The disorders that may be the focus of clinical attention.
By: SOPHIA F. DZIEGIELEWSKI
This group of conditions are
not mental disorders. Probst (2013) highlights the importance of this topic in
that there may be a fine line
between a life problem and a mental disorder.
Life transitions are rich
with behavioral transitions, material deprivations, and abandonments that could easily be documented as a mental disorder to
facilitate service reimbursement (Probst, 2014). This incentive provides
fertile ground for documenting the effects ethical dilemmas and abuse can have
on the diagnostic assessment.
To facilitate use of these
codes, the list has nine main subject areas: relational problems; abuse and
neglect; housing and economic problems; educational and occupational problems;
other problems related to the social environment; problems related to crime or
interaction with the legal system; other health service encounters for
counseling and medical advice; problems related to other psychosocial,
personal, and environmental circumstances; and other circumstances of personal
history.
For a comprehensive list of
the main categories that outline the other disorders that may be a focus of clinical attention, see This Quick Reference. For a complete
list of all the codes and subcategories possible in each area, see the DSM-5.
Other Conditions That May Be a Focus of Clinical AttentionRelational ProblemsProblems Related to Family Upbringing Other Problems Related to Primary Support Group Abuse and Neglect Child Maltreatment and Neglect Problems Adult Maltreatment and Neglect Problems Educational and Occupational Problems Educational Problems Occupational Problems Housing and Economic Problems Housing Problems Economic Problems Other Problems Related to the Social Environment Problems Related to Crime or Interaction With the Legal System Other Health Service Encounters for Counseling and Medical Advice Problems Related to Other Psychosocial, Personal, and Environmental Circumstances Other Circumstances of Personal History Problems Related to Access to Medical and Other Health Care Non-adherence to Medical Treatment Source: Summarized from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Copyright 2013 by the American Psychiatric Association. |
With the elimination of the multi-axial diagnostic system used in DSM-IV and DSM-IV-TR, this
newly revised chapter (Chapter 22) of other conditions can be helpful.
Conditions that document stressors and contributing factors that would have
been previously placed on Axis IV allow for some aspect of
recognition. In DSM-5, the V codes remain reflective of
the ICD-(CM),
and the Z
codes are related to ICD-10. See the DSM-5’s Other
Conditions That May Be a Focus of Clinical Attention (pp. 715–727) for a full listing of
these disorders.
When coding for billing or
simply documenting these conditions in the record, the practitioner needs to be
sure that the criteria to justify this support diagnostic category are met.
Often to support this effort, as discussed later in this chapter, further
information may be needed, including psychometric testing such as rapid and
self-administered assessment instruments.
Listing other conditions
that may be a focus of clinical attention pertinent to the diagnosis can
assist in documenting the supportive information that needs to be in the record. Although these conditions are not mental disorders, the symptoms the client is experiencing may initially present in a severe enough form to make the professional consider assigning a diagnosis.
assist in documenting the supportive information that needs to be in the record. Although these conditions are not mental disorders, the symptoms the client is experiencing may initially present in a severe enough form to make the professional consider assigning a diagnosis.
The circumstances listed in
this section are broken into categories. For example, when information is
listed under the relational disorders, these supporting circumstances can influence the presentation of
the disorder. Once a practitioner is aware of these circumstances, they can influence and in some cases
change the disorder identified, as
well as the course of treatment.
For example, an older
client’s reaction to the death of
a loved one may be significant
enough to meet the criteria for bereavement or major depressive disorder (MDD).
In uncomplicated bereavement, however, the individual often recognizes what is
happening and contributing to the symptoms reported. Although the symptoms may
clearly match what might be present in a major depressive disorder, such as
trouble sleeping, lack of appetite, and weight loss, these symptoms could be
considered a normal reaction to the death of a loved one.
In uncomplicated
bereavement, the symptoms experienced become the focus of clinical attention, and all supportive treatment is related directly to the recent death
(APA, 2013). Yet, the individual may ask for treatment and management of these symptoms as a way
to speed the grief process and regain his or her prior level of functioning.
The symptoms combined with the grief reaction make it difficult to determine whether
it is uncomplicated bereavement or indicative of something greater (Wakefield & Schmitz, 2014).
As Frances (2013)
summarized so succinctly, when there is clinical doubt, underdiagnosing is always better than overdiagnosing. The label given to a client could last a
lifetime. In the case of the grief reaction, this mistake could be costly. As part of normal
life transitions as people age, the likelihood of experiencing repeated losses of
partners, family, and friends increases. Repeated losses and the constant
adjustment process can easily lead to feelings of sadness, disturbed sleep, and
loss of appetite—all
symptoms that can resemble depression. Although the individual eventually learns
to cope with these changes and losses, the responses that occur in the
adjustment process vary considerably.
One major change in DSM-5 was the change of name for
this category from bereavement to uncomplicated bereavement. This change in title
was made to highlight that the symptoms experienced are not beyond a normal
reaction to the death of the loved one. Furthermore, taking research evidence
into account, the task group also agreed to delete the 2-month bereavement
exclusion from major depressive disorder (MDD).
The time frame in the previous edition of the DSM was questioned because research evidence was lacking to support what
constitutes normal bereavement, especially in terms of the time frame (2 months
versus 6 months versus 1 year) (Wakefield &
Schmitz, 2014). Whether clearly supported in the literature or not, taking this
information into account and utilizing it provided one important reason for eliminating
the bereavement exclusion. Elimination of the 2-month waiting period was formalized in DSM-5 when grief-related systems could be better explained by normal
reactions to the death of the loved one. See Chapter 7 on depressive disorders
and MDD criteria for a more comprehensive explanation of this change and how it
relates to the manifestation of depression and suicidal ideation and intent.
The revised categories such
as uncomplicated bereavement are intended to help the client and family and friends within his or her support system, as well as other
professional and nonprofessional helpers, to better understand and explain the
individual’s behaviors. This
diagnostic category can also avoid giving the client a label that might not be
appropriate.
Another example of this
category under other circumstances of personal history, further subdivided into non-adherence to medical treatment, is malingering (coded as
V65.2 or Z76.5). Although a client may present with multiple severe individual,
occupational, and social problems, if the client meets the criteria for the condition
of malingering, careful evaluation and documentation are required.
Malingering is not a mental
disorder. It involves “the
intentional production of false or grossly exaggerated physical or psychological
symptoms, motivated by external incentives such as avoiding” (APA, 2013, p. 726).
Acknowledging and clearly documenting these intentionally created symptoms is
essential for the practitioner. Examining these symptoms and contrasting them
with any external incentives is important for a comprehensive diagnostic
assessment.
This category also outlines
several situational and environmental conditions where avoidance is most likely to occur, such as military duty, employment, seeking financial compensation, or trying to avoid criminal prosecution. To apply this further, consider a client
who wants to qualify for a documented disability in order to receive a disability check. In
desperation, the client may feign or grossly exaggerate what he or she is feeling to obtain the
disability status. In actuality, with this type of planned, deliberate behavior,
the client would not qualify as having a mental disorder related to the reason
for visit. In such cases, the client’s
behaviors are viewed as primarily manipulative. Therefore, a diagnosis of a mental disorder would be inappropriate.
When the chapter is
utilized properly, it is easy to see that the conditions that may be the focus
of clinical attention can support completion of a thorough comprehensive
diagnostic assessment. Although important for use, these conditions should not
be applied haphazardly.
For example, to better define malingering, DSM-5 goes beyond what was
described in the previous version. The current version defines four circumstances that
can help to identify malingering. The first is
identifying the reason for the referral. Referrals that come from an attorney
with litigation pending or self-referrals in similar circumstances are suspect.
The second area is the actual assessment, especially when discrepancies do not
match the overall presentation and the practitioner questions if the client is accurately
presenting information. The third area relates directly to the client’s attitude and whether he
or she is cooperative and interested in the assessment process. Does the client
either avoid pertinent questions or providing information that could facilitate
the diagnostic assessment? Fourth, the client who qualifies for antisocial personality
disorder would not meet the criteria supportive of malingering. Using a combination
approach and taking into account all four of these items could make a
difference in whether this term is applied.
In summary, conditions that
may be the focus of clinical intervention can be used to support the diagnosis. This article discusses only some of the supportive conditions. Documenting
these conditions is considered essential for completing a comprehensive diagnostic
assessment. Although they are not mandatory for inclusion, I believe they should
be. Use of this supplemental supporting information is highly encouraged, as life
circumstances can often impede any clinical presentation. When they are
present, be sure to note them. All practitioners should be familiar with them
and able to utilize them in the supportive and supplemental way intended.
References
SOPHIA F. DZIEGIELEWSK,
2015, DSM-5TM
in Action, by John Wiley & Sons, Inc.
Read Also
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Assessment Factors with Older Adults
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Assessment Factors with Older Adults
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