D S M V HI G HL I G HT S

HOW TO USE
DSM IV-TR – MULTIAXIAL SYSTEM
• I –CLINICAL DISORDER AND CONDITIONS THAT ARE THE FOCUS OF TREATMENT
• II – PERSONALITY DISORDERS AND MR
• III – GENERAL MEDICAL CONDITIONS
• IV – PSYCHOSOCIAL AND ENVIRONMENTAL FACTORS
• V- GLOBAL ASSESSMENT OF FUNCTIONING
DSM IV-TR SAMPLE DX
SITUATION
• DEPRESSED MALE WHO ALSO DRINKS A LOT, HAS • I – 296.23 MDD, SINGLE EPISODE, MODERATE.
• ALCOHOL DEPENDENCE,MODERATE
DIABETES. MANY RELATED ISSUES.
• II – NONE
OCCASIONALLY SUICIDAL • III – TYPE 2 DIABETES
• IV – FINANCIAL, FAMILY CONFLICTS, EMPLOYMENT, MEDICAL
• V- 40
AXIS V-GAF NOT USED IN DSM V
• GENERALIZED ASSESSMENT OF FUNCTIONING
• NUMBERS REPRESENT CLIENT’S BEHAVIORS (AND HENCE ABILITY TO COPE)
• CURRENT GAF
• HIGHEST GAF (DSM IV- NOT ABSOLUTELY REQUIRED)
• LOWEST LEVEL OF FUNCTIONING PRIOR TO HOSPITALIZATION OR INITIATION OF SERVICE IS SUGGESTED
• GOOD WAY TO COMPARE LEVEL OF FUNCTIONING
• *** STILL USED CURRENTLY – INSURANCE COMPANIES LIKE IT
IMPORTANCE
• SCORES INDICATE “LEVEL OF CARE” (TX)
• LESS THAN 30 USUALLY INDICATES HOSPITALIZATION
• 40’S RANGE & SLIGHTLY HIGHER MAY INDICATE IOP/PHP
• LEVEL OF FUNCTIONING IS WHAT YOU ARE LOOKING AT
• NOT EXPECTED TO MEMORIZE THE SCALE –
• WAY TO TRACK CLIENTS PERFORMANCE (ALSO USED BY INSURANCE COMPANIES FOR LEVEL OF CARE/TX)
DSM V – NON-AXIAL SYSTEM
• COMBINED ATTENTION TO CLINICAL DISORDERS, INCLUDING PERSONALITY DISORDERS & INTELLECTUAL
DISABILITIES; OTHER CONDITIONS THAT ARE THE FOCUS OF TREATMENT; RELEVANT MEDICAL CONDITIONS

• REASON FOR VISIT, PSYCHOSOCIAL & CONTEXTUAL FACTORS

• EXPANDED V CODES AND Z CODES

• END OF NOS (NOT OTHERWISE SPECIFIED)

• END OF POLYSUBSTANCE ABUSE – ALL MUST BE NAMED
V CODES
•INCLUDE IN OFFICIAL DX IF FOCUS OF TREATMENT
•GREATLY EXPANDED- THINGS SUCH AS HOMELESSNESS,
CURRENT MILITARY DEPLOYMENT STATUS, SOCIAL
EXCLUSION/REJECTION, TARGET OF DISCRIMINATION, ETC
Z CODES
• OTHER PROBLEMS RELATED TO PRIMARY SUPPORT GROUP, INCLUDING FAMILY CIRCUMSTANCES
• Z63.0 PROBLEMS IN RELATIONSHIP WITH SPOUSE OR PARTNER
• Z63.1 PROBLEMS IN RELATIONSHIP WITH IN-LAWS
• Z63.3 ABSENCE OF FAMILY MEMBER
• Z63.31 …… DUE TO MILITARY DEPLOYMENT
• Z63.32 OTHER ABSENCE OF FAMILY MEMBER
• Z63.4 DISAPPEARANCE AND DEATH OF FAMILY MEMBER
• Z63.5 DISRUPTION OF FAMILY BY SEPARATION AND DIVORCE
Z CODES
• Z63.6 DEPENDENT RELATIVE NEEDING CARE AT HOME
• Z63.7 OTHER STRESSFUL LIFE EVENTS AFFECTING FAMILY AND HOUSEHOLD
• Z63.71 STRESS ON FAMILY DUE TO RETURN OF FAMILY MEMBER FROM MILITARY DEPLOYMENT
• Z63.72 ALCOHOLISM AND DRUG ADDICTION IN FAMILY
• Z63.79 OTHER STRESSFUL LIFE EVENTS AFFECTING FAMILY AND HOUSEHOLD
• Z63.8 OTHER SPECIFIED PROBLEMS RELATED TO PRIMARY SUPPORT GROUP
• Z63.9 PROBLEM RELATED TO PRIMARY SUPPORT GROUP, UNSPECIFIED
SUGGESTIONS
•LIST ALL RELEVANT DISORDERS IN ORDER OF FOCUS
•MAKE “PROVISIONAL” (TENTATIVE) DIAGNOSIS AS NEEDED
•INCREASE USE OF V CODES (ACTUALLY IMPORTANT FOR SOCIAL WORKERS-
MORE STRESS ON SOCIAL ENVIRONMENT AND OTHER FACTORS
•INCLUDE MEDICAL DIAGNOSIS IF DOCUMENTED AND RELEVANT TO WHAT IS
GOING ON
SAMPLE DIAGNOSIS (DSM V)
SITUATION
• CLIENTS MEETS CRITERIA FOR DEPRESSION &
USES ETOH EXCESSIVELY- UNABLE TO CONTROL
HIS DIABETES DUE TO THIS SITUATION
DSM V DX
296.23 – MAJOR DEPRESSIVE DISORDER, SEVERE,
SINGLE EPISODE, SEVERE
303.90 – ALCOHOL USE DISORDER, MODERATE
E11 – TYPE II DIABETES MELLITUS
ICD-10
• INTERNATIONAL CLASSIFICATION OF DISEASES
• BY WHO (WORLD HEALTH ORGANIZATION)
• BEGAN 1893 BY A DIFFERENT NAME (INTERNATIONAL LIST OF CAUSES OF DEATH)
• CLASSIFIES DISEASES AND OTHER HEALTH PROBLEMS
• HELPS RETRIEVE STATS ON MORBIDITY & MORTALITY
TOGETHER

• ICD & DSM HAVE COLLABORATED WITH SIMILAR CODES FOR BOTH
• ICD & DSM ARE MOST CONCERNED WITH DX
• CPT CODES ARE MORE CONCERNED WITH PROCEDURES (FOR REINBURSEMENT)
ETHICS & LEGAL CONSIDERATIONS

• 1. BE AWARE OF RULES – NATIONAL & STATEWIDE FOR THE PROFESSION OF SOCIAL WORK
• 2. CODE OF ETHICS –BE FAMILIAR
• 3. ACCURATE & CAREFUL DOCUMENTATION
• 4. CONFIDENTIALITY & PRIVACY ISSUES
• 5. RECORD OBJECTIVE DATA (BEST TO AVOID INTERPRETATION OF BEHAVIORS IN DOCUMENTS)
CONSIDERATIONS

• 6. USE DIRECT CLIENT STATEMENTS WHENEVER POSSIBLE (I LIKE TO USE “QUOTES”)

• 7. YOU CANNOT DOCUMENT AIDS WITHOUT CLIENT’S PERMISSION (LEGAL)
• **** THE INFORMATION TO GATHER AND DOCUMENT ABOUT THE CLIENT LIVES ON AND ON AND
ON……………………………
PROVISIONAL IN DSM V

• WHEN THE DX IS CORRECT BUT LACKS SUFFICIENT HISTORY TO SUPPORT DX OR IT IS STILL EARLY IN THE
COURSE OF ILLNESS
SEVERITY & OTHER SPECIFIERS

• SEVERITY SELF EXPLANATORY (MILD, MODERATE, SEVERE)

• OTHER SPECIFIERS : WITH OR WITHOUT, CERTAIN ACCOMPANYING SX, DEGREES OF REMISSION, COURSE
FEATURES (EARLY OR LATE) OF RECOVERY
DSM 5- WHAT IS A MENTAL DISORDER?
• 1. MENTAL DISORDERS DESCRIBE PROCESSES NOT PEOPLE. PATIENTS WITH THE SAME DIAGNOSIS MAY
BE QUITE DIFFERENT FROM ONE ANOTHER IN MANY IMPORTANT ASPECTS – INCLUDING SX’S,
PERSONALITY, AND OTHER DX THEY MAY HAVE

• 2. SOME OF WHAT’S ABNORMAL, AND OF COURSE WHAT ISN’T IS DETERMINED BY A PERSON’S CULTURE
• 3. DON’T ASSUME THERE ARE SHARP, DISTINCT BOUNDARIES BETWEEN DISORDERS OR BETWEEN ANY
DISORDER AND “NORMALITY” – FOR EXAMPLE ALL BIPOLAR CONDITIONS LIKELY FIT SOMEHWERE ALONG
A CONTINUUM.
• 4. WE KNOW WHAT CAUSES MANY PHYSICAL CONDITIONS (PNEUMONIA OR DIABETES) BUT WE DO NOT
KNOW WHAT CAUSES MOST MENTAL ILLNESSES.

• 5. DSM 5 FOLLOWS THE MEDICAL MODEL OF ILLNESS. IT IS DESCRIPTIVE DERIVED MOSTLY FROM
SCIENTIFIC STUDIES OF GROUPS OF PATIENTS WHO APPEAR TO HAVE A LOT IN COMMON.

• 6. WITH A FEW EXCEPTIONS, DSM 5 MAKES NO ASSUMPTION ABOUT THE ETIOLOGY OF MOST MENTAL
DISORDERS. THIS NOTION HAS BEEN PRAISED AND CRITICIZED.
WHAT IS ABNORMAL?????

• PLEASE VIEW THE FOLLOWING PICS AND DECIDE IF THEY ARE “NORMAL”
• BE CAREFUL!!!!!
LOLA CANCUN
PEPE SANTA
LOLA BIKINI
DSM 5 – MORE TIPS
• JUST BECAUSE A DISORDER IN NOT IN THE BOOK DOES NOT MEAN IT DOES NOT EXIST. THERE ARE
PROBABLY MORE CONDITIONS WAITING TO BE DISCOVERED

• DIAGNOSIS IS NOT FOR “ROOKIES.” IT IS MORE THAN JUST CHECKING OFF BOXES. EDUCATION,
TRAINING, PATIENCE IS NEEDED

• DSM 5 MAY NOT BE UNIFORMLY APPLICABLE TO ALL CULTURES. THE CRITERIA COME FROM STUDIES OF
MOSTLY NORTH AMERICANS AND EUROPEANS

• DSM 5 IS A LONG WAY FROM PERFECT. IT IS A GUIDELINE!!!

 Always consider culture bound
syndromes – often ignored by
practioners

Example: Susto

CULTURAL “fright/loss of soul”

ASPECTS
Prevalent in Mexico, some countries
Central/South America

“frightening event causing the soul to

leave the body”
 NOT for “lay people”
(untrained/educated)

Never suggest to a client to read

about a disorder in DSM

DSM-5
DSM is very complex

Role of practitioner is to interpret the

diagnostic criteria & work w/ client
for best interventions/actions
DSM-5 is not enough

Assessment is a process!

Each criteria is important

DX of mental D/O alone cannot be used to

determine competence, criminal
responsibility, or disability.

In Forensic setting, use of diagnostic

label cannot be used as legal definition
of mental disorder or disability
 Practitioner interpretation is
critical

Clinically significant indicates

practitioner has clearly linked the
CLINICALLY Sxs present in the mental d/o WITH
SIGNIFICANT how the sxs either stop or impair
client’s current level of
functioning

DX should only be given when Sxs

severe enough to interfere w/ or
disturb functioning
 Factors such as:

Age

ALSO Culture

Gender…..Must be considered!

Regardless of diagnostic sx if the

behavior is not considered clinically
significant then NO DX should be made
 Diagnostic tests –explain or
confirm the cause/etiology
of disorder

LAB FINDINGS & Confirmatory of DX: most

ASSOCIATED tests do not necessarily
FEATURES reveal cause or etiology

Findings assoc as
complications of condition:
factors not directly related
to Dx but often found in
conjunction with it
 Electrolyte imbalance
often seen with
anorexia or other
eating disorders

EXAMPLE
Dehydration often
found w/ bipolar
(lithium use) or mania
(not caring for self)
1. Age of ONSET

2. How long symptoms existed

KEY
CONSIDERATION
3. Severity of symptoms S

4. Gender
SYMPTOMS – what the client reports!
Personal experience of what is going
on (may not always be accurate or
helpful_

SIGNS – What the clinician observes!!

SIGNS &
SYMPTOMS
Need to put them together to figure
out what is really going on
DSM 5 – MORE TIPS
• JUST BECAUSE A DISORDER IS NOT IN THE BOOK DOES NOT MEAN IT DOES NOT EXIST. THERE ARE
PROBABLY MORE CONDITIONS WAITING TO BE DISCOVERED

• DIAGNOSIS IS NOT FOR “ROOKIES.” IT IS MORE THAN JUST CHECKING OFF BOXES. EDUCATION,
TRAINING, PATIENCE IS NEEDED

• DSM 5 MAY NOT BE UNIFORMLY APPLICABLE TO ALL CULTURES. THE CRITERIA COME FROM STUDIES OF
MOSTLY NORTH AMERICANS AND EUROPEANS

• DSM 5 IS A LONG WAY FROM PERFECT. IT IS A GUIDELINE!!!