C01 07/15/2010 11:54:23 Page2 3GFFIRS 08/22/2013 11:50:50 Pagei DSM-5 TM E-Chapter Update to DSM-IV-TR TM in Action Second Edition SOPHIA F. DZIEGIELEWSKI 3GFFIRS 08/22/2013 11:50:50 Page ii Cover image: top image: © iStockphoto.com/blackred, bottom image: © iStockphoto.com/DNY59 Cover design: Wiley Copyright © 2014 by John Wiley & Sons, Inc. All rights reserved. Published by John Wiley & Sons, Inc., Hoboken, New Jersey. Published simultaneously in Canada. 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Some material included with standard print versions of this book may not be included in e-books or in print-on-demand. If this book refers to media such as a CD or DVD that is not included in the version you purchased, you may download this material at http://booksupport.wiley.c om. For more information about Wiley products, visit www.wiley.com. ISBN:978-1-118-78603-1(ebk) ISBN:978-1-118-78614-7(ebk) 3GCHAPTER 08/23/2013 8:22:12 Page1 DSM-5™ Update to DSM-IV-TR™ in Action, Second Edition INTRODUCTION concepts of the diagnostic assessment applying the DSM-5 as the primary means for mental Formulating and completing a diagnostic assess- health assessment. This book, supported by mentisembeddedintheuseofsupportingtexts, this last chapter with the DSM-5 updates, is to oftenreferredtoasthe“bibles”ofmentalhealth, continuetobeusedasthefoundationtosupport such as the Diagnostic and Statistical Manual of behavior-based practice strategy and treatment Mental Disorders, Fourth Edition, Text Revision planning. It is also expected to identify and (DSM-IV-TR™) and the International Classifica- provideupdatesrelativetoAPA’snewestversion tionofDiseases,NinthEdition(ICD-9).Thesetwo of the DSM and explain how these changes will versionsoutliningdiagnosticstandardsformental relate to the diagnostic assessment and subse- health practice have represented state-of-the-art quent treatment efforts. assessments for over a decade. Therefore, it should come as no surprise to mental health professionalsthatpresentationofthenewedition THEDSMANDTHEICD:THEBIBLES of the Diagnostic and Statistical Manual of Mental OFMENTALHEALTH Disorders, Fifth Edition (DSM-5™) and expected utilization for insurance billing of International The DSM-IV-TR (2000) was the standard for Classification of Diseases, Tenth Edition (ICD-10) assessment until the revision to this edition withitslatestmandatoryrequirementforusagein (DSM-5) was released in May, 2013. The October 2014, will bring forth what some con- DSM-IV-TR and DSM-5 state clearly that these sider earth-shaking changes. For example, the booksaredesignedtobeusedinawidevarietyof committee responsible for the DSM-5 made the settings, including inpatient and outpatient set- decisionearlyontoeliminatetheromannumeral tings as well as consultation and liaison work. from the title, changing it from the expected Furthermore, the latest versions of the DSM DSM-V to DSM-5. It is also expected that the remain designed to be used by professionals revisions will follow a similar pattern with the and are not to be used as self-help books for first edition titled DSM-5 and each subsequent the lay public. Paris (2013) questions this, how- revisionfollowedbyaDSM-5.1,DSM-5.2,and ever, stating that clients have a right to know so on. theirowndiagnosisandthemoretheyknowthe Thepurposeofthischapteristoupdate,and moretheycanbecomeempoweredtoparticipate insomecasesreintroduce,thereadertothecore in self-help strategy. Also, with the Internet and 1 3GCHAPTER 08/23/2013 8:22:12 Page2 2 DSM-5™ E-CHAPTER UPDATE TO DSM-IV-TR™ IN ACTION other forms of information so readily accessible, policydecisions.Whatremainsconsistentamong clients become active in gathering information allversionsoftheDSMisthatitdoesnotsuggest related to their own mental health. Clients treatmentapproaches.Therefore,othersupport- shouldnotbekept inisolationoftheirdiagnosis ivebooks,aswellasthepreviouschaptersofthis andthecriteriathatcontributestoit,asdoingso textthatsuggesttreatmentstrategy,remainrele- createsadisservicethatforcesthemtobepassive vant for achieving comprehensive, efficient, and consumers of their own health care. Arguments effective care. that the DSM is very complex and could over- The International Classification of Diseases whelm a client unfamiliar with the technical (ICD) is said to have its origins in the 1850s. jargon have been questioned and active partici- When completing diagnostic assessment, the pation on the part of the client has become importance of the ICD cannot be underesti- expected (Paris, 2013). mated. The World Health Organization Similar to previous versions of the DSM, (WHO), after assuming responsibility for the DSM-5 suggests the book is for use by profes- ICD,wascreditedasthefirstofficialinternational sionalpractitionerssuchaspsychiatristsandother classification system for mental disorders. This physicians, psychologists, social workers, occu- beganwiththefirstedition(ICD-6)publishedin pational and rehabilitation therapists, and other 1948, under the auspices of WHO. Following health and mental health professionals (APA, this early publication of the ICD, the APA 2000, 2013). Because these professionals can all published its first edition of the DSM in 1952. have very different training and expertise, par- Originally, the APA developed the DSM for ticular attention to following the diagnostic statistical, epidemiological, and reporting pur- criteria is expected, coupling this with clinical poses,whereastheICDwasdevelopedtoreflect skill and judgment designed to achieve similar clinical approaches to diagnosis and training determinations. Before putting the DSM-5 into (Sorensen, Mors, & Thomsen, 2005). This is practice, professionals will need to be trained in probably why the ICD remains the global stan- how to use categorical and dimensional dard for diagnostic classification and why it is approaches,aswellasbeingawareofthepoten- recognized for service reimbursement. After the tial for misuse. When using any diagnostic sys- WorldHealthAssemblyadoptedthenomencla- tem, care and consideration should always be ture outlined by WHO, use of the ICD for given to protect the rights of the patients being mortality and morbidity statistics was adopted served. by all member states in 1967. The ICD is a In the United States, the DSM is often used classification system that creates a global linkage to classify mental health disorders. True to its and allows for disorders across the world to be historical roots, the most current version of the viewedatonepointintime;therefore,scientific DSMsupportsthispurposebystatingthatitisto progressultimatelyrequiresrevisionandupdates be used for statistical and assessment purposes as (Sartorios, 1992). Similar to the DSM, the ICD wellaseducationalsupport.ThismakestheDSM has gone through many changes and updates. an important reference for students, researchers, The latest version of the ICD is ICD-10, which and clinicians. For clinicians, it provides the replaced ICD-9-CM (WHO, 1979, 1990). Sub- starting point for determining the nature of a sequently, it is expected that ICD-11 will be client’s problem. It also provides supportive released in 2015. informationonprevalencerateswithinthelarger The ICD-10 was originally released in 1990 population that have been gathered to inform andreceivedfullendorsementbyWHOin1994. 3GCHAPTER 08/23/2013 8:22:12 Page 3 DSM-5™UpdatetoDSM-IV-TR™inAction,SecondEdition 3 QUICKREFERENCE1 WEBSITES FOR GENERAL ICD-10 INFORMATION ICD-10-CM files, information related to diseases, functioning, and disability http://www.cdc.gov/nchs/icd/icd10.htm ICD-9-CM files related to diseases, functioning and disability http://www.cdc.gov/nchs/icd/icd9cm.htm In 2002, it was published in 42 languages and in APA states clearly that the categories are general 1999, the United States implemented it for mor- enough to match the categories in the ICD, tality (death certificates). Currently, it consists of ensuring clarity and uniformity between the three volumes. Volume 1 has tabular lists that two texts may once again become a concern. contain cause of death titles and the codes that This will be most evident to those trained on accompany the cause of death titles; Volume 2 has DSM-IV and DSM-IV-TR as these texts closely description guidelines and coding resources; and match the ICD-9-CM. For billing purposes, Volume 3 provides an alphabetical index to dis- there were few discrepancies between the cate- eases and the nature of injury, external causes of gories listed and both books DSM-IV and DSM- injury, and table of drugs and chemicals (see Quick IV-TR could be used interchangeably. In the Reference 1). ICD-10 hosts more than 141,000 application to treatment, however, all versions of codes with many different diagnostic categories the book should remain helpful as the classifi ca- compared to the 17,000 codes present in the ICD- tion systems cross all theoretical orientations but 9-CM (AAPC, 2013). do not suggest treatment. The DSM-IV-TR is similar to the ICD in Since the DSM provides more comprehen- terms of diagnostic codes and the billing catego- sive diagnostic support than the ICD, it has gained ries. Concern has been voiced that although the its greatest popularity in the United States. This codes are listed for both the ICD 9-CM followed recognition has made it the resource tool most by the codes for ICD-10-CM, the criteria needed often used by psychiatrists, psychologists, psychi- for the diagnosis may not match what has been atric nurses, social workers, and other mental updated in DSM-5. Similar to what happened in health professionals. Similar to what has been the late 1980s with DSM-III , some professionals suggested in the past, related to the close relation- fear that once again the diagnostic and billing ship between placing the diagnosis and reimburse- categories won’t match. Since these two books mentandbillingrequirements,cliniciansneedto need to go hand-in-hand, categories with criteria remain knowledgeable of both books. listed in one book that are not listed in the other can be extremely problematic for proper coding and reimbursement. These two books have to SOWHATABOUTBILLING? work together and when clinicians use the ICD for billing while referring to the DSM for clarity For diagnostic classification and billing, ICD is of the diagnostic criteria, both books need to consideredtheglobalstandard.InOctober2014, have similar matching criteria. Although the the ICD-10 codes for service will replace the 3GCHAPTER 08/23/2013 8:22:12 Page 4 4 DSM-5™ E-CHAPTER UPDATE TO DSM-IV-TR™ IN ACTION ICD-9-CM codes currently in use across the reimbursement leaders all agreed to wait until United States (CMS, 2013). The reason for October 2014. To date, some agencies and adopting the new version is three-fold: (1) It is organizations moved forward to utilize the sys- expected to provide improved data for measur- tem conversions as originally mandated. For ing health care and service quality; (2) it will help those agencies that already made billing system information technology systems to record more changes as originally posted, either the ICD-9- specific and comprehensive diagnostic informa- CM or ICD-10 codes can be used temporarily. tion; and (3) it can improve documentation and Regardless,allagenciesthatdoelectronicbilling billing information by helping to better identify will need to complete the transition by the due specific health conditions (UnitedHealthcare date,whichwaslastscheduledforOctober2014. Online, 2013). ICD conforms to the Health Insu- In summary, for the most part DSM-IV and rance Portability Accountability Act (HIPAA) of DSM-IV-TRparalleltheICD-9-CMbutDSM-5 1996 that seeks to protect consumers, among does not directly parallel ICD-10 in quite the other things, by creating standardized mecha- sameway.NordoesitparallelICD-11,whichis nisms for electronic data exchanges involving the expected to be released in 2015. It is highly transfer and subsequent usage of consumer pri- recommendedthattrainingbeprovidedforbill- vate health-care related data. In 2000, ICD-9- ing staff and practitioners who intend to use the CM, inclusive of its three volumes, was adopted billing categories outlined in ICD-10-CM. For for reporting of diagnoses, other health prob- practitioners in private practice without billing lems, causes of injury, diseases, and impairments staff, training on ICD-10-CM is also recom- in all standard billing transactions. Furthermore, mended, as well as the suggestion that practi- according to the Secretary of the Department of tioners become familiar with both books, the Health and Human Services, a ruling was ICD and the DSM. released and published in the Federal Register on January 16, 2009, to adopt the ICD-10-CM standards and the Procedural Coding System DSM-5:SUPPORTINGTHECHANGES (PCS). The final rule is posted on: http:// www.gpo.gov/fdsys/pkg/FR-2009–01–16/pdf/ According to the DSM-5 task force, all changes E9–743.pdf. This means that everyone covered madeinthisversionchartedthefollowingprem- by HIPAA must be ICD-10 compliant. ises. First, the priority was always given to Some professionals may question why it increasing clinical utility by making the book took so long to adopt the ICD-10 and there is as relevant and helpful to clinicians as possible. nosimpleanswer.Forthemostpart,theoriginal This would allow clinicians to make the transi- push was to make ICD-10 the standard back in tion from the previous edition and see how the 2003.Thepushback wasso great, however, and changes support improved diagnostic acumen. filled with concerns about it being too big a Second, changes were based on research change to adopt while also trying to work with evidence. The DSM-IV and the DSM-IV-TR newly designated HIPAA regulations. There- were no strangers to research as many of the fore, the implementation date has been pushed sweeping diagnostic changes made in the previ- backseveraltimes.Whentheyoriginallytriedto ous version were also research supported. Since makeithappenin2013,theinpatientversionof this was one of the major weaknesses in earlier the ICD-10-PCS was so complicated and diffi- editionsoftheDSM,DSM-IVandDSM-IV-TR cult to incorporate into the Content Manage- addressed this shortfall by basing the diagnostic ment Systems (CMS), administrative and changes on: (1) literature reviews, (2) data 3GCHAPTER 08/23/2013 8:22:12 Page5 DSM-5™UpdatetoDSM-IV-TR™inAction,SecondEdition 5 analysis and reanalysis, and (3) field trials. Fur- Lastly,DSM-5seekstoclarifytheboundaries thermore,researchincludedsystematicandcom- between what constitutes normal human func- puterized reviews, to support the suggestions tioning and what constitutes a mental disorder. made by the individual work groups as well as This is an important distinction, especially when data analysis and reanalysis. DSM-IV-TR also workingwithchildrenandadolescents.Forexam- included12fieldtrialseachwith5to10different ple, when does the agitated teenager represent sites and over 1,000 participants (APA, 2000). whatcouldbeconsideredatypicalimpulsiveactin Thus, the two most recent editions of the responsetoaproblemandwhenisitassessedtobe DSM, unlike their predecessors, have made something more? When looking at depressive efforts to incorporate the best mix of practice symptomsintheadult,theysimplymaynotpre- wisdomandresearchfordeterminingthecriteria sentthesameasinadolescents.Inthe30-year-old and characteristics of categories presented. This male, for example, the mood may be depressed trendwasexemplifiedinDSM-5,comprisingnot andthecongruentaffectissadorblunted,whereas only clinical field trials but also including large intheadolescentthemoodmaystillbedepressed academicfieldtrials.Inaddition,specialattention butmaypresentasangryandagitated.Thisangry was given to establishing reliability information andimpulsivebehaviorcouldinturnresultinone related to the criteria included and the modifi- ormorerepeatedactsthatareinterpretedasmood cations made. Similar to DSM-IV, the literature swings similar to bipolar disorder. reviews were conducted to elicit clinical utility, reliability (i.e., did the same criteria continue to present from case to case), as well as testing new DSM-5:THREESECTIONS measurement instruments and criteria related to psychometric performance. The DSM-5 has had major changes to the struc- Third, there were also periods during the ture and the format of the book, resulting in all development that provided open windows of chapters being organized in the lifespan order. opportunity for practicing clinicians to provide Within this new organizational structure, the clinical feedback related to the diagnostic cate- mental disorders that can occur in infants, chil- gories and changes proposed. This allowed all dren,andadolescentsarelistedfirstineachrespec- clinicians to comment and make suggestions for tive chapter. This leads to the elimination of the criteria changes. These suggestions were viewed ChildDisorderssectionoutlinedinDSM-IVand without the expectation of predetermined con- DSM-IV-TR.Terminologythatmaybehelpfulto straints on changing structure and format, espe- note in DSM-5 involves the terms neurodevelop- cially if it was noted to be problematic. mentalandneurocognitive(seeQuickReference2). QUICKREFERENCE2 DEFINITIONS AND THE LIFESPAN APPROACH Neurodevelopmental: Examinesdiagnosesacrossthelifespanandthedisordersmostfrequently diagnosed in childhood. Neurocognitive: Examines diagnoses most frequently diagnosed in adulthood. Source:SummarizedinformationfromtheDiagnosticandStatisticalManualofMentalDisorders,FifthEdition. Copyright2013bytheAmericanPsychiatricAssociation. 3GCHAPTER 08/23/2013 8:22:13 Page6 6 DSM-5™ E-CHAPTER UPDATE TO DSM-IV-TR™ IN ACTION QUICKREFERENCE3 DSM-5—THREE SECTIONS Section I: Introduction and Directions on How to Use the Updated Manual Section II: Outline the Categorical Diagnoses That Eliminated the Multiaxial System (20 Disorder Chapters and 2 Additional Categories) Section III: Conditions That Require Future Research, Cultural Formulations, and Other Information The DSM-5 manual has been restructured This is followed by 20 chapters that outline the andbrokendownintothreesections(seeQuick documentedmentaldisordersfoundinSectionII Reference3).SectionIprovidesanintroduction (seeQuickReference4).SectionIIIoutlinesthe to the manual, some rationale for the changes, conditions that require future research, cultural and instructions for using the updated manual. formulations, and other information. QUICKREFERENCE4 SECTION II—CATEGORICAL SECTIONS: 20 DISORDERS AND 2 ADDITIONAL CATEGORIES DSM-5Chapters NeurodevelopmentalDisorders EliminationDisorders SchizophreniaSpectrumandtheOther Sleep-WakeDisorders PsychoticDisorders BipolarandtheRelatedDisorders SexualDysfunctions DepressiveDisorders GenderDysphoria AnxietyDisorders Disruptive,ImpulseControl,andConductDisorders Obsessive-CompulsiveandtheRelatedDisorders SubstanceUseandAddictiveDisorders TraumaandStressor-RelatedDisorders NeurocognitiveDisorders DissociativeDisorders PersonalityDisorders SomaticSymptomDisorders ParaphilicDisorders FeedingandEatingDisorders OtherDisorders *OtherConditionsThatMayBeaFocusof *Medication-InducedMovementDisordersand ClinicalAttention OtherAdverseEffectsofMedication *Includesotherconditionsandproblemsthatrequire *Notconsideredmentaldisorders. clinicalattentionbutnotmentaldisorders.