DSM5577 - SECTION 3: COMPREHENSIVE ASSESSMENT AND DIAGNOSIS
Section III: Comprehensive Assessment and Diagnosis
Since the introduction of the DSM-II in 1968, the purpose behind refinements to the diagnostic process is to create increased clarity about the full nature and extent of a client’s condition. A successful diagnostic process adequately notes the full extent of a client’s problems – in areas related to health, mental health and the complex relationship between the two. Knowledge of the full extent of a client’s problems would then point in the direction of the full range of treatment approaches that are helpful in meeting the client’s needs.
A well-considered, accurate diagnosis encapsulates these items within an optimally concise framework using a common knowledge base, shared and understood by all parties in generally the same way. This approach allows for the best coordination and continuity of care, to insure that the key information from a complex assessment process is readily available. Additionally, the order and manner in which information is presented will list the most important information first - and with maximum clarity – in order to inform best treatment choices.
The approach is an evolving system, constantly seeking to find the best balance between comprehensiveness and concision. When an assessment process is more comprehensive, more useful information can be gathered by the clinician(s) providing treatment, allowing for better targeting of the most effective treatment modalities for the designated clinical condition. A concise and thorough assessment allows for more efficient and rapid sharing of that information among all treatment providers.
In the years since the introduction of the multi-axial system, there has been a significant expansion of neuroscience research. This provides a new understanding of the etiology of personality disorders and the complex relationship between the physical body and the mental/emotional world of the client. The new research pointed in the direction of finding “no meaningful difference in the distinction between the different types of mental disorders”, suggesting that “the axis system became unnecessary.” (APA, 2013)
This multi-axial classification system that began with DSM III and continued through DSM IV TR ended in September 2015 with the official start of the DSM 5. The committee responsible for the DSM-5 therefore elected to abandon the use of the multi-axial system. There will instead be an expansive and comprehensive set of codes that will cover all conditions previously denoted on the Axis I-IV, and each will be recorded without reference to an axis. The APA noted that “(D)oing so removes artificial distinctions among conditions, benefiting both clinical practice and research use.” (APA, 2013)
Key Knowledge Point to Follow:
“We do not believe that a single score from a global assessment, such as the GAF, conveys information to adequately assess each of these components (symptom assessment, dangerousness to self and others, decrements in self-care and social functioning), which are likely to vary independently over time. . . Therefore we are recommending that clinicians continue to assess the risk of suicidal and homicidal behavior and use available standardized assessments for symptom severity, diagnostic severity, and disability such as the measures in Section III of the DSM-5. For those who relied on the use of a GAF number, there will clearly be a transitional period from the GAF to the use of separate assessments of severity and disability.” (APA, 2013)
For clinicians who came of age during the era of the DSM-III through DSM-IV-TR, this will require a major shift in how a comprehensive diagnostic picture is recorded.
Below is an example of how Axis I-III diagnoses would be recorded under the old and new systems:
Previously: Under DSM-IV-TR Diagnosis
Axis I: Dysthymia Code: 300.4__________
Axis I: Alcohol Abuse ______ Code: 305.00_________
Axis II: Borderline Personality Disorder_______________________ Code: 301.83_________
Axis III: Oral Contraceptives Code: E932.2__________
Currently: Under DSM-5 Diagnosis
Diagnosis: Persistent Depressive Disorder ____________ Code: F34.1
Diagnosis: Alcohol use disorder, mild Code: F10.10
Diagnosis: Borderline Personality Disorder___________________ Code: F60.3
Diagnosis: Oral Contraceptives _ Code: Z79.3
Key Knowledge Point to Follow:
Under the new diagnostic system, there can be more than one disorder listed at a time. If the goal is to present as thorough a diagnostic picture as possible, all relevant conditions should be noted and recorded. Currently, if there is more than one disorder, all disorders should be listed, with the disorder most responsible for the recent visit listed first (APA, 1994). An example of this is shown below:
Diagnosis: Alcohol Use Disorder, Moderate _ Code: F10.20
Diagnosis: Attention Deficit Hyperactivity Disorder, Combined Presentation Code: F90.2
This approach has the function of clarifying in a very efficient way the relative importance to treatment for each area of difficulty the client is facing. It is a rank ordering of what the primary focus of treatment should be. There are several important considerations to address concerning the many aspects of this process of recording diagnoses.
When enough information has been gathered from the assessment to arrive at a diagnosis, you refer to the DSM to get the numeric code and list it in the client’s record. This is a concise way to provide important information. However, the DSM-5 has gone to great lengths to expand the amount of information that clinicians are expected to report along with the code.
While a number of key areas of diagnosis are covered in this course, each clinician should expect to allocate time on an ongoing basis to engage in a full and comprehensive reading of each DSM-5 section. Studying the conditions presented by her/his clients will help the clinician to develop the high degree of familiarity necessary to create a fluid and accurate diagnosis. There is no substitute for time, study and repetition.
Key Knowledge Point to Follow:
For every diagnosis you include, write out the diagnosis beside the numeric code. Write the correct name of the diagnosis in full, along with any specifiers related to the diagnosis.
In this edition of the DSM, there is heightened emphasis on the importance of writing out the specifiers in full, and considerable text is allocated to covering all the specifiers that are attached to each diagnosis. Later in this section, time will be spent addressing the complications related to the many specifiers present in the DSM-5. This altered emphasis may necessitate the overhaul of the psychosocial assessment forms that individuals and organizations use. The creation of new forms must create the necessary room to include the more expanded diagnoses with numerous specifiers.
Even if the client does not present with complicated conditions with several specifiers, it is important to write out the diagnosis in full in addition to the correct diagnostic code. Omitting this information can create difficulties if other medical personnel – who are not mental health specialists - are involved in the treatment of the patient. For this reason clarity is primary.
Additionally, the use of specifiers provides the opportunity to show specific, measurable changes in client progress from one session to the next. For example, when a patient moves from partial remission to full remission, this information will be noted on the specifiers that accompany the diagnosis, and a clearer picture of the client’s progress will be clear to any provider who provides services to the patient.
Key Knowledge Point to Follow:
Please note that the diagnostic record should list any medical condition(s) or medication(s) that may alter a client’s mental, emotional or psychological well being in order to provide a thorough diagnostic picture. Mental health clinicians do not need to record any medical conditions or medications that are not related to the mental health issues being addressed.
However, should any medical condition(s) or medication(s) be included in the mental health record, these are no longer separated out into a different axis. They are considered as another piece of the overall diagnostic picture, equally relevant for understanding the full complexity of the client’s condition.
The DSM-5 clarifies that the principal diagnosis for the mental health visit should be noted as such, using the qualifying phrases “principal diagnosis”, or “reason for visit”. This provides another level of clarity to the information so that other providers can better understand your conceptualization of the client’s case. In most instances, this is stated in the first diagnosis that is noted in the record. This is shown below:
Diagnosis: Persistent Depressive Disorder (Principal Diagnosis) Code: F34.1__
Key Knowledge Point to Follow:
However, there are exceptions and complications here that must be clearly understood. The principal diagnosis for mental health treatment will not always be listed first. The DSM-5 states that “ICD coding rules require that the etiological medical condition be listed first.” (DSM-5) As an example, if a client is experiencing psychosis related to a brain tumor, the medical condition responsible for the concurrent mental health condition would be the first diagnosis listed, followed by the mental health diagnosis, e.g., Psychotic Disorder Related to malignant brain neoplasm, with delusions, F06.2.
Obviously, the diagnosis for any primary medical condition would be determined not by the mental health clinician, but by the physician assessing and treating the medical condition. The mental health clinician would only have that information because it would be forwarded to her/him through case coordination. However, in order to accurately record the diagnosis, your records must indicate the presence of the medical condition that most accurately explains the client’s full diagnostic picture. Treatment of an underlying medical condition will typically resolve the associated mental health problems, whereas the inverse is not true.
ICD-10 became the standard for recording diagnoses on October 1, 2015. Knowledge and awareness of the changes to medical diagnoses must be recorded – when relevant – as part of the client’s record. To help prepare the clinician for this change, some of the more common medical diagnoses that mental health clinicians might encounter in their work are listed.
Common Medical Diagnoses Likely to Be Encountered.
Below are some medical diagnoses likely to be encountered:
Diseases of the Nervous System:
ICD-10: F00.x…………………………Alzheimer’s disease
ICD-10: G56.01………………………Carpal tunnel syndrome
ICD-10: G44.0xx…………………..Headache, cluster
ICD-10: G43.xxx…………………..Migraine headache
ICD-10: G20…………………..………Parkinson’s disease, primary
Diseases of the Circulatory System:
ICD-10: I10………………………Hypertension, essential
ICD-10: I34.1…………..….…..Mitral valve prolapse
Diseases of the Respiratory System:
ICD-10: J44.9………………....Asthma, chronic obstructive
ICD-10: J43.9…………….…….Emphysema
Neoplasms:
ICD-10: C81.9………….…...Hodgkin’s disease
Endocrine Diseases:
ICD-10: E11.xx……………...Diabetes mellitus, type II / non-insulin-dependent
ICD-10: E10.xx……………...Diabetes mellitus, type I / insulin-dependent
ICD-10: E03.9………………..Hypothyroidism, unspecified
Nutritional Diseases:
ICD-10: E66.xx……………...Obesity
Metabolic Diseases:
ICD-10: E87.8………………….Electrolyte imbalance
ICD-10: M10.xx…………..….Gout
Diseases of the Digestive System:
ICD-10: K70..………………...Cirrhosis, alcoholic
ICD-10: K51.xx……….……..Colitis, ulcerative
ICD-10: B18.2………………..Hepatitis, viral C
ICD-10: K58.0…………….….Irritable bowel syndrome
ICD-10: K25.x………………..Ulcer, gastric
Genitourinary System Diseases:
ICD-10: N97.2…………………Infertility, female
ICD-10: N46.xxx…………..…Infertility, male
ICD-10: N95.x………..…….…Menopausal or postmenopausal disorder
Hematological Diseases:
ICD-10: D50.0…………………Anemia, iron-deficiency
ICD-10: D57.1………………..Anemia, sickle-cell
Diseases of the Eye:
ICD-10: H40.xxx…………….…Glaucoma
Diseases of the Ear, Nose, and Throat
ICD-10: J32.9………..………...Sinusitis, chronic
Musculoskeletal System and Connective Tissue Diseases:
ICD-10: M05.xxx……………….Arthritis, rheumatoid
ICD-10: M81.0…………..…..…Osteoporosis
Diseases of the Skin:
ICD-10: L40.xx………………….Psoriasis
Congenital Malformations, Deformations, and Chromosomal Abnormalities:
ICD-10: Q90.9………………….Down syndrome
ICD-10: Q86.0……………......Fetal alcohol syndrome
Diseases of Pregnancy, Childbirth, and the Puerperium:
ICD-10: O14.13…………..….Pre-eclampsia, severe
Infectious Diseases:
ICD-10: B00.xx………….……..Herpes simplex
ICD-10: B20…………….……….HIV infection (symptomatic)
Provisional Diagnoses, Deferred Diagnoses, Diagnoses Ruled Out
There are also occasions when we are not presented with sufficient information to make a clear and certain diagnosis. In such instances, do not record a diagnosis as if certainty had been reached. There are a number of choices of how to record the client’s problems in ways that clarify this state of uncertainty about the diagnosis. Some of these choices are noted and formally endorsed within the DSM-5. Some of these are not noted formally in the DSM-5, but are widely used and understood by clinicians as methods to record the diagnostic uncertainty that is present. We will cover these options here, and look at the distinctions between the options.
Let us take for an example a client who presents for treatment with some of the signs and symptoms of serious depression, with the data from the gathered history suggesting a possible diagnosis of Major Depressive Disorder, Recurrent, Moderate (296.32). However, during the first phases of the relationship with the client, there has not been sufficient time to confirm these first impressions.
Moreover, there is information present in the history that may point in a different direction. The client’s reports also indicate that there may have been a period in which a manic or hypomanic episode had been present, suggesting the need to consider the possibility of a diagnosis of bipolar disorder, with bipolar depression as the primary noted symptom.
If the role of the diagnosis is to provide a concise method of clarification, there does not appear to be solid enough evidence to warrant a definitive diagnosis. How should the clinician proceed?
If the clinician is inclined to believe that the final diagnosis selected will in all likelihood be Major Depressive Disorder, Recurrent, Moderate (296.32), but there remains enough uncertainty to proceed cautiously, then the word “provisional” would simply be added to the end of the diagnosis, either separated by a comma, or placed in parentheses:
Diagnosis: Major Depressive Disorder, Recurrent Moderate (Provisional) Code: 296.32
This clarifies within the record the position of the clinician in ways that would be understood by other clinicians. This format is formally endorsed and addressed within the instructions for the DSM-5.
Less formally, it would then be appropriate to address the presence of the symptoms related to a possible diagnosis of bipolar disorder by noting the following as a second diagnosis:
Diagnosis: Major Depressive Disorder, Recurrent Moderate (Provisional) Code: F33.1
Diagnosis: Rule out Bipolar II Disorder___ __ Code: F31.81
The "rule out" diagnosis is not covered within the framework of the Diagnostic and Statistical Manual, but it is an approach so widely adopted that it is considered valid practice. It is, however, important to understand clearly the difference between a diagnosis that is provisional and a diagnosis that is being ruled out.
Key Knowledge Point to Follow:
The "rule out" diagnosis is more likely to be used when the clinician sees symptoms pointing towards a certain diagnosis, but there is a fair degree of doubt whether the diagnosis criteria will ultimately be met. When a clinician is seeing two competing diagnoses, the “rule out” diagnosis is the one that the clinician believes is the less likely alternative.
The “provisional” diagnosis is the more likely alternative under this same set of conditions. It is more appropriate to use “provisional” when symptoms suggest that a diagnosis is likely, but more information is needed to reach a point of clear confirmation. The provisional diagnosis enters into the record an appropriate note of caution in choosing a diagnosis before all the facts are in.
Key Knowledge Point to Follow:
The specifier “provisional” may also be used in another situation. There are diagnoses where the criteria include a requirement for the symptoms to be present for a specified period of time. For example, Persistent Depressive Disorder requires that symptoms be present for a period of two years prior to a diagnosis being made. When all information points to arriving at that diagnosis, but the specified period of time has not yet elapsed, e.g., less than two years, the diagnosis may be noted as provisional until the time criteria have been met.
This approach can include the addition of some clarifying text with the diagnosis: “Client’s symptoms have not been present for sufficient time to meet criteria.” This will alert other clinicians as to the circumstances being addressed. Again, the purpose behind diagnosis is to create an optimal degree of clarity. Once the necessary period of time has been reached, the diagnosis can be changed to remove the provisional specifier.
Situations Where No Diagnosis Fits the Evidence
What options exist when it is clear that a mental disorder of some sort is present but an assessment of the symptoms does not provide sufficient clarity to arrive at any specific diagnosis? In such instances, there are two possible choices.
The first choice that a clinician may elect to make in situations where the diagnosis is uncertain is Diagnosis deferred. This diagnosis is still permitted under DSM-5. In contrast to the other diagnostic choices, the "R69, deferred" diagnosis is utilized when there is still a substantial amount of uncertainty about any specific diagnosis, often when the assessment session has been interrupted or the assessment process has been too brief to allow for the formation of a reasonable idea of the patient's likely diagnosis. This is designed to be used as a temporary measure pending resumption of the assessment process when the client returns for additional sessions.
“‘Diagnosis deferred’ can use the code R69. It is preferable to use an “unspecified” diagnosis rather than a deferred diagnosis, if clinically indicated. Because the multiaxial system is no longer in use, the commonly used “diagnosis deferred on Axis II” is no longer needed.” (www.dsm.org)
Key Knowledge Point to Follow:
This brings us to the second option, the diagnosis “Unspecified Mental Disorder”, F99. This diagnosis is used in instances in which symptoms are present that cause clinically significant distress and/or impairment in social functioning, but which do not meet full criteria for any more specific diagnosis, nor clarify the client’s condition in ways that allow for even a provisional diagnosis.
This diagnosis is appropriate to use in two situations: 1) when it is not expected that a more precise diagnosis will ultimately be reached either through gathering additional information or by the passage of more time, or 2) when the treatment circumstances will not permit time for more clarifying assessment to occur, e.g., by physicians in emergency room settings who are attending to more pressing medical problems and will not allocate time to fully assess the mental health issues present, but who still want to place in the record concerns about the presence of mental health issues.
It is permitted for a clinician to utilize this diagnosis in conjunction with one or more “Rule Out” diagnoses, if this will provide some information about the overall cluster(s) of symptoms being seen. Please note that all of the diagnostic choices represent an attempt to maximize the degree of clarity about what the assessing clinician is seeing. It alerts other parties who may be involved in treatment to see both what is known and what is not known about a client’s presentation of symptoms.
Other Clarifying Specifiers
In addition to the “rule out” specifier that is commonly used within diagnostic summaries to provide greater clarity about a client, Heimsch & Polychronopoulos (2009) point out a few other informal diagnostic labels not listed in the DSM-5 that can be helpful in communicating additional information. These are noted below:
“Traits—this person does not meet criteria, however, he or she presents with many of the features of the diagnosis (e.g., borderline traits or cluster B traits).
By history—previous records (another provider or hospital) indicate this diagnosis; records can be inaccurate or outdated (e.g., alcohol dependence by history).
By self-report—the client claims this as a diagnosis; it is currently unsubstantiated; these can be inaccurate (e.g., bipolar by self-report).”
Again, it is always important to consider the purposes behind diagnosis as choices are made as to what to include in the record. If clarifying specifiers help to create a clearer and more accurate diagnostic picture, then it is clinically appropriate to use them.
No Diagnosis
In addition to the options noted above, there are circumstances in which the client’s presentation does not suggest the presence of any diagnosable mental health condition. In such cases, it is appropriate to simply note “Z99, No diagnosis” in the form section designated for diagnosis. For instance, a young child may be referred to a clinician because the parent is concerned about a behavior that the parent does not understand is completely age and/or developmentally appropriate. Pursuant to some psychoeducation to the parent on the part of the clinician, the behaviors are viewed differently by the parent and no diagnosis need be indicated on the forms.
In another instance, a patient may appear at a health center with low energy, flat affect, and a sense of hopelessness – symptoms consistent with some kind of depressive disorder. However, the patient also presents with a fever of 102 degrees and the onset of influenza. With the administration of some medication to reduce the fever, the mental health symptoms are alleviated and the patient’s energy, affect and hopefulness return. In such instances - where there are transient symptoms that look like a mental health problem - a mental health diagnosis would not be appropriate to note on a patients record.
Psychosocial and Environmental Codes
Additionally, there have been some important changes in the ways that psychosocial and environmental codes have been reformulated under DSM-5. Whereas before these codes were listed under Axis IV – without accompanying code numbers – DSM-5 has created a wide range of diagnostic codes to utilize in shaping a comprehensive diagnostic picture. It is now considered best practices to utilize these codes, with accompanying text to provide a further degree of clarity, where indicated.
Below is an example of how psychosocial and environmental factors would be recorded under the old and new systems:
Previously: Under DSM-IV-TR Diagnosis
Axis IV: Housing uncertainty, financial stresses, social isolation.
Currently: Under DSM-5 Diagnosis
Diagnosis: Inadequate housing Code: Z59.1__________
Diagnosis: Extreme poverty Code: Z59.5__________
Diagnosis: Problem related to living alone___________________ Code: Z60.2__________
On a thorough assessment form, these kinds of factors may also be noted by identifying significant psychosocial and contextual features, as shown below:
Currently: Under DSM-5 Diagnosis
Diagnosis: Persistent Depressive Disorder Code: F34.1__________
Diagnosis: Alcohol Use Disorder Code: F10.10_________
Diagnosis: Borderline Personality Disorder___________________ Code: F60.3_________
Diagnosis: Inadequate housing Code: Z59.1__________
Diagnosis: Extreme poverty Code: Z59.5__________
Diagnosis: Problem related to living alone___________________ Code: Z60.2__________
Significant psychosocial and contextual features: Financial instability and housing insecurity affect the ability of the client to access treatment on a regular basis.
Again, diagnostic codes are designed to find a good balance between efficiency and comprehensiveness/clarity. If the clinician deems it necessary – for clarity about the diagnostic picture - to add text to the diagnoses, the minor loss in efficiency is more than compensated for by the increased clarity that is created.
The Use of Numeric Specifiers
There are many diagnoses for which numeric specifiers are used to indicate important features of the disorder and provide more depth and clarity about the nature and extent of the condition. It is important for clinicians to have a thorough understanding of how to use these specifiers. To begin with, there are some general principles about what the specifiers indicate.
The first number after the decimal point typically indicates subtype of the disorder. For instance, clients may present with a disorder that can occur with different manifestations, as in the case of Bipolar Disorder, which can appear with a primarily manic phase or a primarily depressed phase. This is shown below:
Diagnosis: Bipolar Disorder, Most recent episode manic, mild Code: F31.11
Versus
Diagnosis: Bipolar Disorder, Most recent episode depressed, mild Code: F31.31
The subtype specifier is most frequently seen with more serious disorders, such as mood disorders and thought disorders.
Key Knowledge Point to Follow:
The last digit in the hundredth decimal place .0x would typically indicate the course of the symptoms and disorder, and would be shown so as to designate the course of the disorder as mild, moderate or severe.
For example:
Diagnosis: Bipolar Disorder, Most recent episode depressed, mild Code: F31.31
Versus
Diagnosis: Bipolar Disorder, Most recent episode depressed, Moderate Code: F31.32
The DSM-5 will typically provide guidance and direction concerning what constitutes the difference between mild, moderate and severe presentations of a condition. This determination may be based upon number of symptoms, the severity or intensity of the symptoms, and/or the impairment to normal functioning created by the presence of the symptoms.
There are also instances in the DSM-5 where this last digit represents some other aspect of the condition that is a marker of the severity or complexity of the disorder, including the presence of other features or symptoms such as delusions or hallucinations. For instance:
Diagnosis: Major Depressive Disorder, Recurrent, Severe Code: F33.2
Versus
Diagnosis: Major Depressive Disorder, Recurrent, with psychotic features Code: F33.3
The DSM-5 asks each clinician to spend more time turning the complete clinical presentation of the client into a relatively concise diagnostic picture that can be understood and interpreted quickly by other medical personnel who may treat the client. It is expected that the years from 2015 to 2020 will see a full transition to the use of electronic medical records by all medical personnel, including mental health clinicians. The DSM-5 was developed with this understanding in mind, and with the goal of allowing clearer and faster understanding of the clinical picture as patient files become more easily available to any provider who assumes some responsibility for the case.
Key Knowledge Point to Follow:
With the implementation of ICD-10-CM, the code will move from a format that allows up to five digits (e.g., 296.32, Major Depressive Disorder, Recurrent Episode, Moderate) to a format that allows for up to seven digits (e.g., F40.232, Specific Phobia, Fear of Medical Care). The new codes, with up to seven digits, will allow for the recording of additional specifiers within the code numbers. This will allow for increased specificity designed to allow for greater precision, accuracy and clarity.
However, it is considered best practice to write out all features of the diagnosis – including all of the expanded specifiers – in order to create the highest degree of certainty possible for the diagnostic picture assessed.
Additional Resource Recommendation
If you are very new at learning about mental health and need practice, you may want to consider purchasing the DSM-5 Guidebook: The Essential Companion to the Diagnostic and Statistical Manual of Mental Disorders, Black DW and Grant JE, (2013) American Psychiatric Association: Washington, D.C.
The next sections will present some of the key changes in the transition from the DSM-IV-TR to the DSM-5.