Also from James Morrison

Diagnosis Made Easier: Principles and Techniques for Mental Health Clinicians, Second Edition

The First Interview, Fourth Edition

When Psychological Problems Mask Medical Disorders:

A Guide for Psychotherapists

For more information, see www.guilford.com/morrison

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DSM-5® Made Easy The Clinician’s Guide to Diagnosis

James Morrison

THE GUILFORD PRESS New York London

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Epub Edition ISBN: 9781462515448; Kindle Edition ISBN: 9781462515455

© 2014 The Guilford Press A Division of Guilford Publications, Inc. 72 Spring Street, New York, NY 10012 www.guilford.com

All rights reserved

No part of this book may be reproduced, translated, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, microfilming, recording, or otherwise, without written permission from the publisher.

Last digit is print number: 9 8 7 6 5 4 3 2 1

The author has checked with sources believed to be reliable in his effort to provide information that is complete and generally in accord with the standards of practice that are accepted at the time of publication. However, in view of the possibility of human error or changes in behavioral, mental health, or medical sciences, neither the author, nor the editor and publisher, nor any other party who has been involved in the preparation or publication of this work warrants that the information contained herein is in every respect accurate or complete, and they are not responsible for any errors or omissions or the results obtained from the use of such information. Readers are encouraged to confirm the information contained in this book with other sources.

Library of Congress Cataloging-in-Publication Data

Morrison, James R., author. DSM-5 made easy : the clinician’s guide to diagnosis / James Morrison. p.; cm. Includes bibliographical references and index. ISBN 978-1-4625-1442-7 (hardcover : alk. paper) I. Title. [DNLM: 1. Diagnostic and statistical manual of mental disorders. 5th ed 2. Mental Disorders—

diagnosis—Case Reports. 3. Mental Disorders—classification—Case Reports. WM 141] RC469 616.89'075—dc23

2014001109

DSM-5 is a registered trademark of the American Psychiatric Association. The APA has not participated in the preparation of this book.

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For Mary, still my sine qua non

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About the Author

James Morrison, MD, is Affiliate Professor of Psychiatry at Oregon Health and Science University in Portland. He has extensive experience in both the private and public sectors. With his acclaimed practical books—including, most recently, Diagnosis Made Easier, Second Edition, and The First Interview, Fourth Edition— Dr. Morrison has guided hundreds of thousands of mental health professionals and students through the complexities of clinical evaluation and diagnosis. His website (www.guilford.com/jm) offers additional discussion and resources related to psychiatric diagnosis and DSM-5.

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Acknowledgments

Many people helped in the creation of this book. I want especially to thank my wife, Mary, who has provided unfailingly excellent advice and continual support. Chris Fesler was unsparing with his assistance in organizing my web page.

Others who read portions of the earlier version of this book, DSM-IV Made Easy, in one stage or another included Richard Maddock, MD, Nicholas Rosenlicht, MD, James Picano, PhD, K. H. Blacker, MD, and Irwin Feinberg, MD. I am grateful to Molly Mullikin, the perfect secretary, who contributed hours of transcription and years of intelligent service in creating the earlier version of this book. I am also profoundly indebted to the anonymous reviewers who provided input; you know who you are, even if I don’t.

My editor, Kitty Moore, a keen and wonderful critic, helped develop the concept originally, and has been a mainstay of the enterprise for this new edition. I also deeply appreciate the many other editors and production people at The Guilford Press, notably Editorial Project Manager Anna Brackett, who helped shape and speed this book into print. I would single out Marie Sprayberry, who went the last mile with her thoughtful, meticulous copyediting. David Mitchell did yeoman service in reading the manuscript from cover to cover to root out errors. I am indebted to Ashley Ortiz for her intelligent criticism of my web page, and to Kyala Shea, who helped get it web borne.

A number of clinicians and other professionals provided their helpful advice in the final revision process. They include Alison Beale, Ray Blanchard, PhD, Dan G. Blazer, MD, PhD, William T. Carpenter, MD, Thomas J. Crowley, MD, Darlene Elmore, Jan Fawcett, MD, Mary Ganguli, MD, Bob Krueger, PhD, Kristian E. Markon, PhD, William Narrow, MD, Peter Papallo, MSW, MS, Charles F. Reynolds, MD, Aidan Wright, PhD, and Kenneth J. Zucker, PhD. To each of these, and to the countless patients who have provided the clinical material for this book, I am profoundly grateful.

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Contents

Also from James Morrison

Title Page

Copyright Page

Dedication Page

About the Author

Acknowledgments

FREQUENTLY NEEDED TABLES

INTRODUCTION

CHAPTER 1 Neurodevelopmental Disorders

CHAPTER 2 Schizophrenia Spectrum and Other Psychotic Disorders

CHAPTER 3 Mood Disorders

CHAPTER 4 Anxiety Disorders

CHAPTER 5 Obsessive–Compulsive and Related Disorders

CHAPTER 6 Trauma- and Stressor-Related Disorders

CHAPTER 7 Dissociative Disorders

CHAPTER 8 Somatic Symptom and Related Disorders

CHAPTER 9 Feeding and Eating Disorders

CHAPTER 10 Elimination Disorders

CHAPTER 11 Sleep–Wake Disorders

CHAPTER 12 Sexual Dysfunctions

CHAPTER 13 Gender Dysphoria

CHAPTER 14 Disruptive, Impulse-Control, and Conduct Disorders

CHAPTER 15 Substance-Related and Addictive Disorders

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CHAPTER 16 Cognitive Disorders

CHAPTER 17 Personality Disorders

CHAPTER 18 Paraphilic Disorders

CHAPTER 19 Other Factors That May Need Clinical Attention

CHAPTER 20 Patients and Diagnoses

APPENDIX

Essential Tables

Global Assessment of Functioning (GAF) Scale

Physical Disorders That Affect Mental Diagnosis

Classes (or Names) of Medications That Can Cause Mental Disorders

INDEX

About Guilford Press

Discover Related Guilford Books

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Frequently Needed Tables

TABLE 3.2 Coding for Bipolar I and Major Depressive Disorders

TABLE 3.3 Descriptors and Specifiers That Can Apply to Mood Disorders

TABLE 15.1 Symptoms of Substance Intoxication and Withdrawal

TABLE 15.2 ICD-10-CM Code Numbers for Substance Intoxication, Substance Withdrawal, Substance Use Disorder, and Substance-Induced Mental Disorders

TABLE 16.1 Coding for Major and Mild NCDs

Purchasers of this ebook can download copies of these tables from www.guilford.com/morrison2-forms.

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Introduction

The summer after my first year in medical school, I visited a friend at his home near the mental institution where both of his parents worked. One afternoon, walking around the vast, open campus, we fell into conversation with a staff psychiatrist, who told us about his latest interesting patient.

She was a young woman who had been admitted a few days earlier. While attending college nearby, she had suddenly become agitated—speaking rapidly and rushing in a frenzy from one activity to another. After she impulsively sold her nearly new Corvette for $500, her friends had brought her for evaluation.

“Five hundred dollars!” exclaimed the psychiatrist. “That kind of thinking, that’s schizophrenia!”

Now my friend and I had had just enough training in psychiatry to recognize that this young woman’s symptoms and course of illness were far more consistent with an episode of mania than with schizophrenia. We were too young and callow to challenge the diagnosis of the experienced clinician, but as we went on our way, we each expressed the fervent hope that this patient’s care would be less flawed than her assessment.

For decades, the memory of that blown diagnosis has haunted me, in part because it is by no means unique in the annals of mental health lore. Indeed, it wasn’t until many years later that the first diagnostic manual to include specific criteria (DSM-III) was published. That book has since morphed into the enormous fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), published by the American Psychiatric Association.

Everyone who evaluates and treats mental health patients must understand the latest edition of what has become the world standard for evaluation and diagnosis. But getting value from DSM-5 requires a great deal of concentration. Written by a committee with the goal of providing standards for research as well as clinical practice in a variety of disciplines, it covers nearly every conceivable subject related to mental health. But you could come away from it not knowing how the diagnostic criteria translate to a real live patient.

I wrote DSM-5 Made Easy to make mental health diagnosis more accessible to clinicians from all mental health professions. In these pages, you will find descriptions of every mental disorder, with emphasis on those that occur in adults. With it, you can learn how to diagnose each one of them. With its careful

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use, no one today would mistake that young college student’s manic symptoms for schizophrenia.

WHAT HAVE I DONE TO MAKE DSM-5 EASY?

Quick Guides. Opening each chapter is a summary of the diagnoses addressed therein—and other disorders that might afflict patients who complain about similar problems. It also provides a useful index to the material in that chapter.

Introductory material. The section on each disorder starts out with a brief description designed to orient you to the diagnosis. It includes a discussion of the major symptoms, perhaps a little historical information, and some of the demographics—who is likely to have this disorder, and in what circumstances. Here, I’ve tried to state that which I would want to know myself if I were starting out afresh as a student.

Essential Features. OK, that’s the name I’ve given them in in DSM-5 Made Easy, but they’re also known as prototypes. I’ve used them in an effort to make the DSM-5 criteria more accessible. For years, we working clinicians have known that when we evaluate a new patient, we don’t grab a list of emotional and behavioral attributes and start ticking off boxes. Rather, we compare the data we’ve gathered to the picture we’ve formed of the various mental and behavioral disorders. When the data fit an image, we have an “aha!” experience and pop that diagnosis into our list of differential diagnoses. (From long experience and conversations with countless other experienced clinicians, I can assure you that this is exactly how it works.)

Very recently, a study of mood and anxiety disorders* has found that clinicians who make diagnoses by rating their patients against prototypes perform at least as well as, and sometimes better than, other clinicians who adhere to strict criteria. That is, it can be shown that prototypes have validity even greater than that of some DSM diagnostic criteria. Moreover, prototypes are reported to be usable by clinicians with a relatively modest level of training and experience; you don’t have to be coming off 20 years of clinical work to have success with prototypes. And clinicians report that prototypes are less cumbersome and more clinically useful. (However—and I hasten to underscore this point—the prototypes used in the studies I have just mentioned were generated from the diagnostic criteria inherent in the DSM criteria.) The bottom line: Sure, we need criteria, but we can adapt them so they work better for us.

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So once you’ve collected the data and read the prototypes, I recommend that you assign a number to indicate how closely your patient fits the ideal of any diagnoses you are considering. Here’s the accepted convention: 1 = little or no match; 2 = some match (the patient has a few features of the disorder); 3 = moderate match (there are significant, important features of the disorder); 4 = good match (the patient meets the standard—the diagnosis applies); 5 = excellent match (a classic case). Obviously, the vignettes I’ve provided will always match at the 4 or 5 level (if not, why would I use them as illustrative examples?), so I haven’t bothered to grade them on the 5-point scale. But you should do just that with each new patient you interview.

Of course, there may be times you’ll want to turn to the official DSM-5 criteria. One is when you’re just starting out, so you can get a picture of the exact numbers of each type of criteria that officially count the patient as “in.” Another would be when you are doing clinical research, where you must be able to report that participants were all selected according to scientifically studied, reproducible criteria. And even as an experienced clinician, I return to the actual criteria from time to time. Perhaps it’s just to have in my mind the complete information that allows me to communicate with other clinicians; sometimes it is related to my writing. But mostly, whether I am with patients or talking with students, I stick to the prototype method—just like nearly every other working clinician.

The Fine Print. Most of the diagnostic material included in these sections is what I call boilerplate. I suppose that sounds pejorative, but each Fine Print section actually contains one or more important steps in the diagnostic process. Think of it this way: The prototype is useful for purposes of inclusion, whereas the boilerplate is useful largely for the also important exclusion of other disorders and delimitation from normal. The boilerplate verbiage includes several sorts of stereotyped phrases and warnings, which as an aid to memory I’ve dubbed the D’s. (I started out by using “Don’t disregard the D’s” or similar phrases, but soon got tired of all the typing; so, I eventually adopted “the D’s” as shorthand.)

Differential diagnosis. Here I list all the disorders to consider as alternatives when evaluating symptoms. In most cases, this list starts off with substance use disorders and general medical disorders, which despite their relative infrequency you should always place first on the list of disorders competing for your consideration. Next I put in those conditions that are most treatable, and hence should be addressed early. Only at the end do I include those that have a dismal prognosis, or that you can’t do very much to treat. I call this the safety principle of differential diagnosis.

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Distress or disability. Most DSM-5 diagnostic criteria sets require that the patient experience distress or some form of impairment (in work, social interactions, interpersonal relations, or something else). The purpose is to ensure that we discriminate people who are patients from those who, while normal, perhaps have lives with interesting aspects.

As best I can tell, distress receives one definition in all of DSM-5 (Campbell’s Psychiatric Dictionary doesn’t even list it). The DSM-5 sections on trichotillomania and excoriation (skin-picking) disorder both describe distress as including negative feelings such as embarrassment and forfeiture of control. It’s unclear, however, whether the same definition is employed anywhere else, or what might be the dominant thinking throughout the manual. But for me, some combination of lost pride, shame, and control works pretty well as a definition. (DSM-IV didn’t define distress anywhere.)

Duration. Many disorders require that symptoms be present for a certain minimum length of time before they can be diagnosed. Again, this is to ensure that we don’t go around indiscriminately handing out diagnoses to everyone. For example, nearly everyone will feel blue or down at one time or another; to qualify for a diagnosis of a depressive disorder, it has to hang on for at least a couple of weeks. Demographics. A few disorders are limited to certain age groups or genders.

Coding Notes. Many of the Essential Features listings conclude with these notes, which supply additional information about specifiers, subtypes, severity, and other subjects relevant to the disorder in question.

Here you’ll find information about specifying subtypes and judging severity for different disorders. I’ve occasionally put in a signpost pointing to a discussion of principles you can use to determine that a disorder is caused by the use of substances.

Sidebars. To underscore or augment what you need to know, I have sprinkled sidebar information throughout the text (such as the one above). Some of these merely highlight information that will help you make a diagnosis quickly. Some contain historical information and other sidelights about diagnoses that I’ve found interesting. Many include editorial asides—my opinions about patients, the diagnostic process, and clinical matters in general.

Vignettes. I have based this book on that reliable device, the clinical vignette. As a student, I found that I often had trouble keeping in mind the features of

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diagnosis (such as it was back then). But once I had evaluated and treated a patient, I always had a mental image to help me remember important points about symptoms and differential diagnosis. I hope that the more than 130 patients I have described in DSM-5 Made Easy will do the same for you.

Evaluation. This section summarizes my thinking for every patient I’ve written about. I explain how the patient fits the diagnostic criteria and why I think other diagnoses are unlikely. Sometimes I suggest that additional history or medical or psychological testing should be obtained before a final diagnosis is given. The conclusions stated here allow you to match your thinking against mine. There are two ways you can do this. One is by picking out from the vignette the Essential Features I’ve listed for each diagnosis. But when you want to follow the thinking of the folks who wrote the actual DSM-5, I’ve also included references (in parentheses) to the individual criteria. If you disagree with any of my interpretations, I hope you’ll e-mail me ([email protected]). And for updated information, visit my website: www.guilford.com/jm.

Final diagnosis. Usually code numbers are assigned in the record room, and we don’t have to worry too much about them. That’s fortunate, for they are sometimes less than perfectly logical. But to tell the record room folks how to proceed, we need to put all the diagnostic material that seems relevant into verbiage that conforms to the approved format. My final diagnoses not only explain how I’d code each patient; they also provide models to use in writing up the diagnoses for your own patients.

Tables. I’ve included a number of tables to try to give you an overall picture of various topics—the variety of specifiers that apply across different diagnoses, a list of physical disorders that can produce emotional and behavioral symptoms. Those that are of principal use in a given chapter I’ve included in that chapter. A few, which apply more generally throughout the book, you’ll find in the Appendix.

My writing. Throughout, I’ve tried to use language that is as simple as possible. My goal has been to make the material sound as though it was written by a clinician for use with patients, not by a lawyer for use in court. Wherever I’ve failed, I hope you will e-mail me to let me know. At some point, I’ll try to put it right, either in a future edition or on my website (or both).

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STRUCTURE OF DSM-5 MADE EASY

The first 18 chapters* of this book contain descriptions and criteria for the major mental diagnoses and personality disorders. Chapter 19 comprises information concerning other terms that you may find useful. Many of these are Z-codes (ICD-9 calls them V-codes), which are conditions that are not mental disorders but may require clinical attention anyway. Most noteworthy are the problems people with no actual mental disorder have in relating to one another. (Occasionally, you might even list a Z-code/V-code as the reason a patient was referred for evaluation.) Also described here are codes that indicate medications’ effects, malingering, and the need for more diagnostic information.

Chapter 20 contains a very brief description of diagnostic principles, followed by some additional case vignettes, which are generally more complicated than those presented earlier in the book. I’ve annotated these case histories to help you to review the diagnostic principles and criteria covered previously. Of course, I could include only a small fraction of all DSM-5 diagnoses in this section.

Throughout the book, I have tried to give you clinically relevant and accessible information, written in simple, declarative sentences that describe what you need to know in diagnosing a patient.

QUIRKS

Here are a few comments regarding some of my idiosyncrasies.

Abbreviations. I’ll cop to using some nonstandard abbreviations, especially for the names of disorders. For example, BPsD (for brief psychotic disorder) isn’t something you’ll read elsewhere, certainly not in DSM-5. I’ve used it and others for the sake of shortening things up just a bit, and thus perhaps reducing ever so slightly the amount of time it takes to read all this stuff. I use these ad hoc abbreviations just in the sections about specific disorders, so don’t worry about having to remember them longer than the time you’re reading about these disorders. Indeed, I can think of two disorders that are sometimes abbreviated CD and four that are sometimes abbreviated SAD, so always watch for context.

My quest for shortening has also extended to the chapter titles. In the service of seeming inclusive, DSM-5 has sometimes overcomplicated these names, in my view. So you’ll find that I’ve occasionally (not always—I’ve got my obsessive– compulsive disorder under control!) shortened them up a bit for convenience.

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You shouldn’t have any problem knowing where to turn for sleep disorders (which DSM-5 calls sleep–wake disorders), mood disorders (bipolar and related disorders plus depressive disorders), psychotic (schizophrenia spectrum and other psychotic) disorders, cognitive (neurocognitive) disorders, substance (substance- related and addictive) disorders, eating (feeding and eating) disorders, and various other disorders from which I’ve simply dropped and related from the official titles. Similarly, I’ve sometimes dropped the /medication from substance/medication-induced [just about anything].

{Curly braces}. I’ve used these in the Essential Features and in some tables to indicate when there are two mutually exclusive specifier choices, such as {with} {without} good prognostic features. Again, it just shortens things up a bit.

Severity specifiers. One of the issues with DSM-5 is its use of complicated severity specifiers that differ from one chapter to another, and sometimes from one disorder to the next. Some of these are easier to use than others.

For example, for the psychoses, we are offered the Clinician-Rated Dimensions of Psychosis Symptom Severity (CRDPSS?), which asks us to rate on a 5-point scale, based on the past 7 days, each of eight symptoms (the five psychosis symptoms of schizophrenia [p. 58] plus impaired cognition, depression, and mania); there is no overall score, only the eight individual components, which we are encouraged to rate again every few days. My biggest complaint about this scale, apart from its complexity and the time required, is that it gives us no indication as to overall functioning—only the degree to which the patient experiences each of the eight symptoms. Helpfully, DSM-5 informs us that we are allowed to rate the patient “without using this severity specifier,” an offer that many clinicians will surely rush to accept.

Evaluating functionality. Whatever happened to the Global Assessment of Functioning (GAF)? In use from DSM-III-R through DSM-IV-TR, the GAF was a 100-point scale that reflected the patient’s overall occupational, psychological, and social functioning—but not physical limitations or environmental problems. The scale specified symptoms and behavioral guidelines to help us determine our patients’ GAF scores. Perhaps because of the subjectivity inherent in this scale, its greatest usefulness lay in tracking changes in a patient’s level of functioning across time. (Another problem: It was a mash-up of severity, disability, suicidality, and symptoms.)

However, the GAF is now G-O-N-E, eliminated for several reasons (as described in a 2013 talk by Dr. William Narrow, research director for the DSM-5 Task Force). Dr. Narrow (accurately) pointed out that the GAF mixed concepts

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(psychosis with suicidal ideas, for example) and that it had problems with interrater reliability. Furthermore, what’s really wanted is a disability rating that helps us understand how well a patient can fulfill occupational and social responsibilities, as well as generally participate in society. For that, the Task Force recommends the World Health Organization Disability Assessment Schedule, Version 2.0 (WHODAS 2.0), which was developed for use with clinical as well as general populations and has been tested worldwide. DSM-5 gives it on page 747; it can also be accessed online (www.w

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