using dsm-5: a brief summary handout packet #...

Using DSM-5: A Brief Summary

Carlton Munson, PhD

Professor

University of Maryland Baltimore

School of Social Work

8/16/2013 Copyright © 2013 Dr. Carlton Munson 1

Handout Packet # 1

Disclaimer


DSM and DSM 5 are registered trademarks of the American Psychiatric

Association (APA). The APA is not affiliated with this training and does not

endorses this seminar or its content. Material under APA Copyright in this

presentation is used according to U.S. Copyright Office regulations regarding fair

use (sections 107 through 118 of the copyright law (title 17, U. S. Code. Permission is

NOT granted to participants in this training to copy and distribute the paper copy

handouts used in the presentation.

For further information about APA and the DSM-5 visit the official APA DSM-5

website at www.dsm5.org.

http://www.dsm5.org/

DSM-5 Collection

August September

2013

8/16/2013

Copyright © 2013 Dr. Carlton Munson

John Barnhill

Philip Muskin

Donald Black & Jon Grant

Laura Weiss Roberts &

Michael First

Alan K. Louie

Name will officially be DSM-5 Not DSM-V

Pages missing apparent rush to publication without thorough proof reading

DSM-5: Online


DSM-5 ON-LINE AVAILABLE FALL September 2013 There will be an on-line DSM-5

DSM-IV-TR version was $490 annually DSM-5 version $420 annually

“There will be price restructuring related to the product options”

This resource can be helpful for students and others adjusting to

the DSM-5 changes

Licensing Exam Conversion to DSM-5

• Social Work – LCSW Exam Does not apply to this exam no questions on

DSM there are questions on assessment

– LCSW-C Examination January 2015

– NOTE: In Maryland in October 2013 LGSWs can diagnose when under supervision of LCSW-C

• Psychologists – Conversion August 2014

• CPC, CPC-MFT, CAC-AD, & CSC-AD – No information posted at the ACA or MD BOPC website

–


Changes in Social Work Licensing Statute

• OCTOBER 1, 2013 CHANGES IN THE SOCIAL WORK STATUTE § 19-101 Definitions Section • Deleted from the general definition of social work practice: • FORMULATING DIAGNOSTIC IMPRESSIONS • Added to the definition of graduate and certified social work: • FORMULATING A DIAGNOSIS, UNDER THE DIRECT SUPERVISION OF A LICENSED CERTIFIED SOCIAL

WORKER-CLINICAL • Treatment of BIOPSYCHOSOCIAL CONDITIONS • TREATMENT OF mental disorders.............. • Added to the definition of clinical social work: • PETITIONING FOR EMERGENCY EVALUATIONS UNDER TITLE 10, SUBTITLE 6 OF THE HEALTH-

GENERAL ARTICLE • § 19-307 Scope of license A licensed Bachelor social worker may not ENGAGE IN PRIVATE

PRACTICE • Changed • A licensed Graduate social worker may not diagnose a mental disorder WITHOUT THE DIRECT

SUPERVISION OF A LICENSED CERTIFIED SOCIAL WORKER- CLINICAL • A licensed Graduate social worker may not ENGAGE IN PRIVATE PRACTICE WITHOUT THE DIRECT

SUPERVISION OF A LICENSED CERTIFIED SOCIAL WORKER-CLINICAL • A licensed Certified social worker may not diagnose a mental disorder WITHOUT THE DIRECT

SUPERVISION OF A LICENSED CERTIFIED SOCIAL WORKER- CLINICAL


SLIDE KEY • Some material in this presentation is keyed to color and symbols

• Text in blue indicates a change for DSM-5

• Green indicates my interpretation or a relevant study or information

• This symbol represents a change with questionable rationale or outcome (i.e., no empirical basis)

• This symbol indicates disorder or section new to DSM-5

• Indicates a reading assignment slide

• Most slides have DSM-5 page references and participants who have DSMs can follow the presentation of the new material and make notes in the manual

• Some slides in the presentation are not in the handouts due to copyright restrictions 8/16/2013 Copyright © 2013 Dr. Carlton Munson 7

DSM History

3-106-132

11-185-92

15-26-482

15-297-482

16-365-886

16-365-889

20-365-1,000+

Coding: Categories-Disorders-Pages

Diagnostic

Inflation ?

Research Domain Criteria – RDoC Thomas Insel on March 06, 2012


-Most genes associated with risk for schizophrenia also contribute to risk for bipolar disorder and autism. -RDoC primary focus is neural circuits. Accumulating findings on neural circuitry that generates behavior is making it possible to use this approach. -Genes cut across current diagnostic labels and neuroimaging often helps sub-divide current groups. -By studying patterns of brain activity either at rest or with activation the brain tell us different forms of mood, anxiety, or psychotic disorders. -This is the diagnostic approach in neurology, where imaging is used routinely for localizing lesions, rather than relying exclusively on motor or sensory changes. -Current systems see disorders as present or absent. RDoC approach is dimensional-RDoC incorporates magnitude or severity measures, analogous to tests of blood pressure or cholesterol. -RDoC will develop administered tests of dimensional information in reliable and valid ways. -RDoC framework is a heuristic to facilitate incorporation of behavioral neuroscience in the study of psychopathology.

http://www.nimh.nih.gov/about/director/directors-biography.shtml

Mental Illness Context


-In US 50% will have lifetime incidence of a mental disorder -20-25% met criteria for a mental disorder during any 12-month period -78% of cases are mild to moderate severity -22% have significant impairment severity -75% of all lifetime disorders have onset by age 24 -Conclusion: Interventions should be aimed at young people, but mental illness increasing in the elderly

My General Principles of DSM-5 Diagnostic Criteria

• Clinical Relevance – Is it necessary or appropriate to assign a DSM-5

diagnosis? (E.g., Avoidant PD)

• Clinical Significance – Are symptoms/behaviors/problems at a level that

warrants a DSM-5 diagnosis? E.g., (PTSD diagnosis)

• Clinical Judgment – Among competing or cross-cutting symptoms

what diagnosis (es) appropriate? (E.g., MDD and/or Anx. Disorder)

11 8/16/2013

DSM-5: Definition of a Mental Disorder


DSM-5: A mental disorder is a syndrome characterized by clinically significant disturbance in an individual’s cognition, emotion regulation, or behavior that reflects a dysfunction in the psychological, biological, or developmental processes underlying mental functioning. Mental disorders are usually associated with significant distress or disability in social, occupational, or other important activities. An expectable or culturally approved response to a common stressor or loss, such as the death of a loved one, is not a mental disorder. Socially deviant behavior (e. g., political, religious, or sexual) and conflicts that are primarily between the individual and society are not mental disorders unless the deviance or conflict results from the dysfunction in the individual, as described above.

See p. 20 for details

8/16/2013 11:19:43 AM Copyright © 2013 Dr. Carlton Munson 13

Where have all the flowers gone? First and foremost, where has the multiaxial format gone?

Converted to severity

Measures in individual

disorders

Sent to Other Conditions That May

Be a Focus of Clinical Attention

section

Combined and presented in

vaguely defined narrative format

AXIS I Axis II AXIS III Axis IV Primary Support group

Social Environment Educational Problem Occupational Problems Housing Economic Problems Access to healthcare Problems with the legal system Other P/S Problems

Axis V 3 Basic Types of Specifiers

Specify if: With anxious distress Specify current severity mild, moderate, severe Specify whether: 314.01 (F90 0.2) Combined presentation:

Listed as “Notations”

Continue to list code, diagnosis and medical Conditions

Nonaxial Assessment Diagnosis Good news! It provides latitude

2 Psychosocia

l factors now “notations”

3 Axis 5 now “disability” Meaning severity

4 Medical

Conditions

I now report Dx. formulation categories of: 1. Diagnosis 2. Notations 3. Disability Severity 4. Medical conditions

P. 16

DSM-5:Sections


DSM-5 Classification -AKA Table of Contents -Codes & page #s for 20 Categories of disorders Preface

Section I DSM-5 Basics -Introduction -Use of the Manual -...Forensic Use of DSM-5

Section II -Diagnostic Criteria and Codes -HEART OF THE MANUAL

Section III Emerging Measures and Models -Assessment Measures -Cross-Cutting Symptom Measures -Clinician-Rated...Psychosis ...Severity -Cultural Formulation -Alternative ...Model...for personality -Conditions for further Study

Appendices -Highlights of Changes -Glossary of Technical Term -Glossary of Cultural concepts of Distress -Alphabetic Listings of Diagnoses/Codes -Numeric Listing of Codes (ICD-9-CM) -Numeric Listing of Codes (ICD-10-CM) -DSM-5 Advisors & Contributors -Index

What is in side DSM-5?

Note: This information In a different format in handout

DSM-5 Organizational Changes: Section II: Essential Elements: Diagnostic Criteria and Codes


Neurodevelopmental disorders Schizophrenia spectrum and other psychotic disorders Bipolar and related disorders Depressive disorders Anxiety disorders Obsessive-compulsive and related disorders Trauma- and stressor-related disorders. Dissociative disorders Somatic symptom and related disorders Feeding and eating disorders Elimination disorders Sleep-wake disorders. Breathing-related sleep disorders. Parasomnias Sexual dysfunctions Gender dysphoria Disruptive, impulse-control, and conduct disorders Substance related and addictive disorders Neurocognitive disorders Personality disorders Paraphilic disorders Other mental disorders Medication-Induced Movement Disorders and Other Adverse Effects of Medication Z and V Codes

Reordering is “sequential” to reflect “attenuated” (weak) effort to suggest dimensional approach to entire manual based on childhood features, adult disorders, and the 5-Factor Model originally proposed in 2 books published by APA

Notice Grouping

Begins with

Ends with

DSM-5 Organizational Changes: Section III: Emerging Measures and Models


Assessment Measures Cultural Formulation Alternative DSM-5 Model for Personality Disorders Conditions for Further Study Attenuated Psychosis Syndrome

Depressive Episodes With Short-Duration Hypomania Persistent Complex Bereavement Disorder Caffeine Use Disorder Internet Gaming Disorder Neurobehavioral Disorder Due to Prenatal Alcohol Exposure (ND-PAE) Suicidal Behavior Disorder Nonsuicidal Self-Injury

Cultural Formulation Interview (CFI) Separate formats for client and informant Replaces Outline for Cultural Formulation and Glossary of Culture-Bound Syndromes

Cross-cutting measures, Level 1 and Level 2 AREA TO WATCH FOR EBP Some used in clinical field trials. I will explain them if you want me to

All “Section 3” items new to DSM-5

I recommend you ignore and not use this section of DSM-5

DSM-5 Section: Appendix and Index [pp. 808-947]


Highlights of changes from DSM-IV to DSM-5 (p. 809) Glossary of technical terms (75 terms in DSM-IV 183 in DSM-5) [p. 817] Glossary of cultural concepts of distress (25 in DSM-IV 9 in DSM-5) [p. 833] Alphabetical listing of DSM-5 diagnoses and codes(ICD-9-CM) and ICD-10-CM) Numerical Listing of DSM-5 diagnoses and codes (ICD-9-CM) [p.863] Numerical listing of DSM-5 diagnoses and codes (ICD-10-CM) [p.877] DSM-5 advisors and other contributors [p. 897-916, See p. 915) Index [p. 917-947]

I worked hard for

that small

recognition

In MH Hx!!!

Index much improved. You will need to use It to master the

changes

8/16/2013 11:19:43 AM Copyright © 2003 Dr. Carlton Munson 19

Where have all the flowers gone? Where have all disorders gone?

ICA Disorders R/O

Rule out

By

Prior

History

Asperger's

Disorder RELD

OUT

Schizophrenia

Subtypes

Substance

Abuse

IN

Global

Developmental

Delay

DMDD Hoarding

Disorder Excoriation DSED PTSD

CHILD

Criteria

Binge

Eating

Disorder

DMDD = Disruptive Mood Dysregulation Disorder DSED = Disinhibited social engagement disorder PDD = Premenstrual Dysphoric Disorder

PDD

Diagnostic Criteria Organization

for the 20 Categories of Disorders


Brief Introduction

Text

Diagnostic Criteria

Summary

Detailed Descriptive

Text

Unspecified Disorders

Other Specified Disorders

-Disorder capitalization eliminated -Text section titles right justified -Number of text sections vary for some disorders

Some redundancy

In the sections

DSM Fundamental

core

NOTE: In this slide persistent depressive disorder in depressive disorders classification used as an example. Go to the pages indicated as each icon is explained

p. 168-169

p. 155

p. 183

p. 169-171

p. 184

Essentially Replace NOS

See following slide

See following slide

Text Accompanying Each DSM-5 Disorder

• Diagnostic Criteria

• Diagnostic Features

• Associated Features Supporting Diagnosis

• Prevalence

• Development And Course

• Risk And Prognosis Factors

• Culture-Related Diagnostic Issues

• Gender-related Diagnostic Issues

• Diagnostic Markers

• Functional Consequences Of .....

• Differential Diagnosis

• Comorbidity


Note: Diagnostic Criteria are

At the beginning of the text

and not at the end as in DSM-IV

Orienting to the DSM-5 Read the Sections Below in the Order Recommended

Experienced Users • Review Table of Contents • Read Use of the Manual (pp. 19-24) • Review Highlights of Changes From DSM-IV to DSM-

5 (pp.809-816) • Review Other Conditions That May be a Focus of

Clinical Attention (pp. 715-727) • Review DSM-5 Classification (pp. xiii-xI) • Review the diagnostic criteria and text for disorders

you use most • Review Cultural Formulation (pp. 749-760 &

Glossary of Cultural Concepts of Distress (pp. 833-837)

• Review Glossary of Technical Terms (pp. 817-831) • Review Assessment Measures (pp.733-748) •

Beginning Users • Review Table of Contents • Read Use of the Manual (pp. 19-24) • Review DSM-5 Classification (pp. xiii-xI) • Review diagnostic criteria and text for

disorders that you plan to use the most • Review closely Glossary of Technical Terms

(pp. 817-831) • Read in detail the text section of the

disorders you begin to use • Review Other Conditions That May be a

Focus of Clinical Attention (pp. 715-727) • Review Cultural Formulation (pp. 749-760 &

Glossary of Cultural Concepts of Distress (pp. 833-837)

• Review Assessment Measures (pp.733-748)


Persistent Depressive Disorder pp. 168-169

This disorder is consolidation of DSM-IV chronic major depressive disorder and dysthymic disorder.

A. Depressed mood for most of the day, for more days than not, as indicated by subjective account or observation by others, for at least 2 years

B. Presence, while depressed, of 2 or more of the following:

1. Poor appetite or overeating

2. Insomnia or hypersomnia

3. Low energy or fatigue

4. Low self-esteem

5. Poor concentration or difficulty making decisions

6. Feelings of hopelessness.

C. During a 2-year period (1year for children /adolescents), individual has never been without the symptoms in criterion A and B for more than 2 months at a time.

D. Criteria for a major depressive disorder may be continuously present for 2 years

E. There has never been a manic episode, hypomanic episode, or criteria met for cyclothymic disorder

F. Disturbance not better explained by a persistent schizoaffective and disorder, schizophrenia, etc.

G. The symptoms are not attributable to physiological effects of a substance

H. Symptoms cause clinically significant distress…

300.4 (F34.1)

Persistent Depressive Disorder

Specify if:

With anxious distress

With mixed features

With melancholic features

With atypical features

With pericardium onset

With mood congruent psychotic features

With mood incongruent psychotic features

Specify if:

In partial remission

In full remission

Specify if

Early Onset

Late onset

Specify If: With pure dysthymic syndrome With persistent major depressive episode With intermittent major depressive episodes with current episode With intermittent major depressive episodes, without current episode Specify if current severity: Mild (p. 188) Moderate (p. 188) Severe (p. 188)

Refers to separate section of depressive disorders, Specifiers for Depressive Disorders, that details specifiers for this class od disorders

How to Record DSM-5 Dx.


296.23 major depressive disorder, recurrent episode, severe, with seasonal pattern

Course Specifier

DSM-5 Code

Record disorder or condition

Specifier Course Specifier

A Holiday Dx.

Provisional Diagnosis (p. 23)


...strong presumption full criteria

will ultimately be met for a disorder,

but not enough information available

to make a firm diagnosis...

...Clinician can indicate diagnostic

uncertainty by recording

“(provisional)” following the

diagnosis...

Diagnosis

295.90 Schizophreniform, With good prognostic features, mild (provisional)

305.60 Phencyclidine use disorder, severe

Notations

V62.29 Other problem related to employment

V15.59 Personal history of self harm

Medical Conditions

No reported medical problems

see p. 726

see p. 723

Schizophreniform Disorder

295.40 (F20.81)

2+ present sig. portion of time for 1+m of at least 1 must be

1, 2, or 3:

1. Delusions

2. Hallucinations,

3. Disorganized speech

4. Grossly disorganized or catatonic behavior

5. Negative symptoms

B. Episode 1-m but less than 6m

C. Not other psychotic disorder

D. Not due to substance or other medical condition

See. pp. 96-97

Provisional Diagnosis (p. 23)


...strong presumption full criteria

will ultimately be met for a disorder,

but not enough information available

to make a firm diagnosis...

...Clinician can indicate diagnostic

uncertainty by recording

“(provisional)” following the

diagnosis...

Diagnosis

295.90 Schizophreniform, With good prognostic features, mild (provisional)

305.60 Phencyclidine use disorder, severe

Notations

V62.29 Other problem related to employment

V15.59 Personal history of self harm

Medical Conditions

No reported medical problems

see p. 726

see p. 723


295.40 (F20.81)


1, 2, or 3:

1. Delusions

2. Hallucinations,




B. Episode 1-m but less than 6m



See. pp. 96-97

DSM-5 Cultural Formulation and Concepts of Distress


Cultural Formulation pp. 749-759

Glossary of Cultural Concepts of Distress pp. 833-837

Blue text indicates new to DSM-5

Ataque de nervios

Dhat syndrome

Khyal cap

Kufugisisa Maladi noun Nervios

Shenjing Shuairuo

Susto

Taijin Kyofusho

Outline for Cultural Formulation -Cultural identity of the individual

-Cultural conceptualization of distress -Psychosocial stressors & cultural features of vulnerability & resilience -Cultural features of relationship of individual & clinician -Overall cultural assessment

Cultural Formulation Interview (CFI) -16 questions may use about impact of culture in areas of: -perceptions of cause, context, support -Self-coping & past help seeking -Current help seeking -Supplement modules: www.psychiatry.org/dsm5 -Used with other received information -Used in entirety or selective -Client and informant versions

Neurodevelopmental Disorders


Intellectual Disabilities Intellectual Disability (Intellectual Developmental Disorder) Global Developmental Delay Unspecified Intellectual Disability (Intellectual Developmental Disorder) Communication Disorders Language Disorder Speech Sound Disorder (previously Phonological Disorder) Childhood Onset Fluency Disorder (Stuttering) Social (Pragmatic) Communication Disorder Unspecified Communication Disorder Autism Spectrum Disorder Autism Spectrum Disorder Attention-Deficit/Hyperactivity Disorder Attention-Deficit/Hyperactivity Disorder Other Specified Attention-Deficit/Hyperactivity Disorder Unspecified Attention-Deficit/Hyperactivity Disorder Specific Learning Disorder Specific Learning Disorder Motor Disorders Developmental Coordination Disorder Stereotypic Movement Disorder Tic Disorders Tourette’s Disorder Persistent (Chronic) Motor or Vocal Tic Disorder Provisional Tic Disorder Other Specified Tic Disorder Unspecified Specified Tic Disorder Other Neurodevelopmental Disorders Other Specified Neurodevelopmental Disorder Unspecified Neurodevelopmental Disorder

Intellectual Disabilities

A: Deficits in intellectual functioning confirmed by both clinical assessment and intelligence testing.

B: Deficits in adaptive functioning with failure to meet developmental & sociocultural standards for personal independence and social responsibility. W/O support adaptive deficits limit functioning in 1 or more areas of: Communication, social participation, & independent living across environments (home, school, work, & Community)

C: Onset of intellectual and adaptive deficits during the developmental period

(childhood or adolescence)

Coding note: ICD-9-CM code for ID is 319, which is assigned regardless of severity

specifier

Specify current severity (see Table 1): (F70) Mild (F71 )Moderate (F72) Severe (F73) Profound

Intellectual disability (intellectual developmental disorder) is a disorder with onset during

the developmental period that includes both intellectual and adaptive functioning deficits

in conceptual, social and practical domains. The following three criteria must be met:

Intellectual Disability

(Intellectual Developmental Disorder)

Diagnostic Criteria

Note the layout difference Disorder name to far right Coding is a note and not at the head of the disorder title This format varies for some disorders

* Specify current severity (see Table 1): 317 318.0 318.1 318.2 (F70) Mild (F71) Moderate (F72) Severe (F73) Profound

Necessitated by removal of “Prior History ”specifier (diagnosis) DSM-IV, p. 2

Sample Dx.


DIAGNOSIS

Koma Smith reportedly has had two episodes of mental health treatment and

mental health diagnosis in the past. Koma cannot remember the Dx. received and

cannot remember the physician’s name or the hospital name. Based on the clinical

interview, scales administered and collateral information, the following diagnoses

were made as part of this assessment:

317, Intellectual developmental disorder, Moderate

V61.8 high expressed emotion level within family

V15.41 Personal history (past history) of spouse violence, Physical

V61.20 Parent-child relational problem

V60.1 Inadequate housing

V60.2 Low income

Another Sample DSM-5 Diagnosis Based on my evaluation the following is my DSM-5 diagnostic

formulation:

Diagnoses

-317 Intellectual Disability (Intellectual Developmental disability), Mild

Notations

-V61.20 Parent-Child Relational Problem

-Unspecified Bipolar Disorder by prior diagnosis that may be controlled

with medication

-309.81 PTSD by prior diagnosis current symptom level not clear due to

client guarded reporting

Disability Severity

-This woman’s diagnoses are of a magnitude that impairs ability to

parent children

Medical Conditions

-Patient reported only medical condition as asthma


...Reserved for individuals under age 5 years when clinical severity level cannot be assessed during early childhood .Dx. when individual fails to meet expected developmental milestones in several areas of intellectual functioning, and child is not able to undergo standardized testing. Requires periodic reassessment

...Reserved for individuals over age 5 when assessment of ID (IDD) by locally available procedures or difficult or impossible due to sensory or physical impairments, as in blindness or pre-lingual deafness; locomotor disability; or presence of severe problem behaviors or co-occurring mental disorder. Used only in exceptional circumstances. Requires periodic reassessment

Unspecified Intellectual Disability

(Intellectual Developmental

disorder)

319 (F79)

315.8 (F88)

Global Developmental Delay

Other Neurodevelopmental Disorders

...Reserved for individuals under age 5 years when clinical severity level cannot be assessed during early childhood .Dx. when individual fails to meet expected developmental milestones in several areas of intellectual functioning, and child is not able to undergo standardized testing. Requires periodic reassessment

...Reserved for individuals over age 5 when assessment of ID (IDD) by locally available procedures or difficult or impossible due to sensory or physical impairments, as in blindness or pre-lingual deafness; locomotor disability; or presence of severe problem behaviors or co-occurring mental disorder. Used only in exceptional circumstances. Requires periodic reassessment

Unspecified Intellectual Disability

(Intellectual Developmental

disorder)

319 (F79)

315.8 (F88)

Global Developmental Delay

Note change. Coding is under disorder heading

Intellectual Disability (Intellectual Developmental Disorder) was Mental Retardation in DSM-IV

Measured by

Clinical assessment and standardized measures like

Vineland

ABS & AAIDD ABS

cA: Deficits in reasoning, problem-solving, planning, abstract thinking, judgment, academic & experience learning Confirmed by clinical assessment & standardized testing

Severity criteria: • 319 Mild (IQ 50-70) • 319 Moderate (IQ 35-55) • 319 Severe (IQ 20-40) • 319 Profound (IQ <25)

cB: Sig. Limitations in adaptive functioning in 2 skill areas of: Communication / Social participation / independent living at home, school, work, & community

cC: Onset during developmental period

Note: Borderline

Intellectual

Functioning in

OCTMBFCA

p. 727

Generally IQ 70-85 but not

specified in DSM-5

Intellectual Disability in Maryland DDA 2 levels of eligibility for funded services

1. Developmental Disability

• Severe, chronic disability that : – Attributable to physical/mental

impairment, other than Dx of MI or combo of mental/physical impairment

– Likely to continue indefinitely

– Inability to live independently

– Intellectual Developmental Disorder

2. Support Services Only

• Eligibility for person with severe, chronic, disability that: – Attributable to

physical/mental impairment other than sole Dx. of MI, or combo of mental/physical impairment, and

– Is likely to continue indefinitely

– Intellectual Disability


Communication Disorders pp. 41-49


315.39 (F80.9) Language Disorder 315.39 (F80.0) Speech Sound Disorder 315.35 (F80.81) Childhood-Onset Fluency Disorder 315.39 (F80.89) Social (Pragmatic) Communication Disorder 307.9 (F80.9) Unspecified Communication Disorder

Used to Dx. RELDs

In DSM-IV

Neurodevelopmental Disorders pp. 50-59

A. Persistent deficits in social communication and social interaction across multiple contexts, as manifested by the following, currently or by history (examples are illustrative, not exhaustive see text):

1. Deficits in social emotional reciprocity

2. Deficits in nonverbal communication behaviors used for social interaction...

3. Deficits in developing, maintaining, and understanding relationships...

Specify current severity:

Severity is based on social communication impairments and restricted, repetitive patterns of behavior (see table 2).

299.00 (F84.0)

Autism Spectrum Disorder

DSM-5 allows adult Dx. by noting symptoms may not be apparent until adolescence or adulthood. Severity scale may substantiate need for supportive employment and accommodations in the workplace

ASD Continued


B. Restricted, repetitive patterns of behavior, interests, or activities, as manifested by at least 2 of the following... 1. Stereotyped or repetitive motor movements, use of objects, or speech... 2. Insistence on sameness, inflexible adherence to routines, or ritualized patterns of verbal or nonverbal behavior... 3. Highly restricted, fixated interest that are abnormal in intensity or focus 4. Hyper-or hyporactivity to sensory input or unusual interest in sensory aspects of the environment... Specify current severity...(See severity specification in cA above) C. Symptoms must be present in the early developmental period D. symptoms cause clinically significant impairment in social occupational or other important areas of current functioning E. These disturbances are not better explained by intellectual disability (intellectual developmental disorder) or global developmental delay

ASD Continued


Specify if: With or without accompanying intellectual impairment With or without accompanying language impairment Associated with any known medical or genetic condition or environmental factor (Coding note: Use additional code to identify associated medical or genetic condition.) Associated with another neurodevelopmental, mental, or behavioral disorder (Coding note: Use additional codes to identify the associated neurodevelopmental, mental, or behavioral disorder.) With catatonia (refer to criteria for catatonia associated with another mental disorder, pp. 119-120 for definition (Coding note: Use additional code 293. 89 (F06.1) catatonia associated with autism spectrum disorder to indicate presence of comorbid catatonia

DSM-5: “Severity scale” Descriptive of ASD ADLs.

3 point severity level:

LEVEL 3 “Requiring very substantial support” Level 2 “Requiring substantial support”

Level 1 “Requiring support”

Note: Need for support defined separately for social communication deficits and restricted interests and repetitive behaviors

An individual may be a Level 3 for social communication, and level 2 for repetitive behaviors which need only a moderate level of support


DSM-5: Autism Spectrum Disorder

Severity of impairment in areas of development:

Reciprocal

social

interaction

skills

Communication

skills

Restricted: Behavior

“RRBs” Interests

Activities

Reciprocal

social

interaction

skills

Communication

skills



Activities

Reciprocal

social

interaction

skills

Communication

skills



Activities

Level 1 Level 2 Level 3

Level 1

Level 1 Level 2

Level 2

Level 3

Level 3

SLIDER BUTTON

pp. 50-59

DSM-5: Autism Spectrum Disorder (ASD) Alternative Diagnoses

• Some who no longer meet criteria for ASD in DSM-5 may meet criteria for other DSM-5 diagnoses, including:

– Intellectual Disability

– Communication Disorder

– Anxiety Disorders, and/or

– Attention Deficit/Hyperactivity Disorder – This position of APA and not this presenter


ADHD Criteria DSM-5 ADHD

24% increase in ADHD Dx. from

2001 To 2010

Increase from 3% to 10%

of population

Before age 12

Subtypes Become Specifiers

Addition of ADHD other & Unspecified

Fewer symptoms for adult ADHD. Research: Symptoms< w age, but remain- Adult 5 Sx after age 17 Children 6 Sx

“In partial remission”

added

Co

mb

ined

Attention-Deficit /Hyperactivity Disorder: Slide 1 pp. 59-66


A. Persistent Sx. of inattention and /or hyperactivity impulsivity interfering with functioning or development characterized by 1 and/or 2: 1. Inattention: 6+ of following Sx. for 6+ months inconsistent with developmental level and negatively impacts directly SAO activities: Note: Sx. not part of oppositional behavior, defiance, hostility or failure to understand tasks or instructions. For older adolescents and adults (age 17+), 5+ symptoms required. a. Often lacks close attention to details or makes careless mistakes. b. Often has difficulty sustaining attention in tasks or play activities. c. Often does not seem to listen when spoken to directly. d. Often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace. e. Often has difficulty organizing tasks and activities. f. Often avoids, dislikes, reluctant to engage in tasks requiring sustained mental effort. g. Often loses things necessary for tasks or activities. h. Is often easily distracted by extraneous stimuli. i. Is often forgetful in daily activities.

Attention-Deficit /Hyperactivity Disorder

Diagnostic Criteria

“Sx.”= symptom (s) “SOA”= Social, academic, occupational



2. Hyperactivity and impulsivity: 6+ of the following Sx. for 6+ months to a degree inconsistent with the developmental level and negatively impacts SOA activities: a. Often fidgets with or taps hands or feet or squirms in seat. b. Often leaves seat in situations when remaining seated is expected. c. Often runs about or climbs in situations where it is inappropriate. (Note: Adolescence or adults, may be limited to feeling restless). d. Is often “on the go,” acting as if “driven by a motor.” f. Often talks excessively. g. Often blurts out an answer before a question has been completed. h. Often has difficulty waiting his or her turn. i. Often interrupts or intrudes on others. B. Several inattentive or hyperactive impulsive Sx. present prior to age 12. C. Several inattentive or hyperactive impulsive symptoms present 2+ settings. D. Evidence Sx. Interfere with or reduce quality of SAO functioning. E. Sx. do not occur exclusively during schizophrenia or other psychotic disorder and not better explained by another mental disorder.


Diagnostic Criteria



Specify whether: 314.01 (F90 0.2) Combined presentation: If both criteria A1 and criteria A2 are met for past 6 months. 314.00 (F90 0.0) Predominantly inattentive presentation: If criteria A1 is met, but criteria A2 is not met for the past 6 months. 314.01 (F90 0.1) Predominantly hyperactive/impulsive presentation: If criteria A2 is met and A1 is not met for the past 6 months. Specify if: In partial remission: Full criteria were previously met, fewer than full criteria have been met for the past 6 months and Sx. still resulting in impairment in SAO functioning. Specify current severity: Mild: Few, if, any symptoms, present and symptoms resulting in no more than minor impairments in SAO functioning. Moderate: Sx. or functional impairment between “mild” and “severe” are present. Severe: Many Sx. in excess of those required to make diagnosis, or several Sx. are particularly severe, are present or the Sx. result in marked impairment in SAO functioning.


Diagnostic Criteria


8/16/2013 Copyright © 2013 Dr. Carlton Munson

48

314.01 Attention-Deficit /Hyperactivity Disorder, Combined presentation,

moderate.

314.00 Attention-Deficit /Hyperactivity Disorder, Predominantly

inattentive presentation, mild, in partial remission.

314.01 Predominantly hyperactive/impulsive presentation, severe.

314.01 Attention-Deficit /Hyperactivity Disorder, Combined presentation,

Severe, in partial remission.

Also note possible use of:

314.01 Other Specified Attention-Deficit/hyperactivity Disorder, child has

symptoms in one setting, home, but no other settings. (See cC)

314.01 Unspecified Attention-Deficit/hyperactivity Disorder due to lack of

information from the school and parent reluctance to have child

medicated.


Sample diagnoses:


A. Difficulties Learning and using academic skills, indicated by presence of 1+ of the following symptoms that have persisted for 6 months despite intervention:

1. Inaccurate or slow and effortful word reading...

2. Difficulty understanding the meaning of what is read...

3. Difficulties with spelling...

4. Difficulties with written expression...

5. Difficulties mastering number sense, number facts, or calculation...

6. Difficulty with mathematical reasoning

B. Affected academic skills are substantially below those expected for the

individual’s chronological age

C. Learning difficulties begin in during school age years....

See DSM-5 for specifier categories (p.67)

314.01 (F90.9)

Specific Learning Disorder

RECEPTIVE EXPRESSIVE LANGUAGE DISORDER (RELD) 76% OF CHILDREN WHO HAVE EXPERIENCED TRAUMA MEET RELD DX. CRITERIA

DSM-5: Motor Disorders & Tic Disorder pp. 74-86


The following motor disorders are included in DSM-5 neurodevelopmental disorders chapter: Motor Disorders Developmental Coordination Disorder Stereotypic Movement Disorder Tic Disorders Tourette’s Disorder Persistent (Chronic) Motor Or Vocal Tic Disorder Provisional Tic Disorder Other Specified Tic Disorder Unspecified Tic Disorder .

DSM-5: Schizophrenia Spectrum and Other Psychotic Disorders


Schizotypal Personality Disorder (New Strategy of dual listing) Delusional Disorder Brief Psychotic Disorder Schizophreniform Disorder Schizophrenia Schizoaffective Disorder Substance/Medication-Induced Psychotic Disorder Psychotic Disorder Due to Another Medical Condition Catatonia Associated With Another Mental Disorder (Catatonia Specifier) Shared Psychotic Disorder deleted? Catatonic Disorder Due to Another Medical Condition Unspecified Catatonia Other Specified Schizophrenia Spectrum and Other Psychotic Disorder Unspecified Schizophrenia Spectrum and Other Psychotic Disorder

DSM-4 subtypes eliminated

Brief Psychotic Disorder

298.8 (F23)

cA. 1+ of 1 must 1, 2, or 3:

1. Delusions,

2. Hallucinations

3. Disorganized speech & behavior

B. For 1 day but less than 1 month


Schizophrenia

295.90 A. Same as Schizophreniform Disorder

B. Failure to achieve expected levels of

functioning

C. 6m+ duration...

Suicide risk in all

Schizophrenia phases Psychotic Ds rare in children. Onset in early

20’s for males late 20a for females. Prev

.7% of population

Prodromal refers to

early

sign/symptom of a

disorder

DSM-5 Schizophrenia Spectrum and Other Psychotic Disorders pp. 87-122

Eliminated b/o low reliability poor validity

Delusional Disorder

297.1 (F22)

A. Delusions for 1+ months

B. cA for Schizophrenia never met


295.40 (F20.81)


1, 2, or 3:

1. Delusions

2. Hallucinations,




B. Episode 1 m but less than 6 m



Brief Psychotic Disorder

298.8 (F23)

A. 1+ of 1 must 1, 2, or 3:

1. Delusions,

2. Hallucinations

3. Disorganized speech & behavior

B. For 1 day but less than 1 month


Schizophrenia

295.90 A. Same as Schizophreniform Disorder

B. Failure to achieve expected levels of

functioning

C. 6m+ duration...

DSM-5 Schizophrenia Spectrum and Other Psychotic Disorders pp. 87-122

Delusional Disorder

297.1 (F22)

A. Delusions for 1+ months

B. cA for Schizophrenia never met

Attenuated Psychosis Syndrome

Proposed criteria

A. 1+ present in attenuated form with relatively intact reality testing and is of severity to warrant clinical attention:

1. Delusions

2. Hallucinations,


B. Symptoms present 1+ week for past month

C. Symptoms begum or worsened in past year

D. Symptoms distressing at level requiring clinical attention

E. Not due to another mental disorder

F. Criteria for psychotic never met See pp. 783-786

Schizophrenia & Other Psychotic Disorders

• 295.70 Schizoaffective Disorder

• 297.1 Delusional Disorder – Delusions for 1 month

• 297.3 Shared Psychotic Disorder (Folie a Deux)

• 293.xx Psychotic Disorder Due to GMC – 293.81 With Delusions

– 293.82 With Hallucinations

• Substance-Induced Psychotic Disorder (Use specific substance coding, see p. 343) – Clarifies distinction of substance-induced psychotic Dsrd and other psychotic w

Dsrd comorbid substance use

• 298.9.9 Psychotic Disorder NOS

Removed nonbizarre distinction

Change to a longitudinal diagnosis

Deleted as separate diagnosis and and making it as specifier for delusional dsrd

NEC

295.70 Schizoaffective disorder, depressive type,

multiple episodes, currently in acute episode,

delusions present & severe (4), negative symptoms

present & moderate (3), depression, present & severe

(4). IP has at least three prior episodes of illness

with OP Tx and 3 hospitalizations. IP is not

currently threat to others, but is threat to self with

suicidal thoughts including consideration of

suicide methods V62.4 Social exclusion & rejection.

Rx. = Hospitalization

295.70 Schizoaffective disorder, depressive type,

multiple episodes, currently in acute episode

IP has at least three prior episodes of illness with OP

Tx and 3 hospitalizations. IP is not currently threat

to others, but is threat to self with suicidal thoughts

including consideration of suicide methods. V62.4

Social exclusion & rejection. Rx. = Hospitalization

Diagnostic Recording Example Schizoaffective Disorder (pp. 105-106)


Nutshell Criteria cA. Schizophrenia cA 2+ 1m delusions, hallucinations Disorganized speech Gross disorganized or catatonic Behavior Negative Sx. With mood episode cA1 (Major depressive or manic) Present cB. Delusion or hallucinations 2+ Weeks absent mood episode cC. Mood Sx. present in active & residual phase cD. Not due to substances

See pp. 743-745

p. 106, “Dx. can be made w/o using this specifier” so the alternative Dx recording is:

See pp. 724

Necessitated by removal of Axis 5 GAF <20

Clinician-Rated Dimensions of Psychosis Symptoms Survey

DSM-5: Bipolar and Related Disorders


Bipolar I Disorder Bipolar II Disorder Cyclothymic Disorder Substance/Medication-Induced Bipolar and Related Disorder Bipolar and Related Disorder Due to Another Medical Condition Other Specified Bipolar and Related Disorder Unspecified Bipolar and Related Disorder

NEW SECTION

A specifier added for anxious distress identifies anxiety symptoms not part of bipolar diagnostic criteria

cA for manic and hypomanic episodes now includes emphasis on changes in activity and energy as well as mood.

Bipolar I Dsrd, mixed episode requiring individual meeting full criteria for both mania & depressive episode removed & specifier, “with mixed features,” added & can be applied to episodes of mania or hypomania when depressive features present

Bipolar I Disorder pp. 123-127

For diagnosis of bipolar I disorder, it is necessary to meet the following criteria for a manic episode. The manic episode may have been preceded by and may be followed by hypomanic or major depressive episodes.

Manic Episode

A. A distinct period of abnormality and persistently elevated, expansive, or irritable mood and abnormally and persistently increased goal directed activity or energy lasting at least 1 week and present most of the day…(or any duration if hospitalization is necessary).

B. During the period of mood disturbance and increased energy activity 3 or more of the following symptoms (4 if the mood is only irritable) are present to a significant degree and represent and noticeable change from usual behavior:

See list of 7 symptoms in DSM 5

C. Mood disturbance is sufficiently severe to cause marked impairment in social or occupational functioning or to necessitate hospitalization to prevent harm to self or others, or there are or psychotic features.

D. the episode is not attributable to the physiological effects of a substance

Major Depressive Episode

A. 5 (or more) of the following symptoms have been present during the same 2-week period and represent a change from previously functioning; at least 1of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure:

See list of 9 symptoms in DSM-5

Specify; With anxious distress With Mixed Features With rapid cycling

With melancholic features With atypical features With mood congruent psychotic features

With peripartum onset With catatonia With mood incongruent psychotic features

With catatonia With seasonal pattern

Bipolar I Disorder

Coding in text section

4 mood episodes in 12 months

Bipolar II Disorder pp. 132-135

For diagnosis of bipolar II disorder, it is necessary to meet the following criteria for a current or past hypomanic episode and the following criteria for a current or past major depressive episode:

Hypomanic Episode

A. A distinct period of abnormality and persistently elevated, expansive, or irritable mood and abnormally and persistently increased goal directed activity or energy lasting at least 4 consecutive days and present most of the day, nearly every day.

B. During the period of mood disturbance and increased energy activity 3 or more of the following symptoms (4 if the mood is only irritable), represent and noticeable change from usual behavior and have been present to a noticeable degree:

See list of 7 symptoms in DSM 5

C. The episode is associated with an unequivocal change in functioning that is uncharacteristic of the individual when not symptomatic

D. The disturbance in mood and the change in functioning are observable by others.

E. The episode is not severe enough to cause marked impairment in social or occupational functioning or to necessitate hospitalization. If there are psychotic features, the episode is by definition manic.

F. The episode is not attributable to the physiological effects of a substance

Major Depressive Episode

A. 5 (or more) of the following symptoms have been present during the same 2-week period and represent a change from previously functioning; at least 1of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure:

See list of 9 symptoms in DSM-5

See specifiers on pp. 134-135 they are slightly different than specifiers for BPI

296.89 (F31.81)

Bipolar I Disorder

DSM-5: Depressive Disorders In DSM-4 Mood Disorders section


Disruptive Mood Dysregulation Disorder Major Depressive Disorder, Single and Recurrent Episodes Persistent Depressive Disorder (Dysthymia) Premenstrual Dysphoric Disorder Substance/Medication-Induced Depressive Disorder Depressive Disorder Due to Another Medical Condition Other Specified Depressive Disorder Unspecified Depressive Disorder

Depression & Affective Disorders Association DRADA

Most likely extensive specifiers survived

A specifier added for anxious distress identifies anxiety symptoms not part of depressive Dsrd diagnostic criteria

Disruptive Mood Dysregulation Disorder pp. 156-160

A. Severe recurrent temper outbursts manifested verbally and or behaviorally toward people or property that are grossly out of proportion in intensity or duration to the situation or provocation.

B. The temper outburst are inconsistent with developmental level.

C. The temper outbursts occur, on average, 3 or more times per week

D. Mood between temper outburst is persistently irritable or angry most of the day nearly every day, and is observable by others.

E. Criteria A-D present for 12+ months with no more than 3 consecutive months without the symptoms

F. Criteria A. and D. are present in at least 2 of 3 settings

G. The diagnosis should not be made for the first time before age 6 or after age 18

H. By history or observation, the age at onset of criterion A-E is before age 10

I. Never been a distinct period lasting more than 1day during which the full symptom criteria, except duration, for a manic or hypomanic episodes have been met. See not in DSM-5 p. 156.

J. Behaviors do not occur exclusively during an episode of major depressive disorder and not explained by another disorder.

K. Symptoms not attributable to physiological effects of substance or other medical/neurological condition

296.99 (F34.8)

Disruptive Mood Dysregulation Disorder

Doing a Major Depressive Disorder Diagnosis


Review Descriptive Text pp. 162-168

Review Diagnostic Criteria pp. 160-161

Select Code From Coding Table Diagnostic Criteria p. 162

Select Coding Recording Procedures p. 162

Select Specifier From Specifier List p. 162

“In recording the name of a Dx. , terms should be listed in following order: major depressive disorder, single or recurrent episode, severity /psychotic/remission specifiers, followed by as many of specifiers w/o codes that apply.”

296.31 major depressive disorder, recurrent episode, Mild, with

anxious distress, mild

Captured from text coding table

1

2

3

4

5

Consult Specifiers for Depressive Disorders pp. 184-188

6

Major Depressive Disorder pp. 160-162

A. 5+ of following symptoms present during the same 2-week period and represent change from previous functioning. At least 1 of the symptoms is either (1) depressed mood or (2) loss of interest in pleasure.

1. Depressed mood most of the day, nearly everyday, as he indicated by subjective report or observation made by others (Note: In children and adolescents can be irritable mood).

2. Markedly diminished interest or pleasure in all or almost all, activities most of the day, nearly every day.

3. Significant weight loss when not dieting or weight gain (note: In children,… failure expected weight gain)

4. Insomnia or hypersomnia nearly every day.

5. Psychomotor agitation or retardation nearly every day.

6. Fatigue or loss of energy nearly every day.

7. Feelings of worthlessness or excessive or inappropriate guilt.

8. Diminished ability to think or concentrate, or indecisiveness, nearly every day.

9. Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide.

B. Symptoms cause clinically significant distress or impairment in social occupational or other important areas of functioning.

C. Episode is not attributable to the physiological effects of the substance or to another medical condition.

D. … not better explained by schizoaffective disorder, schizophrenia, schizophreniform disorder ….

E. There is never been a manic episode or hypomanic episode

Coding in text section

Major Depressive Disorder


Severity/course specifiers Single episode Recurrent episode* Mild (p. 188) 296.21 (F32.0) 296.31 (F. 33.0) Moderate (p. 188) 296.22 (F32.1) 296.32 (F33.1) Severe (p.188) 296.23 (F32.2) 296.33 (F33.2) With psychotic features** (p. 186) 296.24 (F32.3) 296.34 (F33.3) In partial remission (p.188) 296.25 (F32.4) 296.35 (F33.41) In full remission (PA. 188) 296.26 (F32.5) 296.36 (F33.42) Unspecified 296.20 (F32.9) 296.30. (F33.9)

Major Depressive Disorder pp. 160-162

Coding and Recording Procedures The diagnostic codes for major depressive disorder is based on whether this is a single or recurrent episode, current severity, presence of psychotic features, and remission status. Current severity and psychotic features are only indicated if full criteria are currently met for a major depressive episode. Remission specifiers are only indicated if the

full criteria Are not currently met for a major depressive episode. Codes are as follows:

*For an episode to be considered recurrent, there must be an interval of at least 2 consecutive months between separate episodes in which criteria are not met for a major depressive episode. The definitions of the specifiers are found on the indicated pages. **If psychotic features are present code the “with psychotic features” specifier irrespective of episode severity. In recording the name of a diagnosis, terms should be listed in the following order major depressive disorder, single or recurrent episode, severity/psychotic/remission specifier, followed by as many of the following specifiers or without codes that apply to the current episode.( see p.162 for the specifiers list).

See Explanatory section, Specifiers for Depressive Disorders, for depressive disorders

Sample Dx.


DIAGNOSIS

Mr. Jones reported he has never received a mental health diagnosis in the past.

Based on the clinical interview, scales administered and collateral information, the

following diagnoses were made as part of this evaluation.

296.31 major depressive disorder, recurrent episode, Mild, with anxious distress,

mild

312.31Gambling Disorder, episodic, mild

V61.8 high expressed emotion level within family

V60.2 insufficient social insurance or welfare support

Back injury with significant pain associated with ATV accident in 2009.


Major Depressive Disorder Bereavement Note pp. 160-162

Note: In distinguishing grief from a major depressive episode (MDE) it is useful to consider that in grief the predominant affect is feelings of emptiness and loss, while in MDE it is persistent depressed mood and the inability to anticipate happiness or pleasure. The dysphoria and grief is likely to decrease in intensity over days to weeks and occurs in waves, the so-called pains of grief. These waves tend to be associated with lots or reminders of the deceased. The depressed mood of MDE is more persistent and not tied to specific thoughts or preoccupations. The pain of grief may be accompanied by positive emotions and humor that are uncharacteristic of the pervasive unhappiness and misery characteristic of MDE. The thought content associated with grief generally features a preoccupation with thoughts and self esteem is generally preserved whereas in MDE feelings of worthlessness and self loathing are common. If self derogatory ideation is present in grief, it typically involves perceived failings vis-a-vis the deceased (e.g., not visiting frequently enough, not telling the deceased how much he or she was loved). If a bereaved individual thinks about death and dying, such thoughts are generally focused on the deceased and possibly about “mourning” the deceased, whereas in MDE such thoughts are focused on ending one's own life because of feeling worthless, undeserving of life, or unable to cope with the pain of depression. :

Bereavement and Major Depressive Episode Symptoms Compared p.161

• BEREAVEMENT • 1.Feelings of emptiness and loss

• 2.Dysphoria gradual decrease with waves of grief about the loved one

• 3. Grief accompanied by positive emotions and humor about loved one

• 4. Preoccupied thoughts & self-esteem preserved

• 5. Self derogatory of failing deceased while alive

• 6. Death/dying thoughts focused on the deceased and possibly about “mourning” the deceased, whereas in MDE such

• MAJOR DEPRESSIVE EPISODE (MDE) • 1. Inability to anticipate happiness & pleasure

• 2. Pain persistent and not tied to specific thoughts or preoccupations

• 3. Unfocused and pervasive unhappiness and misery

• 4. Feelings of worthlessness in general w/o self esteem

• 5. General self loathing of self w/o cause or explanation

• 6. thoughts are focused on ending one's own life b/o of worthless, undeserving of life, or pain of depression


Persistent Depressive Disorder pp. 168-169

This disorder is consolidation of DSM-IV chronic major depressive disorder and dysthymic disorder.

A. Depressed mood for most of the day, for more days than not, as indicated by subjective account or observation by others, for at least 2 years

B. Presence, while depressed, of 2 or more of the following:

1. Poor appetite or overeating 2. Insomnia or hypersomnia 3. Low energy or fatigue

4. Low self-esteem 5. Poor concentration or difficulty making decisions

6. Feelings of hopelessness.

C. During a 2-year period (1year for children /adolescents), individual has never been without the symptoms in criterion A and B for more than 2 months at a time.

D. Criteria for a major depressive disorder may be continuously present for 2 years

E. There has never been a manic episode, hypomanic episode, or criteria met for cyclothymic disorder

F. Disturbance not better explained by a persistent schizoaffective and disorder, schizophrenia, etc.

G. The symptoms are not attributable to physiological effects of a substance

H. Symptoms cause clinically significant distress…

See specifiers on next slide…

300.4 (F34.1)


Specify if:

With anxious distress With mixed features With melancholic features

With atypical features With pericardium onset With mood congruent psychotic features

With mood incongruent psychotic features

Specify if:

In partial remission In full remission

Specify if:

Early Onset Late onset

Specify If:

With pure dysthymic syndrome With persistent major depressive episode

With intermittent major depressive episodes with current episode

With intermittent major depressive episodes, without current episode

Specify if: current severity:

Mild (p. 188) Moderate (p. 188) Severe (p. 188)

Persistent Depressive Disorder Specifiers pp. 168-169

300.4 (F34.1)


Consult Specifiers for Depressive Disorders pp. 184-188

using dsm-5: a brief summary handout packet #...

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