The Diagnostic and Statistical Manual of Mental Disorders (DSM) functions as the map of the galaxy that is the behavioral health world.
When an employee requests leave for a behavioral health diagnosis, the coding for that diagnosis is based on the DSM. The diagnostic code impacts virtually every aspect of the claim: the medical care, the way the claim is handled by a health plan or insurance carrier or third party administrator (TPA), the projected disability duration, and the return to work process for the employee.
In recent years, it has become clear that the diagnosis of mental health disorders is not as neat and clean as the categorical classification of the DSM-IV has implied. In the DSM-5, the American Psychiatric Association (APA) attempts to begin the transformation to a more dimensional and accurate approach to diagnosis.
The DSM-51 brings with it many changes big and small, global and specific, and some that have been long awaited by the mental health community since the 1994 release of DSM-IV.2 While there are numerous modifications, this article focuses on the top five areas impacting your claims, and language you may hear from providers, carriers or TPAs:
- The historic diagnostic system of “Multi-Axial Diagnosis” has been eliminated;
- Also eliminated is a behavioral functional assessment tool, the “Global Assessment of Functionality” or GAF score;
- Another functional assessment tool was recommended, the World Health Organization Disability Assessment Schedule 2.0 (WHODAS 2.0)3;
- Criteria were changed for Posttraumatic Stress Disorder (PTSD), opening the possibility of an increase in PTSD claims;
- The “bereavement exclusion” for depression claims was eliminated, so clinicians may be involved more often to assess the behavioral impact of the death of a loved one.
It is important to note that the DSM-5 was released on May 22, 2013. The APA recognized that it would take some time for the mental health community to adjust to these changes. Clinics, government agencies, and insurance companies all need to update internal procedures and internal and external forms to reflect these changes. The APA allowed time for these adjustments and recommended that the transition be completed by January 1, 2014. However, we continue to see DSM-IV diagnoses and GAF scores. This suggests that implementation of the new DSM-5 will be slower than anticipated.
Multi-Axial Assessment: A Thing of the Past
Disability and absence managers may still see occasional references to the discontinued five-axis diagnostic format of DSM-IV:
Axis I: Clinical Disorders, Other Conditions That May Be a Focus of Clinical Attention
Axis II: Personality Disorders, Mental Retardation
Axis III: General Medical Conditions
Axis IV: Psychosocial and Environmental Problems
Axis V: Global Assessment of Functioning (GAF)
The DSM-IV used this system to facilitate comprehensive evaluation with attention to the entire person, including mental disorders, general medical conditions, psychosocial factors, and level of functioning that might be overlooked if the focus were solely on the mental disorder. It provided a format for organizing and communicating clinical information.
Despite the adoption of the DSMIV multi-axial system by insurance companies and government agencies, it was never a required format to make a psychiatric disorder diagnosis. The multiaxial distinction among diagnoses was also not meant to imply that physical conditions, behavioral factors, or psychosocial factors were unrelated to mental health disorders. Elimination of this multi-axial system is consistent with both the World Health Organization (WHO) and International Classification of Diseases (ICD) diagnostic formats.
The DSM-5 Task Force determined that the DSM should not develop its own classification system that would address disability but should maintain uniformity with the other diagnostic formats and should focus mainly on providing diagnoses for treatment.Theoretically, you should start to see only simple listings of primary and secondary diagnoses, with no reference to the five-axis system. But as noted earlier, the transition from DSM-IV to DSM-5 is progressing more slowly than expected.
No More GAF Score
The DSM-IV Global Assessment of Functioning score was eliminated for two key reasons: the lack of conceptual clarity and the questionable reliability and validity of the GAF score in routine practice. This should come as no shock to those of you who have had claimants described as being unable to work despite GAF scores of 75 (suggesting high functionality) or claimants noted to be volunteering at a school and able to do their daily activities despite GAF scores of 30 (suggesting significant impairment). DSM-5 proposes an alternative system for functional assessment called the World Health Organization Disability Assessment Schedule 2.0 (WHODAS 2.0).
What Is the WHODAS 2.0?
The WHODAS 2.0 is a 36-item, self-administered questionnaire that can be given to individuals ages 18 and older on a frequent basis to assess functionality and response to treatment. If the individual is unable to complete the form, a “knowledgeable informant” may complete a proxy-administered version. (A “knowledgeable informant” is defined as a “friend, relative or carer,” with “carer,” a form of “caregiver” used in the WHODAS 2.0.) The questionnaire can be used for all health conditions, not just mental health.
The primary construct being measured is overall daily functioning. The 36 items are divided into six domains:
- 1. Understanding and Communicating
- Getting Around
- Getting Along with People
- Life Activities—Household and School/Work
- Participation in Society
On each item, the individual is asked how much difficulty he or she has had with each activity in the past 30 days.
The items are rated 1 to 5 (None=1, Mild=2, Moderate=3, Severe=4, and Extreme/cannot do=5). The treating clinician, however, can adjust the ratings. In other words, the clinician looks at the patient’s responses and can change them if he or she thinks specific ratings are too low or too high, theoretically making it more objective.
The WHODAS, 2.0 can be scored by both a “simple” method and a “complex” method. You should not expect to see the complex method very often because it involves putting item scores into a complex algorithm to produce overall results. However, you may start seeing the simple method being used. This is a hand-scored method that divides the total sum of all the item scores by 36 to yield a general disability score of from 1 to 5 (1=None, 2=Mild, 3=Moderate, 4=Severe, and 5=Extreme).
Posttraumatic stress disorder (PTSD) is no longer listed in the Anxiety Disorders section of the DSM. It is now in a separate category called Trauma and Stress-Related Disorders. PTSD criteria have also been altered in DSM-5.
The first major change is in the type of event that is considered traumatic for the purpose of qualifying for a diagnosis of PTSD. The DSM-5 now includes sexual violence as a traumatic experience.
The second change is the addition of first responders; they are now included as individuals who could develop PTSD in the course of doing their work. It is important to note that exposure to a traumatic event via electronic media, television, movies, or pictures does not apply unless the exposure is work-related. Work issues such as promotions, demotions, and adverse performance reviews do not qualify for this diagnosis.
A third significant change is that in order to qualify for a PTSD diagnosis, the claimant’s response to the event no longer has to include intense fear, helplessness, or horror. This change was made because the person may not feel anything initially after the event; he or she may be numb or in shock.
What do the PTSD changes mean for you? The bottom line is that you will likely start seeing an increase in PTSD diagnoses and, consequently, an increase in PTSD claims. The new DSM-5 criteria are less restrictive, making it easier for a person to qualify for this diagnosis.
Removal of the Bereavement Exclusion
DSM-IV included a bereavement exclusion, which stipulated, with few exceptions, that major depressive disorder could not be diagnosed after the loss of a loved one if the symptoms had been less than two months in duration. The bereavement exclusion has been eliminated in the DSM-5, since it has now been recognized that:
- Bereavement typically lasts longer than two months;
- It can trigger a major depressive episode; and
- Bereavement-related depression responds to the same treatments that other types of depression do.
Distinguishing between bereavement and major depressive disorder is now based on analysis of six primary factors:
- Types of symptoms being expressed
- Course of the symptoms
- Whether any positive emotion can be experienced
- Type of thought content
- Triggers associated with the symptoms
- Details of suicidal thoughts
To distinguish bereavement from major depressive disorder, disability and absence managers may have to rely on clinicians more often than in the past.
Although the new DSM-5 was released nearly a year ago with a January 1, 2014, implementation target, some government agencies, carriers, and providers may not have fully made the transition. The use of DSM-IV diagnostic language should taper off. The Multi-Axial Assessment system, for example, was discontinued in DSM-5.
So was the unreliable Global Assessment of Functioning (GAF) score. It was replaced by the World Health Organization Disability Assessment Score 2.0 (WHODAS 2.0), a patient self-report survey that clinicians may adjust, based on their assessment of the patient’s functionality. Posttraumatic stress disorder (PTSD) was moved into a new category, “Trauma- and Stress-Related Disorders,” and PTSD diagnoses may increase. Separating bereavement-related depression from other categories of depression has become more complex, requiring clinician involvement.
As if these changes aren’t enough, the DSM-5 contains numerous other changes not discussed here. Don’t be surprised if you start hearing rumblings of additional enhancements or text revisions coming. When it comes to the DSM series, 19-year revision intervals most likely will be a thing of the past, and change may become the new normal.
- American Psychiatric Association. Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Association. 2013.
- American Psychiatric Association. Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: American Psychiatric Association. 1994.
- World Health Organization. Measuring health and disability—Manual for WHO Disability Assessment Schedule. Geneva: World Health Organization. 2010.
By Jennifer Kurtz, PsyD, LP, Clinical Director, Behavioral Medical Interventions. This article first appeared in the May 2014 issue of @Work magazine.