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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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
Goals of presentation
Familiarity with basic components of DSM Understanding the structure of DSM
Goals of presentation
Familiarity with basic components of DSM Understanding the structure of DSM Introduction to the use of DSM
Goals of presentation
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
Goals of presentation
What’s not covered: When do you play at a crooked card game?
Goals of presentation
What’s not covered: When do you play at a crooked card game?
When it’s the only game in town.
Goals of presentation
What’s not covered: When do you play at a crooked card game?
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
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?
Two metaphors for DSM-IV-TR A house
“Constructed”, not “found”
Two metaphors for DSM-IV-TR A house
Constructed, not “found” Constrained by nature of phenomenon
Two metaphors for DSM-IV-TR A house
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
Two metaphors for DSM-IV-TR A house A language
used to communicate
Two metaphors for DSM-IV-TR A house A language
used to communicate
used to capture as much information about the case as possible
Two metaphors for DSM-IV-TR A house A language
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
The central role played by the examiner in DSM You are the standard by which almost all
judgments are made: The decision as to whether a problems is
severe enough to significantly impairment functioning and adjustment
The central role played by the examiner in DSM You are the standard by which almost all
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 central role played by the examiner in DSM You are the standard by which almost all
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
The central role played by the examiner in DSM You are the standard by which 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 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
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
Sources of confusion
The complexity of the subject/task Human behavior is among the most complex
and challenging phenomena we attempt to understand
Sources of confusion
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
Sources of confusion
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)
Sources of confusion
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)
Sources of confusion
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?
Sources of confusion
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?
Sources of confusion
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
Clinical significance
Distress Impairment
Clinical significance
Distress Impairment
In order to reduce false positive diagnoses almost all DSM-IV-TR diagnoses reiterate the distress/impairment criteria for a mental disorder
Clinical significance
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
Clinical significance
Distress Impairment This is what makes a “mental disorder” in
DSM
Clinical significance
Distress Impairment This is what makes a “mental disorder” in
DSM, this is the fundamental decision, differentiation you are making
Clinical significance
Distress Impairment This is what makes a “mental disorder” in
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
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.”
Use of DSM: multiple diagnoses Three general exceptions to multiple
diagnoses: General Medical Condition/Substance Use Associated feature of a more pervasive disorder
Use of DSM: multiple diagnoses Three general exceptions to multiple
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 . . . .”
Use of DSM: multiple diagnoses Three general exceptions to multiple
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
Use of DSM: multiple diagnoses Three general exceptions to multiple
diagnoses: Associated feature of a more pervasive disorder
more pervasive diagnoses usually take precedence over more focal or narrow diagnoses
Conduct Disorder has precedence over ODD
Use of DSM: multiple diagnoses Three general exceptions to multiple
diagnoses: Associated feature of a more pervasive disorder
more pervasive diagnoses usually take precedence over more focal or narrow diagnoses
Conduct Disorder has precedence over ODD
Mood Disorders have precedence over Anxiety Disorders
Use of DSM: multiple diagnoses Three general exceptions to multiple
diagnoses: Associated feature of a more pervasive disorder
more pervasive diagnoses usually take precedence over more focal or narrow diagnoses
Conduct Disorder has precedence over ODD
Mood Disorders have precedence over Anxiety Disorders
Autistic Disorder has precedence over ADHD
Use of DSM: multiple diagnoses Three general exceptions to multiple
diagnoses: Associated feature of a more pervasive disorder
more pervasive diagnoses usually take precedence over more focal or narrow diagnoses
General rule: skip first chapter and diagnose from front of text toward the back of the text
Use of DSM: multiple diagnoses Three general exceptions to multiple
diagnoses: Associated feature of a more pervasive disorder
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
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
Use of DSM: multiple diagnoses With more than one diagnosis, the principal
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:
Use of DSM: the most important phrase in DSM “The essential features of . . . .” The NOS (Not Otherwise Specified)
diagnoses have two requirements: The condition must meet the criteria for a “mental
disorder”
Use of DSM: the most important phrase in DSM “The essential features of . . . .” The NOS (Not Otherwise Specified)
diagnoses have two requirements: The condition must meet the criteria for a “mental
disorder” Significant function impairment or Significant personal distress or suffering
Use of DSM: the most important phrase in DSM “The essential features of . . . .” The NOS (Not Otherwise Specified)
diagnoses have two requirements: The condition must meet the criteria for a “mental
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 criteria for a mental disorder?......“Yes”
Meets essential criteria for group?.........“Yes”
Meets specific criteria for diagnosis?.....“Not quite”
Categorical NOS Diagnosis
Meets criteria for a mental disorder?......“Yes”
Meets essential criteria for group?.........“Yes”
Meets specific criteria for diagnosis?.....“No”
Mental Disorder NOS
Meets criteria for a mental disorder?......“Yes”
Meets essential criteria for group?.........“No”
Meets specific criteria for diagnosis?.....“No”
799.9 Diagnosis Deferred
Meets criteria for a mental disorder?......“Not sure”
Meets essential criteria for group?.........“Not sure”
Meets specific criteria for diagnosis?.....“No”
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
Use of DSM: severity specifiers Severity: mild, moderate, severe
Usually reflects the number of symptoms evident Mild: just meets or barely exceeds minimum requirement
to support diagnosis
Use of DSM: severity specifiers Severity: mild, moderate, severe
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
Use of DSM: severity specifiers Severity: mild, moderate, severe
Usually reflects the number of symptoms evident Mild: just meets or barely exceeds minimum requirement
to support diagnosis
Moderate: number of symptoms intermediate between mild and severe
Severe: meets almost all or all diagnostic symptoms
Use of DSM: severity specifiers Severity: mild, moderate, severe
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
Use of DSM: course specifiers Course: (present), in partial remission, in full
remission, prior history In general “In Partial Remission” means full
criteria were previously met and only some of the symptoms remain currently
Use of DSM: course specifiers Course: (present), in partial remission, in full
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
cont.
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
995.53 focus of clinical attention is victim
V61.21 Neglect of Child
995.52 focus of clinical attention is victim
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)
Use of DSM: Axis III
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
Use of DSM: 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?
The process of mental health diagnosis The fundamental questions:
What are the problems? What are the domains involved?
The process of mental health diagnosis The fundamental questions:
What are the problems? What are the domains involved?
Cognitive Behavior Emotion Interpersonal Environmental
The process of mental health diagnosis The fundamental questions:
What are the problems? What are the domains involved? Is there a Mental Disorder?
The process of mental health diagnosis The fundamental questions:
What are the problems? What are the domains involved? Is there a Mental Disorder?
What diagnosis best accounts for the available data?
The process of mental health diagnosis The fundamental questions:
What are the problems? What are the domains involved? Is there a Mental Disorder?
What diagnosis best accounts for the available data? Are there remaining important features of the case that
need accounting for?
The process of mental health diagnosis The fundamental questions:
What are the problems? What are the domains involved? Is there a Mental Disorder?
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
Ethical & Legal Issues
Diagnostic classification can have multiple, far ranging, and long lasting consequences for your clients and students
Ethical & Legal Issues
Diagnostic consequences: Educational (stigma, accommodation) Vocational (ADHD and the military) Financial (mood diagnoses and insurance) Personal esteem and identity Treatment
Ethical & Legal Issues
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
Ethical & Legal Issues
We do not usually get into trouble for making mistakes
Ethical & Legal Issues
We do not usually get into trouble for making mistakes
We can and will get into trouble for not playing by the rules
Ethical & Legal Issues
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
Ethical & Legal Issues
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
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
min
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(2)
(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
Sally
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:
60
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]
Maude
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 III: No medical problems reported
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]
Lucy
Axis I: Alcohol Dependence, With Physiological Dependence Withdrawal Increased drinking Unsuccessful efforts to cut down Great deal of time spent Activities given up
Axis II: No disorder on Axis II
Axis III: No medical problems reported
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 II: V71.09 No disorder on Axis II
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]
Fred
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 II: No disorder on Axis II
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 II: V71.09 No disorder on Axis II
Axis III: Dental problems reported
Axis IV: Problems with access to health care
Axis V: Global Assessment of Functioning: 45
Danny
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 II: No disorder on Axis II
Axis III: No medical problems reported [family history of mood disorder]
Axis IV: None
Axis V: 15
Axis I: 300.4 Dysthymic Disorder
Axis II: V71.09 No disorder on Axis II
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
Take Home Points Continued
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
Take Home Points Continued
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
Take Home Points Continued
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
Take Home Points Continued
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/
309 – 438 – 8508
Department of PsychologyIllinois State UniversityNormal, IL 61790-4620