Part 3 of 5

1. 8/20/15'
1'
+
DSM-5: Substance Use Disorders
Dr. Christine Chasek LIMHP, LADC
University of Nebraska at Kearney
+

2. 8/20/15'
2'
+ Substance Abuse - Overview of “Old” to “New”
! Biggest Change!! Eliminated the distinction between
Abuse and Dependence
! The DSM-5 combines the Abuse and Dependence
Categories into a single disorder that is measured on a
continuum from mild to severe.
! Each substance is addressed as a separate disorder (i.e.
alcohol, cannabis) HOWEVER:
! all are evaluated based on the same overarching criteria
! Rationale: Criteria have been strengthened, better able
to match the symptoms to the client’s experience
+ Substance-Related Disorders and Addictive Disorders
! The Substance-Related Disorders are divided into Two Groups:
1. Substance Use Disorders
! Substance use disorders are patterns of symptoms resulting from use of a
substance which the individual continues to take, despite experiencing problems
as a result.
2. Substance Induced Disorders
! Intoxication, Withdrawal, and Other Substance/Medication Induced Mental
Disorders
! i.e. substance induced psychosis, substance induced bipolar and related
disorders, substance induced depressive disorders, substance induced anxiety
disorders, substance induced obsessive-compulsive and related disorders,
substance induced sleep disorders, substance induced sexual dysfunctions,
substance induced delirium and substance induced neurocognitive disorders.
! The disorder must have occurred within 1 month of substance intoxication or
withdrawal, and the involved substance must be capable of producing the
mental disorder

3. 8/20/15'
3'
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Criteria~ What has changed?
+ Substance Use Disorder Criteria
! Taking the substance in larger amounts or over a longer period of time than was intended
! Persistent desire or unsuccessful efforts to cut down or control use
! Spending a great deal of time getting, using, or recovering from use of the substance
! Craving, or a strong desire or urge to use the substance
! Recurrent use resulting in failure to fulfill major obligations at work, home or school
! Continuing to use despite having persistent or recurrent social or interpersonal problems
! Important social, occupational or recreational activities are given up or reduced because of substance
use
! Recurrent use in situations that are physically hazardous
! Continuing to use, despite knowledge of having persistent or recurrent physical or psychological
problems that is likely to have been caused or made worse by the substance
! Tolerance as defined by;
! A need for markedly increased amounts for the substance to achieve the desired effect or intoxication
! A markedly diminished effect with the continued use of the same amount of the substance
! Withdrawal as manifested by ;
! The characteristic withdrawal syndrome for the substance
! Use of the substance is taken to relieve or avoid withdrawal symptoms

4. 8/20/15'
4'
+ Severity and Specifiers
! Substance Use Disorders are categorized on a continuum from mild to severe.
! The severity is based on the number of symptom criteria endorsed.
Course Specifiers
! In early remission: after full criteria met none of the criteria have been met for at least 3
months but for less than 12 months (exception: Craving may have been met)
! In sustained remission: after full criteria has been met, none of the criteria has been met for
12 months or longer (exception: Craving may have been met)
! In a controlled environment: no access to the substance due to environment
! On maintenance therapy: taking a prescribed medication and none of the criteria has been
met for that class of medication
Severity Category # of Symptoms
Mild 2-3
Moderate 4-5
Severe 6 +
+ Substance-Related Disorders and Addictive
Disorders
! Ten separate categories of Substances:
! Alcohol
! Caffeine
! Cannabis
! Hallucinogens
! Inhalants
! Opioids
! Sedatives, Hypnotics, Anxiolytics
! Stimulants
! Tobacco
! Other / Unknown Substances
When recording the diagnosis need to use the actual name of the substance within the
class:
! 305.70 (F15.10) Mild Methamphetamine Disorder (or Mild Stimulant
Disorder; it’s been recorded both ways)

5. 8/20/15'
5'
+
Other Changes
! Deleted Legal Criterion in the Criteria for diagnosis
! Added Craving Criteria – Based on brain research
! Removed Physiological Subtype
! Eliminated Polysubstance Disorder as a diagnosis
! Added Cannabis Withdrawal
! Added Caffeine Withdrawal
! Changed Nicotine to Tobacco: Added Tobacco Use Disorder
+
Addictive Disorders
! Gambling Disorder
! Moved out of Impulse control disorders to Substance-Related and
Addictive Disorders
! APA’s way of formerly recognizing addictive disorders
! Reflects research findings that gambling disorder is similar to
substance-related disorders in clinical expression, brain origin,
comorbidity, and treatment

6. 8/20/15'
6'
+ Substance-Related and Addictive
Disorders
For Further Study~~~ Section III
! Caffeine Use Disorder
! Internet Gaming Disorder
What Didn’t Make It In~~~~
! Majority of “Behavioral” Disorders- Addictive Disorders
! Sexual Addiction
! Shopping Addiction
! Exercise Addiction
! Reason?? Insufficient Research at this time
+
Schizophrenia Spectrum and Other
Psychotic Disorders
DSM-5

7. 8/20/15'
7'
+ 5 Key Features that Define
Psychotic Disorders
! Delusions (Positive Symptom)
! A fixed belief that does NOT change despite
evidence to the contrary
! Types of Delusions:
! Persecutory
! Referential
! Grandiose
! Erotomanic
! Nihilistic
! Somatic
+ Key Features-Cont.
! Hallucinations (Positive Symptom)
! Perception-like experiences occurring
without external stimulus
! Auditory hallucinations are the most
common
! Disorganized Thinking/Speech
(Positive Symptom)
! Switch from topic to topic; tangential
conversation; incoherent

8. 8/20/15'
8'
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Key Features-Cont.
! Grossly Disorganized or Abnormal Motor Behavior
! Unpredictable motor agitation; catatonia; rigid or
bizarre posture; echoing of speech; mutism
! Negative Symptoms
! Diminished emotional expression
! Avolition: lack of drive or motivation
! Alogia: diminished speech
! Anhedonia: flat affect; depressed; no pleasure in
things
! Asociality: lack of interest in social activities
+ Changes in Diagnostic
Criteria for Schizophrenia
! For Criterion A in Schizophrenia- the special attribution of bizarre
delusions and Schneiderian first-rank auditory hallucinations (two or
more voices conversing) have been eliminated;
! Because of this 2 Criterion A symptoms are necessary for a diagnosis.
! Also there must be at least one “positive” symptom present in
Criterion A; delusions, hallucinations, or disorganized speech
! The subtypes have been eliminated (paranoid, disorganized, catatonic,
etc) instead a dimensional approach is used to rate severity.
! Specifiers are also used for the course of the disorder and to specifify
is Catatonia is present.
! 295.90 (F20.9) Schizophrenia (add specifiers here)

9. 8/20/15'
9'
+ Schizophrenia Spectrum and Other
Psychotic Disorders (pgs 87-122)
! 295.70 (F25.0) Schizoaffective Disorder, Bipolar type
! 295.70 (F25.1) Schizoaffective Disorder, Depressive type
! Primary change is the requirement that a major mood episode
be present for a majority of the disorder’s total duration.
+ Schizophrenia Spectrum and Other
Psychotic Disorders (pgs 87-122)
! 297.1 (F22) Delusional Disorder
! Good news!! The delusions no longer have to be
Bizarre " (Sorry that’s my twisted sense of humor!)
Others—no real changes:
! 298.8 (F23) Brief Psychotic Disorder
! 295.40 (F20.81) Schizophreniform Disorder
! Substance/Medication-Induced Psychotic Disorder : Code by
type of substances
CATATONIA
! 293.89 Catatonia Associated with Another Mental Disorder (Catatonia
Specifier)
! 293.89 (F06.1)Catatonic Disorder Due to Another Medical Condition

10. 8/20/15'
10'
+ Treatment for Schizophrenia and
Psychotic Disorders
Medication followed by Psychotherapy after stabilizing the symptoms
! Antipsychotics
! Typical (Older Medications 1950’s)
! Thorazine, Haldol, Etrafon, Prolixin
! Atypical (Newer medications 1990’s)
! Risperdal, Zyprexa, Seroquel, Geodon, Abilify, Invega
! Psychotherapy: Psychosocial Treatments
! Cognitive-behavioral therapy (CBT)
! Illness Management Skills
! Integrated Substance Abuse Treatment
! Rehabilitation / Clubhouse Model
! Family Education
! Self-Help Groups
+Addiction in Schizophrenia
! Addiction to Nicotine is the most common form of substance
abuse in people diagnosed with Schizophrenia
! Addiction to Nicotine is three times higher in the Schizophrenic
population than in the general population
! Researchers are determining if there is a biological basis
connecting Schizophrenia and Smoking

11. 8/20/15'
11'
+
Bipolar and Related Disorders
DSM-5
Dr. Christine Chasek LIMHP, LADC, NCC
+
! Bipolar disorder causes serious shifts in mood, energy,
thinking and behavior from the highs of mania on one
extreme to the lows of depression on the other. The change
in DSM-5 is the emphasis on changes in activity and energy
as well as mood.
! The diagnosis of Bipolar I Disorder, Mixed Episode has been
removed; instead there is a new specifier to capture this
information more accurately; With Mixed Features.
! An Anxious Distress Specifier has also been added to this
disorder class as well as the depressive disorders.

12. 8/20/15'
12'
+
Diagnosis included in this category
of 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
! All the specifiers are described on pages 149-154
Bipolar I Disorder pg 123-132
! For a diagnosis of Bipolar I Disorder, criteria for a Manic
Episode must be met at least once during the client’s lifetime.
! Page 124 in DSM-5 lists the criteria for a Manic Episode; criteria
A-D must be met for a Manic Episode to be diagnosed.
! In Bipolar I Disorder the Manic Episode may be followed by a
Hypomanic Episode (pg. 124-125) or a Major Depressive
Episode (pg. 125-126), however this is not a criteria that needs
to be met. Between Manic Episodes the client can return to a
fully functional level of life.
! The actual criteria and coding procedures are found on page
126-127. Follow the charts to determine the code and name for
the Bipolar I disorder; remember to also use the specifiers found
on page 127.
! The Narrative for the specifiers are found are pages 149-154.

13. 8/20/15'
13'
Coding Charts
Page 127
+ 296. 89 (F31.81) Bipolar II Disorder
pg. 132-139
! Client must meet the criteria for a current or
past Hypomanic Episode and the criteria for a
current or past Major Depressive Episode.
! These criteria are listed on pages 132 and 133.
! There must have never been a Manic Episode.
! There is only one code for Bipolar II Disorder
296. 89 (F31.81), the features and specifiers are
listed in narrative form. (see page 134 for
example).
! The essential feature of Cyclothymic Disorder is a
chronic and fluctuating mood that cycles between
periods of hypomanic and depressive symptoms for a
time period of at least 2 years (or 1 year in adolescents
or children).
! 301.13 (F34.0) Cyclothymic Disorder

14. 8/20/15'
14'
+
Substance Induced and Medical
Condition Bipolar Diagnosis
! Substance/Medication-Induced
Bipolar and Related Disorders
! Pg 142-145
! There must be evidence from
laboratory findings that the
symptoms developed during or
soon after substance intoxication or
withdrawal or exposure to a
medication
! Coding is specific to the substance
or drug
! Bipolar and Related Disorder Due
to Another Medical Condition
! Pg 145-147
! There must be evidence that the
symptoms are related to another
medical condition.
! The code for for this condition is
293.83 with the ICD 10 code (the
one in following) depends on the
the specifiers; see page 146).
+
Other and Unspecified Bipolar
Diagnosis
! 296.89 (F31.89) Other Specified
Bipolar and Related Disorder
! Pg 148
! Used when there is evidence of
bipolar disorder criteria that causes
significant distress but does not
meet all the required criteria for a
specific bipolar or other related
disorder
! Clinician describes the reasons for
this diagnosis
! 296.80 (F31.9) Unspecified
Bipolar and Related Disorder
! Pg 149
! Used when there is evidence
of bipolar disorder criteria
that causes significant distress
but does not meet all the
required criteria for a specific
bipolar or other related
disorder but the clinician does
NOT want to describe the
reasons for this diagnosis

15. 8/20/15'
15'
+
Depressive Disorders
DSM-5
Dr. Christine Chasek LIMHP, LADC, NCC
+ Overview
! What is a Depressive Disorder?
! Mood is a person’s subjective emotional state: Affect is the
objective appearance of mood
! The common feature of all the Depressive Disorders
(according to DSM-5) is the presence of sad, empty, or irritable
mood; accompanied by somatic and cognitive
changes that affect functioning capacity.
! DSM-5 contains several new depressive
disorders
! Disruptive Mood Dysregulation
! Premenstrual Dysphoric Disorder
! Persistent Depressive Disorder

16. 8/20/15'
16'
+ DSM-5 Depressive Disorders
! Disruptive Mood Dysregulation Disorder *NEW*
! Major Depressive Disorder
! Persistent Depressive Disorder (Dysthymia) *NEW*
! Premenstrual Dysphoric Disorder *NEW*
! Substance/Medication-Induced
Depressive Disorder
! Depressive Disorder Due to Another
Medical Condition
! Other Specified Depressive Disorder
! Unspecified Depressive Disorder
+ Specifiers for Depressive Disorders
(pg184-188)
! Specify if
! With anxious distress
! With mixed features
! With melancholic features
! With atypical features
! With psychotic features
! With catatonia
! With peripartum onset
! With seasonal pattern
! Specify if
! In partial remission
! In full remission
! Specify current severity
! Mild, Moderate, Severe

17. 8/20/15'
17'
+ NEW DIAGNOSIS!
296.99 (F34.8) Disruptive Mood
Dysregulation Disorder (pg 156)
! This is a diagnosis for children between ages 6 and 18
! The onset must be before age 10
! The defining feature of this disorder is chronic, severe, and
persistent irritability in children
! The manifestation of the irritability must include 2 features:
! Frequent temper outbursts that meets the designated criteria
(Criterion A-C)
! Chronic irritable or angry mood between the temper outbursts
! The disorder has specific duration and time limits (Criterion
E-F)
! Must also look at co-existing and differential diagnosis
(Criterion I-J)
+
Major Depressive Disorder
! No significant changes were made in this diagnosis however there
are many specifiers to consider when diagnosing the Depressive
Disorders- need to take this into account when diagnosing.
! Must determine if the depressive episode is a natural
response to grief (pg. 161)
! Bereavement Exclusion: The exclusive criteria in DSM-
IV-TR was eliminated in DSM-5; the 2 month exclusion is
gone; grief is culturally determined and very
individualized. DSM-5 leaves the decision to determine
if the depressive symptoms are a normal part of
grieving for the individual or if it is a result of a
depressive episode. A key is to assess whether the
sadness comes in waves (as is a grief response) or is
long-standing with no relief from the sadness
(depression).

18. 8/20/15'
18'
+
Coding for Major Depressive
Disorder (pg. 162)
! The coding for MDD is based on whether the depressive
episode is a single or recurrent episode, current severity,
presence of psychotic features, and remission status.
! See Chart Pg. 162 and Specifiers pg. 184-188
+ 300.4 (F34.1) Persistent Depressive
Disorder (Dysthymia) (pg 168-171)
! Depressed mood nearly every day for > 2 years (>1
year in children
! Associated with ≥ 2 of the following:
! decreased or increased appetite
! decreased or increased sleep
! low energy or fatigue
! low self-esteem
! poor concentration or indecisiveness
! hopelessness
! No more than 2 months symptom free; Causes
impairment in major life functions, not attributed to
another disorder or substance/medical condition

19. 8/20/15'
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+
Persistent Depressive Disorder
When diagnosing, include the specifiers in
the narrative (pg 169)
+311 (F32.8) Other Specified Depressive Disorder
311 (F32.9) Unspecified Depressive Disorder (pg 183-184)
! Other Specified Depressive Disorder:
! Use when there is a clinical presentation of a depressive
disorder that causes clinical distress and impairment but the
criteria for any given disorder is not fully met
! Use when you choose to communicate the specific reasons
that the client does not meet criteria
! Record the Other Specified Depressive Disorder and then the
reason
! i.e. 311 (F32.8) Other Specified Depressive Disorder, Short-
duration depressive episode
! Unspecified Depressive Disorder:
! Use when there is a clinical presentation of a depressive
disorder that causes clinical distress and impairment but the
criteria for any given disorder is not fully met AND the
clinician does NOT choose to note why

20. 8/20/15'
20'
+ Major Depressive Disorder:
Psychotherapy and Medication
! Good evidence for efficacy of CBT and IPT
(Interpersonal Therapy); less for
psychodynamic therapy
! Psychotherapy may be just as effective as
medications in mild-moderate illness
! Combination of medications and psychotherapy
may be better than either alone
+ Utilize screening and assessment tools available to
help in diagnosis, treatment planning and
communicating with client
Can also use to measure progress in therapy; there
are available measures on the DSM-5 Website
to use Depression Assessment