diagnosis & treatment planning final exam

under what category will you find excoriation disorder*

obsessive-compulsive & related disorders

under what category would you find Frotteuristic Disorder*

paraphilic disorder

diagnoses in which personality cluster appear as dramatic, emotional, and erratic*

Cluster B

which of these possible symptoms of a panic attack is considered cultural-specific*

neck soreness

how many possible symptoms are under criterion A in separation anxiety disorder*

8

which of these conditions is characterized by “a pervasive and excessive need to be taken care of”*

dependent personality disorder

what is the alternative term used to refer to specific learning disorder with impairment in reading*

dyslexia

which of these paraphilias is based on an anomalous activity preference*

exhibitionist disorder

while “panic attack” can be a specifier, it is not a coded diagnosis on its own that can be billed to insurance*

true?

z-codes are typically billable to insurance on their own*

false

what diagnosis must typically be ruled out as a root cause before giving a diagnosis of pyromania*

conduct disorder

enuresis is often present in children with encopresis*

true

which of these disorders has a minimum age for diagnosis explicit in criteria*

antisocial personality disorder (can’t diagnose until 18 or older)

while substances have their own substance use disorder codes, all SUD criteria follow the same structure*

true

schizoid personality disorder can be distinguished from ASD by the absence of what symptom*

stereotyped behaviors and interests

components of a MSE

• appearance: are they physically healthy, kept together?

• behavior: inappropriately laughing, smiling?

• motor activity: tics, psychomotor agitation, walking on toes?

• speech: regular volume pattern, is their language use appropriate, hyper-verbal, or talk a lot, someone who is very hesitant or stops a lot, tone of voice?

• mood: the client’s subjective report - are they saying they feel happy, amazing, sad?

• affect: your clinical interpretation of what you see (can align with mood but not always)

• thought process: the way they are thinking — are they bouncing from one idea to the next or do they have a logical process of thoughts?

• thought content: the actual content of their thoughts — maybe they’re having suicidal ideation, all they are thinking about is their job, etc.

• perceptions: hallucinations, delusions, do they have accurate or inaccurate perceptions; paranoia

• cognition: things like are they alert and oriented (oriented x4 - oriented to person, place, time, and event or oriented x3 - oriented to person, place, and time), memory

• insight: the person’s understanding or conception of their own condition — what is their understanding of their own function

• judgment: is your client repeating the same mistakes they know are mistakes?

elements of a treatment plan

• behavioral definition of problems and goals for change

• therapeutic interventions (what will specifically be done to achieve the goals?)

• outcome measures of change (how will progress be detectable?)

treatment goals

• include long-term and short-term objectives

• long-term goals directly related to the presenting issues/behavioral definitions that were listed in the first section of the treatment plan

• short-term goals are subgoals

• goals need to be SMART — specific, measurable, achievable, relevant, and time-based

What are neurodevelopmental disorders

• differences in brain processes that produce impairment of personal, social, academic, or occupational functioning

• typically have a childhood onset

• diagnosis requires symptoms and impaired function

• can often be co-occurring

• subcategories:

  • intellectual development disorders

  • communication disorders

  • autism spectrum disorder

  • attention-deficit/hyperactivity disorder

  • specific learning disorder

  • motor disorders

specific learning disorder

• neurodevelopmental disorder — biological origin

• impairment in reading, mathematics, and/or written expression

• prevalence is more common in males than females

differentiating IDD and specific learning disorder

• specific learning occur in the presence of normal levels of intellectual functioning

• SLD can be diagnosed in concurrence with IDD but only if the difficulties in the learning domain are in excess of what would be expected for the severity of IDD diagnosed

autism spectrum disorder

• all specifiers for criterion a must be met

• pay attention to differential diagnosis section

ADHD

• criterion a is divided into two subcategories — inattention and hyperactivity/impulsivity (one or both can be met)

• symptoms must have begun by age 12

• there are substantial differential diagnoses notes

• more common in males — females are more likely to present with inattentive features

motor disorders

• developmental coordination disorder: involves a delay in the development of motor skills and is made in conjunction with medical examination and psychometric assessment

• stereotypic movement disorder: involves repetitive and seemingly purposeful motor behaviors, like tic disorders, but typically has an earlier onset and is localized differently

• Tic disorders: are diagnosed hierarchically (Tourette,s Persistent Motor/Vocal Tic Disorder/Provisional Tic Disorder in that order) and consider which types of tics are present, the onset and duration, and the waxing/waning quality of presentation

  • Onset: before age 18 

  • Duration: at least 1 year

what characterizes psychotic disorders?

• Delusions: fixed beliefs that are not mendable to change in light of conflicting evidence; deemed bizarre when implausible and not understandable to same-culture peers and do not deviate from typical life experience 

• Hallucinations: experiences of perception without an external stimuli 

  • The experience of perception without stimuli 

• Disorganized thoughts: derailment, tangentiality, incoherence, etc. 

• Grossly disorganized or abnormal motor behavior: can include both increased behavior (such as childlike behavior) or a marked decrease in reactivity to the environment (catatonia) 

• Diminished emotional expression: reduction in expression of emotions 

Anhedonia: decreased ability to take pleasure in activities

types of psychotic disorders

• Delusional Disorder: the primary presentation is for persistent delusions (if hallucinations are present they must be directly related to the delusional theme) 

• Schizophrenia: multiple psychotic symptoms; lasting for more than 6 months 

• Schizophreniform: same as Schizophrenia but between 1-6 months 

• Brief Psychotic Disorder: characterized by its short duration 

• Schizoaffective Disorder: distinguished from Schizophrenia spectrum by Manic and/or Depressive episodes; Criteria B and C are used to differentiate from Schizophrenia and Bipolar Disorder 

Other medical conditions such as migraines, metabolic conditions, Huntington’s disease, and urinary tract infections, can cause psychotic features. Substance use also can cause psychotic presentations

catatonia — categorized by at least 3 of these

• Stupor: lack of psychomotor activity (shutting down physically) 

• Catalepsy: prolonged rigidity of the body not influenced by external stimuli (ex: holding someone’s arm out and it just stays there) 

• Waxy flexibility: resistance to movement of the limbs 

• Mutism: no/little verbal response 

• Negativism: no response to external stimuli 

• Posturing: holding odd body positions 

• Mannerism: odd ways of performing action 

• Stereotypy: repetitive non-goal directed movements 

• Agitation: (without external stimuli) 

• Grimacing 

• Echolalia: mimicking speech 

• Echopraxia: mimicking movement 

bipolar and related disorders

• found between the chapters on schizophrenia spectrum and other psychotic disorders and depressive disorders

• differential diagnosis will require careful consideration of the presence of symptoms

manic episode

• elevated, expansive, or irritable mood and abnormally and persistently increased activity or energy

• lasts at least a week and it must be present nearly every day for most of the day

• 3 (4 if irritable mood) must be present and deviate from the person’s typical behavior:

  • inflated self-esteem/grandiosity

  • Decreased need for sleep (e.g. feels rested after 3 hours of sleep) 

  • More talkative than usual 

  • Flight of ideas or feeling that thoughts are racing 

  • Distractibility (observed or reported) 

  • Increase in goal-directed activity or psychomotor agitation 

  • Excessive involvement in activities that have a high potential for painful consequences (high-risk behaviors) 

• requires that the mood disturbance is severe enough to cause “marked impairment” in functioning or necessitates hospitalization to prevent harm to self or others (or psychotic features are present) 

bipolar I

• need to have at least one manic episode at some point in their life

• bipolar II: cannot have manic episodes, but must have at least one hypomanic episode and one major depressive episode

• cyclothymic disorder: must have numerous periods of hypomanic and depressive symptoms, but never have met the criteria for a hypomanic episode or a major depressive episode

hypomanic episode

• same symptoms as manic episode but they need to last at least 4 consecutive days

• the impairment of a hypomanic episode is not severe enough to cause marked impairment in social or occupational functioning

major depressive episode

• 5+ of these symptoms present during the same 2-week period representing a change in functioning

• at least 1 must be 1 or 2

• 1. depressed mood most of the day nearly every day

• 2. diminished interest/pleasure in all or most activities most of the day nearly every day

• 3. significant weight loss or weight gain, increase/decrease in appetite nearly every day

• 4. insomnia or hypersomnia nearly every day

• 5. psychomotor agitation or retardation nearly every day

• 6. fatigue or loss of energy nearly every day

• 7. feelings of worthlessness or excessive or inappropriate guilt nearly every day

• 8. diminished ability to think or concentrate or indecisiveness nearly every day

• 9. recurrent thoughts of death, recurrent si without plan, or attempt, or specific plan

major depressive disorder

• does not have the manic and/or hypomanic episodes seen in bipolar disorders

• consider the medications and medical conditions of the client

depressive disorders

• premenstrual dysphoric disorder — consider whether a charting of symptoms follows the premenstrual pattern

• remember some substances and medications can induce depressive moods in clients

anxiety disorders examples

• Separation anxiety disorder 

• Selective mutism  

• Specific phobias 

• Social anxiety disorder 

• Panic disorder 

• Agoraphobia 

• Generalized anxiety disorder 

• Anxiety disorder due to another medical condition 

• Other specified/unspecified

anxiety disorders

• Characterized by features of excessive fear and anxiety 

• FEAR is described by the DSM-5-TR as the emotional response to real or perceived imminent threat

• ANXIETY is described by the DSM-5-TR as anticipation of future threat

• Anxiety disorders typically appear in childhood and occur more frequently in girls

• high level of comorbidity

separation anxiety

• prevalence much higher among children

• may develop after some sort of life stress

• duration — 6 months in adults and 4 weeks in children/adolescents

selective mutism

• aka situational mutism

• duration must be at least one month and can not be limited to the first month of school

• fluency/communication disorders must be ruled out

• can’t occur exclusively during a psychotic episode

specific phobia

• Fear/anxiety must be persistent (last six months or more) 

• Fear/anxiety must be causing clinically significant distress

• If phobia arises after traumatic event, consider if PTSD criteria are met

• agoraphobia must be ruled out

social anxiety disorder

• children — must also be present in peer settings

• fear/anxiety must be out of proportion

• possible specifier of performance only can be used if fear is restricted to public speaking/presentation/performance

• agoraphobia must be ruled out

• level of insight must be considered (rule out delusions) as well as their capacity for social communication (rule out ASD)

panic disorder

• characterized by panic attacks

• attacks must be followed by either worry about additional attacks and/or significant maladaptive changes as a result of the attacks

panic attack

• An abrupt surge of intense fear or intense discomfort that reaches a peak within minutes (literally, we are talking 2 or 3 minutes) during which 4+ of the following symptoms are present:

• Heart palpitations 

• Sweating 

• Trembling/shaking

• Shortness of breath 

• Feelings of choking 

• Chest pain/discomfort 

• Nausea/abdominal distress 

• Feeling dizzy/light-headed 

• Chills or heat sensation 

• Paresthesias (numbness) 

• Derealization/depersonalization

• Fear of losing control (going crazy) 

• Fear of dying

• NOT A DISORDER WITH A CODE — OCCURS DURING OTHER DISORDER

Generalized anxiety disorder

• Excessive anxiety and worry must occur most days over a period of at least 6 months 

• 3+ symptoms must be present (only 1 for children)

• restlessness or feeling keyed up or on edge 

• Being easily fatigued 

• Irritability 

• Difficulty concentrating or mind going blank 

• Muscle tension 

• Sleep disturbances

• These symptoms must be related to the anxiety/worry

other medical conditions/substance-induced

• For substance or medication-induced anxiety disorder, the predominant clinical feature is the anxiety or panic attacks

• An important specifier for substance/medication-induced is the specifier for onset: is it during symptoms, during withdrawal, or after medication use?

obsessions & compulsions

• obsessions: defined by the DSM-5-TR as recurrent and persistent thoughts, urges, or images that are experienced as intrusive and unwanted 

• Compulsions: defined by the DSM as repetitive behaviors or mental acts that an individual feels driven to perform in response to an obsession or according to rules that must be applied rigidly 

obsessive-compulsive disorder

• Characterized by the presence of obsessions, compulsions, or both 

• For obsessive thoughts, the individual must attempt “to ignore or suppress such thoughts, urges, or images, or to neutralize them with some other thought or action” 

• For compulsions, the repetitive behaviors or mental acts are “in response to an obsession or according to rules that must be applied rigidly” 

• Specify if the individual also has a current/past tic disorder diagnosis 

  • Two reasons: 

  • High comorbidity between OCD and tic disorders 

  • Helps us parse through whether compulsions might or might not be related to the tic disorders 

• Behaviors must be time-consuming or cause clinically significant distress 

body dysmorphic disorder

• Preoccupation with one or more perceived defects or flaws in physical appearance that are not observable or appear slight to others 

• Repetitive behaviors or mental acts (compulsions) must have occurred at some point during the course of the disorder (mirror checking, excessive grooming, comparing self to others, etc.)

• Preoccupation causes clinically significant distress or impairment in functioning 

hoarding disorder

• The primary clinical presentation is persistent difficulty parting with possessions regardless of their actual value 

• Distress is associated with discarding items; perceived need to save 

• Must cause clinically significant distress or impair functioning

• “With excessive acquisition” is a common specifier in upward of 80% of cases

• hoarding disorder is NOT diagnosed if the symptoms are judged to be a direct consequence of typical obsessions/compulsions in obsessive-compulsive disorder

trichotillomania and excoriation disorder

• Trichotillomania (hair-pulling disorder) is characterized by the recurrent pulling out of one’s hair with repeated attempts made to stop/decrease hair-pulling 

• Excoriation (skin picking) disorder – characterized by recurrent skin picking resulting in skin lesions with repeated attempts to stop/decrease skin picking 

• Either must cause clinically significant distress or impairment

other specified obsessive-compulsive and related disorders

• Some examples: 

  • Body dysmorphic-like disorders with actual flaws 

  • Body dysmorphic-like disorder without repetitive behaviors 

  • Obsessional jealousy 

  • Olfactory reference disorder (olfactory reference syndrome) 

  • Shubo-kyofu (related to excessive fear of having a bodily deformity) 

  • Koro (related to an intense anxiety episode that penis/vulva/nipples will recede into the body, possibly leading to death) 

• The culture and psychiatric diagnosis section is important here 

trauma and stress-related disorders

• Exposure a traumatic or stressful event is listed as a diagnostic criterion for each

• Reactive attachment disorder 

• Disinhibited social engagement disorder 

• Posttraumatic stress disorder 

• Acute stress disorder 

• Adjustment disorder 

• Prolonged grief disorder

reactive attachment disorder

• The key diagnostic feature is “absent or grossly underdeveloped attachment” between a child and caregivers

• Child’s ability to express positive emotions is absent or diminished

• Signs must be evident before age 5 to meet the criteria, and the child must have a developmental age of at least 9 months 

• Autism Spectrum Disorder must be ruled out

disinhibited social engagement disorder

• The primary clinical indicator is “a pattern of culturally inappropriate, overly familiar behavior with relative strangers” 

• cannot be given before (developmental age of 9 months) 

• The insufficient care is presumed to be responsible for the behaviors

PTSD

• experiencing a traumatic event does not automatically equal a PTSD diagnosis 

• Requires exposure: direct experience, witnessing in person, learning about the event occurring to a close connection, repeated exposure to adverse details 

• Avoidance or attempts to avoid distressing memories and/or external reminders of the traumatic event 

• To be diagnosed as PTSD, disturbances must occur for at least one month 

acute stress disorder

• The criteria for acute stress disorder mirror those of PTSD 

• The distinguishing factor of Acute Stress Disorder is the duration of symptoms 

• Acute stress disorder involves symptom patterns that resolve within one month of the onset

• Symptom pattern must last at least 3 days to be diagnosable as an acute stress disorder

adjustment disorder

• most prevalent of mental health diagnoses

• The activating incident does not need to meet the high level of criteria required for diagnosis of PTSD or Acute Stress Disorder

• Development must occur within three months of the onset of the stressor and last no more than 6 months after the stressor ends 

prolonged grief disorder

• primary clinical concern is “a prolonged maladaptive grief reaction”

• the death of a person who was close to the bereaved must have occurred at least 12 months ago (or at least 6 months in children) 

• “an intense yearning or longing for the deceased person.. Or preoccupation with thoughts or memories of the deceased”

dissociative disorders

• Characterized by a disruption of and/or discontinuity in the normal integration of consciousness, memory, identity, emotion, perception, body representation, motor control, and behavior 

• When dissociative disorders appear, it is frequently in the aftermath of a traumatic experience

dissociative identity disorder

• Characterized by two or more distinct personality states (can be described in some cultures as possession) 

• Discontinuity in sense of self and sense of agency accompanied by alterations in affect, behavior, consciousness, memory, perception, cognition, and/or sensory-motor functioning 

• Recurrent gaps in recall of everyday events

dissociative amnesia

• Inability to recall important autobiographical information, usually of a traumatic or stressful nature, that is inconsistent with ordinary forgetting

• Dissociative Fugue  unexpectedly travels or engages in new activities, often without memory of the episode (“purposeful travel or bewildered wandering”)

• typical response to trauma

depersonalization/derealization disorder

• Depersonalization:  Experiences of unreality, detachment, or being an outside observer with respect to one’s thoughts, feelings, sensations, body, or actions 

• Derealization: Experiences of unreality or detachment with respect to surroundings (e.g., unreal, dreamlike, foggy, distorted)

•  involves persistent or recurrent experiences of one or both of these symptoms 

eating disorders

• Rumination disorder: repeated regurgitation of food over a period of time. Food can be re-chewed, re-swallowed, or spit out 

• Anorexia Nervosa: restriction of food intake, intense fear of weight gain, distorted body image — two types: restrictive and binge/purge type 

• Bullimia nervosa: cycles of binge eating followed by compensatory behaviors (purging, excessive exercise, fasting) 

• Binge eating disorder: recurrent episodes of binge eating without compensatory behaviors 

• Avoidant/restrictive food intake disorder (ARFID): extreme food avoidance due to sensory issues, fear of choking, or lack of interest in eating 

• Atypical anorexia nervosa: similar to anorexia nervosa, but individuals maintain a weight within or above the normal range 

• Orthorexia: an unhealthy obsession with eating foods that one considers pure or healthy, often to the point of avoiding entire food groups. The most normalized form of disordered eating

somatic symptom disorder

• One or more somatic symptoms that are distressing or result in significant disruption of daily life must be present 

• At least one of the following: 

  • Disproportionate and persistent thoughts about the seriousness of one’s  symptoms 

  • A persistently high level of anxiety about health or symptoms 

  • Excessive time and energy devoted to these symptoms or health concerns

illness anxiety disorder

• Characterized by a preoccupation with having or acquiring a serious illness

• somatic symptoms are not present

factitious disorder

• Characterized by the falsification of physical or psychological symptoms or induction of injury or disease, associated with identified deception 

• The individual presents themselves to others as ill, impaired, or injured 

• The deceptive behavior is evident even in the absence of obvious external rewards

elimination disorders

• The inappropriate elimination of urine or feces 

• Elimination disorders are most commonly first diagnosed in childhood or adolescence 

  • Nocturnal: occurring during nighttime sleep 

  • Diurnal: occurring during waking hours

enuresis

• Voiding of urine into bed or clothes 

• Clinical significance can be established through frequency (at least twice a week for 3 consecutive months) or through impairment of functioning 

• The client must be at least 5 years of age (developmentally)

• most common during nighttime

encopresis

• Repeated passage of feces into inappropriate places (e.g., clothing, floor, etc.) 

• Frequency of at least once a month for 3 months 

• Client must be at least 4 years of age

substance use criteria

• Criteria 1-4, Impaired control over substance use 

• Criteria 5-7, Social Impairment 

• Criteria 8-9, Risky Use (alcohol use disorder— physically hazardous alcohol use – continue using alcohol even though you have a live condition that can worsen) 

• Criteria 10, Tolerance 

• Criteria 11, Withdrawal (greatly varies across substances)

substance intoxication

• Criterion A: Recent ingestion of a substance 

• Criterion B: clinically significant problematic behavioral or psychological changes associated with intoxication 

• Criterion C: substance-specific signs and symptoms 

• Criterion D: Symptoms not better attributed to a medical condition or another mental health disorder 

• OFTEN co-occurring with substance use disorder, but the criteria for substance use disorders do NOT need to be met to have this diagnosis

substance withdrawal

• Criterion A: development of substance-specific problematic behavioral, physiological, and cognitive symptoms resulting from the cessation or reduction in prolonged substance use 

• Criterion B: Substance-specific symptoms 

• Criterion C: Symptoms (in criterion B) cause clinically significant distress or impaired functioning 

• Criterion D: Symptoms not better explained by a medical condition or other mental disorder

gambling disorder

• Diagnosable if at least 4 of 9 specific criteria are met in a 12-month period 

• The gambling cannot be better explained by a manic episode 

• Severity is specified by the number of criteria met 

• Specify whether episodic or persistent 

• A common feature is “chasing one’s losses” 

sleep-wake disorders

• Dissatisfaction with sleep 

  • Quality

  • Timing

  • Amount

Core features are the resulting daytime distress and impairment

sleep-wake disorders examples

• Insomnia disorder 

• Hypersomnia disorder 

• Narcolepsy 

• Breathing-related sleep disorders (Apnea, Hypoventilation, etc.) 

• Circadian Rhythm Sleep-Wake Disorders 

• Parasomnias (Sleepwalking, Sleep terror, nightmare disorder, REM sleep behavior disorder) 

• Restless Leg Syndrome 

• A whole host of other specified and unspecified categories ,depending on the specific presentation

insomnia disorder

• There must be adequate opportunity to sleep

  • This is a common error, providing this diagnosis when some ecological factor is impairing sleep.

• It cannot be better explained or occur only during another sleep-wake disorder (e.g., parasomnia)

hypersomnolence disorder

• We have the inverse of insomnia in many ways

• Feelings of sleepiness despite an appropriate main sleep period

• It is more than just fatigue, it needs at least one of three specific symptoms

  • Recurrent periods of sleep or lapses into sleep within the same day

  • A prolonged main sleep episode of more than 9 hours per day that is nonrestorative

  • Difficulty being fully awake after abrupt awakening.

narcolepsy

• “Recurrent periods of irrepressible need to sleep, lapsing into sleep, or napping occurring within the same day” present at least 3 times per week over the past 3 months

• There must be at least one of the three specific symptoms present:

  • Cataplexy (loss of muscle control with full conscious awareness)

  • Hypocretin deficiency (medical test required)

  • REM latency (nocturnal polysomnography required)

nightmare disorder

• Must have REPEATED OCCURRENCES

  • Dreams must be well remembered, extended, and extremely dysphoric in nature.

  • Must have rapid orientation to reality and alertness upon waking

  • Clinically significant distress or impairment from sleep disturbance

sexual dysfunction disorders

• Erectile Disorder: Difficulty achieving or maintaining an erection sufficient for sexual activity. (important to ask what types of substances they may be taking, was this sudden, or have they had it for years) 

• Female Sexual Interest/Arousal Disorder: Lack of or significantly reduced sexual interest or arousal in females. 

• Male Hypoactive Sexual Desire Disorder: Persistently low sexual desire or lack of sexual fantasies in males. 

• Female Orgasmic Disorder: Difficulty or inability to achieve orgasm after adequate sexual stimulation in females.

• Delayed Ejaculation: Marked delay in or absence of ejaculation during sexual activity in males.

• Premature (Early) Ejaculation: Ejaculation occurs within one minute of penetration or before the individual desires it.

• Genito-Pelvic Pain/Penetration Disorder: Pain during intercourse, fear or anxiety about vaginal penetration, or difficulties with vaginal penetration.

• Substance/Medication-Induced Sexual Dysfunction: Sexual dysfunction caused by the use of substances or medications.

gender dysphoria

• The primary diagnostic feature is “a marked incongruence between the gender to which they have been assigned” and the client’s “experienced/expressed gender.”

• For diagnosis, there must be evidence of distress related to this incongruence (remember, it is the dysphoria that is of clinical concern)

conduct disorder

• Characterized by “repetitive and persistent pattern of behavior” violating the rights of others or age-appropriate societal norms 

• At least 3 of 15 specific behavioral indicators must be met 

• If the client is over 18 years old, Antisocial Personality Disorder must be ruled out

oppositional defiant disorder

• “Frequent and persistent pattern of angry/irritable mood, argumentative/defiant behavior, or vindictiveness” (note: presentation cannot only be toward siblings) 

• Presentation of behaviors without the angry/irritable mood symptoms is not uncommon 

• Persistence and frequency need to be determined

intermittent explosive disorder

• Outbursts can involve verbal or physical aggression 

• A developmental age of at least 6 years old is required for diagnosis 

• Magnitude of outbursts must be out of proportion with antecedent; outbursts are not premeditated (onset is typically very rapid); outbursts are not associated with some tangible objective 

pyromania and kleptomania

• Both Dx deal with recurrent episodes of failing to control specific impulses

• Both involve tension or affective arousal before the act, followed by relief/pleasure after the completion

• Pyromania: Deliberate fire setting (not done for monetary gain, expression of ideology, attempt to conceal criminal activity, hallucinations, etc.). Fascination, interest, curiosity, and/or attraction to fire is part of the criteria.Kleptomania: Recurrent failure to resist stealing objects (not needed for personal use or their monetary value; not done to express anger or in response to a hallucination/delusion).

personality disorders

• Enduring pattern of inner experience and behavior that deviates markedly from the norms and expectations of the individual’s culture, it pervasive and inflexible, has an onset in adolescence or early adulthood, is stable over time, and leads to distress or impairment 

• Cluster A: Odd or eccentric 

  • Paranoid, schizoid, schizotypal 

• Cluster B: Dramatic, Emotional, or Erratic 

  • Antisocial, borderline, histrionic, narcissistic 

• Cluster C: Anxious or fearful 

  • Avoidant, dependent, obsessive-compulsive

personality disorder traits

• An enduring pattern of inner experience and behavior that deviates from the norms/expectations of the individual’s culture 

• The pattern is inflexible and present across a broad range of personal and social settings 

• Pattern leads to clinically significant distress or impairment 

• Pattern is stable and long-term, must be traced back to at least adolescence/early adulthood 

cluster a (personality disorders)

• Paranoid Personality Disorder: 

• Characterized by a pervasive mistrust of others. There is a belief (without merit) that others will exploit, harm, or deceive them 

  • Must meet 4+ specific symptoms

• Schizoid Personality Disorder: 

  • Characterized by detachment from social relationships and a restricted range of emotions (beginning by early adulthood) 

  • Must meet 4+ specific symptoms

  • do not seek relationships (not just that they lack them), and gain no pleasure from being a part of a family or social group 

• Schizotypal Personality Disorder: 

  • Characterized by social and interpersonal deficits with reduced capacity to form close relationships 

  • The presence of cognitive or perceptual distortions and eccentricities of behavior are present, starting by early adulthood and present in multiple settings 

cluster b (personality disorders)

• Antisocial Personality Disorder: 

  • Characterized by “a pervasive pattern of disregard for and violation of the rights of others” 

  • At least three specific symptoms

  • Cannot be diagnosed before age 18

  • evidence of conduct disorder with onset before age 15 

  • lack empathy and are described as callous or cynical

• Borderline Personality Disorder: 

  • Characterized by “a pervasive pattern of instability of interpersonal relationships, self-image, and effects, and marked impulsivity” 

  • Must begin by early adulthood and be present across many contexts 

  • Intense fears of abandonment; commonly seen with an intolerance of being alone and a need of having people with them 

  • Unstable self-image or sense of self is a key diagnostic indicator 

• Histrionic Personality Disorder: 

  • Characterized by “a pervasive pattern of excessive emotionality and attention seeking” beginning by early adulthood

  • Five or more of eight specific criteria

  • Individuals feel uncomfortable or underappreciated when they are not the center of attention.

  • May be overly concerned with impressing others and fish for compliments

• Narcissistic Personality Disorder: 

  • Characterized by pervasive patterns of “grandiosity, need for admiration, and lack of empathy” across a variety of contexts and beginning by early adulthood 

  • Must meet five or more specific symptoms

  • A sense of entitlement is present; commonly insist on only working with the “top” professionals

  • very sensitive to criticism or defeat

cluster c (personality disorders)

• Avoidant Personality Disorder: 

  • Characterized by a “pervasive pattern of social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation” 

  • Must have four or more specific symptoms

  • Commonly have a markedly low threshold for criticism 

  • Self-concept (self-esteem and sense of inferiority) is the main distinction between APD and Social Anxiety Disorder

• Dependent Personality Disorder: 

  • Characterized by “a pervasive and excessive need to be taken care of that leads to submissive and clinging behavior and fears of separation” 

  • Difficulty making simple, everyday decisions without input from others can be difficult 

  • Pessimism and self-doubt

  • Passively allow others to take co

• Obsessive-Compulsive Personality Disorder

  • Characterized by “a preoccupation with orderliness, perfectionism, and mental and interpersonal control at the expense of flexibility, openness, and efficiency” 

  • Must demonstrate at least 4 of 8 specific symptoms

  • Painstaking attention to rules, schedules, procedures, lists, and trivial details 

  • Decision-making can become a time-consuming endeavor 

  • Individuals may “have difficulty relating to and sharing emotions” 

majo/minor neurocognitive disorders

• Specific criteria exist for identifying a major or minor neurocognitive disorder; must be met for each specific dx

• The major/minor designation is based on the assessment of level of cognitive decline (see the table for guidance)

• Decline must be from a former level of cognitive performance 

• Codes are determined by the subtypes related to underlying pathology

delirium

• (episodes about a week, but can be long-term)

  • “Acute impairment of consciousness characterized by a disturbance in attention accompanied by reduced awareness of the environment 

    • This must be a change from baseline functioning 

  • The reduced ability to focus, sustain, and shift attention is a key diagnostic criterion for this condition 

  • must be evidence that the disturbance is a direct consequence of another medical condition, substance, or withdrawal

paraphilic disorders

• Paraphilia is defined as “any intense and persistent sexual interest other than sexual interest in genital stimulation or preparatory fondling within phenotypically normal, physically mature, consenting human partners.”

•  paraphilia must cause distress or impairment to the individual or be a paraphilia whose satisfaction entails harm or risk of harm to others 

anomalous activity preferences

• Voyeuristic Disorder 

• Exhibitionist Disorder 

  • Target is specified 

• Frotteuristic Disorder (touching or rubbing against a nonconsenting person)

• Sexual Masochism Disorder 

  • Arousal is from acts upon the individual 

  • Specifier can be made with asphyxiation 

• Sexual Sadism Disorder 

  • Arousal is from acts upon others 

• Specifiers for “in a controlled environment” should be used when the individual is living in a setting where opportunities to engage in behavior are restricted

anomalous targeting preferences

• Pedophilic Disorder 

• Fetishistic Disorder 

  • Specify body part(s), nonliving object(s), or other 

• Transvestic Disorder 

  • Specifically refers to sexual arousal from cross-dressing; there is not an incongruence between gender assigned at birth and the gender experienced by the individual

• Other Specified Paraphilic Disorder 

  • Some specific paraphilias do not meet the criteria of fetishistic disorder (e.g., Zoophilia/animals)

  • Specific reason must be specified (e.g., Paraphilia less than 6 months) 

other problems of attention

• This chapter of the DSM-5-TR is meant to classify the psychosocial and environmental problems that can be a focus of clinical attention or impact diagnosis/treatment/etc. 

• These codes (often referred to as Z-codes) can be coded if…

  • 1. If it is a reason for a current visit 

  • 2. It helps explain the need for a test/treatment/procedure

  • 3. It initiates or exacerbates a mental health diagnosis 

  • 4. It is a problem that should be considered in the case management plan 

• These codes describe circumstances, not illness. They provide context and are not typically billable on their own.