Clarification of the procedures for making an Axis V Global Assessment of Functioning rating
Lack of detail in the instructions regarding application of the Global Assessment of Functioning (GAF) rating have led to misinterpretations of how to apply the GAF. One source of confusion is how to operationalize the “current” time frame for the GAF. Does it strictly refer to how that patient appears and functions during the evaluation procedure? This interpretation might result in a misleadingly high GAF, given that some individuals may experience transient improvement in anticipation of receiving help. For clarity, the text now includes a sentence that states “in order to account for day-to-day variability in functioning, the GAF rating for the “current period” is sometimes operationalized as the lowest level of functioning for the past week.”
Another source of confusion involves how to integrate the potentially disparate contributions of psychiatric symptomatology and functioning to the final GAF score. For example, for a patient who is a significant danger to self (justifying a GAF below 20) but is otherwise functioning well at work and with his family (reflecting a GAF above 60), what should the final GAF be? Some GAF users mistakenly average the two together, resulting in a GAF around 40. In fact, the final correct GAF score should always reflect the lower of the two (i.e., in this case, the GAF should be below 20, despite the higher social and occupational functioning). A paragraph has been added to the GAF instructions to clarify this convention.
Clarification of ambiguity regarding the time frame for the Major Depressive Disorder specifiers
An important use of the Diagnostic and Statistical Manual of Mental Disorders, Fouth Edition (DSM-IV) diagnostic codes is to facilitate analysis of psychiatric practice patterns and quality of care. For example, data from the American Psychiatric Association's (APA's) Practice Research Network was analyzed to examine the use of neuroleptic medication in psychotic mood disorders. During this analysis, an ambiguity was noted in the interpretation of the 5th digit severity codes for mood episodes, specifically regarding the time frame for the application of these severity modifiers. Take, for instance, the modifier “severe with psychotic features,” which is codable by indicating “4” in the 5th digit of the diagnostic code for Major Depressive Disorder or Bipolar I Disorder. There are three possible interpretations:
- it indicates that the person is currently experiencing psychotic symptoms
- that at some time during the current episode (for which the person's mood disturbance still meets criteria) the person had psychotic features
- the person had psychotic features during his or her most recent episode of depression.
Although all three of these scenarios are potentially worth noting in the clinical case record, they each have very different treatment and prognostic implications. The first scenario suggests active use of antipsychotic medication (or electroconvulsive therapy [ECT]), whereas the second and third scenarios indicate risk of developing future psychotic symptoms during depressive episodes, with the second scenario being at higher risk than the third.
Since the first scenario (i.e., the specifier “severe with psychotic features” indicates that psychotic symptoms are currently present) is most consistent with DSM-IV conventions on application of the severity specifiers, the text (and criteria sets) have been rewritten to indicate that the specifiers “mild,” “moderate,” “severe without psychotic features” and “severe with psychotic features” apply only if the criteria are currently met for a Major Depressive Episode and serve to indicate the current severity. If criteria are no longer met, then “in partial remission” or “in full remission” must be applied instead of “mild,” “moderate” or “severe.”
In a related vein, when specifiers such as “with melancholic features” or “with atypical features” are applied to a Major Depressive Episode in partial or full remission, it is understood that the specifier applies to the most recent Major Depressive Episode. For example, the diagnosis “Major Depressive Disorder, Recurrent, in Full Remission, With Melancholic Features” indicates that when the individual was last in a Major Depressive Episode, melancholic features were present when the episode was at its worst. Ambiguity exists, however, in the time frame for application of the criteria for atypical features for past episodes. The diagnostic criteria for “atypical features” indicate that the atypical features specifier applies if the criteria are met during the “most recent two-week period.” While this two-week time frame makes sense for current episodes, it is less meaningful for a past episode (i.e., there is nothing particularly special about the last two weeks of past Major Depressive Episode). Thus, to resolve this ambiguity, it has been clarified that a past episode is atypical if the criteria were met for any two-week period during the episode.
Change in coding conventions for indicating clinically significant psychiatric symptoms occurring as part of a dementia
A coding change adopted by the International Classificaiton of Disease, Ninth Edition, Clinical Modification (ICD-9-CM) Coordination and Maintenance Committee has rendered the subtypes for Dementia of the Alzheimer's Type (i.e., with delusions, with depression, with delirium) obsolete. Specifically, the diagnostic code for Dementia of the Alzheimer's Type is being changed so that the three subtypes that were coded with a fifth digit (i.e., “with delirium,” “with depressed mood,” “with delusions”) are no longer available (see Section 8 for specific details about coding changes).
In order to now indicate comorbid psychiatric symptoms arising from Alzheimer's disease, the new convention is to code the specific mental disorder due to a general medical condition on Axis I alongside the dementia. For example, under Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) coding conventions, an individual with Dementia of the Alzheimer's Type who suffers from the delusion that the aides in the nursing home are trying to poison him would be diagnosed as 290.20 Dementia of the Alzheimer's Type, Late Onset, With Delusions. In Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR), two diagnoses would be assigned: 294.11 Dementia of the Alzheimer's Type With Behavioral Disturbance and 293.81 Psychotic Disorder Due to Alzheimer's Disease, With Delusions. The potential list of secondary conditions that can occur as part of dementia include psychotic disorder due to Alzheimer's disease, mood disorder due to Alzheimer's disease, anxiety disorder due to Alzheimer's disease, personality change due to Alzheimer's disease, and sleep disorder due to Alzheimer's disease.
One complication in adopting this convention, however, is that the DSM-IV criteria set for Personality Change specifically prohibits it from being diagnosed in the presence of dementia (i.e., criterion D states: “The disturbance does not occur exclusively during the course of a delirium and does not meet criteria for dementia”). This exclusion was a carry-over from the Diagnostic and Statistical Manual of Mental Disorders, Third Edition, Revised (DSM-III-R) criteria set for Organic Personality Disorder (which had an identical criterion D). Since the DSM-III-R criteria set for dementia included personality change as one of the defining features, it would have been redundant to allow Organic Personality Disorder to be diagnosed along with dementia. However, since personality change was dropped from the DSM-IV criteria set for dementia, this exclusion should have similarly been dropped from the DSM-IV criteria set for Personality Change due to a General Medical Condition (GMC). Thus, criterion D in Personality Change Due to a GMC has been changed to the following: “D. The disturbance does not occur exclusively during the course of a delirium.”
Adjustment of wording of the clinical significance criterion for the Paraphilias
In the Diagnostic and Statistical Manual of Mental Disorders, Third Edition, Revised (DSM-III-R), the criteria sets for the Paraphilias included a clinical significance criterion (i.e., "the person has acted on these urges, or is markedly distressed by them") in recognition of the fact that the mere presence of paraphilic sexual urges or fantasies do not necessarily warrant a diagnosis of a paraphilia in an individual. During the preparation of Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), the wording of this criterion was adjusted (i.e.,”the fantasies, sexual urges, or behaviors cause clinically significant distress or impairment in social, occupational, or other important areas of functioning") as part of the effort to adopt uniform wording for the clinical significance criterion across the disorders.
An unforeseen side effect of this rewording was that it led to confusion regarding the DSM-IV definition of Pedophilia. Specifically, the replacement of the DSM-III-R phrase “acts on these urges” with the phrase “causes clinically significant…impairment” was misconstrued to represent a fundamental change in the definition of Pedophilia. Some readers misunderstood this new wording as greatly restricting the number of individuals who would be diagnosed with Pedophilia by requiring that they be distressed by their behavior in order to qualify for the diagnosis. This was clearly never intended, since it is well recognized that many (if not most) individuals with Pedophilia are not distressed by their pedophilic urges, fantasies, and behaviors. In fact, rather than restricting the diagnosis of Pedophilia to fewer individuals, the original purpose of the change was to potentially broaden the diagnosis to include individuals whose pedophilic urges interfered with functioning in a variety of ways (e.g., causing impairment in occupational functioning because of a preoccupation with pedophilic thoughts and images at work). There was never any intention to no longer include individuals who acted on their urges.
To remove any possible ambiguity regarding whether acting out pedophilic urges with others is sufficient for a diagnosis of Pedophilia, the original DSM-III-R wording has been reinstated. Furthermore, the original DSM-III-R wording has been reinstated for other paraphilias that inevitably harm their victims (i.e., voyeurism, exhibitionism, and frotteurism). Because some cases of Sexual Sadism may not involve harm to a victim (e.g., inflicting humiliation on a consenting partner), the wording for sexual sadism involves a hybrid of the DSM-III-R and DSM-IV wording (i.e., “the person has acted on these urges with a non-consenting person, or the urges, sexual fantasies, or behaviors cause marked distress or interpersonal difficulty”).
Removal of clinical significance criterion from the criteria sets for Tic Disorders
A "clinical significance criterion" (i.e., “the disturbance causes clinically significant distress or impairment”) was added to the criteria sets of a majority of disorders in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) (Tic Disorders among them) in order to emphasize that a mental disorder should not be diagnosed in trivial cases (i.e., when the disturbance is so mild that it has little impact on the patient), an addition that has been the focus of some criticism. Thus, according to the criteria in DSM-IV, a diagnosis of Tic Disorder can be made only after it is established that the tic causes clinically significant distress or impairment in the child.
After the publication of DSM-IV, concerns were raised about the appropriateness of this criterion for tic disorders by clinicians, researchers, and patient advocacy groups (i.e., Tourette Syndrome Association [TSA]). For example, clinicians have expressed concerns about what to do in relation to children who come for evaluation, whose presentations clearly meet the tic symptomatology criteria for Tourette's Disorder, but who do not have significant impairment or distress from their tics, a situation quite common in clinical experience. Furthermore, in June 1999, the TSA with the support of NIH held the third international symposium on Tourette Syndrome and Associated Disorders. At the symposium, there was general agreement that the impairment criterion was confusing and a burden to research, and as a result was largely ignored. Thus, this criterion has been eliminated from the criteria sets for Tourette's Disorder, Chronic Vocal or Motor Tic Disorder, and Transient Tic Disorder.
Clarification of the definition of Pervasive Developmental Disorder Not Otherwise Specified
Autism was first included in Diagnostic and Statistical Manual of Mental Disorders, Third Edition (DSM-III) in 1980 in a new class of conditions--the Pervasive Developmental Disorders (PDD). A residual category, Atypical PDD, was also included and encompassed difficulties characterized by problems in social interaction and problems in communication or restricted/unusual interests similar to those observed in autism but which did not meet full criteria for either infantile autism or childhood onset pervasive developmental disorder. By implication, individuals with Atypical PDD had to exhibit some problem in the social area and either in communication or unusual interests. In Diagnostic and Statistical Manual of Mental Disorders, Third Edition, Revised (DSM-III-R) the name for the subthreshold class was changed to Pervasive Developmental Disorder Not Otherwise Specified (PDDNOS) but otherwise the approach to diagnosis was the same.
Major changes were made the PDD category in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) based, in part, on a large, multi-site, international field trial. However, an editorial change was made in the description of PDDNOS during the final phase of production that had an unintended effect on the definition of PDDNOS. Instead of requiring “impairment in social interaction and in verbal or nonverbal communication skills” (DSM-III-R, p. 39), DSM-IV states that the “category should be used where there is a severe and pervasive impairment of reciprocal social interaction or verbal and nonverbal communication skills, or when stereotyped behavior, interests, and activities are present” (DSM-IV, pp. 77-78). Thus, a child with an impairment in only one area (e.g., a child with stereotyped behavior, interests and activities but without evidence of disturbed social interactions could theoretically qualify for a diagnosis of PDDNOS.
To assess the impact of the DSM-IV wording, Volkmar and colleagues performed a series of reanalyses of the DSM-IV autism/PDD field trial data (Volkmar FR, Shaffer D, First M. PDD-NOS in DSM-IV. J Autism Dev Disord 2000 Feb;30(1):74-75). A series of comparisons were conducted to evaluate sensitivity/specificity. Using clinicians' judgment of the presence or absence of PDDNOS as the standard, the DSM-IV wording had an excellent sensitivity of .98. However, the specificity was only .26, i.e., about 75% of cases identified by the clinician as not having PDDNOS (true negatives), were incorrectly identified as having PDDNOS according to the DSM-IV. These results lend support to the concern that the DSM-IV wording inappropriately broadened the PDDNOS construct. If problems are required in the social area and either communication or restricted interest (i.e., at least 2 criteria present one of which must be from the social area) the sensitivity was .89 and specificity .56.
These results supported a change in the wording of PDDNOS to revert to the original construct. The new wording in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR) is as follows:
“This category should be used when there is a severe and pervasive impairment in the development of reciprocal social interaction associated with impairment in either verbal and nonverbal communication skills, or with the presence of stereotyped behavior, interests, and activities, but the criteria are not met for a specific Pervasive Developmental Disorder, Schizophrenia, Schizotypal Personality Disorder, or Avoidant Personality Disorder.”
Clarification of Concept of Polysubstance Dependence
It is not uncommon for clinicians to inappropriately use the term “Polysubstance Dependence” to refer the heavy drug users who are dependent on a number of different types of substances. Instead, multiple co-morbid diagnoses of Substance Dependence (one for each class that the person is dependent on) should be given. For example, an individual who smokes crack several times a week, injects heroin daily, and smokes several joints a day would receive three diagnoses: Crack Dependence, Heroin Dependence, and Marijuana Dependence and not a diagnosis of Polysubstance Dependence. Polysubstance Dependence should be used only in those clinical situations where the pattern of multiple drug use is such that it fail to meet the criteria for Dependence on any one class of drug. In such settings, the only way to assign a diagnosis of Dependence is to consider all the substances that the person uses taken together as a whole.
To clarify the appropriate use of this diagnosis, the text for Polysubstance Dependence was revised to provide examples of situations in which this diagnosis might apply. In making these revisions, however, it became clear that more than one interpretation of how to apply the Polysubstance Dependence rule is possible. One interpretation (operationalized in the Structured Clinical Interview for DSM-IV (SCID) ), focuses on periods of indiscriminant use of a variety of different substances. Another interpretation is analogous to the concept of “mixed personality disorder,” i.e., one or two dependence criteria are met for a single class of drug but full criteria for Dependence are only met when the drug classes are grouped together as a whole. Since both interpretations are covered by the construct of Polysubstance Dependence, the revised text includes elements of both as follows:
“For example, a diagnosis of Polysubstance Dependence would apply to an individual who, during the same 12-month period, missed work because of his heavy use of alcohol, continued to use cocaine despite experiencing severe depressions after heavy nights of consumption, and was repeatedly unable to stay within his self-imposed limits regarding his use of codeine. In this instance, although the problems associated with the use of any one substance were not pervasive enough to justify a diagnosis of Dependence, his overall use of substances significantly impaired his functioning and thus warrants a diagnosis of Dependence on the substances as a group. Such a pattern might be observed, for example, in a setting where substance use was highly prevalent, but where the drugs of choice changed frequently. For those situations in which there is a pattern of problems associated with multiple drugs and the criteria are met for more than one specific Substance-Related Disorder (e.g., Cocaine Dependence, Alcohol Dependence, and Cannabis Dependence), each diagnosis should be made.”