The ICD-10 and the DSM-5 Made Simple . . . Kind Of, Part I
I’m guessing that by now you probably heard lots of talk about the new International Statistical Classification of Diseases and Related Health Problems (10th edition), or ICD-10, and hopefully you’ve attended a training or two. Unfortunately, many counselors have very little understanding about what the ICD-10 is and how is going to affect the work that we do. The little bit that we have been hearing is frightening since there is so much emphasis on the fact that “something” went into effect on October 1, 2015.
You also have probably heard that the Diagnostic and Statistical Manual of Mental Disorders (4th edition), or DSM-IV was updated a couple of years ago and that there were several changes made to the newest addition, the DSM-5 (2013). You may or may not have begun to understand those changes or implement those changes in your clinical work. And many of us are not sure how the DSM-5 and ICD-10 are related and what if anything we as treatment providers need to do differently.
So, in this first column of a two-part series, I am going to give an overview of the DSM-5. In my column in the next issue of Counselor, I will go over the ICD-10. I want to explain how they are connected and what it means to California addiction counselors. I hope these columns provide enough information to get you hungry for more!
A Little Background
Several months ago I was asked if I would be willing to do a training on the ICD-10 and the DSM-5. Being the seasoned educator that I am—and in addition to having an overblown sense of confidence in my abilities—I cavalierly said, “Sure, I can put something together!” Little did I know that I was embarking one of the biggest training commitments of my twenty-nine-year career.
I was not prepared for the hours and hours of studying, writing, and researching that was to come. Just when I thought, “Okay, I think I’ve got a handle on this,” I would learn something new, someone would ask a question I couldn’t answer or correct something I said during a presentation, and then it was back to the office to update my presentation. My first two trainings were a disaster! I realized that I really didn’t know enough about the subject matter to stand in front of 125 people and try to explain it. My ego wouldn’t let me go out like that, so I dug in deep, studied my butt off, and as a result each of the several subsequent trainings and consultations have been better, as I have become quite comfortable with the material.
I say this because many of us don’t bother to really learn new information unless we have a very strong desire to learn and stay current, or unless we have to, and even when we have to, many of us learn just enough to get by. You still have the option to learn the DSM-5 when you get around to it, unless your organization or payer is insisting that you use the most current diagnostic criteria, but you do not have the option to not learn and understand the ICD-10 because as of October 1, 2015, providers are not paid if they submit charges using the old ICD-9 codes.
So let me tell you what all that means in the simplest and easiest terms. Mind you, this is not to assume that the reader is “simple” and unable to understand complex ideas and concepts; it’s actually easier for me to write how I talk, which is, I’m happy to say, “plain and simple.”
So first I’m going to talk about the DSM-5 and the changes that are most significant, in my opinion, to addiction counselors. I will also point you to several resources that you might find useful if you want to learn more about this material.
The DSM-5, written and published by the American Psychiatric Association (APA), came out in 2013. It contains several changes in language, philosophy, diagnostic criteria, and the addition and elimination of several diagnoses that counselors and mental health professionals have been using for years. In the US the DSM serves as a universal authority for psychiatric diagnosis. Treatment recommendations, as well as payment by health care providers, are often determined by DSM classifications, so the appearance of a new version has significant practical importance.
Although it may not be mandatory for you to use this new manual, I would strongly suggest that you do.
History and Revisions
The first version of the DSM came out in 1952 and was 132 pages. It used diagnostic terms like “idiot,” “moron,” and “imbecile.” Most notably homosexuality was listed as a “sociopathic personality disturbance,” and homosexuality was not declassified as a mental illness by the DSM until 1973. So you can see how, fortunately, thinking and language has changed.
New versions of the DSM come out on an average of every fifteen years—DSM-I (1952), DSM-II (1968), DSM-III (1980), DSM-IV (1994), and DSM-5 (2013). This current version is the first version to use the number five instead of the Roman numeral “V.” The reason for this is the expectation that there will be multiple updates, as in the DSM-IV–TR, and those will be labeled DSM 5.1, DSM 5.2, and so on.
Some of the biggest concerns about the DSM are whether psychiatrists are trying to pathologize what could be considered in some cultures “normal” behavior, and in other cases normalize pathological behavior. This leads to the following question: Who gets to determine at what point a different and odd behavior becomes a mental disorder?
One of the biggest changes to this manual is the switch from a black-and-white method of diagnosing to introducing the idea that most disorders fall across a continuum. In other words, it’s not whether or not you are depressed, but how depressed you are. We are all bipolar to a certain degree, but how bipolar are we, and at which point does it become a disorder? We’ve moved from a categorical approach to a dimensional approach to diagnosing.
They also realized that many of the diagnoses in the previous editions were actually different manifestations of the same diagnosis, so they group many diagnoses together under twenty different “clinical umbrellas” or categories. This is particularly important for us addiction counselors because there is no more “substance abuse” and “substance dependence”; those diagnoses are combined and replaced with the diagnosis of “substance use disorder” (SUD). The belief is that the only difference between substance abuse and substance dependence is the severity.
Here are some bullet points of major changes:
- “Recurrent legal issues” was eliminated from the diagnostic criteria due to cultural influences and variances and “cravings” was added.
- In the DSM-IV-TR you only needed one of the criteria for a diagnosis of substance abuse, now you need at least two for a SUD diagnosis.
- They have eliminated the Axes I–V and now want clinicians to list the diagnosis without the Axes in the order of severity, and/or what has caused the client to seek treatment.
- There is no more GAF score, but check out the alternative: Google WHODAS 2.0, which is a very cool tool and much better than the GAF.
- Hoarding disorder, gambling disorder, binge eating disorder, marijuana, and caffeine withdrawal are all new to the DSM-5.
- They eliminated the “bereavement exclusion,” meaning that now a person can be diagnosed and treated for depression even though they experienced a loss of a loved one within the previous sixty days.
- The term “mental retardation” has been eliminated and replaced with “intellectual disability.”
- For those of you who used V codes, they have been eliminated and replaced with the much more descriptive Z codes.
- There is a whole section in the DSM-5 that addresses the variances attributed to culture. This section includes a “cultural formulation interview,” which offers several assessment questionnaires that can be used with many different populations.
- They are proposing significant changes in the way personality disorders are assessed and treated, and offer some new and interesting perspectives.
Of the twenty categories of disorders listed in the DSM-5, I am only going to speak in this article on substance-related and addictive disorders in detail.
SUDs are divided into ten separate classes of drugs, and you will now need to list each drug the person uses and describe it as “mild,” “moderate” or “severe.” For example, a client might have stimulants use disorder (severe), alcohol use disorder (severe), and cannabis use disorder (moderate).
The ten drug classes are as follows:
- Sedatives, hypnotics, and anxiolytics
- Other (or unknown) substances
There are eleven diagnostic criteria, but some classes of substances have only ten criteria. Clients must have two or more within a twelve-month period and must include a pattern of use leading to clinically significant impairment or distress to be considered. To interpret the symptoms, note that two to three criteria indicate a “mild” specifier, three to five indicate “moderate,” and six or more indicate “severe.”
- Substance often taken in larger amounts or over a longer period of time than intended (impaired control)
- A persistent desire or unsuccessful efforts to cut down or control use (impaired control)
- A great deal of time spent in activities necessary to obtain the substance, use it, or recover from its effects (impaired control)
- Craving, or strong desire or urge to use (impaired control)
- Recurrent use resulting in failure to fulfill major role obligations at work, school or home (social impairment)
- Continued use despite having persistent or recurrent social/interpersonal problems caused or exacerbated by use (social impairment)
- Important social, occupational or recreational activities given up or reduced because of use (social impairment)
- Recurrent use in situations which is physically hazardous (risky use)
- Use is continued despite knowledge of having a persistent or recurrent physical/psychological problem likely to have been caused or exacerbated by use (risky use)
- Tolerance: the need for markedly increased amounts of substance to achieve intoxication or desired effect, or a markedly diminished effect with continued use of same amount (pharmacological)
- Withdrawal: a characteristic syndrome, or use to relieve or avoid withdrawal (pharmacological)
Notice that criteria one through four relate to use, criteria five through eight relate to behavioral issues associated with use, and criteria nine through eleven relate to physical/emotional issues. Furthermore, a client can be diagnosed as having a severe SUD without having tolerance or withdrawal.
You will be blown away about how much information is available on this topic. In my next column, I will tackle the ICD-10 and explain how it is different from the DSM-5.
American Psychological Association (APA). (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.