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Feeding and Eating Disorders: DSM-5 Diagnostic Codes





Feeding disorders: Overview

Some of the more common feeding disorders in infants and young children include pica, rumination disorder, and avoidant/restrictive food intake disorder. These disorders can be very complex and difficult to treat. Successful feeding requires a nurturing relationship between the child and caregiver. Among individuals with feeding disorders, frequently a serious disruption has occurred, or some type of psychopathology has been found between the child and caregiver. The temperament of the child may also be a factor in the development of feeding difficulties. As in eating disorders, feeding disorders feature avoidant and restrictive food intake although unlike with eating disorders, feeding disorders usually are first identified in early childhood rather than in the adolescent years. Currently, prevalence rates for feeding disorders are not well defined.

Eating Disorders: Overview

Eating disorders in adolescents and adults are very similar to feeding disorders in children and infants in that they are very complex, multifaceted and difficult to treat. Also, like feeding disorders, eating disorders have a significant impact upon an individual’s daily functioning. Eating disorders affect a person’s diet in very significant, negative ways. The disorder can be manifested in various ways including eating either very small amounts or absolutely no food at all (NIMH, 2013). Disorders can affect every aspect of an individual’s life including their physical and emotional health as well as their relationships with others. The eating disorders described in this section include anorexia nervosa, bulimia nervosa and binge eating disorder.

Prevalence Rates and Risk of Eating Disorders:

It is believed that as many as 20 million women and possibly 10 million men have suffered from some type of eating disorder at some time in their lives. It is believed that the rates of eating disorder have increased since the 1950’s. The American Psychiatric Association (2013) concluded that the prevalence rates of eating disorders vary significantly, but as published in the DSM-5, the prevalence rate for anorexia nervosa is approximately 0. 4% among the general population and bulimia nervosa is 1% to 1.5% over a 12-month period of time.

Eating disorders are most often first identified in the adolescent years. Issues related to image, weight and body shape that seem to underlie eating disorders may possibly even begin at a much younger age with approximately 40% to 60% of elementary school girls identifying some concern for their body weight or of becoming fat.
Although eating disorders are more frequently seen in females, males may also be at risk. Most often, men with eating disorders are more focused on making their bodies larger and more muscular as opposed to women who seem to be more interested in making their bodies lighter and smaller.




Cause of Feeding Disorders:

Issues associated with feeding are common among infants and small children although not all of these problems result in feeding disorders. However, it is important to recognize that without intervention, sometimes these difficulties can result in a feeding disorder. The specific interventions require a recognition of developmental and medical causation which may then necessitate specific interventions by either parents, medical or mental health professionals.

Clinicians should consider the characteristics of both the children and caregivers interdependently rather than separately. It is especially important to look at maternal factors when considering the cause of feeding disorders in recognition of the fact that maternal depression, anxiety and other eating disorder symptoms in pregnancy have been found to predict feeding difficulties.

The temperament of the child is also very important. It has been found that many of the children with feeding difficulties seem to have a difficult temperament including displays of angry moods, temper tantrums and aggression.

Cause of Eating Disorders:

As with feeding disorders, eating disorders may be caused by a variety of biological, behavioral, genetic and psychological factors (NIMH, 2013). While some researchers seem to focus on cultural considerations among individuals with eating disorders, it is difficult to identify the relative level of socio-cultural considerations in the development of these disorders. It is imperative to consider eating disorders from a holistic perspective and recognize that the interaction between genetic factors, social and cultural factors such as media images determine their relative contributions.

Many clinicians and researchers focus more on the social and cultural aspects in that the beauty ideals of Western culture seem to overemphasize thinness among women, resulting in a higher level of risk in the development of an eating disorder. Although mainstream media seems to focus on the thinness ideal of media images possibly underlying anorexia nervosa, many people are exposed to these same images and do not develop eating disorders.

Feeding and Eating Disorders Treatment:

Because of the multifactorial social and psychological etiology of feeding and eating disorders which makes these disorders so difficult to treat, treatment also needs to be multi-dimensional in most cases. The specific treatment will be according to the specific presentation and individual, social, psychological, and interpersonal factors involved, with special attention to behavioral, physical and emotional health. Also, of consideration will be the necessary level of care, which can range from inpatient to residential to outpatient treatment. The specific treatment venue will frequently depend upon the severity and/or the presentation of the symptoms.

Because of the secretive nature of eating disorders, these disorders often severely isolate individuals and cause them to be very reluctant to see a therapist or talk to a doctor. It is very common among these patients to refuse treatment for their condition. Psychologists and mental health professionals need to focus on the development of an appropriate, supportive therapeutic relationship and help the individual to understand why treatment may be necessary.

Some of the more common therapeutic treatments for eating disorders are cognitive behavioral therapy, interpersonal psychotherapy and dialectical behavior therapy. Cognitive behavioral therapy is often used for people who experience anorexia and bulimia whereas interpersonal psychotherapy seems to be more effective for individuals battling binge eating. While dialectical behavior therapy has been used to treat various eating disorders, it is often used for patients who have tried other therapeutic interventions and have not been successful.

Special Concerns for Individuals with Eating Disorders:

It is of special concern for counselors and mental health clinicians treating individuals with eating disorders to consider the high level of mortality. The mortality rates of eating disorders may be as high as 4% for anorexia nervosa, 3.9% for bulimia nervosa and 5.2% for eating disorder NOS (Crow et al., 2009). Also due to the complex nature of eating disorders in both the development and treatment, counselors will most likely need to collaborate with various other treatment professionals including physicians, psychiatrists, dietitians and other medical professionals to assist with appropriate treatment.

Additional information related to the specific feeding and eating disorders follow below.

Feeding and Eating Disorders: DSM-5 Diagnostic Codes

The following specifiers apply to feeding and eating disorders where indicated:
Specify if: In Remission
Specify if: In partial remission, In full remission
Specify current severity: Mild, Moderate, Severe, Extreme

307.52 (___.__) Pica
(F98.3) In children
(F50.8) In adults

307.53 (F98.21) Rumination Disorder

307.59 (F50.8) Avoidant/Restrictive Food Intake Disorder

307.1 (___.__) Anorexia Nervosa

Specify whether:
(F50.01) Restricting Type
(F50.02) Binge-eating/purging type

307.51 (F50.2) Bulimia Nervosa

307.51 Binge-eating disorder

307.59 (F50.8) Other Specified Feeding or Eating Disorder

307.50 Unspecified Feeding or Eating disorder

Some information adapted by Paul Susic Ph.D. Licensed Psychologist from the following sources
.
References:

American Psychiatric Association (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: Author.

Crow, S. J., Peterson, C. B., Swanson, S. A., Raymond, N.C. Specker, S., Eckert, E. D., & Mitchell, J. E. (2009). Increased mortality in bulimia nervosa and other eating disorders. American Journal of Psychiatry, 166, 1342-1346.

National Institute of Mental Health. (2013). Eating disorders. Retrieved from http: //www.nimh.nih.gov/health/topics/eating-disorders/index.shtml


Personality Disorders Symptoms and DSM-V Diagnosis




Personality Disorders Symptoms and Diagnosis: An overview

Personality disorders symptoms are not always easy to distinguish from relatively normal behaviors, although the consequences can be tremendously different. Personality disorders are groups of traits and characteristics that have become very rigid and dysfunctional, severely limiting functioning and most often resulting in severe distress and impairment. These thinking and behavioral patterns have usually been identified in these individual for a long time and in most cases since late adolescence or early adulthood.

The characteristics associated with personality disorders should probably be considered dimensional rather than categorical in that they are also seen in normal individuals to a significantly lesser degree. The DSM-V however has continued the traditional structure of categories that has been used over the last 30 years.

Common Characteristics of the Personality Disorders:

In order to receive a diagnosis of a personality disorder there needs to be an enduring pattern of negative behaviors, thoughts, feelings and sensations that are substantially different from the individual’s culture. This pattern includes an individual’s affect, cognition, control of impulses, and interpersonal relationships. This pattern of behaving and thinking has to apply in a broad-based manner over the individual’s personal and social life.




Personality disorders usually begin in adolescence (sometimes childhood) or early adulthood and manifest themselves in many social and personal contexts and cause a high level of distress and disability in an individual’s working and educational experience, as well as social and personal functioning. These characteristics cannot be associated with substance abuse, other mental disorders, physical illness, other personality disorders or personality changes associated with other medical conditions. The hallmark of personality disorders is their level of early onset (most commonly late teens), intensity of characteristics and pervasive nature in that it affects multiple aspects of an individual’s life including work, personal and social life.

A couple of the problems associated with the recognition and diagnosis of personality disorders is that they are frequently overlooked and at other times may be over-diagnosed. Two of the more notorious over diagnosed personality disorders are probably the narcissistic and borderline personality disorders. In DSM-V Made Easy, James Morrissey identified several things for a clinician keep in mind when making a diagnosis of personality disorder.

1. Verify the duration of the symptoms. Make sure that your patient’s symptoms have been present at least since early adulthood (before age 15 for antisocial personality disorder).
2. Verify that the symptoms affect several areas of the patient’s life.
3. Make sure that the patient fully qualifies for the particular diagnosis in question.
4. If the patient is under age 18, make sure that the symptoms have been present for at least the past 12 months.
5. Rule out other mental pathology that may be more accurate and have greater potential for doing harm.
6. Search for other personality disorders. Evaluate the entire history to learn whether any additional personality disorders are present.
7. Record all personality and non-personality mental diagnosis.

The following are the most commonly diagnosed personality disorders:


Cluster A Personality Disorders:

The Cluster A personality disorders usually involve behaviors described as suspicious, cold, withdrawn and/or irrational.

F60.0 (301.0) Paranoid Personality Disorder
F60.1 (301.20) Schizoid Personality Disorder
F21 (301.22) Schizotypal Personality Disorder

Cluster B Personality Disorders:

People who experience Cluster B Personality Disorders usually tend to be dramatic, very emotional and attention seeking with shallow, fluctuating moods. They often have intense interpersonal problems.

F60.2 (301.7) Antisocial Personality Disorder
F60,3 (301.83) Borderline Personality Disorder
F60.4 (301.50) Histrionic Personality Disorder
F60.81 (301.81) Narcissistic Personality Disorder

Cluster C Personality Disorders:

The Cluster C Personality Disorders usually feature characteristics of being typically tense, anxious and being over controlled.

F60.6 (301.82) Avoidant Personality Disorder
F60.7 (301.6) Dependent Personality Disorder
F60.5 (301.4) Obsessive-Compulsive Personality Disorder

Other Personality Conditions:

F07.0 (301.1) Personality Change Due to Another Medical Condition
F60.89 (301.89) Other Specified Personality Disorder
F60.9 (301.9) Unspecified Personality Disorder

By Paul Susic Ph.D. Licensed Psychologist



Persistent Depressive Disorder (Dysthymia) Symptoms and Related DSM–5 Diagnosis




Persistent Depressive Disorder (Dysthymia) 300.4 (F34.1)

Information related to Persistent Depressive Disorder (Dysthymia) as well as the specific symptoms follow below. While some of these Persistent Depressive Disorder (Dysthymia) symptoms may be recognized by family, teachers, legal and medical professionals, and others, only properly trained mental health professionals (psychologists, psychiatrists, professional counselors etc.) can or should even attempt to make a mental health diagnosis. A multitude of factors are considered in addition to the psychological symptoms in making a proper diagnosis, including medical and psychological testing considerations. This information is for information purposes only and should never replace the judgment and comprehensive assessment of a trained mental health clinician.

Persistent Depressive Disorder (Dysthymia) diagnostic criteria 300.4 (F34.1):

This disorder represents a consolidation of DSM-4-defined Chronic Major Depressive Disorder and Dysthymic Disorder.




A. Depressed mood for most of the day, for more days than not, is indicated by either subjective account or observation by others, for at least two years.
Note: In children and adolescents, mood can be irritable and duration must be at least one year.

B. Presence, while depressed, of two (or more) of the following:
1. Poor appetite or overeating.
2. Insomnia or hypersomnia.
3. Low energy or fatigue.
4. Low self-esteem.
5. Poor concentration or difficulty making decisions.
6. Feelings of hopelessness.

C. During the two-year period (1 year for children or adolescents) of the disturbance, individual has never been without the symptoms in criteria A and B for more than two months at a time.

D. Criteria for a major depressive disorder may be continuously present for two years.

E. There has never been a manic episode or hypomanic episode and criteria have never been met for cyclothymic disorder.

F. The disturbance is not better explained by persistent schizoaffective disorder, schizophrenia, delusional disorder, or other specified or unspecified schizophrenia spectrum and other psychotic disorder.

G. The symptoms are not attributable to the physiological effects of a substance such as a drug of abuse, a medication, or another medical condition such as hypothyroidism.

H. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Note: Because the criteria for major depressive episode include four symptoms that are absent from the symptom list for persistent depressive disorder (dysthymia), a very limited number of individuals will have depressive symptoms that have persisted longer than two years but will not meet criteria for persistent depressive disorder. If the full criteria for major depressive episode have been met at some point during the current episode of illness, they should be given a diagnosis of major depressive disorder. Otherwise, a diagnosis of other specified depressive disorder or unspecified depressive disorder is warranted.

Specify if:

With anxious distress
With mixed features
With melancholic features
With atypical features
With mood-congruent psychotic features
With mood-incongruent psychotic features
With peripartum onset

Specify if:

In partial remission
In full remission

Specify if:

Early onset: If onset is before age 21 years.
Late onset: If onset is at 21 years or older.

Specify if: (For most recent two years of persistent depressive disorder):

With pure dysthymic syndrome: Full criteria for a major depressive episode have not been met in at least the preceding two years.
With persistent major depressive episode: Full criteria for major depressive episode have been met throughout the preceding two-year period.
With intermittent major depressive episodes, with current episode: Full criteria for major depressive episode are currently met, but there have been periods of at least eight weeks in at least the preceding two years with symptoms below the threshold for a full major depressive episode.
With intermittent major depressive episodes, without current episode: Full criteria for a major depressive episode are not currently met, but there has been one or more major depressive episodes in at least the preceding two years.

Specify current severity:

Mild
Moderate
Severe

Adapted by Paul Susic Ph.D. Licensed Psychologist from the Diagnostic and Statistical Manual of Mental Disorders Fifth Edition (DSM-5) American Psychiatric Association


Disruptive Mood Dysregulation Disorder Symptoms and Related DSM–5 Diagnosis




Disruptive Mood Dysregulation Disorder 296. 99 (F34.8)

Information related to Disruptive Mood Dysregulation Disorder as well as the specific symptoms follow below. While some of these Disruptive Mood Dysregulation Disorder symptoms may be recognized by family, teachers, legal and medical professionals, and others, only properly trained mental health professionals (psychologists, psychiatrists, professional counselors etc.) can or should even attempt to make a mental health diagnosis. A multitude of factors are considered in addition to the psychological symptoms in making a proper diagnosis, including medical and psychological testing considerations. This information is for information purposes only and should never replace the judgment and comprehensive assessment of a trained mental health clinician.

Disruptive Mood Dysregulation Disorder diagnostic criteria 296. 99 (F34.8):




A. Severe recurrent temper outbursts manifested verbally such as with verbal rages and/or behaviorally such as in physical aggression toward people or property that are grossly out of proportion in intensity or duration to the situation or provocation.

B. The temper outbursts are inconsistent with the developmental level.

C. The temper outbursts occur, on average, three or more times per week.

D. The mood between temper outbursts is persistently irritable or angry most of the day, nearly every day, and is observable by others such as parents, teachers or peers.

E. Criteria A-D have been present for 12 or more months. Throughout that time, the individual has not had a period lasting three or more consecutive months without all of the symptoms in criteria A-D.Criteria A and D are present in at least two or three settings such as at home, at school, with peers, and are severe in at least one of these.

F. The diagnosis should not be made for the first time before age 6 years or after age 18 years.

G. By history or observation, the age of onset of criteria A-E is before 10 years.

H. There’s never been a distinct period lasting more than one day during which the full symptom criteria, except duration, for manic or hypomanic episode has been met. Note: Developmentally appropriate mood elevation, such as occurs in the context of a highly positive event or its anticipation, should not be considered as a symptom of mania or hypomania.

I. The behaviors do not occur exclusively during an episode of major depressive disorder and are not better explained by another mental disorder such as autism spectrum disorder, posttraumatic stress disorder, separation anxiety disorder, persistent depressive disorder [dysthymia].
Note: This diagnosis cannot coexist with oppositional defiant disorder, intermittent explosive disorder, or bipolar disorder, though it can coexist with others, including major depressive disorder, attention-deficit/hyperactivity disorder, conduct disorder, and substance use disorders. Individuals whose symptoms meet criteria for both disruptive mood dysregulation disorder and oppositional defiant disorder should only be given the diagnosis of disruptive mood dysregulation disorder. If an individual has ever experienced a manic or hypomanic episode, the diagnosis of disruptive mood dysregulation disorder should not be assigned.

J. The symptoms are not attributable to the physiological effects of a substance or to another medical or neurological condition.

Diagnostic Information and Criterion for Disruptive Mood Dysregulation Disorders from the Diagnostic and Statistical Manual of Mental Disorders Fifth Edition American Psychological Association

Additional information by Paul Susic Ph.D. Licensed Psychologist



Depressive Disorders and Related DSM-5 Diagnostic Codes:




Depressive disorders:

The term depression refers to a prolonged period of low mood and energy, feelings of sadness and possible dejection, as well as isolation at times. Depressive disorders are usually diagnosed when an individual’s low mood or depression is prolonged enough to interfere with an individual’s activities of daily living.

Depressive disorders usually affect individuals through disturbance of mood and energy which is frequently accompanied by symptoms of anxiety. The prevalence of depressive disorders is very high among the general population as well as in comparison to other mental health disorders.




Research and clinical experience has found that the prevalence of depression among the general population may be about 10% and is frequently the focus of clinical attention due to its high prevalence, and at times its severity. Depressive disorders can be very disabling. Also, in addition to the symptoms of depression, it is also believed that close to 50% of individuals diagnosed with anxiety disorders also meet the criteria for a depressive disorder. The specific depressive disorders follow below.

Specific Depressive Disorders and Related DSM-5 Diagnostic Codes ICD-9-CM and ICD-10-CM coeds repectively:

296.99 (F34.8) Disruptive Mood Dysregulation Disorder

Major Depressive Disorder: Single Episode

296.21 (F32.0) Mild
296.22 (F32.0) Moderate
296.23 (F32.2) Severe
296.24 (F32.0) With Psychotic Features
296.25 (32.4) In Partial Remission
296.26 (F32.5) In Full Remission
296.20 (F32.9) Unspecified

Major Depressive Disorder: Recurrent Episode

296.31 (F33.0) Mild
296.32 (F33.1) Moderate
296.33 (F33.2) Severe
296.34 (F33.3) With Psychotic Features
296.35 (F33.41) In Partial Remission
296.36 (F33.42) In Full Remission
296.30 (F33.9) Unspecified

300.4 (F34.1) Persistent Depressive Disorder (Dysthymia)

Specify if: In Partial Remission, In Full Remission
Specify if: Early Onset, Late Onset
Specify if: With Pure Dysthymic Syndrome; With Persistent Major Depressive Episode; With

Intermittent Major Depressive Episodes, With Current Episode; With Intermittent Major Depressive Episodes, Without Current Episode.
Specify current severity: Mild, Moderate, Severe

625.4 (N94.3) Premenstrual Dysphoric Disorder

Substance /Medication – Induced Depressive Disorder

Note: See the criteria set and corresponding recording procedures for substance-specific codes and ICD-9-CM and ICD-10-CM coding
Specify if: With onset during intoxication, With onset during withdrawal

293. 83 Depressive Disorder Due to Another Medical Condition

Specify if:
(F06.31) With depressive features
(F06.32) With major depressive-like episode
(F06.34) With mixed features
311 (F32.8) Other specified depressive disorder
311 (F 32.9) Unspecified depressive disorder

311 (F32.8) Other Specified Depressive Disorder



Anxiety Disorders and Related DSM-5 Diagnostic Codes:




Anxiety Disorders

According to the American Psychiatric Association, each of the anxiety disorders share the features of fear and anxiety. Fear is a healthy, rational response to either a real or perceived threat whereas anxiety is anticipatory and is in response to a possible perceived threat in the future.

Anxiety among the general population is very high with estimates as high as 18% or 40 million American adults experiencing anxiety disorders each year. Some researchers feel that the lifetime prevalence rate may be as high as 30%. Almost 50% of people who experience anxiety disorders also meet the criteria for depressive disorder. Clinicians recognize that there is a very high level of comorbidity (shared symptoms) between depressive disorders and anxiety disorders, and believe that there may be a possible shared genetic predisposition.




Anxiety disorders frequently persist over time. Because anxiety disorders are so uncomfortable and often disabling, they are frequently the focus of clinical attention. Anxiety disorders are very responsive to psychotherapeutic treatment modalities as well as medications geared toward their specific symptoms. Please see the following specific diagnostic criterion information related to the anxiety disorders.

Specific Anxiety Disorders and Related DSM-5 Diagnostic Codes:

309. 21 (F93 0) Separation Anxiety Disorder

312. 23 (F94.0) Selective Mutism

300. 29 ( . ) Specific Phobia
Specify if:
(F40.218) Animal
(F40.228) Natural Environment
( . ) Blood Injection-injury
(F40.230) Fear of Blood
(F40.231) Fear of Injections and Transfusions
(F40.232) Fear of Other Medical Care
(F40.233) Fear of Injury
(F40.248) Situational
(F40.298) Other

300. 23 (F40. 10) Social Anxiety Disorder (Social Phobia) Symptoms, Diagnosis and Treatment
Specify if: Performance only

300. 01 (F41.0) Panic Disorder

( . ) Panic Attack

300. 22 (F40. 00) Agoraphobia

300. 02 (F41.1) Generalized Anxiety Disorder

( . ) Substance/Medication – Induced Anxiety Disorder

293. 84 (F06. 4) Anxiety Disorder Due to Another Medical Condition

300. 09 (F41. 8) Other Specified Anxiety Disorder

300. 00 (F41. 9) Unspecified Anxiety Disorder

Diagnostic Information and Criterion for Anxiety Disorders adapted from the Diagnostic and Statistical Manual of Mental Disorders Fifth Edition American Psychological Association by Paul Susic Ph.D. Licensed Psychologist