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 신현근 박사 강의안 - DSM-5 소개  
첨부파일 : f1_20161110114051.pdf
 

과목:  진단과 평가

주제:  Introduction to DSM-5

강사: 신현근 박사 

내용: 강의안 – DSM-5 소개

교재: Reichenberg, L. W. (2014).  DSM-5 Essentials. Hoboken. NJ: John Wily & Sons.

 

1.       Overview

1.1.    In May 2013, the fifth edition of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders was published.

1.2.    The DSM, along with the International Classification of Diseases (ICD), are the two classification systems that mental health professionals turn to for the assessment, diagnosis, and coding of mental disorders.

1.3.    Both classification systems are important for clinicians, because the code numbers that the DSM uses are those listed for similar disorders in the ICD. Both sets of codes (ICD-9 and ICD-10, which takes effect in 2014) are included in DSM-5 and in this book.

 

2.       Introduction TO DSM-5

2.1.    Over the past 60 years, the Diagnostic and Statistical Manual of Mental Disorders (DSM), published by the American Psychiatric Association (APA), has become the standard reference for mental health professionals in the United States.

2.2.     With the publication of the fifth edition earlier this year, DSM-5 (APA, 2013a) has become more consistent with WHO’s International Classification of Diseases Clinical Modifications (ICD-CM, the coding system used in the United States).

2.3.    In December 2012, the Board of Trustees of the APA approved the final changes that now constitute DSM-5.

2.4.    All of the additions or substantive changes to DSM-5 were supported by research and planned with the intent to improve diagnosis and treatment, and to be able to be incorporated into routine clinical practice.

2.4.1.According to the APA, all changes were “intended to more clearly and accurately define the criteria for that mental disorder.

2.4.2.These and other enhancements to DSM-5, such as changes in the organizational structure, use of dimensional and cross-cutting measures, and consistency with ICD codes were planned to increase the manual’s clinical utility and enhance its value for clinicians and researchers alike.

2.4.3.To help clinicians conceptualize and diagnose disorders, DSM-5 is divided into three sections:

2.4.3.1.              Section I provides a basic introduction on how to use the new manual, how to diagnose using a nonaxial system, and a new definition of a mental disorder as a syndrome that causes clinically significant problems with cognitions, emotion regulation, or behavior that results in dysfunctional mental functioning and is “associated with significant distress or disability in social, occupational, or other important activities” (APA, 2013a, p. 20).

2.4.3.2.              Section II provides 20 classifications of disorders that focus on diagnostic criteria and codes.

2.4.3.3.              Section III, Emerging Measures and Models, includes assessment measures, cultural formulation, an alternative model for personality disorders, and conditions for further study.

2.4.3.4.              The Appendix of DSM-5 features highlights of the changes made from DSM-IV to DSM-5, glossaries of terms and cultural concepts of distress, and ICD-9 and ICD-10 codes.

 

3.       Using a Nonaxial System

3.1.    The multiaxial system in DSM-5 has been replaced with a nonaxial system that combines Axis I, Axis II, and Axis III with all mental and other medical diagnoses listed together.

3.1.1.This is consistent with how the WHO’s International Classification of Diseases records diagnoses—listing as many diagnoses as necessary to provide the clinical picture.

3.1.2.The principal diagnosis is the one listed first and reflects either the reason for the visit or the focus of treatment.

3.2.    For example, a person who makes an appointment for treatment of mild depression related to bipolar disorder and who also meets the criteria for borderline personality disorder would be coded as follows:

·              296.51 Bipolar I disorder, mild, most recent episode depressed

·              301.83 Borderline Personality Disorder

3.2.1.This indicates that the focus of treatment will be the bipolar disorder.

3.3.    In keeping with the established WHO guidelines, other conditions that may be the focus of clinical attention will continue to be listed along with the diagnosis to highlight relevant factors that affect the client’s diagnosis, prognosis, or treatment, or if they best represent the client’s presenting problem.

3.3.1. This list of psychosocial and environmental problems has been expanded in DSM-5 with additional V codes (from ICD-9) and Z codes (from ICD-10).

3.3.2. If the same person in the previous example discusses exacerbation of his bipolar depression as a result of separation from his wife, the coding would look like this:

·              296.51 Bipolar I disorder, mild, most recent episode depressed

·              301.83 Borderline Personality Disorder

·               V61.03 Disruption of Family by Separation or Divorce

3.3.3.The Global Assessment of Functioning scale (Axis V) has also been eliminated in DSM-5. In its place, WHO’s Disability Assessment Schedule (WHODAS) is included as a measurement of functioning.

3.3.3.1.              This useful tool can be found in DSM-5’s Section III.

3.3.3.2.              Additional assessment measures are included in the print version of DSM-5 and online at <a href="http://www.psychiatry.org/dsm5" target="_blank">www.psychiatry.org/dsm5</a>.

3.3.4.DSM-5 reassures us that a multiaxial system is not required to diagnose a mental disorder, although that system has been adopted by many insurance companies and governmental agencies.

3.3.4.1.              The elimination of the multiaxial system brings DSM-5 more closely in line with WHO’s nonaxial system of diagnosis.

 

4.       Dimensional Approach to Diagnosis

4.1.    DSM-IV was based on a categorical system of classifying disorders that assessed the presence or absence of a symptom.

4.1.1.This system of categorization had many shortcomings, as many diagnoses are not discrete entities that fit neatly into categories.

4.1.2.The result was excessive comorbidity, fuzzy boundaries between disorders, and excessive reliance by clinicians on the NOS (not otherwise specified) category (Jones, 2012).

4.2.    DSM-5 takes a dimensional approach to diagnosis, providing dimensional and cross-cutting assessments to increase clinical utility and enhance diagnostic specificity on the part of clinicians.

4.2.1.In many instances, separate disorders are not really separate at all but are actually related conditions on a continuum of behavior, with some conditions reflecting mild symptoms, whereas other conditions are much more severe.

4.2.2.Consider, for example, bipolar disorders as a spectrum. Individuals can present with a range of symptoms from mild (cyclothymia), to moderate (bipolar II), or more severe (bipolar I).

4.2.3.DSM-5 adopts the spectrum concept for many disorders, including substance abuse, autism, and schizophrenia. Using a spectrum approach allows clinicians to consider disorders on a continuum of severity.

4.2.4.In DSM-5, specifiers have also been added to many of the disorders to enhance diagnosis and increase clinical utility.

 

5.       Use of Other Specified and Unspecified Disorders

5.1.    In DSM-5, clinicians are given two alternatives to the catchall “Not Otherwise Specified” category. “Other Specified Disorder” and “Unspecified Disorder” can be used when full criteria have not been met for a disorder, according to the following restrictions:

5.1.1.Other specified disorder.

5.1.1.1.              This category enables the clinician to identify presentations in which the symptoms are clinically significant, but do not meet the full criteria for a disorder, and to state the specific reason why the diagnostic criteria for any given disorder has not been met.

5.1.2.Unspecified disorder.

5.1.2.1.              If the presentation is clinically significant and does not meet the full criteria for a disorder, and the clinician chooses not to specify the reason that the criteria have not been met (e.g., insufficient information as what might occur in an emergency room setting), the “unspecified” diagnosis would be given.

5.1.2.2.              In the example given above, it would be recorded as “unspecified bipolar and related disorder.”

5.2.     These two options are available for all disorders and give clinicians more flexibility in diagnosing cases in which clinically significant distress is noted but the client does not meet the full criteria, or the clinician chooses not to specify the reason the criteria are not met if insufficient information is available.

 

6.       Assessments, Self-Report Measures, and Interviews

6.1.    While some measures and scales are included in DSM-5, such as a hand-scored simple version of the World Health Organization Disability Assessment Schedule (WHODAS 2.0), the APA recommends clinicians link in to the eHRS (electronic health records) for more complex assessments of symptoms (APA, 2013a, p. 745).

6.2.    Besides the WHODAS 2.0, DSM-5 includes a number of cross-cutting and assessment tools.

6.3.    These helpful diagnostic tools, including the role of Level 1 and 2 assessment measures, are discussed further in Chapter 3. A comprehensive list of assessments available both online and in the print version of DSM-5 can also be found in Chapter 3. Online assessment measures are available at <a href="http://www.psychiatry.org/practice/dsm/dsm5/online-assessment-measures" target="_blank">http://www.psychiatry.org/practice/dsm/dsm5/online-assessment-measures</a>.

 

7.       A Developmental and Lifespan Approach

7.1.    DSM-5 has adopted a new developmental structure for mental disorders, which reclassifies disorders into 20 sections based on their relatedness to each other and their similarities in characteristics.

7.1.1.As a result, disorders first diagnosed in childhood are no longer a separate chapter, having grown up, so to speak, and been dispersed into the larger family of disorders.

7.1.2.For example, childhood trauma has been relocated to a new chapter on trauma and related disorders, autism spectrum disorder is now found among the neurodevelopmental disorders, and oppositional defiant disorder (ODD) and conduct disorder form the basis for a new classification of Disruptive, Impulse Control, and Conduct Disorders.

7.2.    Some familiar disorders have been subsumed into other sections or eliminated completely.

7.2.1. Asperger’s disorder, for example, has been subsumed into the broader diagnosis of autism spectrum disorders.

7.2.2.Adjustment disorder has been reclassified as a trauma- or stressor-related disorder.

7.2.3.Meanwhile, some disorders have merely changed names (e.g., conversion disorder is now called functional neurological symptom disorder).

7.3.    When possible, the DSM-5 chapters have been organized in keeping with a developmental focus across the lifespan.

7.3.1.Classification ranges from neurodevelopmental disorders (conditions that develop early in life, such as autism) to neurocognitive disorders that develop later in life (e.g., Alzheimer’s).

7.3.2.The chapters in between commonly manifest in adolescence and young adulthood.

7.4.    Disorders have also been reclassified into clusters of disorders based on internalizing and externalizing factors.

7.4.1.Internalizing disorders are those in which anxiety, depression, and somatic symptoms are prevalent.

7.4.2.Externalizing disorders have more disturbances of conduct, impulse control, and substance use.

7.5.    This developmental and lifespan approach is also seen within chapters.

7.6.    Two new disorders included in DSM-5 provide an important developmental bridge between the early recognition of symptoms in childhood and the diagnosis of a full-blown disorder later in life.

7.6.1.Disruptive mood dysregulation disorder (which is discussed later in the section on depressive disorders) focuses on the occurrence between the ages 6 to 17 of extreme emotional dysregulation, without assuming that a diagnosis of more severe magnitude will occur in adulthood.

7.6.2.Clinicians should also be aware of attenuated psychosis syndrome (APS), which is included in Section III, Emerging Measures and Models, as APS pertains to subsyndromal symptoms of psychosis that may appear in adolescence or young adulthood and might be a precursor to a full-blown psychotic disorder.

7.7.    Other disorders currently being studied for further consideration also may have taken root in childhood and adolescence.

7.7.1.Internet gaming disorder, non-suicidal self-injury, and suicidal behavior disorder are all associated, to some degree, with onset in adolescence.

7.7.2.Clinicians who work with young people will want to refer to Chapter 3 for additional information on these emerging disorders.

 

8.       More Cultural and Gender Considerations

8.1.    A welcome enhancement to DSM-5 is the inclusion of additional gender and cultural considerations, where appropriate throughout the text, when symptoms may be informed by a client’s gender, culture, race, ethnicity, religion, or geographic origin.

8.2.    Some of the diagnostic criteria have been made more gender sensitive and culturally sensitive, with variations in presentation provided.

8.2.1.For example, social anxiety disorder now incorporates the fear of offending others, which may be manifested in some Asian cultures that emphasize the importance of not harming others.

8.3.    The Appendix to DSM-5 includes more cultural definitions, examples, and clarifications to help clinicians understand how clients from various cultures may express psychological problems.

 

9.       The International Classification of Diseases (ICD)

9.1.    Most of the world already uses ICD-10 to classify diseases and other health problems, to code health records and death certificates, and to capture national morbidity and mortality statistics.

9.1.1.The ICD-10 has been translated into 43 languages and is used by 117 countries.

9.2.    On October 1, 2014, all U.S. healthcare providers covered under the Healthcare Insurance Portability and Accountability Act (HIPAA) must begin to use the ICD-10-CM diagnosis codes.

9.2.1.The ICD provides the code numbers but limited diagnostic information.

9.2.2.On the other hand, DSM-5 provides more specific and detailed diagnostic criteria and cross-cutting measures to help the clinician make that diagnostic determination.

9.2.3.The complete listing of ICD codes is available for use free of charge from the WHO website: <a href="http://www.who.int/classifications/icd/en" target="_blank">www.who.int/classifications/icd/en</a>.

 

10.   A Brief History of the ICD

10.1.                     The ICD has been the standard diagnostic tool for more than 150 years. It is used to monitor the incidence and prevalence of diseases and other health problems worldwide. This includes epidemiology, health management, clinical purposes, and analysis of the general health situation of population groups.

10.2.                     The ICD system began in the 1850s with the publication of the International List of Causes of Death by the International Statistical Institute. This list, which reported causes of morbidity and mortality, was taken over by the World Health Organization (WHO) in 1948, when the sixth revision was published.

10.3.                     In 1977, the ICD-9 codes were published and are still being used, although the ICD-10 codes were approved in 1990 and came into use in 1994 (WHO, 2010).

10.4.                     Most countries are already using the ICD-10 coding system; only a few (e.g., the United States, Italy) have yet to switch over.

10.5.                     The U.S. Department of Health and Human Services has mandated October 1, 2014 as the deadline for switching over to the ICD-10-CM for diagnostic code reporting across all of health care, and the implementation of ICD-10-PCS (Procedural Coding System) for inpatient procedural reporting for hospitals and payers.

10.6.                     Overall, the number of codes will increase from 17,000 codes currently in ICD-9 to more than 141,000 codes for different medical diagnoses and procedures with the implementation of ICD-10.

10.7.                     Although the primary purpose of the ICD is to code and record causes of mortality and morbidity (disease or illness), for the most part, those who are responsible for mental health diagnosis and coding will be interested in only a small section of the four-volume series put out by WHO: The ICD-10 Classification of Mental and Behavioural Disorders.

11.   A Few Facts to Keep in Mind About ICD Codes

 

11.1.                     Every edition of the DSM has supplied ICD codes.

11.1.1.                   All of the DSM-IV code numbers are ICD-9 codes.

11.2.                     ICD-10-CM is not just an update to the ICD-9-CM codes.

11.2.1.                   ICD-10-CM follows a new alphanumeric coding scheme, and therefore the codes cannot be converted.

 

12.   Conclusion

12.1.                     It is beyond the scope of this introduction to include a complete assessment of the evolution of the Diagnostic and Statistical Manual of Mental Disorders. Interested readers will find such history in the introductory pages of DSM-5.

12.2.                     The takeaway message clinicians need to know to conduct a diagnosis using the DSM-5 classification system is the same guidance they have used in the past: A comprehensive clinical assessment must include a complete biopsychosocial assessment of factors that have contributed to, and that continue to sustain, the mental disorder.

12.3.                     The underlying goal is to conduct an accurate diagnosis so that the appropriate evidence-based treatment can begin.

 


 

THE 20 CLASSIFICATIONS OF DISORDERS

 

1. Neurodevelopmental Disorders 

2. Schizophrenia Spectrum and Other Psychotic Disorders

3. Bipolar and Related Disorders

4. Depressive Disorders

 5. Anxiety Disorders

 6. Obsessive-Compulsive and Related Disorders

7. Trauma- and Stressor-Related Disorders

8. Dissociative Disorders

9. Somatic Symptom and Related Disorders

10. Feeding and Eating Disorders

11. Elimination Disorders

12. Sleep-Wake Disorders

13. Sexual Dysfunctions

14. Gender Dysphoria

15. Disruptive, Impulse-Control, and Conduct Disorders

16. Substance-Related and Addictive Disorders

17. Neurocognitive Disorders

18. Personality Disorders

19. Medication-Induced Movement Disorders and Other Adverse Effects of Medication

20. Other Conditions

 
 
 
 
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