DSM5577 - SECTION 5: IMPORTANT STRUCTURAL CHANGES TO THE DSM
Section V: Important Structural Changes to the DSM
Discontinuation of the Use of Roman Numerals for DSM Editions
Beginning with the DSM-5, Cardinal numbers will replace Roman numerals to mark updated editions of the Diagnostic and Statistical Manual. The latest version of the DSM is not DSM-V, but DSM-5, and the next version will be DSM-6, not DSM-VI.
Discontinuation of the Multi-axial System
As noted in an earlier section, the committee responsible for the DSM-5 ended the use of the multi-axial system. An expansive and comprehensive set of codes covers all conditions previously denoted on the Axis I-IV, and each is recorded without reference to an axis.
As we have noted, under the now discarded multiaxial system in the DSM-IV-TR, Axis I disorders were among the first disorders listed in the DSM, due to their more widespread prevalence in society. They were made easier to find in the manual because you were more likely to use them, as opposed to rarer or more obscure diagnoses. This included such things as depressive disorders, anxiety disorders, panic disorders, eating disorders, substance abuse, etc. Learning disorders and Attention Deficit Disorders were also listed in Axis I.
This approach still makes sense, so it has carried over in the DSM-5 to some degree: these kinds of problems remain positioned closer to the beginning of the manual. This is not to say these diagnoses or conditions are without their complexities. There are some very confusing and complicated areas of overlap between a number of diagnoses of this nature, particularly in the myriad of diagnoses associated with depression and anxiety. We will examine these complications in more detail in a later section.
The diagnoses that used to be covered under Axis II included personality disorders and developmental delays. These are less prevalent than the numerous disorders whose primary symptoms include anxiety and depression. With the abandonment of the multi-axial system, there was some attempt to reshape how these kinds of diagnoses are conceptualized and organized.
Discontinuation of Separate Axis for Personality Disorders
The multi-axial system was abandoned in the DSM-5. Among the driving forces for this change in thinking was a desire to reconceptualize personality disorders, those disorders that tend to involve the habitual use of maladaptive defense mechanisms or maladaptive personality features (APA, 1994). Such difficult disorders include - but are not limited to - borderline personality disorder, antisocial personality disorder, and dependent personality disorder.
While the purpose behind the multi-axial approach was to generate more research about personality disorders, an unfortunate side effect was the prejudice and stigma attached to personality disorders. The removal of this special position for personality disorders will hopefully serve to remove or diminish that stigma. This supports clinicians viewing them as a different manifestation of psychological and emotional difficulties.
The defining features of the different personality disorders are shown and discussed in detail in the DSM-5. For each diagnosis, criteria are defined with examples of other symptoms that could manifest, depending on the current condition. These disorders of a more pervasive nature are less frequently the reason for treatment for mental health, so the sections covering these disorders can be found toward the end of the DSM.
Personality disorders (PD) are characterized by persistent patterns of behavior and experience that begin in adolescence and persist through adulthood. The behaviors and emotional reactivity are seen as 1) inflexible and pervasive; 2) deviating from social expectations and norms; and 3) maladaptive for the person.
There are three clusters of personality disorders typically noted - based on similarities of symptoms. This arrangement remains unchanged from DSM-IV-TR to DSM-5. Cluster A include odd and eccentric behaviors of schizotypal PD, schizoid PD, and paranoid PD. Cluster B includes characteristics of intense emotional reactivity and erratic behavior such as antisocial PD, borderline PD, histrionic PD, and narcissistic PD. Last, Cluster C includes anxious or fearful patterns of relating to others such as obsessive-compulsive PD, avoidant PD, and dependent PD.
There are complications involved in sorting out distinctions between some of the personality disorders within each of these three clusters. We will examine the more confusing of these in some detail in a later section.
Discontinuation of the DSM-IV-TR Chapter Covering Diagnoses First Made in Infancy, Childhood, and Adolescence
The DSM-5 has chosen not to categorize together those diagnoses that were usually first made in infancy, childhood and adolescence. Instead, the diagnoses have been moved into other categories where their primary defining features align with features of the diagnoses with which they are now clumped.
For example, various kinds of learning disorders and Attention Deficit Disorders, which used to be clustered under Axis I, and a number of developmental disorders, which used to be clustered under Axis II, have been combined with into a single section labeled Neurodevelopmental Disorders. From an etiological perspective, this makes sense. These disorders are all created from difficulties with the “hard wiring” of the brain. This is the first cluster of diagnoses covered in the DSM-5.
The decision to cluster these together is the result of advances in our understanding of the neurological problems at the heart of these disorders. Different areas of the brain responsible for intellectual functioning, sensory and information input and output, attention and focus, and other cognitive/emotional capabilities frequently do not develop in neurologically normative ways.
The developmental process limited, slowed or interfered with due to problems in how well the clusters of neurons in important regions of the brain receive and transmit information. These problems are often linked to genetic or chromosomal abnormalities that manifest themselves as neurological insufficiencies.
The problems underlying these conditions are usually not managed by the application of “talk therapy” alone (although supportive counseling is often applied in order to address the secondary effects of these conditions, such as low self-esteem, emotional frustration/distress, and interpersonal difficulties). Some of these conditions can be improved through the application of specialized services that target some combination of neurological strengthening in affected brain areas and adaptive accommodations.
Neurological strengthening is accomplished by pushing the affected areas of the brain to “exercise” more and increase the neurological capacity. Adaptive accommodations are created by using other areas of the brain to work around where the neurological problems occur, trying to “rewire” or “neurologically re-route” around the “roadblocks”. Specialists who engage in this work include Occupational Therapists, special education tutors, neuropsychologists, neurologists and psychiatrists.
A variety of medications are used to enhance the neurological “strength” of certain brain functions or help create adaptive accommodations. An example is the use of stimulant medications for Attention Deficit Disorders to improve neurotransmitter operation in areas of the brain associated with attention and focus.
Mental health clinicians who chose to provide counseling services to individuals with these disorders will usually need to have a network of other professionals to whom they can refer these clients for the other services needed. It may also be prudent to record the diagnoses in this arena as “provisional”, pending confirmation from the other professionals whose area of competence include more thorough diagnostic work with these kinds of problems.
For instance, Intellectual Developmental Disorder, a term that has replaced the discarded term “Mental Retardation”, is characterized by significantly below-average intellectual functioning, accompanied by deficiencies in daily living abilities such as communication, self care, social skills, self direction, work skills, academic skills, leisure skills, safety skills, healthcare, and independent living skills.
Key Knowledge Point to Follow:
There are several changes to this diagnosis from DSM-IV-TR to DSM-5 in the area of Developmental Disability. Under DSM-IV-TR, this diagnosis was determined by the client’s IQ: which needed to fall at 70 or below. This has been de-emphasized in DSM-5, meaning that the diagnosis is developed in a more holistic way, looking at the client’s overall deficits in functioning. However, the following is noted on the APA web site concerning this diagnosis and the DSM-5.
“By removing I.Q. test scores from the diagnostic criteria, but still including them in the text description of intellectual disability, DSM-5 ensures that they are not overemphasized as the defining factor of a person’s overall ability, without adequately considering functioning levels . . . It is important to note that IQ or similar standardized test scores should still be included in an individual’s assessment. In DSM-5, intellectual disability is considered to be two standard deviations or more below the population, which equals an IQ score of about 70 or below.” (DSM5.org)
Because I.Q. still factors in the determination of this diagnosis, this diagnosis should remain provisional until psychological testing provides confirmation of the intellectual disability. Likewise, the degree or level of this disorder can be supported by information about the client’s I.Q. level. While not spelled out as definitively in the DSM-5, it may be helpful to extrapolate the general range for each level from what was used in the DSM-IV-TR: mild (70- 50), moderate (50-35), severe (35-20) and profound (20 or below).
The same approach should also be applied to learning disorders within this section. An experienced mental health clinician may have some good instincts about when a learning disorder is present, but the diagnosis should be listed as provisional until confirmation has been provided by psychological testing that clarifies that nature and extent of the learning disorder present.
In this same section, Attention Deficit Hyperactivity Disorder (ADHD) presents a somewhat different picture, one with additional complications for diagnosis by mental health clinicians. This disorder has been the subject of a considerable amount of controversy over the past few decades, due to a significant increase in the rate at which it has been diagnosed combined with 1) some problems in finding objective measures that can fully support its presence and severity and 2) the fact that a number of other disorders can masquerade as ADHD.
As noted by Gualtieri and Johnson (2005), “There is no frog test for ADHD. The diagnosis is made by taking a history and performing an examination, by reviewing school data, and ruling out alternative disorders.” Disorders that might need to be ruled out include: 1) Post-traumatic Stress Disorder and other disorders in which intrusive anxiety interferes with focus and attention, 2) various learning disorders which interfere with the capacity to process written or auditory information, 3) Sensory Integration Dysfunction, which is another problem related to information processing, or 4) any other kind of disorder that generates distress sufficient to interfere with attention and focus.
This increases the likelihood that a provisional diagnosis might be appropriate when recording this disorder, especially early in the assessment process. This would allow time to determine which additional assessment tools might be most helpful in reaching a more definitive diagnosis.
There are a number of such tools that are used to help arrive at a diagnosis that clarifies the presence of this disorder, such as the Continuous Performance Test (CPT) and the Test of Variables of Attention (TOVA). Unfortunately, there are serious problems even with these computerized, “objective” measures. Again, as noted by Gualtieri and Johnson (2005), “One would expect precise measures of sustained attention, like the CPT, to be the “gold standard” for ADHD diagnosis, but this is not the case. . . What is also clear from the neuropsychological literature is that although many tests indicate impairment in ADHD patients, no one test is sufficient to make the diagnosis on its own.”
That said, “No one has ever maintained that a computerized test is sufficient for establishing the diagnosis of ADHD, but one can argue that it is inappropriate to make the diagnosis of ADHD without using at least one such test.” (Ibid)
Given these realities, when making a diagnosis of ADHD - with or without the support of computerized testing or inventories filled out by parents and teachers - it is appropriate to adopt a somewhat conservative stance. This diagnosis is more defensible if the clinician has had some considerable training and experience in handling cases where ADHD is present, and where assessment has included a thorough review of the full scope of criteria noted in the DSM-5.
Movement from ICD-9 Coding to ICD-10 Coding on October 1, 2015
All diagnoses for mental health conditions are drawn from the International Classification of Diseases system, known more commonly as ICD, which through September 30, 2014 will be in its ninth edition. On October 1, 2015, the United States moved from ICD-9-CM to ICD-10-CM for all healthcare providers and systems. Because all DSM codes are derived from ICD definitions of medical conditions, the introduction of ICD-10-CM will bring significant changes to the diagnostic codes under which mental health conditions are recorded.
The earliest versions of the DSM-5 Reference Guides printed prior to this change contain diagnosis codes under both the old ICD-9-CM system and the new ICD-10-CM system. This allowed clinicians to purchase the newest edition of the DSM without having to purchase another Reference Guide when the ICD system changed. In these earlier versions of the DSM, the ICD-9-CM diagnoses are presented first, with the ICD-10-CM codes following in parentheses. Since the ICD-10-CM system has been fully implemented, ICD-9-CM codes may not be shown in your version of the DSM-5 Reference Guide.
Below is a summary of some of the important features of the new ICD-10-CM codes that are used in diagnosis and medical billing.
ICD-9 Coding: Up to 5 digits ICD-10 coding: Up to 7 digits
As previously noted, with the implementation of ICD-10-CM, codes 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).
ICD-10 coding: All codes begin with letters
Unlike the ICD-9, the new diagnostic codes begin with a letter (e.g., F41.0, Panic Disorder) that designates the general medical area in which the symptoms occur, followed by either a two digit number without a decimal point and other modifiers (F42, Obsessive-Compulsive Disorder) or by a two digit number with a decimal point and other modifiers (e.g., F12.288, Cannabis Withdrawal).
ICD-10 coding: Codes that denote more than one diagnosis
Under the ICD-10-CM system, the diagnosis should not just be listed as a code number, but should list the code first, followed by the diagnosis written out in full. This is because there are a handful of code numbers that are used for more than one disorder. For example, F42 can represent either 1) Obsessive-Compulsive Disorder or 2) Hoarding Disorder. These disorders have similar etiologies, but slightly different ways of being manifested. The presence of the written diagnosis provides that highest level of clarity.
ICD-10 coding: Most common mental health codes begin with the letter ‘F’
Generally speaking, mental health clinicians will have a much more limited number of codes to keep track of than medical personnel. Most codes that will be used by mental health clinicians will be codes that begin with the letter ‘F’, covering a range of disorders that are primarily defined by the kinds of emotional or psychological problems that form the core of our work.
ICD-10 coding: V codes to be replaced by Z codes and T codes
Codes listed as V codes under ICD-9 (e.g., V61.10, Relationship Distress with Spouse or Intimate Partner) have been used for conditions that are not considered to have a medical cause or etiology. Under ICD-10-CM these codes are to be listed as Z codes (e.g., Z63.0, Relationship Distress with Spouse or Intimate Partner) or T codes (e.g., T74.12XA, Child Physical Abuse, Confirmed, Initial Session).
ICD-10 coding: A few notable exceptions to F, Z and T codes
There are a handful of other codes that mental health clinicians might use under ICD-10-CM that do not have F, Z, or T as starting letters. These tend to be found in areas that are primarily medical in nature but which have significant neurological and/or psychological effects. Most sleep-wake disorders, for instance, are coded as G codes, including Insomnia Disorder (G47.00), several different manifestations of Narcolepsy (G47.41 + specifiers), and several manifestations of sleep apnea and other obstructive sleep disorders (G47.3 + specifiers). Likewise, a number of major neurocognitive disorders arising from medical causes (e.g., Alzheimer’s disease, traumatic brain injury, HIV) will be coded using G codes.
There are also G (but also some T codes) that denote problems arising from adverse effects of psychotropic medications. Tardive Dyskinesia (G24.01) and Antidepressant Discontinuation Syndrome (T43.205 + specifiers) would be two examples of diagnoses that might appear in the client’s record. T codes may also be utilized if there are adverse effects of medications not primarily designed to address mental health problems, but which have problematic effects on emotions, mood or behaviors. An example of this would be T38.4X5S, Adverse effects of oral contraceptives.
Typically G and many T codes are placed in the record by medical specialists who have conducted the necessary medical tests to arrive at such a diagnosis. Mental health clinicians – with the exception of medical personnel who are both neurologists and psychiatrists – may note these codes in their records when a medical specialist has forwarded that information, but they should not initiate these codes based upon only their own psychosocial assessment. This would constitute operating outside of one’s area of competence.
ICD-10 coding: Exceptions to the exceptions
There are also a couple of exceptions to the exceptions found in sleep-wake disorders. Three kinds of sleep problems called parasomnias (Sleep Walking, Nightmare Disorder, and Sleep Terror) are coded using F codes (F51.3, F51.4 and F51.5 respectively). Plus one specific kind of sleep disorder, Cheyne-Stoke Breathing is coded with an R code, R06.3. Clinicians must be prepared to see these codes in patient records and understand what they mean, even if they are not providing the primary treatment for the underlying conditions.
ICD-10 coding: Three other common exceptions
Three other exceptions under ICD-10-CM may be relevant for the knowledge base of mental health clinicians. The first is L98.1, Excoriation (Skin-Picking) Disorder. This is a similar disorder to Trichotillomania (Hair Pulling Disorder, F63.3), except the client engages in compulsive picking at his/her own skin instead of compulsive plucking of his/her hair.
The second is N94.3, Premenstrual Dysphoric Disorder. This is a disorder in which the hormonal changes just prior to menstruation create a variety of emotional/psychological and/or behavioral effects that are associated with clinically significant distress and/or disruptions to the client’s major social roles/relationships. This disorder is a new addition to the DSM, and mental health clinicians should be quite careful in its use.
While this diagnosis will typically be reached based upon gathering of assessment information from the client, it is a diagnosis that should be arrived at only by qualified medical personnel. This is another code to be noted in the record only when the diagnosis is forwarded by an appropriate medical specialist.
The final exception is concerned with elimination disorders, which typically encompass disorders such as enuresis (F98.0) and encopresis (F98.1) that have both physical and psychological components. When the manifestation of the problem is the more typical presentation, with psychological elements present, these two disorders will both be coded with an F code under ICD-10-CM.
However, other kinds of elimination disorders, such as urinary or fecal incontinence due to some medical condition, will be coded with an N code for urinary incontinence (N39.498) and an R code for fecal incontinence (R15.9). An unspecified elimination disorder, where the physical etiology cannot be determined, will be coded with an R code for either urinary (R32) or fecal symptoms (R15.9).
Elimination disorders are common in children and they can generate a significant degree of distress. Therefore they deserve mention as part of the overall assessment and diagnostic process. However, because a differential diagnosis is needed to determine whether elimination disorders have a medical or combined physical-psychological origin, this diagnosis is best left to qualified medical personnel. This can be noted in the client’s record, but the diagnosis should originate from a physician.