Becoming Familiar with the DSM 5

1. Becoming Familiar with the DSM 5 Amy McCortney, Ph.D., LPC-S, NCC

2. Multiaxial evaluation review: Making the transition • Axis = Domain of information • Introduced in DSM-III • Ensures attention to • Biological • Psychological • Social • Impairment/severity • Common language

3. Multiaxial evaluation review: Making the transition • 5 axes: • I: Clinical dx, Other conditions • II: Personality dx, Mental Retardation • III: General Medical Conditions (GMC) • IV: Psychosocial and environmental conditions • V (Global Assessment of Functioning): scale of 0 to 100

4. Axis I Clinical disorders Other conditions that may be focus of clinical attn • Includes all current disorders except • Personality disorders • Mental retardation • List principal diagnosis first • List all Axis I • Include major stressors if focus • Ok to defer or assign no diagnosis

5. Axis II Personality disorders Mental Retardation • Includes • Personality disorders • Mental retardation • Personality traits • Defense mechanisms • Note if principal reason • List all Axis II • OK to defer to assign no diagnosis

6. Axis III General Medical Conditions • Relevant to understanding or management • Directly causes disorder (xx due to yy) • Causes d/o to worsen • D/o is a reaction to medical dx • Choice of meds is influenced • Management or safety is issue • Incidental • Specify • “None” if none • “Deferred” if in progress • “By patient history” if not formal

7. Axis IV Psychosocial and environmental problems • May include problems that… • affect dx, tx, prognosis • Put one at risk for mental d/o • are a result of mental d/o • Include • Relevant in past year • Very salient context/history • If focus, also gets coded on Axis I • Often include “mild” “moderate” “severe”

8. Primary support group Social environment Educational Occupational Housing Economic Health care Legal system Others Axis IV Psychosocial and environmental problems

9. Axis V Global Assessment of Functioning (GAF) • Level of psych, soc, and occ functioning • 100-point scale includes attention to • Severity • Functioning • Rate • current period (lowest past week) • past year • discharge/termination

10. Axis V Global Assessment of Functioning (GAF) • Often used to determine level of care • Generally… • 50-70 Outpatient • 30-50 Intensive outpatient/partial hosp • 1-30 Inpatient

11. Axis V Determining a GAF Score • Start at top and use “EITHER OR” logic Is either severity OR level of functioning worse? • Move down until range matches severity OR functioning (WHICHEVER WORSE) • Go one lower to make sure both are TOO SEVERE • Determine SPECIFIC number within 10-point range

12. GAF scores (for ex.) • 91-100 Superior functioning in a wide range of activities, life’s problems never seem to get out of hand, is sought out by others because of his or her many positive qualities. No symptoms. • 81-90 Absent or minimal symptoms (e.g., mild anxiety before an exam), good functioning in all areas, interested and involved in a wide range of activities, socially effective, generally satisfied with life, no more than everyday problems and concerns (e.g. an occasional argument with family members).

13. GAF Example 1 A 35 year old advertising executive with Borderline Personality Disorder cuts her wrists deeply with a piece of glass after the married man with whom she spent the weekend informs her that he does not want to see her again. On admission, she states she is sorry she did this and no longer feels acutely suicidal.

14. GAF Example 2 A 27 year old man with Schizophrenia, working nights sorting mail at the post office, is seen at a Community MHC for his monthly appointment to manage his antipsychotic meds. He has not had delusions or hallucinations for the past five years, but is tangential, has few friends, and spends most of his free time watching television. He lives at home with his parents.

15. GAF Example 3 A 28 year old graduate student presented for a practice counseling session within a counseling program where she maintained a 3.75 GPA. She discussed feeling overwhelmed with responsibilities from time to time throughout the semester. She reported a recent disagreement with a significant other and attributes this to time spent at school and work. She admits that she has not prepared this week’s assignment because she was focused on this interaction.

16. GAF changing to… WHODAS p. 745 • A 36-item measure measuring compromised functioning in 18 y.o.+ • 6 domains: • Understanding/communicating • Getting around • Self-care • Getting along with others • Life activities (ADLEs) • Participation in society

17. In a nutshell… Communicating severity and impairment • DSM-IV severity specifiers (Axis I) • Co-morbid personality disorders (Axis II) • Co-morbid medical conditions (Axis III) • Listing all stressors (Axis IV) • Overall quality of functioning: GAF (Axis V)

18. And here’s why:

19. Making the transition… DSM IV TR DSM 5 296.23 Major Depressive Disorder, Single Episode 401.9 Hypertension, Unspecified (per client report) V62.29 Other Problem Related to Employment WHODAS: 15, Moderate • I: 296.23 Major Depressive Disorder, Single Episode, Severe Without Psychotic Features • II: V71.09 No diagnosis • III: 401.9 Hypertension, Unspecified (per client report) • IV: V62.2 Occupational problems • V (GAF): 35 (current)

20. Subtypes pp. 21, 271-272 • When the Manual reads “specify whether”, this is a subtype of the disorder itself. • Ex.: 309.81 Posttraumatic Stress Disorder, With dissociative symptoms, Depersonalization

21. Severity & Course Specifiers • When the Manual reads “specify if”, this is a subtype of the disorder itself. • Ex.: 309.81 Posttraumatic Stress Disorder, With dissociative symptoms, Depersonalization, With delayed onset • Mild (Few symptoms in excess of min; minor impair); Moderate; Severe (Many symptoms in excess, several particularly severe symptoms, marked impairment) • Partial remission; Full remission; Prior history

22. Don’t forget… • Proceed to “Cultural considerations” lessons. • For next week: • Do your readings • Tab your DSMs