The use of DSM-IV-TR and ICD-9-CM/ICD-10 in School Settings Alvin E. House, Ph.D. Department of...

The use of DSM-IV-TR and ICD-9-CM/ICD-10 in School Settings

Alvin E. House, Ph.D.

Department of Psychology

Illinois State University

The use of DSM-IV-TR and ICD-9-CM/ICD-10 in School Settings

Charlottesville, VA

October 7, 2008

Goals of presentation

Familiarity with basic components of DSM

Familiarity with basic components of DSM Understanding the structure of DSM

Familiarity with basic components of DSM Understanding the structure of DSM Introduction to the use of DSM

Familiarity with basic components of DSM Understanding the structure of DSM Introduction to the use of DSM What’s not covered:

Concerns about medical model Problems with categorical assessment Everything that is wrong with DSM

What’s not covered: When do you play at a crooked card game?

When it’s the only game in town.

When it’s the only game in town. DSM-IV-TR/ICD-9-CM is the only game in

town with regard to most potential sources of “recovered funds”, “third party carriers”, “reimbursement”, “funding”

Two metaphors for DSM-IV-TR A house

Oh, isn’t that a clever play on words. What, they’re both made from trees? I had to take the morning off for this?

“Constructed”, not “found”

Constructed, not “found” Constrained by nature of phenomenon

Constructed, not “found” Constrained by nature of phenomenon Utility rather than truth criterion for success

Two metaphors for DSM-IV-TR A house A language

used to communicate

used to capture as much information about the case as possible

used to communicate

used to capture as much information about the case as possible

It’s less about getting the “right answer” than getting the clearest message across

The central role played by the examiner in DSM You are the most important element of a

DSM-IV-TR diagnosis

The central role played by the examiner in DSM DSM is at heart a tool prepared by (mostly)

physicians for the use of (mostly) other physicians

The central role played by the examiner in DSM DSM is at heart a tool prepared by (mostly)

physicians for the use of (mostly) other physicians

The clinician is the standard by which almost (almost) all judgments are made

The central role played by the examiner in DSM You are the standard by which almost all

judgments are made

judgments are made: The decision as to whether a problems is

severe enough to significantly impairment functioning and adjustment

The decision as to whether the client’s suffering and distress is clinically significant

The decision as to whether the client has a mental disorder

judgments are made

judgments are made Clinical judgment and responsibility are

critical factors in DSM

The central role played by the examiner in DSM Sign/symptom Syndrome Disorder Disease

The central role played by the examiner in DSM Sign/symptom

Sign: objective manifestation of pathological condition observed by examiner (p. 827)

Symptom: subjective manifestation of pathological condition reported by affected individual (p. 828)

The central role played by the examiner in DSM Sign/symptom If you see it, it’s a sign, If it’s reported to you, it’s a symptom

The central role played by the examiner in DSM Sign/symptom If you see it, it’s a sign, If it’s reported to you, it’s a symptom Guess which have the most weight in the

world of DSM?

Sources of confusion

The complexity of the subject/task

The complexity of the subject/task Human behavior is among the most complex

and challenging phenomena we attempt to understand

We would all like the world and our jobs to be a little simpler/easier

There’s not; that’s the way it is; move on (at least we don’t get bored very often)

The complexity of the subject/task Errors in the references

Very first case in DSM-IV-TR Case Studies shows a diagnosis of Mental Retardation on Axis I (p. 4)

The complexity of the subject/task Errors in the references Ambiguities in the document

What counts for a “setting” (besides “school” and “home”) for ADHD?

The complexity of the subject/task Errors in the references Ambiguities in the document

What counts for a “setting” (besides “school” and “home”) for ADHD?

Does an Adjustment Disorder diagnosis take precedence over a thematic NOS diagnosis?

The complexity of the subject/task Errors in the references Ambiguities in the document The number of diagnostic categories

DSM-IV-TR Multiaxial AssessmentAxis I Clinical Syndromes

Other Conditions That May Be a Focus of Clinical Attention

Axis II Mental Retardation

Borderline Intellectual Functioning (not a mental disorder)

Personality Disorders

Personality Traits

DSM-IV-TR Multiaxial Assessment Continued

Axis III General Medical Conditions

Axis IV Psychosocial & Environmental Problems

Axis V Global Assessment of Functioning (GAF) Scale

“DSM-IV-TR diagnosis”

_ _ _ . _ _a number

The 3-5 digit number is the ICD-9-CM code for the condition or disorder being recorded

________ Disordera title

The condition or disorder being recorded (title, criterion set, other features) is an entry from DSM-IV-TR

All DSM-IV-TR diagnoses are legitimate ICD-9-CM and ICD-10 diagnoses

DSM-IV Conceptualization of Mental Disorder “In DSM-IV, each of the mental disorders is

conceptualized as a clinically significant behavioral or psychological syndrome or pattern that occurs in an individual and that is associated with present distress (e.g., a painful symptom) or disability (i.e., impairment in one or more important areas of functioning) or with a significantly increased risk of suffering death, pain, disability, or an important loss of freedom.”

DMS-IV-TR, 2000, p. xxxi

DSM-IV Conceptualization of Mental Disorder Continued Clinically significant Syndrome/pattern Occurs in an individual Not expectable & culturally sanctioned response to

a particular event Conflicts between individual and society are not

mental disorders, unless the deviance or conflict is a symptom of a dysfunction in the individual

Classified disorders that people have, not people

Clinical significance

Distress

Distress Impairment

In order to reduce false positive diagnoses almost all DSM-IV-TR diagnoses reiterate the distress/impairment criteria for a mental disorder

Distress Impairment

In order to reduce false positive diagnoses almost all DSM-IV-TR diagnoses reiterate the distress/impairment criteria for a mental disorder

An interesting exception is one of the few criterion changes made in the TR revision: Tourette’s Disorder

Distress Impairment This is what makes a “mental disorder” in

DSM, this is the fundamental decision, differentiation you are making

DSM, this is the fundamental decision, differentiation you are making:

“If there sufficient evidence of impairment or distress to call this problem a ‘mental disorder’?”

Use of DSM: multiple diagnoses DSM-IV-TR allows/encourages multiple

diagnoses when the criteria for more than one diagnosis are met

Use of DSM: multiple diagnoses DSM-IV-TR allows/encourages multiple

diagnoses when the criteria for more than one diagnosis are met; however, there are three general exceptions to control unbridled comorbidity

Use of DSM: multiple diagnoses Three general exceptions to multiple

diagnoses: General Medical Condition/Substance Use

“not due to the direct effects of a substance (e.g., drugs of abuse or medication) or a general medical condition.”

diagnoses: General Medical Condition/Substance Use Associated feature of a more pervasive disorder

“has never met the criteria for . . . .”

“does not meet the criteria for . . . .”

“does not occur exclusively during the course of . . . .”

diagnoses: Associated feature of a more pervasive disorder

more pervasive diagnoses usually take precedence over more focal or narrow diagnoses

Importance of Associated Symptoms Associated symptoms are not part of a

disorder’s definition or criterion set, but are common observed in the clinical presentation

Associated symptoms tell you what else a given diagnosis will “account for”

Associated symptoms help you decide if a single diagnosis is sufficient to explain the features of your case or if other diagnoses are needed

Course and Associated Symptoms An concurrent diagnosis of a pattern that

normally would be as associated symptom of a more pervasive disorder, would suggest that you had established a history of the independent occurrence of that set of problems

Course and Associated Symptoms An concurrent diagnosis of a pattern that normally would be as associated symptom

of a more pervasive disorder, would suggest that you had established a history of the independent occurrence of that set of problems

For example, diagnosing• Major Depressive Disorder, Single Episode

• and

• Generalized Anxiety Disorder

Would suggest you had established a history of GAD when the Major Depressive Disorder wasn’t present

Course and Associated Symptoms An concurrent diagnosis of a pattern that normally would be as associated

symptom of a more pervasive disorder, would suggest that you had established a history of the independent occurrence of that set of problems

For example, diagnosing• Major Depressive Disorder, Single

Episode• and

• Generalized Anxiety Disorder

Or that you had made a mistake

Conduct Disorder has precedence over ODD

Mood Disorders have precedence over Anxiety Disorders

Autistic Disorder has precedence over ADHD

General rule: skip first chapter and diagnose from front of text toward the back of the text

usually take precedence over more focal or narrow diagnoses

Occasional exception to this rule: when the less pervasive diagnosis becomes the focus of clinical attention (when there is a specific treatment plan)

Use of DSM: multiple diagnoses Three general exception of multiple

diagnoses: General Medical Condition/Substance Use Associated feature of a more pervasive disorder Boundary conditions (clinical judgment required)

“not better accounted for by . . . .”

Use of DSM: multiple diagnoses Three general exception of multiple

diagnoses: General Medical Condition/Substance Use Associated feature of a more pervasive disorder Boundary conditions (clinical judgment required)

“not better accounted for by . . . .” Selective Mutism

“is not better accounted for by a Communication Disorder (e.g., Stuttering) . . . .

Use of DSM: multiple diagnoses With more than one diagnosis, the principal

diagnosis is the condition which leads to the evaluation or the referral for clinical services

Unless otherwise indicated, the principal diagnosis is the first diagnosis on Axis I

diagnosis is the condition which lead to the evaluation or the referral for clinical services

Unless otherwise indicated, the principal diagnosis is the first diagnosis on Axis I Axis I: Enuresis Axis II: Mental Retardation (reason for visit)

Use of DSM: multiple diagnoses With more than one diagnosis on either Axis I

or Axis II, diagnoses should be listed within each axis in the order of clinical focus for attention or treatment

Use of DSM: the most important phrase in DSM “The essential features of . . . .”

Use of DSM: the most important phrase in DSM “The essential features of . . . .” The NOS (Not Otherwise Specified)

diagnoses have two requirements:

diagnoses have two requirements: The condition must meet the criteria for a “mental

disorder”

disorder” Significant function impairment or Significant personal distress or suffering

disorder” The condition must meet the “essential features”

of the diagnosis being considered

Diagnostic Certainty

Specific Diagnosis

Meets criteria for a mental disorder?......“Yes”

Meets essential criteria for group?.........“Yes”

Meets specific criteria for diagnosis?.....“Yes”

Specific Diagnosis, Provisional

Meets specific criteria for diagnosis?.....“Not quite”

Categorical NOS Diagnosis

Meets specific criteria for diagnosis?.....“No”

Mental Disorder NOS

Meets essential criteria for group?.........“No”

799.9 Diagnosis Deferred

Meets criteria for a mental disorder?......“Not sure”

Meets essential criteria for group?.........“Not sure”

Use of DSM: subtypes & specifiers Subtypes: mutually exclusive and jointly

exhaustive subgroupings within a diagnosis Specifiers are not mutually exclusive; provide

for more homogeneous subgroupings of individuals who meet diagnostic criteria

Use of DSM: subtypes & specifiers Subtypes: mutually exclusive and jointly

exhaustive subgroupings within a diagnosis

Conduct Disorder: “a repetitive and persistent of behavior in which the basic rights of others or major age-appropriate social norms or rules are violated”

manifested by presence of at least 3 of 15 symptoms over 12 months, with at least 1 in past 3 months

Use of DSM: subtypes & specifiers Subtypes: mutually exclusive and jointly exhaustive

subgroupings within a diagnosis

Conduct DisorderChildhood-Onset Type: at least 1 criterion

prior to age 10 years

Adolescent-Onset Type: absence of any criterions prior to age 10 years

Use of DSM: severity specifiers Severity: mild, moderate, severe

Usually reflects the number of symptoms evident

Usually reflects the number of symptoms evident Mild: just meets or barely exceeds minimum requirement

to support diagnosis

Severe: meets almost all or all diagnostic symptoms

Moderate: number of symptoms intermediate between mild and severe

Severe: meets almost all or all diagnostic symptoms

Usually reflects the number of symptoms evident For some disorders specific criteria are provided

for severity specifiers (e.g., Mental Retardation, Conduct Disorders, Manic Episode, Major Depressive Episode)

Use of DSM: course specifiers Course: (present), in partial remission, in full

remission, prior history

remission, prior history In general “In Partial Remission” means full

criteria were previously met and only some of the symptoms remain currently

remission, prior history In general “In Partial Remission” means full

criteria were previously met and only some of the symptoms remain currently

“In Full Remission” refers to complete absence of any current symptoms

Use of DSM: course specifiers

In general “In Partial Remission” means full criteria were previously met and only some of the symptoms remain currently

“In Full Remission” refers to complete absence of any current symptoms

No absolute demarcation between In Full Remission and Recovered (when the disorder would no longer be noted)

Use of DSM: course specifiersAgain, there are specific criteria for In Partial

Remission and In Full Remission for some disorders (manic episode, major depressive disorder, substance abuse)

Use of DSM: “mental disorders”Axis I and Axis II comprise the “mental

disorders”: diagnostic categories on both must meet the criteria for a mental disorder (V codes and personality traits do not meet criteria for mental disorders; these are listed on Axis I or Axis II also)

Use of DSM: conditions that are not “mental disorders”Other Conditions That May Be a Focus of

Clinical Attention

316 Psychological Factor Affecting Medical Condition

Medication-Induced Movement Disorders

995.2 Adverse Effects of Medication Not Otherwise Specified

Use of DSM: conditions that are not “mental disorders”Other Conditions That May Be a Focus of

Clinical Attention

Relational Problems

Problems Related to Abuse or Neglect

Additional Conditions That May Be a Focus of Clinical Attention

Other Conditions that May Be a Focus of Clinical AttentionRelational Problems

V61.9 Relational Problem Related to a Mental Disorder or General Medical Condition

V61.20 Parent-Child Relational Problem

V61.10 Partner Relational Problem

V61.8 Sibling Relational Problem

V62.81 Relational Problem Not Otherwise Specified

Other Conditions that May Be a Focus of Clinical AttentionProblems Related to Abuse or Neglect

V61.21 Physical Abuse of Child

965.54 focus of clinical attention is victim

V61.21 Sexual Abuse of Child

V61.21 Neglect of Child

there are also adult codes

Other Conditions that May Be a Focus of Clinical AttentionAdditional Conditions That May be a Focus of

Clinical AttentionV15.81 Noncompliance With TreatmentV65.2 MalingeringV71.01 Adult Antisocial Behavior

V71.02 Child or Adolescent Antisocial BehaviorV62.89 Borderline Intellectual Functioning

IQ 71-84

Other Conditions that May Be a Focus of Clinical AttentionAdditional Conditions That May be a Focus of

Clinical Attention780.9 Age-Related Cognitive DeclineV62.82 BereavementV62.3 Academic ProblemV62.2 Occupational Problem313.82 Identity ProblemV62.89 Religious or Spiritual ProblemV62.4 Acculturation ProblemV62.89 Phase of Life Problem

Additional Codes

300.9 Unspecified Mental DisorderV71.09No Diagnosis or Condition on Axis I799.9 Diagnosis or Condition Deferred on

Axis IV71.09No Diagnosis on Axis II799.9 Diagnosis Deferred on Axis II

Use of DSM: “Disorders usually first evident . . . .”The first grouping of diagnoses in DSM-IV-

TR is labeled, "Disorders Usually First Evident in Infancy, Childhood, or Adolescence." It is an unusual grouping because it is not thematically defined, as are most diagnostic groupings in DSM or etiologically defined (such as the OBS, general medical condition, and drug categories). Caution is necessary because:

Use of DSM: “Disorders usually first evident . . . .”Caution is necessary because: 1) not all

children with mental disorders have mental disorders found in this first grouping

Use of DSM: “Disorders usually first evident . . . .”Caution is necessary because: 2) adults

may be diagnosed with the disorders from the first grouping of diagnoses

Use of DSM: “Disorders usually first evident . . . .”Caution is necessary because: Also, there

is no clear logical or thematic sequencing of the subsections

Finally, recall that Mental Retardation (and Borderline Intellectual Functioning) are diagnosed on Axis II

Most of the subsections in the first grouping of disorders have "The essential feature(s)"

Use of DSM: “Disorders usually first evident . . . .”Finally, recall that Mental Retardation

(and Borderline Intellectual Functioning) are diagnosed on Axis II

Most of the subsections in the first grouping of disorders have "The essential feature(s)"

Use of DSM: “Disorders usually first evident . . . .”

It is therefore useful to train yourself not to speak or think of the first grouping as "the child section", "the child disorders", etc.

Use of DSM: Axis III

Axis III: General Medical ConditionsPhysical disorders and conditions pertinent to understanding or managing the youth’s situation are recorded on Axis III

May be judged to be etiologically relevant (dementia due to brain injury) or may be important to clinical management of case (diabetes precluding use of food reinforcer)

Skolol (1989) discussed issue of use of Axis III by nonmedical mental health professionals

He opined that notation on Axis III does not indicate diagnosis was made by person recording the multiaxial evaluation

He suggests that nonmedical clinicians indicate the source of their information on Axis III

Best Practice Recommendation: If you indicate an Axis III diagnosis always also indicate the source of the information or determination“mother reports child has juvenile onset diabetes”“genetic karyotype indicates trisomy 21”“seizure disorder diagnosed by child’s pediatrician”

Use of DSM: Axis IVPsychosocial and Environmental Problems

problems with primary support groupproblems related to social environmenteducational problemsoccupational problemshousing problemseconomic problemsproblems with access to health care servicesproblems related to interaction with legal systemother psychosocial and environmental problems

Use of DSM: Axis IVPsychosocial and Environmental

Problems

positive stressors are usually not listed

usually past year is reference period

may also be recorded on Axis I if focus of clinical attention

Use of DSM: Axis VGlobal Assessment of Functioning

0 - 100 rating of “overall level of functioning”

“rated with respect only to psychological, social, and occupational [school] functioning”

usually for current period; may also be made for other time periods (“highest level of functioning for at least a few months during the past year”)

Use of DSM: Axis V100-91 superior functioning90-81 no symptoms, good functioning80-71 transient/expected reactions; slight impairment70-61 mild symptoms or difficulty60-51 moderate symptoms or moderate difficulty50-41 serious symptoms or serious impairment40-31 impaired reality testing/comm. or major

impairment in several areas30-21 impaired comm./judgment or inability to function20-11 some danger to self or others or impaired hygiene10-1 persistent danger to self or other or impaired self

care or serious suicide attempt with clear expectation of death

0 inadequate information

Use of DSM: Axis V

100-91 superior functioning90-81 no symptoms, good functioning80-71 transient/expected reactions;

slight impairment

70-61 mild symptoms or difficulty

Use of DSM: Axis V

70-61 mild symptoms or difficulty

60-51 moderate symptoms or moderate difficulty

50-41 serious symptoms or serious impairment

Use of DSM: Axis V

40-31 impaired reality testing/comm. or major impairment in several areas

30-21 impaired comm./judgment or inability to function

Use of DSM: Axis V

20-11 some danger to self or others or impaired hygiene

10-1 persistent danger to self or other or impaired self care or serious

suicide attempt with clear expectation of death

Use of DSM: Axis V

Two general considerations in assignment GAF score:

1) severity of symptoms

2) impairment in functioning

Use of DSM: Axis V

Two general considerations in assignment GAF score:1) severity of symptoms2) impairment in functioning

When these disagree, we are to make the GAF assignment based on the lower score

The process of mental health diagnosis The fundamental questions:

What are the problems?

What are the problems? What are the domains involved?

Cognitive Behavior Emotion Interpersonal Environmental

What are the problems? What are the domains involved? Is there a Mental Disorder?

What diagnosis best accounts for the available data?

What diagnosis best accounts for the available data? Are there remaining important features of the case that

need accounting for?

What diagnosis best accounts for the available data? Are there remaining important features of the case that

need accounting for? Are there any other diagnoses that need to be made?

Ethical & Legal Issues

Mental health diagnosis using DSM-IV-TR is a process of professional, clinical judgment. The activity is regulated by law and by professional practice boards within states. Agencies, school units, and organizations may have additional or supplemental guidelines governing diagnostic practices but these cannot supercede the legal statutes of the state you practice in

Diagnostic classification can have multiple, far ranging, and long lasting consequences for your clients and students

Diagnostic consequences: Educational (stigma, accommodation) Vocational (ADHD and the military) Financial (mood diagnoses and insurance) Personal esteem and identity Treatment

Maintain a clear definition of your professional role: Your job is to provide psychological services as indicated by your client’s situation--not to obtain health care benefits for the client or to recover fees for your agency

We do not usually get into trouble for making mistakes

We can and will get into trouble for not playing by the rules

Being “helpful” and fudging a diagnosis so your client can get coverage from their health care policy (that they are not actually entitled to) is viewed by the insurance company as “fraud” and treated as a crime

Base your diagnosis on your best understanding of the data available regarding the youth’s behavior, feelings, thoughts, and adjustment

If new data (or further consideration) changes your mind, change your diagnosis

Practice in this manner and you will have no problems signing your name to your reports

Additional aspects to billing for mental health services Current Procedural Terminology (CPT) codes

The Physician’s Current Procedural Terminology was developed by AMA in 1966 to provide a coding system to report services performed

It is used by many third-party payers to determine reimbursement on claims

It is now revised annually

Additional aspects to billing for mental health services Current Procedural Terminology (CPT) codes

in 1983 the CPT was adopted by the Health Care Financing Administration (HCFA) as part of its common procedural coding system

this provides the basis for reporting medical services to both Medicare and Medicaid

Additional aspects to billing for mental health services Current Procedural Terminology (CPT) codes Sample CPT codes:

96101 Psychological Testing 96116 Neurobehavioral Status Exam 96118 Neuropsychological Testing 90843 Individual Psychotherapy; app. 20-30

min 90844 Individual Psychotherapy; app. 45-50

Additional aspects to billing for mental health services National Provider Identifier

In 2007 the U.S. government began providing unique identifier numbers for psychologists based on the specialization the psychologist reported

Additional aspects to billing for mental health services National Provider Identifier

NPI website: https://nppes.com.hhs.gov

NPI Enumerator: 1 – 800 – 465 - 3203

Practice cases

Take a few minutes and look at the material on the practice cases

DSM-IV ADHD

“The essential feature of Attention-Deficit/Hyperactivity Disorder is a persistent pattern of inattention and/or hyperactivity-impulsivity that is more frequently displayed and more severe than is typically observed in individuals at a comparable level of development (Criterion A)” (p.85)

A(1) 6 or more have persisted for 6 month to a degree which is maladaptive and inconsistent with development level

(a) Inattention details/careless errors

(b) Difficulty sustaining attention

(c) Does not seem to listen

(d) Poor follow through (not oppositional)

(e) Difficulty organizing

(f) Dislikes/avoids tasks needing sustained effort

(g) Often loses things

(h) Easily distracted

(i) Often forgetful

(a) Fidgets

(b) Leaves seat

(c) Often runs/climbs inappropriately

(d) Difficulty playing quietly

(e) Often “on the go”, as if “driven by a motor”

(f) Talks excessively

(g) Blurts out answers

(h) Difficulty waiting turn

(i) Interrupts/intrudes on others

B. Some symptoms have caused impairment before age 7

C. Some impairment from symptoms in 2 or more settings

D. Clinically significant impairment in social, academic, or occupational functioning

E. Does not occur exclusively during course of: Pervasive developmental disorder Schizophrenia Psychotic Disorder

Not better accounted for by another MentalDisorder

Axis I: Attention-Deficit/Hyperactivity Disorder, Predominantly Inattentive Type

Failure to attend/careless errors Difficulty sustaining attention Doesn’t seem to listen Doesn’t follow through Difficulty organizing Loses things Easily distracted Forgetful

Reading Disorder

Reading achievement below expectation Interferes with academic achievement

[poor spelling, difficulty sounding words out,

history of speech delay, early articulation

problems]

Axis II: No Disorder on Axis II

Axis III: No medical problems reported

Axis IV: Academic problems

Problems with peer relationships

Axis V: 55-60

Axis I: 314.00 Attention-Deficit/Hyperactivity Disorder,

Predominantly Inattentive Type 315.00 Reading Disorder

Axis II: V71.09 No disorder on Axis II Axis III: No medical problems reported Axis IV: Academic problems

Problems with peer relationships Axis V: Global Assessment of Functioning:

George

Axis I: Tourette’s Disorder Motor and vocal tics Two year duration

Attention-Deficit/Hyperactivity Disorder, Predominantly Hyperactive-Impulsive type

Fidgets Problems remaining seated Climbs excessively Difficulty engaging in quiet activities “Driven” Talks excessively Blurts out answers Difficulty awaiting turn Interrupts others

Axis II: No Disorder on Axis II

Axis III: Treatment with CNS stimulant

Axis IV: Problems with peer relationships

Axis V: 45-60

Axis I: 307.23 Tourette’s Disorder 314.01 Attention-Deficit/Hyperactivity Disorder,

Predominantly Hyperactive-Impulsive Type Axis II: V71.09 No disorder on Axis II Axis III: Treatment with CNS stimulant Axis IV: Problems with peer relationships Axis V: Global Assessment of Functioning:

53 [45-60]

Axis I: Oppositional Defiant Disorder Loses temper Argues with adults Noncompliance Provokes others Blames others Easily annoyed Angry/resentful Vindictive

Axis II: No disorder on Axis II

Axis IV: Problems with peer relationships

Problems with parents

Axis V: 45-60

Axis I: 313.81 Oppositional Defiant Disorder

Axis II: V71.09 No disorder on Axis II

Axis III: Problems with peer relationships Problems with parents

Axis IV: Global Assessment of Functioning: 52 [45-60]

Axis I: Alcohol Dependence, With Physiological Dependence Withdrawal Increased drinking Unsuccessful efforts to cut down Great deal of time spent Activities given up

Axis IV: Other psychosocial problems: adjustment to adolescence and high school

Axis V: 35-45

Axis I: 303.90 Alcohol Dependence, With Physiological Dependence

Axis III: No medical problems reported History of withdrawal symptoms reported

Axis IV: Other psychological problems:

adjustment to adolescence and high

school

Axis V: Global Assessment of Functioning:

40 [35-45]

Fear: marked, persistent, excessive, unreasonable

Exposure produces anxiety response Insight Avoidance Duration of avoidance 12 months Not better accounted for

[family history of anxiety problems]

Axis I: Specific Phobia, Blood-Injury Type

Axis III: Dental problems reported

Axis IV: Problems with access to health care

Axis V: 45

Axis I: 309.29 Specific Phobia, Blood-Injury Type

Axis III: Dental problems reported

Axis IV: Problems with access to health care

Axis V: Global Assessment of Functioning: 45

Depressed several years, without sustained relief Low self-esteem Feelings of hopelessness No Major Depressive Episodes, no Manic Episodes,

no Hypomanic Episodes, not during Psychotic disorder, not result of substance or general medical condition

Clinically significant distress [suicidal] Not better accounted for

History of alcohol abuseHistory of cannabis abuse

Axis I: Dysthymic Disorder

Axis III: No medical problems reported [family history of mood disorder]

Axis IV: None

Axis V: 15

Axis I: 300.4 Dysthymic Disorder

Axis III: No medical problems reported [family history of mood disorder]

Axis IV: None

Axis V: Global Assessment of Functioning: 15

Take Home Points

1) DSM-IV-TR is a categorical classification system of mental disorders and other clinically relevant phenomena

2) In DSM-IV-TR mental disorders are recurrent patterns of behavior (syndromes) which persist over at least minimal periods of time and cause clinically significant distress to the client of impairment of the client’s adjustment and functioning

Take Home Points Continued

3) The practicing clinician makes the determination as to whether symptoms are present and whether the client’s distress or impairment meets the criterion of clinically significant; she/he assumes primary responsibility for these decisions and is accorded a great deal of confidence within this framework

4) DSM-IV-TR allows/encourages multiple diagnoses in order to capture as much information as possible about the client, their problems, and their situation; with certain restrictions

5) More pervasive diagnoses usually take precedence over less pervasive diagnosesa) Unless the less pervasive diagnosis is independent of

the more pervasive diagnosisb) Unless, in some instance, the less pervasive diagnosis

become the focus of a treatment plan

6) Medical and substance induced mental disorders take precedence over other DSM diagnoses

7) There are a number of issues of ambiguity that are not resolved by the available texts

8) There are few “child” or “adult” specific diagnoses and the first chapter should not be considered the “child” section of DSM

9) Most specific diagnoses take precedence over Adjustment Disorder diagnoses (regardless of etiology); Adjustment Disorder diagnoses (if criteria are met) appear to take precedence of NOS diagnoses

10) DSM-IV-TR allows the clinician to indicate their level of confidence/certainty regarding the diagnosis made

11) Diagnoses should always and only be based on your best understanding of the data available regarding the youth’s behavior, feelings, thoughts, and adjustment

QUESTIONS?

Thank you for you time and attention.

Alvin E. House, Ph.D.

http://www.psychology.ilstu.edu/aehouse/

aehouse@ilstu.edu

309 – 438 – 8508

Department of PsychologyIllinois State UniversityNormal, IL 61790-4620

The use of DSM-IV-TR and ICD-9-CM/ICD-10 in School Settings Alvin E. House, Ph.D. Department of...

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