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CHAPTER 17: Using the DSM* Introduction The Diagnostic and Statistical Manual of Mental Disorders (DSM; APA, 2013) is a collection of diagnoses of mental disorders accompanied by the typical behaviors and symptoms you might see in a particular diagnosis. The idea behind this manual is to provide a common set of criteria for each mental disorder so that practitioners will be more likely to give the same diagnosis to people with similar symptoms and behaviors regardless of where they are being treated or who is seeing them. Thus the manual provides a common language that everyone in the helping professions can use in diagnosing individuals, discussing their symptoms and issues, and planning their care. Students may want to use the Quick Reference to the Diagnostic Criteria from DSM 5, a smaller book with the basic information sufficient for students to work with this material. Many students wonder why they need to learn about the Diagnostic and Statistical Manual of Mental Disorders (DSM; APA, 2013) when it appears to be a tool used exclusively by mental health practitioners. Actually the DSM is a valuable tool you will use in many different settings. Although the majority of people receiving services in the broad human service system do not have mental disorders, the DSM sometimes helps to define what the client is experiencing and what that person needs. For instance, people who come to agencies as victims of abuse or assault often suffer from posttraumatic stress disorder. Workers in agencies dealing with the problems of growing older will encounter people who have dementia or cognitive symptoms that resulted from a stroke or other long-term, debilitating illness. Those who work with children in a variety of settings will encounter children who have learning difficulties or behavior issues. Familiarity with the language and process of the DSM enables you to participate in planning for the client more competently. Is DSM Only a Mental Health Tool? Today, with deinstitutionalization of the mentally ill, those with mental disorders come for services at many social service agencies, and more often than in the past, we see people who have more than one problem. You might be working at a shelter for victims of domestic violence and do an intake for a woman who also suffers from bipolar disorder. You might find that a person has both a mental disorder and an addiction to heroine. People who seek our help no longer fit into neat boxes with no overlapping problems. For that reason, it is important to be familiar with this system. The DSM is the language of insurance companies and other funding sources with regard to behavioral treatments such as drug and alcohol treatment or treatment for those with mental health problems, addiction issues, or intellectual disabilities. In addition, the DSM contains information about situations and problems that may not constitute a mental disorder but may be the focus of attention in a clinical setting. Many of these disorders come to the attention of social service agencies not equipped to treat them. You will need good information to make sound referrals. Your ability to understand the DSM and your acquaintance with the various classifications of mental disorders will enable you to be more conversant with others in the field and to recognize a mental disorder when you encounter one. Cautions Having spelled out why the DSM is important in human service practice, it is equally important to understand that most people who come for services in social service agencies are not suffering from a mental disorder. The DSM cannot be used to help you understand every client. If you try to give a psychiatric label to everyone you see, you will unnecessarily burden individuals who are well but are grappling with life transitions and disruptions such as unemployment or grief. Labeling people can have lifelong consequences for them. In addition, these labels can make a person seem much sicker than they really are. Diagnosing calls for caution. Further, the DSM comes from the medical model. That is, the model suggests that individuals are labeled with an illness and are then treated as sick. This is a view of the client that can cause you to lose sight of the fact that the person has strengths and successes. Although a diagnosis is useful to clinicians in providing treatment, to case managers it can have the subtle effect of diminishing the client as a whole person. Moreover, people have a right to know what their diagnosis is. This is part of informed consent. They also have the right to know who else will see the diagnosis: The insurance company? The companies and businesses where clients work? Knowing who will see the diagnosis is also part of informed consent. Finally, be cautious about diagnoses that do not seem to take into account what might be normal for people of a particular culture. There is always the danger that we judge behavior and problems according to what is normal in the dominant culture or in our own culture and forget to consider the culture from which the person came. The agency where you work will have policies and guidelines about using the DSM. Many agencies do not rely on the manual at all. Agencies that do rely on the manual generally are required to give diagnoses in order to be reimbursed for services. When you must rely on the DSM, be very careful not to categorize people or to allow their diagnoses to color your complete understanding of them as individuals. Who Makes the Diagnosis? You are not studying the DSM to make final diagnoses. The responsibility for overseeing how people are diagnosed generally lies with a physician or a senior staff person, usually with a PhD. Nevertheless, the DSM contains a language that is universally understood. Your experience with this language and with the mental disorders in the manual will facilitate your communication and reports to those responsible for giving the diagnoses. It could happen, on a rare occasion, that a harried emergency room physician with a waiting room filled with medical emergencies would turn to the emergency worker from a social service agency and ask that the worker give a provisional diagnosis to facilitate admission to the hospital (where the diagnosis will be reevaluated in less pressing circumstances). Further, it is becoming common practice for insurance companies and other payers to require a diagnosis at the completion of intake. Case managers responsible for intakes may need to give a provisional diagnosis at the time of the intake so the agency can be reimbursed. These diagnoses may be changed later by senior professionals, but case managers need to be familiar with the common diagnoses seen in their agencies. For this reason, the exercises at the end of this chapter are for you to become acquainted with the DSM. The discussions you and your classmates have will help you to explore the manual and learn more about it. It is important for you to keep in mind that additional clinical information is always needed to help round out the picture and make the best diagnosis and treatment plan. Much of that additional information in many settings will come from your social histories and notes. Portions of this chapter are based on the work of Anthony L. LaBruzza (1994), whose book Using DSM-IV: A Clinician’s Guide to Psychiatric Diagnosis, gives excellent background on how DSMs have evolved over the years until the DSM-IV. Background Information Until the 1600s, physicians used a patient’s horoscope to diagnose mental disorders. Medieval physicians looked at the four humors to account for differences in human personality and temperament. The humor that predominated accounted for the patient’s disposition—with blood accounting for a happy temperament; choler contributing to a fiery, competitive temperament; phlegm resulting in a cold, delicate disposition; and bile causing melancholy. Psychiatry Attempts to Classify Mental Disorders In colonial times, most individuals with mental illness were managed at home by their families. Many were abused and exploited or were confined to workhouses and almshouses in which varying theories about the reasons for their illnesses caused harsh treatment in most cases. Between 1800 and 1860, a number of people became concerned with placing those with mental illness in “asylums” in which a more humane approach and more respect for the patient would be the rule. Such treatment was referred to as “moral treatment” (LaBruzza, 1994). Dorothea Dix was active in this movement; and when her attempts to start a federal asylum program failed, she became instrumental in founding state hospitals in Pennsylvania and New Jersey, which bear her mark to this day. Mental illness was little understood; and in the census of 1840, people were classified as either sane or “idiocy/insanity.” The shift from the asylum to treatment, research, and education occurred in the late 1800s and early 1900s. At that time, research was beginning to provide a clearer picture of the anatomy of the brain, and the diagnostic system became more refined. By 1880, there were seven categories of mental disorder. Diagnosis continued to be the focus of research. Wilhelm Greisinger (1817–1868) in Germany looked at the mental disorders as diseases of the brain, an organic view. Another German, Emil Kraepelin (1855–1926), looked at syndromes or collections of symptoms and made statistical records of the symptoms patients exhibited, the course of their diseases, and the outcomes. His goal was to be able to accurately predict the outcome of a disorder for a patient based on certain combinations of symptoms. He used a behavioral and descriptive approach that made it easier for others to use his concepts. Others also contributed their views of the brain and nervous system in creating a diagnostic classification system. Most influential in the United States was a Swiss-born psychiatrist, Adolph Meyer (1866–1950). Mental disorder, in his view, was a response to psychosocial stressors. This view was widely accepted because individuals drafted into the military during both world wars appeared to break down under the stress of combat. Had his view continued to be influential, mental illness would have been seen today as an adaptive response. Instead, mental disorders gradually came to be seen as discrete psychiatric diseases. In the 1920s, the American Psychiatric Association (APA) decided to find a way to standardize the medical terminology psychiatrists used. A national conference in 1928 looked at how diseases were named. The classification system that emerged focused only on the most severe forms of mental disorders, those that would most likely cause the patient to be institutionalized. The classification became broader when World War II veterans returned with less severe disorders. In the 1940s, there were 10 types of psychoses, 9 neuroses, and 7 disorders related to behavior, intelligence, and character. In 1952, the APA published the first Diagnostic and Statistical Manual. In an attempt to keep up with international changes in the way mental disorders were classified, in 1965 the APA revised the original manual and brought out the second edition, DSM-II. This manual seemed to return to the Kraepelian descriptive model for diagnosis. Those who did the revisions eliminated terms that implied a particular theory of etiology (or cause) for the disorder. This successfully did away with Meyer’s idea of seeing mental disorders as a response to stress. Nevertheless, psychoanalytic terminology remained because psychoanalysis was still quite popular and influential among psychiatrists. The 1950s, 1960s, and 1970s At this point, the manual was still quite unreliable. Psychiatrists would give different diagnoses to the same symptoms, making replication of research impossible. Anthony LaBruzza (1994) stated, “[T]he possibility that two psychiatrists would agree on the same diagnosis in the 1950s and 1960s was nearly random.” In the 1960s, psychiatry was out of favor with the public as famous court cases pitted psychiatrists against each other in what appeared to be a nebulous theoretical system, and motion pictures, such as One Flew Over the Cuckoo’s Nest, introduced moviegoers to the possibility that institutions were punitive and that the staff in such places were not much healthier than the patients. This was a time when all authority was challenged, and a number of books challenged the authority of psychiatry, particularly Thomas Szasz’s book, The Myth of Mental Illness. Many saw psychiatry and psychiatric diagnoses as stigmatizing and as wielding undue social control. In addition, insurance companies began to cut back on the amount of psychiatric care for which they were willing to pay, in part because the diagnosis of mental illness was unreliable and there seemed to be no consensus on the best treatments. No studies had been conducted to determine which illness responded to which treatment. Psychiatry Becomes More Medical The third edition of the manual, DSM-III, came out in 1980. Every edition of the manual since DSM-III has been an expansion or refinement of that document. This manual relied on a more medical, research-oriented model of disease, and it also relied more heavily on the Kraepelian use of descriptions. In addition, it was no longer slanted toward psychoanalytic descriptions or causes; in fact, causes were, for the most part, left to research to determine. Responding to the concerns voiced about psychiatry, the third edition of the manual contained 14 discrete and specific mental disorders with very explicit descriptions. These descriptions had operational criteria that allowed them to be measured statistically. All references to unconscious motives were removed, and the clinician based the diagnosis strictly on what could be seen. The changes in the third edition of the manual could be summarized as follows: 1. There was every attempt to use clear English, and not mental health scientific jargon. 2. Disorders were labeled, and not people. 3. Patient was dropped in favor of words like person or individual. 4. The manual was tested for reliability for the first time by clinicians using it in the field. 5. A multiaxial system was adopted to give a fuller diagnostic picture of the person. 6. Decision trees were included to help the physician rule out similar disorders and narrow the diagnostic choice to one. 7. The words disease and illness were dropped in favor of the word disorder. 8. All the pet theories about causes of disorders were eliminated. 9. Each disorder had a working definition that contained operational criteria (criteria that could be observed and measured). After publication of DSM-III, psychiatrists were far more likely to make the same diagnosis for the same set of symptoms. This enabled research to be done more effectively, particularly field trials of medications that treated specific psychiatric symptoms. In other words, it became more likely that practitioners would all agree on the diagnosis for certain clusters of symptoms, regardless of where they were practicing. If everyone was seeing the same thing when they looked at a cluster of symptoms, then it was possible to treat that cluster of symptoms in various ways to determine the best approach to alleviating the symptoms. Now clinicians could communicate reliably in a common language about diagnoses. This common language facilitated good research. Pharmaceutical companies supported this research for products they developed for these specific disorders. From DSM-III to DSM-IV With all the field testing that took place as a result of DSM-III, revisions were inevitable. Thus, in 1987, DSM-III-R (or revised) came out; this edition included 27 new categories and revisions to some older diagnoses. The number of categories went from 265 to 292. An appendix contained further categories requiring additional research. The DSM-III-R made another important shift, moving from the monothetic diagnosis to the polythetic diagnosis. The old DSMs used the monothetic diagnosis. They gave a series of symptoms that constituted a disorder, and unless all of them were present you could not use the diagnosis. This meant that a diagnosis was only as useful as the least useful item in the series of symptoms. In a polythetic approach, the series of symptoms is given, and the patient must have several, but not all, of them. This has improved the reliability of diagnoses. Another important shift was the move to give a patient more than one diagnosis if the patient met the criteria for more than one. Previously the clinician had to choose the diagnosis that was most obvious or urgent. Other diagnoses that coexisted with the first diagnosis or were, perhaps, part of a larger clinical problem were not mentioned. This narrowed the clinical picture of the patient. Now a fuller clinical picture was possible. The DSM-III-R also lined up with the new version of International Classification of Diseases (ICD-10), which made it easier for American clinicians to talk to clinicians internationally. The DSM-IV contained as few changes as possible, and those changes were based on good research with empirical results. To establish the empirical basis for changes, the work committees (those committees working on various classifications) systematically reviewed the literature for different diagnostic categories, reanalyzed previous data, and conducted field trials to make certain the diagnoses were reliable in many different settings and in many different types of clinical work. The DSM-IV also did away with all sexist language. The DSM-IV-TR The DSM-IV-TR (or text revision) refined the diagnostic categories still further and brought new information to the diagnostic process. The following are some of the features you would find in this manual: 1. Every disorder has a name, numerical code, the criteria needed to give the diagnosis, the subtypes of the disorder, the specifiers (modifiers), recording procedures, and examples that illustrate the disorder. 2. Associated features and associated disorders may include such items as clinical features that may be present but are not always seen in the disorder; disorders that precede, often co-occur, or generally follow the disorder in question; typical laboratory findings; physical signs and symptoms; and typical medical conditions. 3. The typical age at onset and any cultural and gender-related information. 4. The prevalence of the disorder, the incidence, and the risk. 5. A description of the typical clinical course of the disorder. 6. Any complications that might be applicable to the disorder. 7. Typical predisposing factors discovered through research. 8. Family patterns if there are genetic or suspected genetic components to the disease. 9. Differential diagnoses or disorders that share similar symptoms and information on how to distinguish among similar disorders (LaBruzza, 1994, pp. 57–58). The Transition from DSM-IV-TR to DSM 5. A new manual, DSM 5, was developed and came out in 2013, but it will take some time for the DSM 5 to be used universally. Insurance companies, social service agencies, medical records, and physicians’ offices will have to find ways to accommodate the new system. For that reason, you are likely to see DSM-IV-TR diagnoses in client charts and on other forms for some time. Figure 17.1 shows you how the diagnosis was made using DSM-IV-TR. The individual received a diagnosis along five separate dimensions, referred to as axes. Each axis gives different information about the person. This was thought to provide a more accurate clinical picture than would be possible with a single axis. The diagnosis was called a multiaxial diagnosis. You will find that the diagnoses entered on axis I and II will have both names and numbers, the numbers being useful for insurance and billing purposes. Each axis served a different purpose. FIGURE 17.1: Dimensions used in multiaxial diagnosis Figure 17.1 shows what information is coded on each axis. The clinical disorders were all listed on Axis I or II. Every disorder has a name, numerical code, the criteria needed to give the diagnosis, the subtypes of the disorder, the specifiers (modifiers), recording procedures, and examples that illustrate the disorder. As you practice you are very likely to find individuals whose diagnosis is written according to the DSM-IV-TR because the new DSM 5 has only recently been published. Therefore, specific information on DSM-IV-TR can be found in the appendix and you can use this to better understand diagnoses you come across that are written according to this former system. DSM 5, the Current Diagnostic Manual When you begin practice, the DSM 5 will be the diagnostic manual that is in current use. Initially this material may seem daunting. Keep in mind, however, that this is a manual written for clinicians and not for case managers. Whereas previously a clinician had to spell out a diagnosis on five separate axes, related to five different aspects of a person’s clinical picture, now a clinician only needs to write out the diagnosis or list diagnoses if there is more than one. All you need to do as a case manager is become somewhat familiar with this book in order to be able to understand discussions about the conditions and treatments of people seeking help and to understand how categories of disorders are grouped by chapter. The chapters are arranged so that similar disorders are in adjacent chapters. Each chapter also presents the course and development of a particular disorder so that you can see how it differs as people age. Where it seemed appropriate the DSM 5 also looks at gender and cultural issues that could affect a diagnosis. To help you better understand and work with the exercises at the end of this chapter, it would be a good idea to purchase the Quick Reference to the Diagnostic Criteria from DSM 5. The DSM 5 has some new features worth noting: 1. The DSM 5 looks at genetics and neuroimaging. The APA contends, “Given the explosion in neuroscience, neuropsychology, and brain imaging over the past 20 years, it was critical to convey the current state-of-the-art in the diagnosis of specific types of disorders.” (DSM 5, 2013). 2. In addition to the manual and numerous print materials available about DSM 5, you can find what the APA calls “on-line supplemental information” to help clinicians make an accurate diagnosis. 3. The World Health Organization Disability Assessment Schedule 2.0 (WHODAS.2.0) is found on page 747 of the manual and can be self-administered by the client. This is used to give a better picture of how well the person is functioning with a severity scale for scoring the person’s capacity related to the various tasks and abilities. It can be used to track improvement or deterioration over time. 4. DSM 5 contains (onpages 743–44) a symptom severity chart for psychosis allowing a person to define better the degree of psychosis and how severe the symptoms are for the person. 5. The ICD numerical codes are included to bring diagnoses into line internationally. We will look at this further. Before Making a Diagnosis Before you can make a diagnosis you need to have an idea where in the DSM your client falls. If a person tells you that he or she is having trouble sleeping you would look in the chapter titled “Sleep-Wake Disorders.” If a person presents hearing voices or hallucinating you would look at the chapter titled “Schizophrenia Spectrum and other Psychotic Disorders.” Each chapter contains disorders that are to some extent similar. For instance, if a young person tells you she is not eating because she believes she is fat and she is really painfully thin, you would look in the chapter on “Feeding and Eating Disorders.” You would also go to that chapter if a young mother tells you that her child is eating dirt and leaves. Both of these problems have to do with eating. Making yourself familiar with the 21 categories of disorders in the DSM will help you to better pin down what disorder your client is presenting. The chapters and the disorders contained within them are listed in your Quick Reference to the Diagnostic Criteria from DSM 5. Each chapter, as noted, contains a group of somewhat similar or related disorders. Eating disorders are together, psychotic disorders are together, learning and developmental disorders are together, and so forth. Once you have turned to the appropriate chapter you would be looking for a diagnosis that looks very much like what your client is presenting. Each disorder has a list of criteria to use in making the diagnosis. Often this list is followed by specifiers. In other words, you could be asked to specify if the onset of the disorder is recent or in the past. You might be asked to specify if the disorder is in partial remission or full remission. In another instance you might be asked to specify if the disorder is mild, moderate, severe, or extreme. Making the Code Using DSM 5 In DSM 5 there are no more axes, greatly simplifying the coding process. A person coming in with a clear mental disorder would simply have that written out. If there is more than one disorder, you would list these. Writing a diagnosis, often referred to as coding, is done in the following order: • The number of the disorder • The name of the disorder • The severity of the disorders (when required) • Any specifiers that apply (when appropriate or required) The Number of the Disorder. All the disorders in the DSM have a numerical code. This is the ICD-9 code. Next to the number is a second number preceded by a letter. This second number is the number that will be used by the ICD-10. In order to have a common language about these disorders internationally, the United States will adopt these second numbers on October 1, 2015, and the first numbers will no longer be used. It appears that from this point on the DSM will coordinate the DSM numbering system with the ICD numbering system. The Name of the Disorder. Every disorder has a name. For example, if a person had a diagnosis of schizophrenia it would be written as 295.90, schizophrenia Or when using the ICD-10 code it will be written as F20.9, schizophrenia Other examples WRITTEN WITH DSM 5 ICD-9 CODE Before October 1, 2015 WRITTEN WITH ICD-10 CODE After October 1, 2015 300.3, Hoarding Disorder F42, Hoarding Disorder 780.52, Insomnia Disorder G47.00, Insomnia Disorder 308.3, Acute Stress Disorder F43.0, Acute Stress Disorder The Severity of the Disorder. By noting the severity of a disorder you are indicating the degree to which the disorder interferes with the person’s ability to function. Not all diagnoses ask you to specify severity. However, if you are asked to do so, you would write that next to the disorder. Take for example 312.31, gambling disorder. The DSM asks you to specify if this disorder is mild, moderate, or severe. For 300.82, somatic symptom disorder, you are asked to specify if the disorder is mild, moderate, or severe. When looking at the eating disorders you are asked to specify if the disorder is mild, moderate, or severe or is it extreme. These terms are defined so that you know what constitutes a mild case or what constitutes a severe case for that particular disorder. With anorexia it is Body Mass Index (BMI). The lower the BMI, the more severe the disorder is for that person. With Bulimia these terms are defined by the number of “compensatory episodes” a person has in a week. For example, a person engages in binge eating and then uses a compensatory method to prevent gaining weight such as self-induced vomiting. How many times in a week the person engages in this compensatory behavior tells you how severe the condition is for this person. If the person only uses self-induced vomiting one to three times a week, it is considered mild. However, 14 or more episodes would be considered extreme. Specifiers That Apply. Many of the diagnoses will have other specifications you are asked to note. With enuresis (urinating into clothes or bedding), you are asked to specify whether this is “nocturnal only,” “diurnal only,” or “nocturnal and diurnal.” A disorder may ask for several different specifiers to distinguish clearly what the diagnosis involves. For 300.4, persistent depressive disorder, the DSM asks for a list of specifiers. You are asked to specify if the person experiences additional distress or features and these are listed for you. They include things like “with anxious distress” or “with melancholic features.” Next you are asked to specify if the disorder is in partial or full remission. You are then asked to specify early onset (before age 21) or late onset (21 or older). Finally, you are asked to specify for the most recent 2 years of persistent depressive disorder whether it was pure dysthymic syndrome, which is defined, or if it involved other forms of depression such as major depressive episode or intermittent major depressive episodes, and so forth. Think of specifiers as clarifying and individualizing the person’s disorder. Multiple Diagnoses It is possible for people to have more than one diagnosis and you would want to note all of those that apply. If a person comes to your office seeking help with a disorder and the professionals in your agency diagnose the person with more than one disorder, the disorder that brought the person in or the one that is most prominent and most in need of relief would be listed first. All others would be listed below in order of importance. Other Conditions That May Be a Focus of Clinical Attention There are many times people seek help for their problems, but they do not have a DSM 5 disorder. Not everyone will have one, but there are many personal problems that bring people into agencies for help. Usually agencies simply describe the problem in the notes but you may work in a place that is required to note some diagnosis in order for your agency to be reimbursed. In the back of the DSM is a section titled “Other Conditions That May Be a Focus of Clinical Attention.” Here you will find an array of problems people can have without having a psychiatric disorder. Usually their distress is a normal reaction to what is going on in their lives. In this section you will find a number of relationship problems, abuse and neglect issues, domestic violence, and work and income troubles. All of these have a number and many of the numbers begin with the letter V causing them to be referred to by clinicians as V codes. Sometimes a person does have a disorder as well as one of these conditions. For example, a man might come in and he is diagnosed with 300.2, Generalized Anxiety Disorder. In the course of the intake interview the case manager learns that the person is having considerable difficulty with a hostile neighbor. The neighbor has threatened the man repeatedly and threatened the man’s pets. The police have made only half-hearted attempts to stop this behavior. When the man comes to see you he is torn between bringing charges, which could further inflame the situation or trying to live with this frightening neighbor next door. After listing 300.2, generalized anxiety disorder, you would list V60.89, discord with neighbor. Your social history will describe the situation in more detail, but listing this makes it clear that the man is experiencing stress related to his neighbor. Combined with the first diagnosis we get a clearer picture and some sense of why this man is anxious. When the Diagnosis Does Not Quite Fit People may describe their symptoms and those symptoms sound a lot like depression but the person’s symptoms do not meet any of the criteria for the disorders listed in the chapter on “Depressive Disorders.” You look there and you see that the person does not have disruptive mood dysregulation disorder because there are no “severe recurrent temper outbursts ….” The person does not really have “(F)ive or more” of the symptoms for major depressive disorder and the picture does not look like dysthymia either. It can’t be premenstrual dysphoric disorder because the person is a man and he is not using substances or medications, which rules out substance/medication-induced depressive disorder. Further, it does not appear that the person has a medical condition that would give him a diagnosis of depressive disorder due to another medical condition. In each chapter you will find at the end a section that gives you other choices. This section is titled “Other Specified Disorders.” For our person we would look at that section titled “Other Specified Depressive Disorders” and see if any of those options fit better. If the other specified disorders do not fit what you are seeing in the client then turn to the end of the chapter. Each chapter ends with a section titled “Unspecified Disorders.” In our example we would turn to 311, Unspecified Depressive Disorder, as the diagnosis. The DSM states, “(T)his category applies to presentations in which symptoms characteristic of a depressive disorder that cause clinically significant distress or impairment in social, occupational, or other important areas of functioning predominate but do not meet the full criteria of any of the disorders in the depressive disorder diagnostic class.” This statement, as it applies to each category of disorders, can be found at the end of every chapter. It is used when we know the symptoms belong in a certain category of disorders, but the person does not entirely meet the criteria for any of them. When There Is No Number Sometimes you will find a diagnosis in the DSM 5 that has no number. For example, your client has a major depressive disorder but when you turn to page 160, Major Depressive Disorder has no number with which to code it. In cases like this one the DSM 5 is asking you for more specific information. If you turn to page xvii you can see the information that is required. First, you are asked if this is a single episode or is it recurrent. Is this the first time this has happened or has this person been depressed on other occasions? For our purposes we will say she has experienced depression several other times in the past. We would go to recurrent episode and see that we need to indicate what this episode is like. Is it mild, moderate, or severe or does it have psychotic features? Is this episode in partial remission, in full remission, or is this recurrent episode unspecified? The choice you make here has a number and that number gives the next person looking at the diagnosis more information about the current depression than that the person is simply depressed. Summary While DSM 5 has simplified diagnosing mental disorders, the DSM is a complex manual. It takes practice and good clinical skills to use the manual effectively. Nevertheless, entry-level individuals are being asked to understand the categories of disorders and discuss diagnoses with clinicians. In this course, we begin to look at how you would use the manual in your work as a case manager. As you practice, you will begin to understand more clearly how disorders are defined and treatments are assigned. As you work with the DSM over a period of time, diagnoses will become more familiar to you and easier to use. You will also be able to note such diagnoses more quickly with practice.

CHAPTER 17: Using the DSM* Introduction

The Diagnostic and Statistical Manual of Mental

Disorders (DSM; APA, 2013) is a collection of diagnoses of mental disorders accompanied by the

typical behaviors and symptoms you might see in a particular diagnosis. T

he idea behind this

manual is to provide a common set of criteria for each mental disorder so that practitioners will be

more likely to give the same diagnosis to people with similar symptoms and behaviors regardless of

where they are being treated or who

is seeing them. Thus the manual provides a common language

that everyone in the helping professions can use in diagnosing individuals, discussing their

symptoms and issues, and planning their care. Students may want to use the Quick Reference to

the Diagno

stic Criteria from DSM 5, a smaller book with the basic information sufficient for students

to work with this material. Many students wonder why they need to learn about the Diagnostic and

Statistical Manual of Mental Disorders (DSM; APA, 2013) when it app

ears to be a tool used

exclusively by mental health practitioners. Actually the DSM is a valuable tool you will use in many

different settings. Although the majority of people receiving services in the broad human service

system do not have mental disorder

s, the DSM sometimes helps to define what the client is

experiencing and what that person needs. For instance, people who come to agencies as victims of

abuse or assault often suffer from posttraumatic stress disorder. Workers in agencies dealing with

the

problems of growing older will encounter people who have dementia or cognitive symptoms that

resulted from a stroke or other long

term, debilitating illness. Those who work with children in a

variety of settings will encounter children who have learning di

fficulties or behavior issues. Familiarity

with the language and process of the DSM enables you to participate in planning for the client more

competently. Is DSM Only a Mental Health Tool? Today, with deinstitutionalization of the mentally ill,

those with

mental disorders come for services at many social service agencies, and more often than

in the past, we see people who have more than one problem. You might be working at a shelter for

victims of domestic violence and do an intake for a woman who also suf

fers from bipolar disorder.

You might find that a person has both a mental disorder and an addiction to heroine. People who

seek our help no longer fit into neat boxes with no overlapping problems. For that reason, it is

important to be familiar with this

system. The DSM is the language of insurance companies and

other funding sources with regard to behavioral treatments such as drug and alcohol treatment or

treatment for those with mental health problems, addiction issues, or intellectual disabilities. In

addition, the DSM contains information about situations and problems that may not constitute a

mental disorder but may be the focus of attention in a clinical setting. Many of these disorders come

to the attention of social service agencies not equipped to

treat them. You will need good information

to make sound referrals. Your ability to understand the DSM and your acquaintance with the various

classifications of mental disorders will enable you to be more conversant with others in the field and

to recogni

ze a mental disorder when you encounter one. Cautions Having spelled out why the DSM

is important in human service practice, it is equally important to understand that most people who

come for services in social service agencies are not suffering from a me

ntal disorder. The DSM

cannot be used to help you understand every client. If you try to give a psychiatric label to everyone

you see, you will unnecessarily burden individuals who are well but are grappling with life transitions

and disruptions such as un

employment or grief. Labeling people can have lifelong consequences for

them. In addition, these labels can make a person seem much sicker than they really are.

Diagnosing calls for caution. Further, the DSM comes from the medical model. That is, the model

suggests that individuals are labeled with an illness and are then treated as sick. This is a view of

the client that can cause you to lose sight of the fact that the person has strengths and successes.

Although a diagnosis is useful to clinicians in prov

iding treatment, to case managers it can have the

subtle effect of diminishing the client as a whole person. Moreover, people have a right to know what

their diagnosis is. This is part of informed consent. They also have the right to know who else will

see

the diagnosis: The insurance company? The companies and businesses where clients work?

Knowing who will see the diagnosis is also part of informed consent. Finally, be cautious about

CHAPTER 17: Using the DSM* Introduction The Diagnostic and Statistical Manual of Mental

Disorders (DSM; APA, 2013) is a collection of diagnoses of mental disorders accompanied by the

typical behaviors and symptoms you might see in a particular diagnosis. The idea behind this

manual is to provide a common set of criteria for each mental disorder so that practitioners will be

more likely to give the same diagnosis to people with similar symptoms and behaviors regardless of

where they are being treated or who is seeing them. Thus the manual provides a common language

that everyone in the helping professions can use in diagnosing individuals, discussing their

symptoms and issues, and planning their care. Students may want to use the Quick Reference to

the Diagnostic Criteria from DSM 5, a smaller book with the basic information sufficient for students

to work with this material. Many students wonder why they need to learn about the Diagnostic and

Statistical Manual of Mental Disorders (DSM; APA, 2013) when it appears to be a tool used

exclusively by mental health practitioners. Actually the DSM is a valuable tool you will use in many

different settings. Although the majority of people receiving services in the broad human service

system do not have mental disorders, the DSM sometimes helps to define what the client is

experiencing and what that person needs. For instance, people who come to agencies as victims of

abuse or assault often suffer from posttraumatic stress disorder. Workers in agencies dealing with

the problems of growing older will encounter people who have dementia or cognitive symptoms that

resulted from a stroke or other long-term, debilitating illness. Those who work with children in a

variety of settings will encounter children who have learning difficulties or behavior issues. Familiarity

with the language and process of the DSM enables you to participate in planning for the client more

competently. Is DSM Only a Mental Health Tool? Today, with deinstitutionalization of the mentally ill,

those with mental disorders come for services at many social service agencies, and more often than

in the past, we see people who have more than one problem. You might be working at a shelter for

victims of domestic violence and do an intake for a woman who also suffers from bipolar disorder.

You might find that a person has both a mental disorder and an addiction to heroine. People who

seek our help no longer fit into neat boxes with no overlapping problems. For that reason, it is

important to be familiar with this system. The DSM is the language of insurance companies and

other funding sources with regard to behavioral treatments such as drug and alcohol treatment or

treatment for those with mental health problems, addiction issues, or intellectual disabilities. In

addition, the DSM contains information about situations and problems that may not constitute a

mental disorder but may be the focus of attention in a clinical setting. Many of these disorders come

to the attention of social service agencies not equipped to treat them. You will need good information

to make sound referrals. Your ability to understand the DSM and your acquaintance with the various

classifications of mental disorders will enable you to be more conversant with others in the field and

to recognize a mental disorder when you encounter one. Cautions Having spelled out why the DSM

is important in human service practice, it is equally important to understand that most people who

come for services in social service agencies are not suffering from a mental disorder. The DSM

cannot be used to help you understand every client. If you try to give a psychiatric label to everyone

you see, you will unnecessarily burden individuals who are well but are grappling with life transitions

and disruptions such as unemployment or grief. Labeling people can have lifelong consequences for

them. In addition, these labels can make a person seem much sicker than they really are.

Diagnosing calls for caution. Further, the DSM comes from the medical model. That is, the model

suggests that individuals are labeled with an illness and are then treated as sick. This is a view of

the client that can cause you to lose sight of the fact that the person has strengths and successes.

Although a diagnosis is useful to clinicians in providing treatment, to case managers it can have the

subtle effect of diminishing the client as a whole person. Moreover, people have a right to know what

their diagnosis is. This is part of informed consent. They also have the right to know who else will

see the diagnosis: The insurance company? The companies and businesses where clients work?

Knowing who will see the diagnosis is also part of informed consent. Finally, be cautious about