Michael B. First, MD

The approach that has been used for revising the 

 since its inception has been to overhaul the diagnostic classification in its entirety at fixed intervals. While revising the entire DSM in this way has some advantages, such as ensuring the uniformity and stability of the diagnostic definitions during the interval in which the manual is in effect, a significant disadvantage is that it prevents the incorporation of new scientific knowledge into DSM as it emerges.

Advances in digital publishing that allow instantaneous dissemination of changes at minimal cost have paved the way toward the adoption of a continuous improvement model for DSM, in which revisions are pegged to specific scientific advances. Thus, rather than waiting until the next wholesale revision to implement a clinically useful change (such as incorporating a clinically validated biomarker into the definition of a disorder), such a change could be put into effect as soon as it has been determined that it is diagnostically advantageous to do so. Moreover, implementing a continuous data-driven approach has the added advantage of discouraging changes that are not well supported by empirical evidence.

It is expected that most submissions will originate from interested persons who are external to the APA committee overseeing the DSM revision process (eg, psychiatric researchers, individual clinicians). This is in marked contrast to the way prior DSM revisions were done, during which proposals were drafted by DSM workgroup members who were also responsible for providing supportive literature reviews and data re-analyses.

) was set up by the APA at the beginning of this year to field proposals for changes to DSM-5. Proposals must be accompanied by supportive information including the reasons for the change and, depending on the nature of the proposal, data documenting improvements in validity across a range of validators, evidence of reliability and clinical utility, and a consideration of potential deleterious consequences associated with the proposed change.

This new continuous revision process is being overseen by a Steering Committee (analogous to the DSM Task Force). Five standing Review Committees, with about 6 members each, will work with the Steering Committee to consider the evidence in support of the proposed change. Proposals submitted to the DSM web portal will first be reviewed by the Steering Committee, which will refer the proposal to the appropriate review committee if it appears that the evidence for the proposal is substantially likely to meet the criteria for approval.

The Review Committee will undertake whatever additional investigation might be needed, such as consultation with relevant experts. It will then forward the reviewed proposal back to the Steering Committee to decide whether the proposal is suitable to be posted for public comment.

If the Steering Committee determines that the proposal has met the criteria for approval, it will submit the proposal and a summary of the public comments for review by the Board of Trustees of the APA. Once approved, changes will be publicized by the APA and digital versions of the manual will be updated to reflect the change.

The DSM-5 web portal has identified 3 types of proposals that require substantial empirical support, each with explicit criteria regarding the type of evidence that is expected to be submitted. In general, proposals should include a thorough review of the relevant literature and the results of any secondary data analyses conducted by those making the proposal.

 proposals involve changes to an existing diagnostic criteria set that purport to markedly improve the validity, reliability, or clinical utility of a criteria set, or to substantially reduce identified deleterious consequences

 proposals involve the addition of a new diagnostic category, subtype, or specifier

 proposals entail deleting an existing category or subtype or specifier

Proposals involving corrections and clarifications of existing criteria that do not require empirical support (type 4 proposals) are being considered on an expedited basis by a subcommittee of the Steering Committee. Included here are instances of lack of clarity or ambiguity in the meaning of the wording of criteria or text; inconsistencies or contradictions within the text or criteria (eg, diagnostic criteria that conflict with corresponding descriptions in the text); and errors of omission or inadvertent inclusion.

The first set of proposed changes to DSM-5 since the web portal was opened for submissions are now being posted for public comment on the DSM-5 web site, with comments being accepted from November 22, 2017 until December 22, 2017.

The first proposal concerns the ICD-10-CM diagnostic codes that apply to situations in which in a patient taking a medication, which is capable of causing physiological dependence, that is being taken as prescribed (ie, not abused), a withdrawal syndrome in the context of stopping the medication develops. The ICD-10-CM codes currently listed in DSM-5 for the categories of Opioid Withdrawal, Sedative, Hypnotic, or Anxiolytic Withdrawal, Cannabis Withdrawal, and Stimulant Withdrawal apply only to cases of withdrawal that develop in the context of a diagnosis of a substance use disorder. This proposal involves a change to the coding notes for these conditions so that they include the ICD-10-CM codes, which apply to cases of withdrawal that occur in the absence of a substance use disorder.

The second proposed change involves the definitions of Other/Unspecified Depressive Disorder and Other/Unspecified Anxiety Disorder, categories respectively reserved for cases in which the patient presents with depressive (or anxiety) symptoms that do not meet diagnostic criteria for any of the specific depressive disorders (or anxiety disorders). Since DSM-III, patients who present with mood or anxiety symptoms that do not meet criteria for one of the specified DSM disorders receive a diagnosis of either an Adjustment Disorder (if there is an identified causative psychosocial stressor) or the appropriate depressive or anxiety residual category (eg, Atypical Depression in DSM-III, Depressive Disorder NOS in DSM-III-R and DSM-IV, and Other/Unspecified Depressive Disorder in DSM-5). To make Adjustment Disorder take precedence over the residual categories, the definition of the residual category must indicate that the residual category NOT be diagnosed if the criteria are met for an Adjustment Disorder. This exclusion for Adjustment Disorder, inadvertently omitted from DSM-5, has been added.

 The third proposal applies to situations in which a patient’s response to exposure to a traumatic stressor does not meet criteria for PTSD. According to DSM-5, if the duration of the symptomatic response lasted 6 months or less, the diagnosis should be Adjustment Disorder. If the symptoms persist for more than 6 months, however, the Adjustment Disorder diagnosis no longer applies, since the 6-month limit on duration has been exceeded. Such cases should be diagnosed instead as Other Trauma- and Stressor-related Disorder. To clarify that this is the correct diagnosis for such scenarios, the following example has been added to the definition of Other Specified Trauma- and Stressor-related Disorder: “Persistent response to trauma with PTSD-like symptoms (ie, symptoms occurring in response to a traumatic event that fall short of the diagnostic threshold for PTSD and that persist for longer than 6 months).”

 The fourth proposal corrects an error in the hallucinations dimension that is a component of the Clinician-Rated Dimensions of Psychotic Symptom Severity scale included in DSM-5 Section III (“Emerging Measures and Models”). The anchor points for the hallucination severity dimension incorrectly focus exclusively on the impact of voices on the patient, when it should instead include all types of hallucinations.

 The final proposal corrects an unintended discrepancy between the wording of the stressor criterion (criterion A) in Posttraumatic Stress Disorder and Acute Stress Disorder. Criterion A in PTSD requires “exposure to actual or threatened death, serious injury, or sexual violence,” whereas criterion A in Acute Stress Disorder includes “exposure to actual or threatened death, serious injury, or 

” (italics added). The correct wording for both versions of criterion A is “exposure to . . . sexual violence.”

This article was originally posted on 11/16/17 and has since been updated.

Articles

Advances in digital publishing that allow instantaneous dissemination of changes at minimal cost have paved the way towards the adoption of a continuous improvement model for DSM, in which revisions are pegged to specific scientific advances.

Public Comment Period Opens for First Set of New Proposals to Update DSM-5

Once a year, the National Center for Health Statistics (NCHS), the federal agency responsible for the use of the International Classification of Diseases – 10th revision (ICD-10) in the US, releases an updated version of the ICD-10-CM, the HIPAA-adopted code set for medical diagnoses used by medical providers, insurers, and health care administrators. The 2018 update of the ICD-10-CM took effect on October 1, 2017, meaning that users of the ICD-10-CM are required to start using the updated codes as of that date.

Coding updates affect the ICD-10-CM codes across all areas in medicine and typically are made to improve coding specificity. For example, the diagnostic code for Type 2 Diabetes Mellitus with Ketoacidosis (E11.1) has been altered to allow the clinician to indicate whether the ketoacidosis was accompanied by coma. This year, there are several coding updates that affect the diagnostic coding in the Mental, Behavioral, and Neurodevelopmental chapter (F00-F99) and thus affect the diagnostic codes used by mental health practitioners. As is the case with most of the other coding updates, the changes to the mental disorder codes aim to improve the coding specificity of the diagnoses, which in turn can help optimize medical reimbursement.

One important update involves the diagnostic codes for substance use disorders. The ICD-10-CM diagnostic codes recommended by DSM-5 are F1x.10 for the diagnosis of mild substance use disorder, and F1x.20 for both moderate substance use disorder and severe substance use disorder, where x indicates the class of substance: 0 for alcohol use disorder; 1 for opioid use disorder; 2 for cannabis use disorder; 3 for sedative, hypnotic, or anxiolytic use disorder; 4 for cocaine use disorder; 5 for amphetamine or other stimulant use disorder; 6 for phencyclidine or other hallucinogen use disorder; 7 for tobacco use disorder; 8 for inhalant use disorder; and 9 for other or unknown substance use disorder. Currently, the clinician indicates that the substance use disorder is in early or sustained remission either by writing in the applicable specifier on the chart or by selecting it from a drop-down menu on an electronic health record. Either way, the fact that the substance use disorder is in remission is not reflected in the diagnostic code. For example, mild alcohol use disorder and mild alcohol use disorder in sustained remission have the same diagnostic code: F10.10.

The October 1 update remedies this by providing different ICD-10-CM codes for active substance use disorder and substance use disorder in remission. Whereas mild substance use disorder continues to be F1x.10, moderate substance use disorder continues to be F1x.20, and severe substance use disorder continues to be F1x.20, mild substance use disorder in remission is now coded as F1x.11 and moderate and severe substance use disorder in remission is now coded as F1x.21 (

The other coding update effective October 1, 2017, involves the ICD-10-CM code for avoidant/restrictive food intake disorder (ARFID). It is now changed from F50.89 (a diagnostic code which is shared by other specified eating or feeding disorder) to F50.82, which will be unique to ARFID.

Dr. First is Professor of Clinical Psychiatry at Columbia University in New York.

Several updates to ICD-10-CM affect the diagnostic codes used by mental health practitioners. One important update involves the codes for substance use disorders. Details here.

New Diagnostic Codes for Substance Use Disorders and Avoidant/Restrictive Food Intake Disorder

“Got a challenging case-a patient for whom the diagnosis is unclear or uncertain? Want a diagnostic opinion?

If so, we invite you to submit a brief description of key clinical details (no more than 800 words) plus a description of why you find the case to be diagnostically challenging.

Michael First, MD-nationally recognized expert on psychiatric diagnosis and assessment issues will review those details and offer insights on select cases.

Dr First, Professor of Clinical Psychiatry at Columbia University, is the Editorial and Coding Consultant for DSM-5, Chief Technical and Editorial Consultant on the WHO’s ICD-11 Revision project, an external consultant to the NIMH’s RDoC (Research Domain Criteria) Project and author of a number of books about psychiatric diagnosis, including the DSM-5 Handbook of Differential Diagnosis.”

Only submissions from mental health professionals will be considered. Please include your name and degree with your case along with an e-mail address in case Dr. First needs to contact you for additional information. To help preserve confidentiality, if your case is selected for publication in 

AMENDMENT TO OUR INVITATION: If you are a nurse or nurse practitioner, you may send your case to editor@psychiatrictimes.com for consideration. -The Editors

Got a challenging case-a patient for whom the diagnosis is unclear or uncertain? Want a diagnostic opinion? This is a call for cases. Michael First, MD-a nationally recognized expert on psychiatric diagnosis and assessment issues-will review details and offer insights on select cases.

Call for Challenging Cases

Since 1979, all clinicians-psychiatrists and non-psychiatrists-who practice in the US have had to submit valid ICD-9-CM diagnostic codes with their billing submissions in order to meet government- and insurer-imposed coding requirements. Starting October 1, 2015, we will have to switch from ICD-9-CM to a new coding system, ICD-10-CM.

The reason for this switchover is straightforward: ICD-9-CM was simply running out of codes. ICD-9-CM is a 5-digit numerical coding system that contains approximately 13,000 codes. ICD-10-CM is an alpha-numeric system that contains approximately 68,000 codes: each code starts with a letter followed by anywhere from 2 to 7 numbers. Moreover, these additional available codes allow the clinician to be much more specific when communicating information about the patient’s diagnostic condition. For example, there is a single ICD-9-CM code for diabetes mellitus complicating pregnancy or childbirth: 648.01. In ICD-10-CM, there are 21 corresponding ICD-10-CM codes that require you to indicate whether the diabetes is type 1 or type 2; whether it developed during the first, second, or third trimester or during childbirth; or whether it predated the pregnancy.

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For most clinicians, the ICD-9-CM to ICD-10-CM transition requires extensive retraining of themselves and their staff so that they can take advantage of the increased specificity and maximize appropriate reimbursement. The transition has also required a massive reprogramming of billing and other data collection systems to accommodate the new code set. For this reason, over the years there has been pushback from both the clinical and administrative communities to delay implementation of ICD-10-CM. In fact, its implementation has already been delayed twice. It was originally scheduled for implementation on October 1, 2013, but postponed to 2014. Then, last year-under pressure from the AMA, a provision was added to the annual 1-year “fix” of the Sustainable Growth rate formula for Medicare physician reimbursement. This delayed implementation yet again, this time until October 1, 2015.

But no further delays are likely to happen, and you and your colleagues must now bite the bullet and accept that-in a matter of a few weeks-you will be required to submit bills using ICD-10-CM codes.

The good news? Compared with our non-psychiatric colleagues, psychiatrists are in very good shape when it comes to switching over to ICD-10-CM.

When DSM-5 was published in May 2013, in anticipation of the impending ICD-9-CM to ICD-10-CM switchover, both ICD-9-CM and ICD-10-CM codes were assigned to each of the DSM-5 diagnoses. For example, as can be seen on page 190 of DSM-5, the diagnostic codes for Separation Anxiety Disorder “309.21 (F93.0)” are listed in the upper right hand corner of the criteria set. In this case, 309.21 is the ICD-9-CM code for Separation Anxiety Disorder, and F93.0 is the ICD-10-CM code. Starting October 1, all you need do to become ICD-10-CM–compliant is to start using F93.0 instead of 309.21 when submitting payment for a case of Separation Anxiety Disorder.

Because the diagnostic codes sometimes reflect the use of applicable specifiers, for some disorders the coding is less straightforward. For example, on page 338 of DSM-5, the criteria set for Anorexia Nervosa does not list any diagnostic codes in the upper right hand corner. This is because the diagnostic code depends on which subtype applies. As is seen on page 339, the ICD-10-CM code is F50.01 for the restricting type (no binge eating or purging episodes during the past 3 months) and F50.02 for the binge eating–purging type (recurrent episodes of binge eating or purging).

The reason that both ICD-9-CM and ICD-10-CM codes are included in DSM-5 is that it came out during the time when clinicians were still required to use ICD-9-CM codes. Presumably, future printings of DSM-5 will excise the ICD-9-CM codes and will include only the ICD-10-CM codes.

Part of the reason for the impending anxiety among some psychiatrists about what they need to do to become ICD-10-CM–compliant stems from the mistaken notion that they will be required to use ICD-10-CM instead of the “DSM codes” included in DSM-5. There are, in fact, no “DSM codes” in the DSMs. Since DSM-III, diagnostic codes appearing in DSM have all been valid ICD-9-CM codes.

Let me take a short historical detour here to explain yet another major source of confusion about the ICD coding system. Since 1948, the International Classification of Diseases (ICD) has been produced by the World Health Organization (WHO) to promote uniform collection of health statistics around the world. All countries that are members of the WHO are obligated by treaty to use ICD codes for collecting data about medical diagnoses. The current version of the ICD coding system used internationally since 1992 is ICD-10, ie, the 10th revision of the ICD. Work is now under way by the WHO to produce the next revision, ICD-11, which is expected to be approved by the World Health Assembly in May 2018.

Back in the 1970s, the US government decided that the ICD system was not specific enough for clinical use and developed its own version of the ICD for use in the US. It is called ICD-CM (the CM stands for “Clinical Modification”). The version of the ICD currently used in the US is ICD-9-CM, which became “official” in 1979. So while the rest of the world has been using ICD-10 for reporting health care statistics since the 1990s, the US continues to use the ICD-9-CM system, which is based on the older ICD-9 classification. The US is finally ready to catch up to the rest of the world and implement ICD-10-CM, which as the “CM” designation indicates, is a modified version of ICD-10 for use in the US.

ICD-10-CM was actually ready for use in the US by the mid-1990s, but its implementation was delayed for 20+ years because of opposition from various groups on the grounds that implementation would be costly and not worth it.

What about “differences” between the mental disorders section of ICD-10-CM and DSM-5? Besides the substance use disorder codes (for which there are 3 times as many codes in ICD-10-CM as there are substance use disorders in DSM-5), there are hardly any more diagnostic codes in the mental disorders section of ICD-10-CM as there are in DSM-5. In fact, if you look closely at the mental disorders section of the ICD-10-CM (available on the Web site of the National Center for Health Statistics), you will see that the ICD-10-CM mental disorder section looks essentially the same as DSM-IV-TR in terms of categories and names of disorders. This is not an accident-the APA had a big hand in the development of the ICD-10-CM content and we made a strong effort to get it as close to DSM-IV as possible, since we were expecting the ICD-10-CM to go into effect in the late 1990s, well before any work started on DSM-5.

By the way, the reason for the proliferation of substance use disorder codes is that the ICD-10-CM coding system requires the clinician to combine substance use disorder diagnoses (eg, substance dependence) with substance-induced diagnoses (eg, substance-induced depressive disorder): if you want to make a diagnosis of a substance-induced disorder, you must also indicate the comorbid substance use disorder. For example, when choosing the diagnostic code for a patient with cocaine-induced depression, you must indicate the comorbid pattern of cocaine use as follows: F14.14 for cocaine-induced depressive disorder occurring in the context of mild cocaine use disorder; F14.24 for cocaine-induced depressive disorder occurring in the context of moderate to severe cocaine use disorder; and F14.94 for cocaine-induced depressive disorder occurring without a comorbid cocaine use disorder (see DSM-5, page 176).

So . . . you don’t need to lose sleep over the coming transition. If you already have a copy of DSM-5, you have all of the codes you need for successful ICD-10-CM implementation.

 about the coming transition to ICD-10-CM, please post them in the comment box.

The good news? Compared with our non-psychiatric colleagues, we psychiatrists are in very good shape when it comes to switching over to ICD-10-CM. 

What You Need to Know About DSM-5 and ICD-10-CM

How do you use the DSM, doctor? Is it an integral part of your diagnostic decision making? Do you use it to help you select treatment or gauge a patient’s prognosis? Do you rely on it mainly for coding and billing? For something else entirely?

There is strikingly little information available in the literature regarding how clinicians actually use the DSM in their everyday practice.

Getting a better understanding of how the DSM is used by clinicians is important for several reasons:

• Many of the uses of the DSM (eg, communicating diagnostic information to other clinicians, accurately applying research studies that define study groups using DSM criteria) depend on a relatively faithful application of the DSM criteria.

• Given that one of the primary goals of making DSM revisions is to improve its clinical utility, establishing a baseline of current usage is critical to inform future proposals.

• Knowledge about how clinicians use the DSM is important in determining the likely impact of changes to the diagnostic system on practice patterns-a major source of criticism during the DSM-5 revision process.

 and his fellow members of the Group for the Advancement of Psychiatry (GAP) Psychopathology Committee recently called for additional research that focuses on determining clinicians’ actual use of the DSM. 

 subsequently posted a survey on its Web site that was developed by the GAP Psychopathology Committee.

Although the survey will be analyzed in detail at a later date, we wanted to take this opportunity to provide you with some preliminary results.

 The survey is open for a few more weeks and we welcome your participation: 

To date, 894 readers have completed the survey. The demographic breakdown:

• 62% of respondents reported that they currently use DSM-5; 38% still use DSM-IV

• 92% of respondents provide more than 4 hours per week of direct patient care

• 5% are under age 30; 30% are 30 to 49; 43% are 50 to 64; and 22% are over 65

• 60% of the respondents report being a psychiatrist; 14% are psychologists; 5%, social workers; 6%, counselors; 11%, nurse practitioners or physician’s assistants; and 4%, lawyers, administrators, or “other”

• 88% report being Adult clinicians; 31%, Child clinicians; 19%, Geriatric clinicians; 13%, Forensic clinicians; 20%, Addiction specialists; 17%, Community-based clinicians; and 14%, Consultation-liaison (the percentages do not add up to 100%, since respondents were allowed to indicate more than one specialty)

• 59% report being in outpatient private practice, 35% practice public sector psychiatry, 28% are academically based, and 16% are non-academic hospital-based

• Respondents report spending average times of up to 72% clinical, 16% administrative, 11% research, 13% teaching, 14% consultation, and 12% other.

Respondents were first asked about their everyday DSM usage when making initial diagnoses during the assessment phase of treatment across a variety of different uses (

). They were then asked the same question-but as it pertains to ongoing treatment (

). They were also asked about usefulness of DSM in everyday practice (

In both initial and ongoing everyday practice, the majority of the respondents use DSM codes for administrative/billing purposes. About half report that they “sometimes,” “often,” or “always” use DSM to review specific criteria with the pa-tient or family and more than 60% use it “sometimes,” “often,” or “always” to review relevant text for specific disorders. In the initial evaluation of a patient, close to 85% “sometimes,” “often” or “always” use DSM diagnostic criteria from memory-but not as much during ongoing treatment.

Overall, a significant minority do not find the DSM to be very helpful in selecting treatment, and about half do not find it helpful for determining prognosis. It is seen as most useful in meeting administrative requirements, in communicating with colleagues, and in teaching.

Whatever controversies surround the DSM, this manual is already in widespread use for multiple purposes. This survey gives us the first picture of how clinicians are using the DSM-and for what purposes. We hope that these preliminary findings will stimulate further study of DSM use in clinical practice as part of the American Psychiatric Association’s plans for further revisions.

 First MB, Bhat V, Adler D, et al. How do clinicians actually use the 

Diagnostic and Statistical Manual of Mental Disorders

 in clinical practice and why we need to know more. 

 Kweskin S. Why we need to know how clinicians use the DSM. 

Given that one of the primary goals of making DSM revisions is to improve its clinical utility, establishing a baseline of current usage is critical to inform future proposals. For this and other reasons, the authors provide preliminary results from research focused on determining clinicians’ actual use of DSM.

How Clinicians Actually Use the DSM: Psychiatric Times Survey Results

An expert on psychiatric diagnosis and assessment, Dr First is Professor of Clinical Psychiatry at Columbia University and a Research Psychiatrist at the Biometrics Department at the New York State Psychiatric Institute in New York.

He is a speaker at a preconference program for this year's PsychCongress. In this program, he focuses on the publication of DSM-5, for which he is Editorial and Coding Consultant, and he will give an overview of proper use of the manual. He will also discuss issues related to ICD-9 and ICD-10-CM coding, as well as the 6-step differential diagnosis framework from his book.

Published by American Psychiatric Publishing, Inc., the 

 offers a framework for diagnosing patients, as described on the 

The handbook offers an assortment of approaches to differential diagnosis, and a number of features designed to benefit clinicians in the exam room, including:

A 6-step framework for diagnosing patients that proceeds from determining if the symptom is real to establishing the boundary between disorder and normality, with intermediary steps to rule out substance etiology and medical conditions, as well as to determine the primary disorder and to differentiate adjustment disorders from other mental disorders.

Twenty-nine symptom-oriented decision trees that provide detailed decision points to facilitate the process of generating the differential diagnosis based on the presenting symptoms and eliminate formulating premature conclusions.

Sixty-six differential diagnosis tables, one for each of the most important DSM-5® disorders, cross-referenced with the terminal branches of the decision trees presented in the handbook to provide a head-to-head comparison of each disorder, highlighting similarities and differences.

 classification, to facilitate coding and to provide an overview of all of the DSM-5

 diagnoses that must be considered in formulating a differential diagnosis.

Alphabetical indexes of the decision trees and differential diagnosis tables to help readers readily locate desired material.

A proper psychiatric diagnosis requires the ability to elicit information, identify symptoms, and recognize behavioral patterns. Dr Michael First, author of DSM-5 Handbook of Differential Diagnosis, summarizes key points in this brief video.