Other Conditions That May Be a Focus of Clinical Attention

What are conditions that may be a focus of clinical attention

Psychosocial / relational / environmental / behavioral or historical problems that may affect assessment / treatment / prognosis or clinical management

Are conditions in this chapter mental disorders

No

Why are these conditions included in DSM 5 TR

To help clinicians document important problems that affect mental health assessment and treatment

What type of codes are commonly used for conditions in this chapter

Z codes

When can a condition in this chapter be coded

When it is the reason for the visit / explains need for services / contributes to a mental disorder / or affects the treatment plan

What major categories are included in this chapter

Suicidal behavior and self injury / abuse and neglect / relational problems / educational problems / occupational problems / housing problems / economic problems / social environment problems / legal problems / other psychosocial problems / health care access problems / personal history / counseling encounters / additional clinical conditions

What is suicidal behavior

Potentially self injurious behavior performed with at least some intent to die

Does a suicide attempt have to produce physical injury

No

Can suicidal intent be inferred rather than directly stated

Yes

What is current suicidal behavior

Suicidal behavior that is part of the current clinical presentation

What code identifies history of suicidal behavior

Z91.51

What does history of suicidal behavior mean

Suicidal behavior has occurred at some point during the persons lifetime

What is nonsuicidal self injury or NSSI

Intentional self inflicted bodily damage without suicidal intent

What are examples of nonsuicidal self injury

Cutting / burning / stabbing / hitting / excessive rubbing

What is the defining distinction between suicidal behavior and NSSI

Suicidal behavior includes some intent to die / NSSI occurs without suicidal intent

What code identifies current nonsuicidal self injury

R45.88

What code identifies history of nonsuicidal self injury

Z91.52

Can suicidal behavior and NSSI both occur in the same person

Yes

Why must intent be assessed when evaluating self injury

Intent distinguishes suicidal behavior from nonsuicidal self injury

What broad maltreatment categories are included in this chapter

Physical abuse / sexual abuse / neglect / psychological abuse

Why should clinicians use care when coding abuse and neglect

These conditions can have significant legal implications

Can past abuse or neglect affect current treatment

Yes / it may influence diagnosis / symptoms / treatment response / and prognosis

What is child physical abuse

Nonaccidental physical injury inflicted on a child by a caregiver or responsible person

What are examples of child physical abuse

Punching / kicking / biting / shaking / choking / burning / hitting / stabbing / throwing

Does a caregiver need to intend injury for child physical abuse to qualify

No

When is physical discipline not considered child physical abuse

When it is reasonable and causes no bodily injury according to the DSM description

What is child sexual abuse

Sexual activity involving a child for the sexual gratification of a caregiver or responsible individual

Can child sexual abuse occur without physical contact

Yes

What are examples of noncontact child sexual abuse

Forcing / enticing / threatening / pressuring or exploiting a child for sexual purposes

What is child neglect

Egregious caregiver action or omission that deprives a child of basic age appropriate needs and creates actual or potential harm

What needs can be neglected in child neglect

Supervision / emotional needs / education / medical care / food / shelter / clothing

What is child psychological abuse

Nonaccidental verbal or symbolic acts by a caregiver that cause or may cause significant psychological harm

What are examples of child psychological abuse

Berating / humiliation / threats / extreme scapegoating / confinement / excessive discipline

Can threatening to harm something a child cares about be psychological abuse

Yes

What is spouse or partner physical violence

Nonaccidental physical force causing or potentially causing harm or significant fear in an intimate partner

What behaviors can qualify as partner physical violence

Shoving / slapping / choking / hitting / kicking / restraining / burning / weapon use

Are acts performed solely for legitimate self protection included as partner physical violence

No

What is spouse or partner sexual violence

Physical force or psychological coercion used to compel sexual activity against a partners will

Can sexual activity with a partner unable to consent qualify as partner sexual violence

Yes

What is spouse or partner neglect

Egregious action or omission that deprives a dependent partner of basic needs and creates physical or psychological harm

When is partner neglect especially relevant

When one partner depends heavily on the other for care or assistance with daily functioning

What is spouse or partner psychological abuse

Nonaccidental verbal or symbolic behavior that causes or may cause significant psychological harm

What behaviors can qualify as partner psychological abuse

Humiliation / interrogation / controlling movement / isolation / threats / stalking / economic restriction / blocking access to help / gaslighting

What is gaslighting in the DSM description

Trying to make a partner question their sanity or perception of reality

What is adult abuse by a nonspouse or nonpartner

Physical / sexual / or psychological maltreatment of an adult by another adult who is not an intimate partner

Can restricting access to money be considered psychological abuse

Yes when used as coercive or harmful control

Can social isolation be considered psychological abuse

Yes when intentionally imposed as part of abusive behavior

What is a parent child relational problem

A clinically important disturbance in the quality of the relationship between a child and caregiver

What areas may be impaired in a parent child relational problem

Behavior / cognition / emotion

What are behavioral examples of parent child relational problems

Inadequate supervision / overprotection / excessive pressure / escalating arguments / unresolved avoidance

What are cognitive examples of parent child relational problems

Negative interpretations / hostility / scapegoating / unwarranted estrangement

What are emotional examples of parent child relational problems

Sadness / apathy / anger toward the other person

What should clinicians consider when evaluating parent child relational problems

Developmental needs of the child and cultural context

What is sibling relational problem

A problematic sibling interaction pattern causing significant individual or family impairment

Can sibling relational problem be used for adults

Yes

What relationships count as siblings for this code

Full / half / step / foster / adopted siblings

What is relationship distress with spouse or intimate partner

A significant relationship problem that is the focus of care or affects treatment / prognosis / or health

What problems may occur in intimate relationship distress

Conflict / withdrawal / overinvolvement / negative assumptions / sadness / anger

Does relationship distress require abuse

No

What is disruption of family by separation or divorce

A situation in which intimate partners are living apart because of relationship problems or are divorcing

What is a child affected by parental relationship distress

Negative effects on a child caused by significant parental conflict or relationship distress

What is high expressed emotion within a family

High levels of criticism / hostility / or emotional overinvolvement directed toward an identified family member

Why can high expressed emotion matter clinically

It may affect the course / prognosis / or treatment of a family members condition

What are examples of educational problems

Low literacy / unavailable schooling / failed examinations / underachievement / teacher conflict / inadequate teaching

What is underachievement in school

Performance below what would be expected from the persons intellectual ability

What are examples of occupational problems

Unemployment / job change / threatened job loss / stressful schedule / workplace conflict / hostile work environment / work strain

What is a problem related to current military deployment status

An occupational problem directly associated with current military deployment

Should psychological symptoms caused by deployment be coded only as a deployment problem

No / an adjustment disorder or another mental disorder may better capture the psychological reaction

What is sheltered homelessness

Primary nighttime residence is a shelter / temporary housing / motel / transitional setting or similar shelter arrangement

What is unsheltered homelessness

Living in a location not intended for human habitation

What are examples of unsheltered homelessness

Street / car / abandoned building / public space / cave / makeshift shelter

What is inadequate housing

Housing with conditions such as lack of utilities / infestation / overcrowding / poor sanitation / inadequate sleeping space

Why should culture be considered when evaluating housing adequacy

Housing expectations and norms may differ across cultural contexts

What are major economic problems recognized in this chapter

Food insecurity / unsafe drinking water / extreme poverty / low income / insufficient insurance / insufficient welfare support

What is food insecurity

Lack of reliable access to adequate food

Why are economic problems clinically important

They can affect symptoms / ability to access treatment / adherence / and prognosis

What is a problem related to living alone

Clinically significant difficulty associated with living alone such as loneliness / isolation / or lack of daily structure

What is acculturation difficulty

Difficulty adapting to a new culture following migration or another cultural transition

What is social exclusion or rejection

Repeated exclusion or rejection associated with an imbalance in social power

What behaviors are examples of social exclusion or rejection

Bullying / teasing / intimidation / humiliation / purposeful exclusion

What is adverse discrimination or persecution

Experienced or perceived mistreatment based on membership or perceived membership in a social category

What characteristics may be targets of discrimination

Gender / gender identity / race / ethnicity / religion / sexual orientation / nationality / disability / social status / weight / appearance

What legal system problems may be coded

Criminal conviction / incarceration / release from prison / civil litigation / child custody or support proceedings

Can incarceration itself be clinically relevant even when it is not a mental disorder

Yes

What is a problem related to lifestyle

A lifestyle behavior that is a focus of treatment or directly affects the course or treatment of another condition

What are examples of lifestyle problems

Lack of exercise / poor diet / high risk sexual behavior / poor sleep hygiene

Should a lifestyle problem caused entirely by a mental disorder always receive its own code

No unless it independently requires clinical attention or affects treatment

What psychosocial circumstances can be coded beyond housing and finances

Unwanted pregnancy / victimization / crime / terrorism / torture / disaster / war

What does exposure to disaster war or other hostilities represent

A psychosocial or environmental circumstance that may affect clinical care

What health care access problems can be coded

Unavailable or inaccessible health care facilities / unavailable helping agencies

What is personal history of psychological trauma

A history of past psychological trauma that is clinically relevant to current assessment or treatment

What is personal history of military deployment

A history of military deployment that may be clinically relevant

What is genetic counseling in this chapter

Counseling about genetic risk of disorders for the person or family

What is sex counseling

Counseling related to sexual education / behavior / orientation / attitudes / relationships / or sexual enjoyment

What is dietary counseling

Counseling related to diet or weight management

What is wandering associated with a mental disorder

Clinically significant wandering related to a mental disorder that creates safety or management concerns

What disorders may involve clinically significant wandering

Major neurocognitive disorders / neurodevelopmental disorders

What should be coded first when wandering is associated with a mental disorder

The associated mental disorder

What behavior is excluded from wandering associated with a mental disorder

Running away to escape an unwanted setting or pacing caused by akathisia

What is uncomplicated bereavement

A normal grief reaction following the death of a loved one that becomes a focus of clinical attention