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20 Other Conditions That May Be a Focus of Clinical Attention

V-codes and z-codes

V-codes and Z-codes are conditions that may be the focus of clinical attention but are not considered mental disorders. They correspond to International Classification of Diseases, Ninth Revision, Clinical Modification ICD-9-CM (V-codes) and International Classification of Diseases, Tenth Revision, Clinical Modification ICD-10-CM (Z-codes that become effective in 2015. In most instances, third-party payers do not cover charges for delivering services to an individual if the diagnosis is solely a V- or Z-code alone. If the V- or Z-code is not the primary diagnosis then it should be documented following the primary diagnosis. In addition, when writing the psychosocial assessment any psychosocial and cultural factors that might impact the client's diagnosis should be documented. The psychosocial stressors reflected in these diagnoses are widespread across all classes and cultures and have been shown to impact all aspects of an individual's life from the physical and psychological to the financial. Furthermore, these conditions have been shown to significantly impact the diagnosis and outcome for a multitude of mental and medical disorders. V- and Z-codes are grouped into numerous categories including: relational problems, problems related to abuse/neglect, educational and occupational problems, housing and economic problems, problems related to the social environment, problems related to the legal system, other counseling services, other psychosocial, personal and environmental problems, and problems of personal history ( APA, 2013 ).

   Broadly speaking, the category “Relational Problems” describes interactional problems between family members (e.g., parent/caregiver-child) or partners that result in significant impairment of family functioning or development of symptoms in the distressed individual, spouses, siblings, or other family members. Relational problems are broken down into two categories, Problems Related to Family Upbringing and Other Problems Related to Primary Support Group. For example, in the first category a Parent-Child Relational Problem involves interactional problems between one or both parents and a child that lead to dysfunction in behavioral (e.g., inadequate protection, overprotection), cognitive (e.g., antagonism toward or blaming of the other) or affective (e.g., feeling sad and angry) realms. Here, the critical factor is the quality of the parent-child relationship or when the dysfunction in this relationship is impacting the course and outcome of a psychological or medical condition. Other examples include Sibling Relational Problem, Upbringing Away from Parents, and Child Affected by Parental Relationship Distress. Similarly, family relationships and interactional patterns leading to problems related to primary support group include Partner Relational Problem, Disruption of Family by Separation/Divorce, High Expressed Emotion Level within Family and Uncomplicated Bereavement. For example, Disruption of Family by Separation or Divorce should be used when intimate partners/spouses are living separately due to relationship problems or pending divorce ( APA, 2013 ).

   The V-codes subsumed under the broad category of “Problems Related to Abuse or Neglect” are broken down into two categories, one for children and the other for adults. The Child Neglect category includes the following: Physical Abuse of Child; Sexual Abuse of Child; Neglect of Child, and Child Psychological Abuse. Under Adult Abuse or Neglect the categories include Spouse/Partner Physical Abuse; Spouse/Partner Sexual Abuse; Spouse/Partner Neglect; Spouse/ Partner Psychological Abuse; and Abuse of Adult (non-spouse/partner), which includes physical, sexual, and psychological abuse of an adult. The V-codes are used when the focus of attention is on the perpetrator of child or adult abuse and/or neglect and are not due to a mental disorder. If the focus of the attention is on the victim/survivor of the abuse, the codes 999.5 for children with the 5th digit tied to the type of abuse (e.g., physical 4, sexual 3, psychological 1) and 995.8 for adults with the 5th digit tied to the type of abuse (e.g., physical 1, sexual 3, psychological 2) are used. Also, whether this is an initial or subsequent encounter with the client, and whether the abuse is confirmed or suspected is coded in the ICD-10-CM in T codes in the 7th digit. A past history of abuse/ neglect in the client is coded separately ( APA, 2013 ).

   The remaining broad categories of V-codes include Educational (i.e., problems related to literacy) and Occupational Problems (e.g., Problems related to current Military Deployment status); Housing Problems, Economic Problems (e.g., extreme poverty); Other Problems Related to the Social Environment (e.g., Acculturation Problem and Phase of Life Problem); Problems with the Legal System (e.g., imprisonment or incarceration); Other Counseling and Medical Advice (e.g., sex counseling); Problems Related to Other Psychosocial, Personal, and Environmental Circumstances (e.g., Religious or Spiritual Problem, Victim of Terrorism, Exposure to War); Other Circumstances of Personal History (e.g., Adult or Child Antisocial Behavior); Problems Related to Medical Access and Other Health Care; and Non-adherence to Medical Treatment (e.g., Malingering, Borderline Intellectual Functioning) ( APA, 2013 ).

Assessment

The psychosocial assessment that is most useful for evaluation of V-codes and other psychosocial and environmental stressors can be found at the end of  Chapter 1 . As practitioners a biopsychosocial and spiritual framework should be the guiding factor when making diagnosis and treatment decisions, utilizing a strengths-based and person-centered perspective.

Cultural Considerations

   Stressors that may affect people adversely differ among ethnic groups and cultures. For example, an event that might be perceived and labeled as stressful to an Anglo-American individual may not be considered stressful to an individual living in South America, Japan, China, or the Congo. In addition, how individuals cope with stress is largely defined by the culture and society in which they live. For example, in the United States, families and individuals consider divorce to be a stressful life transition that may require assistance from professionals. In other cultures, leaving a partner may involve only a verbal dissolution of the relationship and change of residence.

   What constitutes a psychosocial stressor in the United States and Western European countries may not be considered stressful or distressful in other cultures. It is important to be sensitive to cultural differences in regard to psychosocial well-being and not label something as a stressor when it may not be considered so in other cultures. By the same token, practitioners need to be cognizant of their own cultural biases and stereotypical ideas. Either minimizing or maximizing symptoms because of a person's cultural background alone could result in an inappropriate psychosocial assessment.

   A large body of literature exists that examines the causes of stress, its impact on individuals' lives, coping strategies, and interventions designed to reduce the negative effects of stress on individuals' mental health. In recent years, researchers have turned their attention to the relationship between sociocultural factors and identifiable stressors experienced by people of different ethnic and social backgrounds in the United States and other countries worldwide. The relationship between stress and socioeconomic status has been examined in relation to behavior disorders in children ( Fergusson, Boden, & Horwood, 2013 ). A comparison of social stressors in lesbian, gay, and bisexual populations and heterosexuals has been studied ( Meyer, 2003 ). The stressors related to being a gay, lesbian, and bisexual youth have been shown to increase the risk and incidence of suicidal behavior ( Hatzenbuehler, 2011 ). The stress and strain related to being a minority group member in a country (termed “acculturative stress”) are delineated in studies of Latino adults ( Torres, Driscoll, & Voell, 2012 ), elderly Asian immigrants ( Mui & Kang, 2006 ), and in Hispanic immigrant women in marital therapy ( Negy, Hammons, Reig-Ferrer, & Carper, 2010 )

   A widely researched model of stress and coping developed by Lazarus and Folkman ( 1984 ) suggests that stressors may impact individuals in a variety of ways depending on how they cognitively process the stressful event. First, the individual makes a “primary appraisal” of the stressful event (What has just happened? Am I in danger? How has this stressor affected me?). Second, the individual makes a “secondary appraisal” of the event (What can I do about this stressor? How will I cope with this event?). Third, the individual uses available coping skills (e.g., avoidance, problem-solving, and emotion-focused skills) to attempt to ameliorate the effects of the stressor. Finally, the individual adapts to the stressor, which results in positive, negative, or neutral consequences.

   Slavin, Rainer, McCreary, and Gowda ( 1991 ) as well as Kuo ( 2011 ) proposed the addition of a multicultural component to Lazarus and Folkman's model. Since the perception of stress is a culturally bound issue, it is important to take into account the cultural experiences of the individual in assessing the impact of stress on the individual. The authors suggest that, in addition to assessing the seriousness of the stressor, the practitioner should be aware of the stressor as related to minority status, potential discrimination, disadvantaged socioeconomic status, and specific cultural customs of the individual experiencing the stress-related event. Second, in regard to the primary appraisal of the event, the counselor should take into consideration the person's or family's cultural definition of the event and the person's or family's cultural frame of reference for understanding the event. Third, from a multicultural viewpoint, assessment of secondary appraisal options (coping mechanisms) should include the individual's culturally bound behavioral options, role definitions, ethnic identity, and definition of family, group, and social network. Attempts to cope with the stressful event should include consideration of the individual's cultural rituals, cultural and mainstream sanctions against certain coping strategies, and biculturation (the incorporation of both minority and mainstream coping skills). Finally, the outcomes of coping strategies should be assessed according to the person's cultural framework and norms for the cultural group. Each of these steps in the process can be added to the basic model proposed by Lazarus and Folkman ( 1984 ) when considering the multicultural factors related to stressful events and situations.

Social Support Systems

The impact of V- and Z- Codes on an individual's social support system can vary dramatically. A primary consideration in assessing the impact is the degree to which one or more members are also being affected by the situation. A person who is not directly affected may be more willing to extend support. At the same time, this less involved individual may find it harder to really empathize with the client's situation. Clearly, when the issues are relational, the possibility of continued (and even escalating) conflict can result in other members of the social support systems withdrawing or aligning themselves with one of the parties.

   Although it was common in the 1980s for insurance companies to reimburse practitioners for treatment of V-codes, the managed-care shift in the new millennium marks the need for creative interventions and solutions for these categories of psychosocial functioning. Support groups can provide critical resources in situations where more formal treatment is not available (or desired). Whether sponsored independently or as part of church-related or nonprofit organizations, most of the resources are organized around a particular concern. For example, support groups dealing with individuals with such difficulties as divorce recovery, relocation, empty-nest syndrome, school-based social networks, chronic illness recovery/caregiving groups, employee assistance programs, relationship/sexual support groups, single persons' support networks, parent education programs, and anger-management group interventions are widely available. There is a unique value in sharing experiences related to stressful situations with mutual-aid support groups. Such safe and confidential environments reduce shame, stigma, guilt, burden, and fear among members. Often, a combination of a few individual therapy sessions along with ongoing support groups can lead to satisfactory outcomes for the individual with a V-code diagnosis.

   Other community resources that might prove useful in certain situations may include recreation or after-school programs for youth, psychoeducational programs or workshops provided by nonprofit agencies, holistic approaches to health (e.g., yoga, meditation groups, or exercise programs), advocacy and service opportunities, meals-on-wheels, mentoring programs, and senior centers.

Case 20.1

Since V-codes are commonly associated with most disorders, cases throughout this text should be considered for their V-code designation. For example, the majority of cases in this workbook contain V-codes that need to be identified. As stated earlier, a thorough assessment as outlined in Chapter 1 includes a focus on the psychosocial and cultural stressors in the person's environment. The practitioner begins the assessment process by talking with the client about any potential psychosocial issues Case 20.1 that may be creating barriers in the person's daily and overall functioning. Only after gathering a comprehensive picture of the client's functioning in the biopsychosocial and spiritual realms will the practitioner be able to make an appropriate diagnosis. Therefore, practice in uncovering the psychosocial issues confronting clients is an integral part of the conceptualization for each of the cases in this text. Please review the cases in  Chapter 21  for more examples of assessing V- and Z-codes.

References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: Author.

Fergusson, D. M., Boden, J. M., & Horwood, L. (2013). Childhood self-control and adult outcomes: Results from a 30-year longitudinal study. Journal of the American Academy of Child & Adolescent Psychiatry, 52(7), 709–717. doi:10.1016/j.jaac.2013.04.008

Hatzenbuehler, M. L. (2011). The social environment and suicide attempts in lesbian, gay and bisexual youth. Pediatrics, 127, 896–903.

Kuo, B. C. H. (2011). Culture’s consequences on coping: Theories, evidences, and dimensionalities. Journal of Cross-Cultural Psychology, 42(6), 1084–1100.

Lazarus, R. S., & Folkman, S. (1984). Stress, appraisal, and coping. New York: Springer.

Meyer, I. H. (2003). Prejudice, social stress, and mental health in lesbian, gay, and bisexual populations: Conceptual issues and research evidence. Psychological Bulletin, 129(5), 674–697.

Mui, A. C., & Kang, S. Y. (2006). Acculturation stress and depression among Asian immigrant elders. Social Work, 51, 243–255.

Negy, C., Hammons, M. E., Reig-Ferrer, A., & Carper, T. M. (2010). The importance of addressing acculturative stress in marital therapy with Hispanic immigrant women. International Journal of Clinical Health and Psychology, 10(1), 5–21. Retrieved March 14, 2014, from  http://www.redalyc.org/pdf/337/33712017001.pdf

Slavin, L. A., Rainer, K. L., McCreary, M. L., & Gowda, K. K. (1991). Toward a multicultural model of the stress process. Journal of Counseling and Development, 70, 156–163.

Torres, L., Driscoll, M. S., & Voell, M. (2012). Discrimination, acculturation, acculturative stress, and Latino psychological distress: A moderated mediational model. Cultural Diversity & Ethnic Minority Psychology, 18(1), 17–25. Retrieved March 14, 2014, from  http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3340887/