 q 2 q 3 q 4 q 5 1. My sleep was restless. q 5 q 4 q 3 q 2 q 1 2. I was satisfied with my sleep. q 5 q 4 q 3 q 2 q 1 3. My sleep was refreshing. q 1 q 2 q 3 q 4 q 5 4. I had difficulty falling asleep. In the past SEVEN (7) DAYS.... Never Rarely Sometimes Often Always q 1 q 2 q 3 q 4 q 5 5. I had trouble staying asleep. q 1 q 2 q 3 q 4 q 5 6. I had trouble sleeping. q 5 q 4 q 3 q 2 q 1 7. I got enough sleep. In the past SEVEN (7) DAYS.... Very Poor Poor Fair Good Very good q 5 q 4 q 3 q 2 q 1 8. My sleep quality was... Total/Partial Raw Score: Prorated Total Raw Score: T-Score:
DIMENSIONAL SEVERITY MEASURES In addition to a diagnosis, DSM MEASURES SEVERITY OF MANY DIAGNOSIS SEVERITY HAS NEVER BEEN CONSISTENTLY MEASURED IN DSM UNTIL NOW ONE EITHER WAS PSYCHOTIC OR ONE WAS NOT THERE WERE NO GRADATIONS
Severity - The DSM uses 2 methods of assessing severity, depending on the diagnosis.. Method 1 involves using a specific dimensional measure or scale Called disorder specific severity measures . These can be find on the DSM 5 website under online assessment measures (DIMENSIONAL SCALE ) Method 2 involves counting the number of symptoms and rating severity based on number of symptoms. For example, mild alcohol use Disorder = 2 3 symptoms: moderate alcohol use disorder = 4 5 symptoms; severe alcohol use Disorder= presence of 6 or more symptoms (Total number of diagnostic crtieria)
Disorder-Specific Severity Measures For Adults Severity Measure for Depression Adult(Patient Health Questionnaire [PHQ-9]) Severity Measure for Separation Anxiety Disorder Adult Severity Measure for Specific Phobia Adult Severity Measure for Social Anxiety Disorder (Social Phobia) Adult Severity Measure for Panic Disorder Adult Severity Measure for Agoraphobia Adult Severity Measure for Generalized Anxiety Disorder Adult Severity of Posttraumatic Stress Symptoms Adult(National Stressful Events Survey PTSD Short Scale [NSESS]) Severity of Acute Stress Symptoms Adult(National Stressful Events Survey Acute Stress Disorder Short Scale [NSESS]) Severity of Dissociative Symptoms Adult(Brief Dissociative Experiences Scale [DES-B]) For Children Ages 11 17 Severity Measure for Depression Child Age 11 17 (PHQ-9 modified for Adolescents [PHQ-A] Adapted) Severity Measure for Separation Anxiety Disorder Child Age 11 17 Severity Measure for Specific Phobia Child Age 11 17 Severity Measure for Social Anxiety Disorder (Social Phobia) Child Age 11 17 Severity Measure for Panic Disorder Child Age 11 17 Severity Measure for Agoraphobia Child Age 11 17 Severity Measure for Generalized Anxiety Disorder Child Age 11 17 Severity of Posttraumatic Stress Symptoms Child Age 11 17 (National Stressful Events Survey PTSD Short Scale [NSESS]) Severity of Acute Stress Symptoms Child Age 11 17 (National Stressful Events Survey Acute Stress Disorder Short Scale [NSESS]) Severity of Dissociative Symptoms Child Age 11 17 (Brief Dissociative Experiences Scale [DES-B]) Clinician-Rated Clinician-Rated Severity of Autism Spectrum and Social Communication Disorders Clinician-Rated Dimensions of Psychosis Symptom Severity (also available in print book) Clinician-Rated Severity of Somatic Symptom Disorder Clinician-Rated Severity of Oppositional Defiant Disorder Clinician-Rated Severity of Conduct Disorder Clinician-Rated Severity of Nonsuicidal Self-Injury
This document is found on page 743 of the DSM. It allows the clinician to rate all of the salient dimensions that might be present in a disorder on the schizophrenia spectrum - IN TERMS OF SEVERITY - using Likert scale to rate the dimensions
Psycho-social HX MSE DSM 5 criteria for major depression A. Five or more of the following symptoms of been present during the same two-week period and represent a change from previous functioning; at least one of the symptoms is either depressed mood or loss of interest or pleasure 1. Depressed mood most of the day, nearly every day as indicated by subjective reporter observation. Yes or no 2. Marked diminished interest or pleasure in all our almost all activities. Most of the day, nearly every day. Yes or no 3. Significant weight loss when not dieting or weight gain or decrease in appetite, nearly every day. Yes or no 4. Insomnia or hypersomnia nearly every day. Yes or no 5. Psychomotor agitation or retardation nearly every day. Yes or no 6. Fatigue or loss of energy nearly every day. Yes or no 7. Feelings of worthlessness or excessive or inappropriate guilt. Yes or no 8. Diminished ability to think or concentrate or indecisiveness nearly every day. Yes or no 9. Recurrent thoughts of death or recurrent suicidal ideation or suicide attempt Yes or no 1. Lead with level I crosscutting symptom measures to assess all symptom domains 2. Follow-up with level II crosscutting measures in order to capture clinical nuances and potential comorbid B. The symptoms cause clinically significant distress or impairment Yes or no C. The episode is not attributable to the physiological effects of a substance or another medical condition Yes or no D. The occurrence of the major depressive disorder is not better explained by schizoaffective schizophrenia schizophreniform or anything else on the schizophrenia spectrum Yes or no E. There has never been a manic episode or hypomanic episode Yes or no 3. Move to categories and check off criteria 4. Assess severity
Adapted from the Patient Health Questionnaire9 (PHQ-9) depression Name: Age: Sex: Male q Female q Date: Instructions: Over the last 7 days, how often have you been bothered by any of the following problems? Clinician Use Item score More than half the days Nearly every day Not at all Several days 1. Little interest or pleasure in doing things 0 1 2 3 2. Feeling down, depressed, or hopeless 0 1 2 3 3. Trouble falling or staying asleep, or sleeping too much 0 1 2 3 4. Feeling tired or having little energy 0 1 2 3 5. Poor appetite or overeating 0 1 2 3 Feeling bad about yourself or that you are a failure or have let yourself or your family down 6. 0 1 2 3 Trouble concentrating on things, such as reading the newspaper or watching television 7. 0 1 2 3 Moving or speaking so slowly that other people could have noticed? Or the opposite being so fidgety or restless that you have been moving around a lot more than usual 8. 0 1 2 3 Thoughts that you would be better off dead or of hurting yourself in some way 9. 0 1 2 3 Total/Partial Raw Score: Prorated Total Raw Score: (if 1-2 items left unanswered) Levels of depressive symptoms severity None Mild depression Moderate depression Moderately severe depression Severe depression PHQ-9 Score 0-4 5-9 10-14 15-19 20-27
Alcohol use disorder A. Problematic pattern of alcohol use leading to clinically significant impairment or distress as manifested by at least two of the following occurring within a 12 month period 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. Tolerance, as defined by a. Increased amounts needed to achieve intoxication or b. Diminished effect Of alcohol 11. Withdrawal From alcohol Alcohol taken in larger amount (need more for increased effect) Persistent desire or efforts to quit Using alcohol Time spent to obtain, use, recover from effects Of alcohol Cravings Or urges to use Alcohol Failure to fulfill significant roles Continued use Alcohol despite persistent and recurrent problems Important social/occupational activities are reduced Recurrent use Of alcohol in physically hazardous situations Use Of alcohol continues despite knowledge of impact of the problem Severity Mild = presence of 2-3 symptoms moderate = presence of four five symptoms severe = presence of six or more symptoms Course specifiers early remission = after full criteria were l for at least three months but less than 12 (with the exception of craving) In sustained remission = after full criteria were previously met none exists except craving during the period of 12 months or more previously met none of the criteria met
2. NO MORE GAF WHODAS DSM IV-TR- HAD SOMETHING CALLED THE GLOBAL ASSESSMENT OF FUNCTIONING THE ONLY DIMENSIONAL MEASURE IN THE DSM IV TR USED BY CLINICIAN; COMPLETELY UNRELIABLE AND NOT VALID REPLACED WITH A SCALE THAT HAS RELIABILITY AND VALIDITY DATA THE WORLD HEALTH ORGANIZATION DISABLITY ASSESSMENT SCALE (WHODAS PP 745-749)
DSM 5 recommends the following 1. Assess symptom severity/severity of diagnosis-use severity scales 2. Use dimensional scales or standardized scales whenever possible 3. Assess suicidality, capacity for self harm or harming others- use separate assessment protocol 4. Use World Health Organization disability assessment scale to assess social and self- care functioning
WHODAS 2.0 Based on the International Classification of Functioning, Disability, and Health (ICF) Applicable to any health condition Reliability and clinical utility established in DSM 5 Field trials
see pages 745 to 748 in DSM 5 WHODAS Assesses the following six areas 1. Understanding and communicating 2. Getting around 3. Self-care 4. Getting along with people 5. Life activities 6. Participation in society
STANDARDIZED WAY TO MEASURE HEALTH AND DISABILITY ACROSS CULTURES DOES NOT TARGET SPECIFIC DISEASE, SO CAN BE USED TO ASSESS DISABILITY ACROSS DISEASE WHODAS 36 ITEM ON NEXT 3 SLIDES (PP745-749 IN DSM) Domain 1 Cognition In the past 30 days, how much difficulty did you have in: Extreme or cannot do None Mild Moderate Severe Concentrating on doing something for ten minutes? D1.1 1 2 3 4 5 D1.2 Remembering to do important things? 1 2 3 4 5 D1.3 Analysing and finding solutions to problems in day-to-day life? 1 2 3 4 5 Learning a new task, for example, learning how to get to a new place? D1.4 1 2 3 4 5 Generally understanding what people say? D1.5 1 2 3 4 5 D1.6 Starting and maintaining a conversation? 1 2 3 4 5 Domain 2 Mobility In the past 30 days, how much difficulty did you have in: D2.1 Standing for long periods such as 30 minutes? Extreme or cannot do None Mild Moderate Severe 1 2 3 4 5 D2.2 Standing up from sitting down? 1 2 3 4 5 D2.3 Moving around inside your home? 1 2 3 4 5 D2.4 Getting out of your home? 1 2 3 4 5 Walking a long distance such as a kilometre [or equivalent]? D2.5 1 2 3 4 5
Domain 3 Self-care In the past 30 days, how much difficulty did you have in: Extreme or cannot do None Mild Moderate Severe D3.1 Washing your whole body? 1 2 3 4 5 D3.2 Getting dressed? 1 2 3 4 5 D3.3 Eating? 1 2 3 4 5 D3.4 Staying by yourself for a few days? 1 2 3 4 5 Domain 4 Getting along with people In the past 30 days, how much difficulty did you have in: Extreme or cannot do None Mild Moderate Severe D4.1 D4.2 D4.3 Dealing with people you do not know? Maintaining a friendship? Getting along with people who are close to you? 1 1 1 2 2 2 3 3 3 4 4 4 5 5 5 D4.4 D4.5 Making new friends? Sexual activities? 1 1 2 2 3 3 4 4 5 5 Domain 5 LIFE ACTIVITIES Because of your health condition, in the past 30 days, how much difficulty did you have in: Extreme or cannot do None Mild Moderate Severe Taking care of your household responsibilities? D5.1 1 2 3 4 5 Doing your most important household tasks well? D5.2 1 2 3 4 5 Getting all the household work done that you needed to do? Getting your household work done as quickly as needed? D5.3 1 2 3 4 5 D5.4 1 2 3 4 5 Domain 5 WORK OR SCHOOL ACTIVITIES Because of your health condition, in the past 30 days how much difficulty did you have in: D5.5 Your day-to-day work/school? D5.6 Doing your most important work/school tasks well? Extreme or cannot do 5 5 None Mild Moderate Severe 1 1 2 2 3 3 4 4 Getting all the work done that you need to do? D5.7 1 2 3 4 5 Getting your work done as quickly as needed? D5.8 1 2 3 4 5 D5.9 Have you had to work at a lower level because of a health condition? No Yes No Yes 1 2 1 2 D5.10 Did you earn less money as the result of a health condition?
Domain 6 Participation Extreme or cannot do In the past 30 days: None Mild Moderate Severe How much of a problem did you have joining in community activities (for example, festivities, religious or other activities) in the same way as anyone else can? D6.1 1 2 3 4 5 How much of a problem did you have because of barriers or hindrances in the world around you? D6.2 1 2 3 4 5 How much of a problem did you have living with dignity because of the attitudes and actions of others? D6.3 1 2 3 4 5 How much time did you spend on your health condition or its consequences? D6.4 1 2 3 4 5 D6.5 How much have you been emotionally affected by your health condition? 1 2 3 4 5 How much has your health been a drain on the financial resources of you or your family? D6.6 1 2 3 4 5 How much of a problem did your family have because of your health problems? D6.7 1 2 3 4 5 How much of a problem did you have in doing things by yourself for relaxation or pleasure? D6.8 1 2 3 4 5
If WHODAS is used, place results at the very end of assessment, after psychosocial stressors
3. How to chart without axes DSM-5 has moved to a nonaxial documentation of diagnosis (formerly Axes I, II, and III), with separate notations for important psychosocial and contextual factors (formerly Axis IV) and disability (formerly Axis V) Taken from Northstar behavioral health system http://www.northstarbehavioral.com/Overview%20of%20DSM%205%20changes%20HO%20Ver sion%20for%20Web%208-13-13.pdf
Axis IV - psychosocial and environmental factors - are now covered through an expanded set of V codes. V codes allow clinicians to indicate other conditions that may be a focus of clinical attention or affect diagnosis, course, prognosis or treatment of a mental disorder Axis V - CGAS and GAF - are replaced by separate measures of symptoms severity and disability for individual disorders. Change to the World Health Organization Disability Assessment Schedule (WHO DAS 2.0) Taken from Northstar behavioral health system http://www.northstarbehavioral.com/Overview%20of%20DSM%205%20changes%20HO %20Version%20for%20Web%208-13-13.pdf
All diagnoses are considered primary diagnosis All diagnoses are listed consecutively (no distinction between diagnosis previously listed on axis I, axis II or axis III) List diagnosis that is the reason for visit 1st Primary-reason for visit, 296.33, major depressive disorder, recurrent, severe. Primary- Medical condition; Parkinson s disease, moderate Primary-305.00 alcohol use disorder, mild. Primary -v15.81 non-adherence to medical treatment. (Patient continues to drink while on antidepressants and does not take antidepressants regularly.) If the principal diagnosis that is a reason for visit is a mental disorder caused by a medical condition, the medical condition is listed 1st Primary-Parkinson's disease-moderate with tremors and newly developed postural instability (scored 3 on Hoehn and Yahr) Primary-Reason for visit, 296.22; major depressive disorder, single episode, moderate
Case example for listing of DX John is a 65-year-old white male who is morbidly obese and has been a smoker for 40 years. He quit smoking 5 years ago after being diagnosed with Parkinson's disease. Over the last 5 years, John's ability to perform physical activity, has progressively deteriorated. Although John reports bouts of depression, beginning in adolescence and continuing throughout his adult life, he was not diagnosed with major depressive disorder until 4 years ago (one year after the diagnosis of Parkinson s). Since that time, he has been on several antidepressant medications, most recently Remeron. John reports that he has been a regular drinker since his days in college. Although he denies it, his alcohol use, according to his wife, has increased since his diagnosis of Parkinsons. However, upon evaluation both john and his wife agree that he drinks no more than 3 times per week usually a six pack. Although John has been advised to discontinue drinking, he has not done so. According to both John and his wife. He misses his medication anywhere from 1 to 3 times per week. About 3 months ago john fell while at home. His wife at first thought it was a result of his drinking. According to John he noticed that he was having more difficulty standing and walking while maintaining his A recent neurological consult indicates that John does NOT have any neurological deficits that are out of normal range for his age but has developed postural instability consistent with a progression of Parkinson s Despite advice to the contrary, John has become progressively more sedentary and has discontinued all forms of exercise. About 1 month ago, John's employers required that John start working part-time and consider filing for early Social Security. According to them, John's ability to work has diminished. They too noted that he was having difficulty walking. For the last 3 weeks, John has met all of the criteria for a severe episode of major depression. Primary diagnosis Primary-reason for visit, 296.33, major depressive disorder, recurrent, severe. Primary- Medical condition; Parkinson s disease-recently upgraded to moderate Primary-305.00 alcohol use disorder, mild. Primary -v15.81 non-adherence to medical treatment. Patient continues to drink while on antidepressants take antidepressants irregularly
