Mastering DSM-5 and ICD-10 Diagnosis — A Lecture: Introduction (13:34)
Professor Emeritus Margaret Bloom will present this lecture with Dr. Alan Bloom. Learning objectives include: better clinical interviewing, improving differential diagnoses, and practicing difficult case examples. The lecture incorporates a common base of understanding, teaches the four step diagnostic method, and explains how syndromes affect differential diagnoses.
DSM-5 Background (09:28)
Bloom reminds participants to treat the whole person by sharing a contest-winning essay by an individual who suffers from mental illness. Mental illness is difficult to diagnose; health professionals use the Diagnostic and Statistical Manual (DSM)-5 and the International Classification of Diseases (ICD)-10. The DSM-5 contains differential diagnoses, features, cultural differences, gender issues, and co-morbidity.
ICD-10 Background (13:56)
ICD-11 will be incorporated around 2021 and will work better with DSM-5. Mental health workers need to select codes; all mental and behavioral codes will begin with an F. Doctors need to take into account the specific background of their client; ICD codes incorporate symptom level, subtypes, key symptoms, and the course of the illness.
Using the DSM-5 and ICD-10 Together (16:22)
Specifiers further describe a patient's diagnosis; learn how to describe the level of severity in the DSM-5 and ICD-10. Genetic mapping and functional MRI's were not invented when the World Health Organization (WHO) created the ICD-10. Practitioners need to think of diagnoses as a list.
DSM-5 Digital Reference (06:38)
The DSM-5 is designed to work with a free web page that provides updates on content and ICD numbers. Learn how to use online assessment tools to administer to clients; Bloom does not recommend the personality inventories.
Diagnosis: Introduction (21:47)
Diagnosis predicts a course of treatment and provides future expectations of client improvement; improving diagnosis is moral, professional, and a public health imperative. The four steps to making an accurate diagnosis include gathering client database, identifying syndromes, differential diagnosis, and creating a diagnosis list. Ask the client to bring a complete list of current medications and have them fill out a crosscut level one symptom measure.
Michelle Adams: Gathering Database (15:50)
Bloom provides a case study of a woman who suffers from extreme back pain; she asks participants to break into pairs and identify one significant symptom in cognition, affect, behavior, and physiology. Her symptoms include paranoia, mistrust, tearful, limp handshake, wheelchair bound, and pain.
Before a Break (06:14)
Spend thirty minutes getting an understanding of the whole client. Mini-mental status exams only notice gross impairment; Bloom recommends St. Louis University Mental Status Exam (SLUMS) or Montreal Cognitive Assessment Tests (MoCA).
Presenting Symptoms Approach (11:06)
Therapists should begin with the onset and progression of concerns, personal development, and social background. Family history and personal mental health history contributes to making a diagnosis. Clients avoid discussing their sexual function, odd ideas, gender bias and cultural bias; give them the cultural formation interview outlined in the DSM-5.
What has Not Been Covered? (08:35)
In phase three, plan a focused investigation of DSM-5 syndromes that did not come up in the course of conversation. The gathering client database stage is complete when the therapist can cluster observations and symptoms into syndromes. An error occurs when a prior diagnosis or what the client says is their diagnosis limits exploration.
Michelle Adams: More Detailed Information (12:03)
Adams stays up late, wakes up multiple times, isolates herself and self-medicates. Participants break into pairs to discuss the new facts and add their findings to the behavioral observation sheet.
Michelle Adams: Transition Step (12:06)
Bloom explains how to look for syndromes from the behavioral observation sheet; Adams' syndromes include daily substance use, depression, and focused thoughts on pain. Consider the differential diagnosis before diagnosing the client; think of at least five alternative diagnoses and include medical disorders.
Michelle Adams: Differential Diagnosis (11:48)
Participants break into teams to decide on five potential diagnoses and report their findings. These include neurological issues, cannabis use disorder, opioid-induced depression, adjustment disorder with depressed mood, and major depressive disorder.
Michelle Adams: Narrow Our Thinking (13:45)
Participants look at the potential diagnoses and remove ones where the client does not meet the criteria. Dr. Alan Bloom explains why opioid use disorder is an inaccurate diagnosis; tolerance does not count in this case.
Michelle Adams: Making Final List (06:45)
The diagnose options are somatic system disorder with predominant pain, major depressive disorder moderate, and cannabis use disorder provisional. The DSM-5 allows mental health workers to make a diagnosis after an initial visit. Co-morbidity means the client has more than one illness simultaneously that interacts.
Depression is the presence of a sad, hopeless, or irritable mood accompanied by somatic and cognitive changes that alters the way a person functions. Level two diagnosis screens for the intensity of specific symptoms. Participants listen to a mini-case study of Marilyn Wilson and diagnose her syndrome as major depressive disorder; Bloom advocates not diagnosing patients for an adjustment disorder if the client meets the criteria for another disorder.
Differential Diagnosis: Depression (17:59)
Frequently, substance abuse and medical conditions can trigger depression. Mental disorders where the dominant symptom is depression include disruptive mood disorder, major depressive disorder, persistent depressive disorder, premenstrual dysphoric disorder, bipolar 1, bipolar 2, and trauma and stressor disorders. Each group of disorders has a hallmark disorder therapists should rule out first.
Joe Jenson: Case Study (18:41)
DSM-5 eliminated axis, the Global Assessment of Functioning, diagnosis deferred, and Not Otherwise Specified (NOS). Jenson becomes suicidal after thinking about turning himself in for embezzling client money; he demonstrates poor judgement and insight on the mental status exam. Participants complete an observation sheet and identify syndromes.
Joe Jenson: Differential Diagnosis (16:42)
Participants brainstorm differential diagnoses including Attention Deficit Hyperactivity Disorder, Major Depressive Disorder, Generalized Anxiety Disorder, Insomnia, Gambling Disorder, bipolar 2 disorder, and conduct disorder. Bloom explains why all should be eliminated except MDD- provisional as the primary diagnosis and its specifiers.
Anxiety Symptoms (10:14)
Clients who exhibit anxiety symptoms have a higher baseline threshold. Symptoms include: feeling nervous, anxious, worried, frightened, and tense. Substance abuse and medical conditions can induce an independent anxiety disorder.
Anxiety Syndromes (20:00)
Mental disorders where the dominant syndrome is anxiety include: anxiety disorders, obsessive compulsive and related disorders, trauma and stressor-related disorders, and somatic symptom disorders. Eliminate disorder options by examining whether the client has panic attacks, repeating behaviors, a traumatic event, or generalized anxiety. People with GAD tell therapists their worries and then repeat them.
Hallmark Condition—GAD (05:34)
Therapists should eliminate GAD before looking at other disorders. For panic disorders, clients need to have recurrent unexpected panic attacks followed by a month of anxiety. In the DSM-5, there is a section describing co-morbidity after the differential diagnosis section of each disorder.
Bob Gray: Case Study (10:43)
Bloom describes a case study of abnormal thinking and cognitive impairment syndromes. Participants analyze the information and decide potential diagnoses. These include: Schizophrenia, substance abuse, dissociative disorder, medical condition, psychosis, neurocognitive disorder, and delirium. Two processes that can be responsible for abnormal cognitive functioning are psychosis and cognitive deficit.
Substances like alcohol, cannabis, inhalants, stimulants, anti-anxiety medication, anticholinergic agents, anticonvulsants, antihistamines, hallucinogens, cardiovascular medications, and NSAIDs can induce psychosis. Adolescent drug use can trigger Schizophrenia. Therapists should eliminate the schizophrenia spectrum before looking at other disorders.
Brandon: Diagnostic Challenge (15:34)
Brandon's mother brings him to a therapist for frequent temper tantrums and declining school performance. Participants brainstorm potential diagnoses such as autism spectrum disorder, intellectual disability, social pragmatic communication disorder, and childhood onset schizophrenia. Bloom reviews mild and major disorders attributed to cognitive impairment.
Cognitive Impairment (13:12)
Symptoms include: selective mutism, intellectual disabilities, and hallucination. Traumatic brain injury, HIV, Prion disease, Alzheimer's disease, Lewy Body disease, Parkinson's disease, and Huntington's disease need to be diagnosed by a medical doctor; think about major neurocognitive disorders last. Participants discuss a follow-up on Gray's case study and debate an updated diagnosis.
Demetrius: Diagnostic Challenge (11:15)
Participants debate whether Demetrius, a tenth grader obsessed with his nose, is afflicted with an adjustment disorder, social anxiety disorder, body dysmorphic disorder, or persistent depressive disorder. Consider repetitive thinking and behavior syndromes when obsessions get in the way of normal activities. Streptococcal infections such as scarlet and rheumatic fever can mimic Obsessive Compulsive Disorder (OCD).
Differential Diagnoses (10:00)
Obsessive disorders differ from depression and anxiety disorders. Deriving pleasure is seen as an addiction rather than part of the category. Disruptive behavior violates the rights of others or incites conflict with societal norms.
Disruptive Behavior (12:04)
Traumatic Brain Injury, partial epilepsy, and neoplasms could create symptoms that mimic disruptive behavior. Bloom recommends "Disruptive Behavior Disorders: Evidence-Based Practice for Assessment and Intervention" by Frank M. Gresham. Co-morbidity can occur with anxiety disorders, depressive disorders, borderline personality disorders, ADHD, and other disruptive behaviors.
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