The DSM-5 Older Adult Diagnostic Interview

CHAPTER

7 The DSM-5 Older Adult Diagnostic Interview

IN Chapter 6, “The 30-Minute Older Adult Diagnostic Interview,” we outlined a diagnostic interview that includes questions to screen for each of the DSM-5 (American Psychiatric Association 2013) categories of mental disorders commonly experienced by older adults. When an older person answers affirmatively to one of those screening questions, the question should become the pathway into the psychiatric diagnostic interview. A good interviewer skillfully travels this path with an older person and, when possible, reaches a specific and accurate diagnosis along the way.

This chapter follows the order of DSM-5 disorder categories, beginning with schizophrenia spectrum and other psychotic disorders. For each category of DSM-5 diagnoses presented, the section begins with one or more screening questions from the model interview presented in Chapter 6 and then presents follow-up questions. If the follow-up questions include a measure of impairment or a measure of time, these measures are a required part of the subsequent diagnostic criteria. By asking follow-up questions before the additional symptom questions in the diagnostic criteria, we make the interview more efficient and precise while reserving the full diagnosis of a mental disorder until later.

The screening and follow-up questions are followed by the diagnostic criteria. When the diagnostic criteria are to be elicited by the interviewer, we offer italicized prompts for the relevant symptom. We structured these questions so that an affirmative answer meets the criteria for that symptom. When the diagnostic criteria are observed rather than elicited, as in the case of disorganized speech, psychomotor retardation, or autonomic hyperactivity, they are listed as instructions to the interviewer, set in roman type. The minimum number of symptoms necessary to reach a particular diagnosis is underlined. We do not list all the possible questions that can be used to elicit a relevant symptom, but the included questions are specifically designed to follow DSM-5. To make the diagnostic process as clear as possible, we have included negative criteria for a DSM-5 diagnosis under the heading “Exclusion(s).” For example, DSM-5 observes that a person’s avoidance of food to the point of significant weight loss does not meet criteria for avoidant/restrictive food intake disorder if it is better explained by food insecurity or a cultural practice such as fasting. These exclusion criteria usually do not require you to ask a specific question but instead depend on the history you elicit. The most common subtypes, specifiers, and severity measures are listed under the heading “Modifiers”; however, the complete array of modifiers is found only in DSM-5.

In the interest of brevity, this guide includes diagnostic questions for the most common DSM-5 disorders. The idea is to focus on learning diagnostic criteria for the most common disorders in each section before exploring the related diagnoses—that is, to know the main streets of DSM-5 before learning its side streets.

In this book, the side streets are labeled as alternatives, a term that is not used in DSM-5. These alternatives include only related diagnoses from the same DSM-5 diagnostic class. For example, schizophreniform disorder is listed as an alternative to schizophrenia because both are grouped in the same chapter in DSM-5. In contrast, major depressive disorder, obsessive-compulsive disorder, and some other diagnoses listed in the DSM-5 differential diagnosis for schizophrenia are not among the alternatives for schizophrenia listed in this chapter because they are in different diagnostic classes in DSM-5. For each diagnosis listed as an alternative, the essential criteria are included, and the interviewer is referred to the corresponding pages in DSM-5 to read the diagnostic criteria and associated material in detail.

We eliminated repetitive DSM-5 criteria, especially for the various mental disorders associated with another medical condition or substance-induced mental disorders, in which, broadly, the symptoms of a disorder are present as a direct effect of another medical condition or the use of a substance.

As this overview suggests, this book is not a substitute for DSM-5. It is a practical diagnostic tool that serves as an operationalized version of DSM-5—the equivalent of the sketched version of a city street that a satellite navigation device displays rather than the detailed portrait of each side street. If you need those details, use the letter and series of numbers that follow a diagnosis to direct you to additional information. For example, after gambling disorder, you will see this notation: [F63.0, 585–589]. The first entry is the ICD-10-CM code corresponding to gambling disorder, and the second entry is the page numbers of the main DSM-5 text for the disorder. These codes and page numbers are provided to assist practitioners with coding and with quickly locating additional information.

Unfortunately, the notations are sometimes more cryptic, as in this notation: [G47.4xx, 372–378]. As before, the first entry is the ICD-10-CM code corresponding to narcolepsy, and the second entry is the page numbers for the DSM-5 text about the disorder. However, the use of “xx” indicates that you need additional information to find the specific ICD-10-CM code. In this case, that additional information is whether a person’s sleep disturbance occurs with or without cataplexy, hypocretin deficiency, or a genetic syndrome, or secondarily to another medical condition. We organized the diagnoses this way to reduce repetitive listing and keep your focus on efficient, accurate diagnoses.

ICD-10-CM codes are complex. Listing every code would double the length of this book and reduce its clinical utility. Listing every code would also shift the focus to accurate coding, when our goal is to help you make an accurate diagnosis as part of understanding another person.

As this strategy suggests, we try to balance brevity and detail. For each diagnosis, the notation always provides the general form of the ICD-10-CM codes along with the page numbers of DSM-5 so that you can quickly find the additional information you need. This book lacks the rich detail of DSM-5 but will deliver you to your diagnostic destination in a timely fashion.

Schizophrenia Spectrum and Other Psychotic Disorders

DSM-5 pp. 87–122

Screening questions: Have you seen visions or other things that other people did not see? Have you heard noises, sounds, or voices that other people did not hear? Do you ever feel as if people are following you or trying to hurt you in some way? Have you ever felt that you had special powers or found special messages from the radio or TV that were seemingly meant just for you?

If yes, ask: Do these experiences change what you do or tell you to do things? Did these experiences ever cause you significant trouble with your friends or family, at work, or in another setting?

If yes, proceed to schizophrenia criteria.

Schizophrenia [F20.9, 99–105]
1. Inclusion: Requires at least 6 months of continuous signs of disturbance, which may include prodromal or residual symptoms. During at least 1 month of that period, at least two of the following symptoms are present, and at least one of these symptoms must be delusions, hallucinations, or disorganized speech.
  1. Delusions: Is anyone working to harm or hurt you? When you read a book, watch television, or work at a computer, do you ever find that there are messages intended just for you? Do you have special powers or abilities?
  2. Hallucinations: When you are awake, do you ever hear a voice different from your own thoughts that other people cannot hear? When you are awake, do you ever see things that other people cannot see?
  3. Disorganized speech such as frequent derailment or incoherence
  4. Grossly disorganized or catatonic behavior
  5. Negative symptoms such as diminished emotional expression or avolition
2. Exclusion: If the disturbance is attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition, do not use this diagnosis.
3. Modifiers
  1. Specifiers
    - First episode, currently in acute episode
    - First episode, currently in partial remission
    - First episode, currently in full remission
    - Multiple episodes, currently in acute episode
    - Multiple episodes, currently in partial remission
    - Multiple episodes, currently in full remission
    - Continuous
    - Unspecified
  2. Additional specifiers
    - With catatonia [F06.1, 119–121]: At least three of the following are present: stupor, catalepsy, waxy flexibility, mutism, negativism, posturing, mannerisms, stereotypies, agitation, grimacing, echolalia, echopraxia.
  3. Severity
    - Severity is rated by a quantitative assessment of the primary symptoms of psychosis, each of which may be rated for its current severity on a five-point scale (see “Clinician-Rated Dimensions of Psychosis Symptom Severity,” DSM-5 pp. 742–744).
4. Alternatives
  1. If a person has eccentric behaviors, perceptions, and thoughts, along with limited capacity for close relationships since early adulthood, consider schizotypal personality disorder [F21, 655–659]. If the disturbance occurs exclusively in the context of schizophrenia, a depressive or manic episode with psychotic features, or autism spectrum disorder, do not use this diagnosis.
  2. If a person experiences only delusions, whether bizarre or nonbizarre, has never met full criteria for schizophrenia, and has functioning that is not markedly impaired beyond the ramifications of her delusion, consider delusional disorder [F22, 90–93]. The criteria include multiple specifiers. Do not use this diagnosis if the delusions are due to the physiological effects of a substance or another medical condition. The diagnosis also should not be used if the delusions are better explained by another mental disorder.
  3. If a person has experienced at least 1 day but less than 1 month of schizophrenia symptoms, consider brief psychotic disorder [F23, 94–96]. The person usually has an acute onset of symptoms, exhibits fewer negative symptoms and less functional impairment, and always experiences an eventual return to her previous level of functioning.
  4. If a person has experienced at least 1 month but less than 6 months of schizophrenia symptoms, consider schizophreniform disorder [F20.81, 96–99]. The criteria include specifiers for catatonia, as well as with and without good prognostic features.
  5. If a person who meets criteria for schizophrenia also experiences major mood disturbances—either major depressive episodes or manic episodes—for at least half the time she has met criteria for schizophrenia, consider schizoaffective disorder [F25.x, 105–110]. Over a person’s lifetime, she also must have experienced at least 2 weeks of delusions or hallucinations in the absence of a major mood episode.
  6. If a substance or medication directly causes a psychotic episode, consider substance/medication-induced psychotic disorder [F1x.x, 110–115].
  7. If another medical condition directly causes the psychotic episode, consider psychotic disorder due to another medical condition [F06.x, 115–118].
  8. If a person experiences psychotic symptoms that cause clinically significant distress or functional impairment without meeting full criteria for another psychotic disorder, consider unspecified schizophrenia spectrum and other psychotic disorder [F29, 122]. If you wish to communicate the specific reason a person’s symptoms do not meet the criteria, consider other specified schizophrenia spectrum and other psychotic disorder [F28, 122]. Examples include persistent auditory hallucinations in the absence of any other psychotic symptom and delusional symptoms in the partner of an individual with delusional disorder.

Bipolar and Related Disorders

DSM-5 pp. 123–154

Screening question: Has there been a time when for many days in a row your mood was super happy, you were more self-confident, and you had much more energy than usual?

If yes, ask: During those times, did you feel this way all day or most of the day? Did something happen that started those feelings? Did those times ever last at least a week or result in your being hospitalized? Did these periods ever cause you significant trouble with your friends or family, at work, or in another setting?

If symptoms lasted a week or caused hospitalization, proceed to bipolar I disorder criteria.
If not, proceed to bipolar II disorder criteria.

Bipolar I Disorder [F31.x, 123–132]
For a diagnosis of bipolar I disorder, it is necessary to meet criteria for at least one manic episode. The manic episode may have been preceded by and may be followed by hypomanic episodes or major depressive episodes.
1. Inclusion: A manic episode—defined as a distinct period of abnormally and persistently elevated or irritable mood and increased goal-directed activity or energy, lasting at least 1 week and present most of the day—requires at least three of the following symptoms.
  1. Inflated self-esteem or grandiosity: During that period, did you feel especially confident, as though you could accomplish something extraordinary that you could not have done otherwise?
  2. Decreased need for sleep: During that period, did you notice any change in how much sleep you needed to feel rested? Did you feel rested after less than 3 hours of sleep?
  3. More talkative than usual: During that period, did anyone tell you that you talked more than usual or that it was hard to interrupt you?
  4. Flight of ideas: During that period, were your thoughts racing? Did you have so many ideas that you could not keep up with them?
  5. Distractibility: During that period, were you having more trouble than usual focusing? Did you find yourself easily distracted?
  6. Increased goal-directed activity: During that period, how did you spend your time? Did you find yourself much more active than usual?
  7. Excessive involvement in activities that have a high potential for painful consequences: During that period, did you engage in activities that were unusual for you? Did you spend money, use substances, or engage in sexual activities in a way that is unusual for you? Did any of these activities cause trouble for anyone?
2. Exclusions
  1. The occurrence of manic or major depressive episode(s) is not better explained by schizoaffective disorder, schizophrenia, schizophreniform disorder, delusional disorder, or other specified or unspecified schizophrenia spectrum and other psychotic disorder.
  2. The episode is not due to the physiological effects of a substance or another medical condition. However, a manic episode that both emerges during antidepressant treatment and persists beyond the physiological effect of the treatment meets criteria for bipolar I disorder.
3. Modifiers
  1. Current (or most recent) episode
    - Manic [F31.x, 126–127]
    - Hypomanic [F31.x, 126–127]
    - Depressed [F31.x, 126–127]
    - Unspecified [F31.9, 126–127]: Use when the symptoms, but not the duration, of an episode meet criteria.
  2. Specifiers
    - With anxious distress
    - With mixed features: At least three of the symptoms of a major depressive episode are present simultaneously.
    - With rapid cycling
    - With melancholic features
    - With atypical features
    - With mood-congruent psychotic features
    - With mood-incongruent psychotic features
    - With catatonia
    - With peripartum onset
    - With seasonal pattern
  3. Course and severity
    - Current or most recent episode manic, hypomanic, depressed, unspecified
    - Mild, moderate, severe
    - With psychotic features
    - In partial remission, in full remission
    - Unspecified
4. Alternatives
  1. If a substance, including a substance prescribed to treat depression, directly causes the episode, consider substance/medication-induced bipolar and related disorder [F1x.xx, 142–145].
  2. If another medical condition causes the episode, consider bipolar and related disorder due to another medical condition [F06.3x, 145–147].
Bipolar II Disorder [F31.81, 132–139]
For a diagnosis of bipolar II disorder, it is necessary to meet criteria for at least one hypomanic episode. The hypomanic episode may have been preceded by and may be followed by major depressive episodes.
1. Inclusion: A hypomanic episode—defined as a distinct period of abnormally and persistently elevated or irritable mood and increased goal-directed activity or energy, lasting at least 4 days and present most of the day—requires the presence of at least three of the following symptoms.
  1. Inflated self-esteem or grandiosity: During that period, did you feel especially confident, as though you could accomplish something extraordinary that you could not have done otherwise?
  2. Decreased need for sleep: During that period, did you notice any change in how much sleep you needed to feel rested? Did you feel rested after less than 3 hours of sleep?
  3. More talkative than usual: During that period, did anyone tell you that you talked more than usual or that it was hard to interrupt you?
  4. Flight of ideas: During that period, were your thoughts racing? Did you have so many ideas that you could not keep up with them?
  5. Distractibility: During that period, were you having more trouble than usual focusing? Did you find yourself easily distracted?
  6. Increased goal-directed activity: During that period, how did you spend your time? Did you find yourself much more active than usual?
  7. Excessive involvement in activities that have a high potential for painful consequences: During that period, did you engage in activities that were unusual for you? Did you spend money, use substances, or engage in sexual activities in a way that is unusual for you? Did any of these activities cause trouble for anyone?
2. Exclusions
  1. If there has ever been a manic episode or if the episode is attributable to the physiological effects of a substance/medication, do not use this diagnosis.
  2. If the hypomanic episode is better explained by schizoaffective disorder, schizophrenia, schizophreniform disorder, delusional disorder, or other specified or unspecified schizophrenia spectrum and other psychotic disorder, do not use this diagnosis.
  3. If the hypomanic episode is severe enough to cause marked impairment in social or occupational functioning or to necessitate hospitalization, do not use this diagnosis.
3. Modifiers
  1. Specify current or most recent episode
    - Hypomanic
    - Depressed
  2. Specifiers
    - With anxious distress
    - With mixed features: At least three of the symptoms of a major depressive episode are present simultaneously.
    - With rapid cycling
    - With mood-congruent psychotic features
    - With mood-incongruent psychotic features
    - With catatonia
    - With peripartum onset
    - With seasonal pattern
  3. Course
    - In partial remission
    - In full remission
  4. Severity
    - Mild
    - Moderate
    - Severe
4. Alternatives
  1. If a person reports 1 or more years of multiple hypomanic and depressive symptoms that never rose to the level of a hypomanic or major depressive episode, consider cyclothymic disorder [F34.0, 139–141]. During the same 1-year period, the hypomanic and depressive periods have been present for at least half the time, and the individual has not been without the symptoms for more than 2 months at a time. If the symptoms are due to the physiological effects of a substance or another medical condition, do not use this diagnosis.
  2. If a person experiences symptoms characteristic of bipolar disorder that cause clinically significant distress or functional impairment without meeting full criteria for a bipolar disorder, consider unspecified bipolar and related disorder [F31.9, 149]. If you wish to communicate the specific reason a person’s symptoms do not meet the criteria, as in short-duration hypomania, short-duration cyclothymia, and hypomania without prior major depressive episode, consider other specified bipolar and related disorder [F31.89, 148].

Depressive Disorders

DSM-5 pp. 155–188

Screening question: Have you been feeling sad, blue, down, depressed, or irritable? If so: Does feeling this way make it hard to do things, hard to concentrate, or difficult to sleep?

If yes, ask: Did those times ever last at least 2 weeks? Did these periods ever cause you significant trouble with your friends or family, at work, or in another setting?

If yes, proceed to major depressive disorder criteria.

Major Depressive Disorder [F3x.xx, 160–168]
1. Inclusion: Requires the presence of at least five of the following symptoms, which must include either depressed
  mood or loss of interest or pleasure (anhedonia), during the same 2-week episode.
  1. Depressed mood most of the day (already assessed)
  2. Markedly diminished interest in activities or pleasures (already assessed)
  3. Significant weight loss or gain: During that period, did you notice any change in your appetite? Did you notice any change in your weight?
  4. Insomnia or hypersomnia: During that period, how much and how well were you sleeping?
  5. Psychomotor agitation or retardation: During that period, did anyone tell you that you seemed to move faster or slower than usual?
  6. Fatigue or loss of energy: During that period, what was your energy level like? Did anyone tell you that you seemed worn down or less energetic than usual?
  7. Feelings of worthlessness or excessive guilt: During that period, did you feel tremendous regret or guilt about current or past events or relationships?
  8. Diminished concentration: During that period, were you able to make decisions or concentrate like you usually do?
  9. Recurrent thoughts of death or suicide: During that period, did you think about death more than you usually do? Have you thought about hurting yourself or taking your own life?
2. Exclusions
  1. If the person has ever had a manic episode or a hypomanic episode, or the major depressive episode is attributable to the physiological effects of a substance or to another medical condition, do not use this diagnosis.
  2. If the major depressive episode is better explained by schizoaffective disorder, schizophrenia, schizophreniform disorder, delusional disorder, or other specified or unspecified schizophrenia spectrum and other psychotic disorder, do not use this diagnosis.
3. Modifiers
  1. Specifiers
    - With anxious distress
    - With mixed features: At least three of the symptoms of a major depressive episode are present simultaneously.
    - With melancholic features
    - With atypical features
    - With mood-congruent psychotic features
    - With mood-incongruent psychotic features
    - With catatonia
    - With peripartum onset
    - With seasonal pattern
  2. Course and severity
    - Single episode
    - Recurrent episode
    - Mild [F3x.0, 162]
    - Moderate [F3x.1, 162]
    - Severe [F3x.2, 162]
    - With psychotic features [F3x.3, 162]
    - In partial remission [F3x.4x, 162]
    - In full remission [F3x.xx, 162]
    - Unspecified [F3x.9, 162]
4. Alternatives
  1. If a person reports experiencing depression or anhedonia for at least 1 year, resulting in clinically significant distress or impairment, along with at least two of the symptoms of a major depressive episode, consider persistent depressive disorder (dysthymia) [F34.1, 168–171]. If a person experiences 2 continuous months without depressive symptoms, do not use this diagnosis. If the person has ever had symptoms that met the criteria for a bipolar disorder or a cyclothymic disorder, do not use this diagnosis. If the disturbance is better explained by a psychotic disorder or is due to the physiological effects of a substance or another medical condition, do not use this diagnosis.
  2. If the episode is directly caused by a substance, including a substance prescribed to treat depression, consider a substance/medication-induced depressive disorder [F1x.x4, 175–180].
  3. If another medical condition causes the episode, consider a depressive disorder due to another medical condition [F06.3x, 180–183].
  4. If a person experiences a depressive episode that causes clinically significant distress or functional impairment without meeting full criteria for a depressive disorder, consider unspecified depressive disorder [F32.9, 184]. To communicate the specific reason a person’s symptoms do not meet the criteria, consider other specified depressive disorder [F32.8, 183–184]. Examples include recurrent brief depression and depressive episode with insufficient symptoms.

Anxiety Disorders

DSM-5 pp. 189–233

Screening questions: During the past several months, have you frequently been worried about a number of things in your life? Is it hard for you to control or stop your worrying? Have you ever felt suddenly frightened, nervous, or anxious for no reason at all?

If yes, ask: Are there specific things, places, or social situations that make you feel very anxious or tearful?

If a specific phobia is elicited, proceed to specific phobia disorder criteria.
If not, first proceed to panic disorder criteria. Then proceed to generalized anxiety disorder criteria.

Specific Phobia [F40.2xx, 197–202]
1. Inclusion: Requires that for at least 6 months, a person has experienced marked fear or anxiety characterized by the following three symptoms.
  1. Specific fear: Do you fear a specific object or situation such as flying, heights, animals, or something else so much that being exposed to it makes you feel immediately afraid or anxious? What is it?
  2. Fear or anxiety provoked by exposure: When you encounter [this object or situation], do you cry or experience an immediate sense of fear or anxiety?
  3. Avoidance: Do you find yourself taking steps to avoid [this object or situation]? What are they? When you have to encounter [this object or situation], do you experience intense fear or anxiety?
2. Exclusion: The fear, anxiety, and avoidance are not restricted to objects or situations related to obsessions, reminders of traumatic events, separation from home or attachment figures, or social situations.
3. Modifiers
  1. Specifiers
    - Animal
    - Natural environment
    - Blood-injection injury
    - Situational
    - Other
4. Alternatives
  1. If an older person reports developmentally inappropriate and excessive distress when separated from home or a major attachment figure, or expresses persistent worry that such a figure will be harmed or die, resulting in reluctance or refusal to be separated from home or the major attachment figure, consider separation anxiety disorder [F93.0, 190–195]. The minimum duration of symptoms necessary to meet the diagnostic criteria is 6 months for adults.
  2. If a person reports at least 6 months of marked and disproportionate fear or anxiety about situations such as public transportation, open spaces, being in shops or theaters, standing in line or being in a crowd, or being outside the home alone, and if these fears cause her to actively avoid these situations, consider agoraphobia [F40.00, 217–221].
  3. If a person reports at least 6 months of marked fear or anxiety about, or avoidance of, social situations in which she fears that other people will observe or scrutinize her out of proportion to the actual threat posed by these situations, these social situations provoke fear or anxiety, and these situations are either avoided or endured, consider social anxiety disorder (social phobia) [F40.10, 202–208].
Panic Disorder [F41.0, 208–214]
1. Inclusion: Requires recurrent panic attacks, as characterized by at least four of the following symptoms.
  1. Palpitations, pounding heart, or accelerated heart rate: When you experience these sudden surges of intense fear or discomfort, does your heart race or pound?
  2. Sweating: During these events, do you find yourself sweating more than usual?
  3. Trembling or shaking: During these events, do you shake or develop a tremor?
  4. Sensations of shortness of breath or smothering: During these events, do you feel as though you are being smothered or cannot catch your breath?
  5. Feelings of choking: During these events, do you feel as though you are choking, as if something is blocking your throat?
  6. Chest pain or discomfort: During these events, do you feel intense pain or discomfort in your chest?
  7. Nausea or abdominal distress: During these events, do you feel sick to your stomach or as if you need to vomit?
  8. Feeling dizzy, unsteady, light-headed, or faint: During these events, do you feel dizzy, light-headed, or as if you may faint?
  9. Chills or heat sensations: During these events, do you feel very cold and shiver, or do you feel intensely hot?
  10. Paresthesias: During these events, do you feel numbness or tingling?
  11. Derealization or depersonalization: During these events, do you feel as if people or places that are familiar to you are unreal or that you are so detached from your body that it is as if you are standing outside your body or watching yourself?
  12. Fear of losing control or “going crazy”: During these events, do you fear you may be losing control, or even “going crazy”?
  13. Fear of dying: During these events, do you fear you may be dying?
2. Inclusion: At least one panic attack is followed by at least 1 month of at least one of the following symptoms.
  1. Persistent concern or worry about additional panic attacks or their consequences: Are you persistently concerned or worried about additional panic attacks? Are you persistently concerned or worried that these attacks mean you are having a heart attack, losing control, or “going crazy?”
  2. Maladaptive behavior change to avoid attacks: Have you made significant changes in your behavior, such as avoiding unfamiliar situations or exercise, in order to avoid attacks?
3. Exclusion: If the disturbance is better explained by another mental disorder or is attributable to the physiological effects of a substance/medication or another medical condition, do not use this diagnosis.
4. Alternative: If a person reports panic attacks as described above but neither experiences persistent worry about consequences nor makes maladaptive changes to avoid attacks, consider using the panic attack specifier (DSM-5, pp. 214–217). This specifier can be used with other anxiety disorders, as well as with depressive, traumatic, and substance use disorders.
Generalized Anxiety Disorder [F41.1, 222–226]
1. Inclusion: Requires excessive anxiety and worry that is difficult to control, occurring more days than not for at least 6 months, about a number of events or activities (e.g., work performance), associated with at least three of the following symptoms.
  1. Restlessness: When you think about events or activities that make you anxious or worried, do you feel restless, on edge, or “keyed up?”
  2. Being easily fatigued: Do you find that you often tire or fatigue easily?
  3. Difficulty concentrating: When you are anxious or worried, do you often find it hard to concentrate or find that your mind goes blank?
  4. Irritability: When you are anxious or worried, do you often feel irritable or easily annoyed?
  5. Muscle tension: When you get anxious or worried, do you often experience muscle tightness or tension?
  6. Sleep disturbance: Do you find it difficult to fall asleep or stay asleep, or do you experience restless and unsatisfying sleep?
2. Exclusion: If the anxiety and worry are better explained by another mental disorder or are attributable to the physiological effects of a substance/medication or another medical condition, do not use this diagnosis.
3. Alternatives
  1. If the episode is directly caused by a substance, including a medication prescribed to treat a mental disorder, consider a substance/medication-induced anxiety disorder [F1x.x8x, 226–230].
  2. If another medical condition directly causes the anxiety and worry, consider an anxiety disorder due to another medical condition [F06.4, 230–232].
  3. If a person experiences symptoms characteristic of an anxiety disorder that cause clinically significant distress or functional impairment without meeting full criteria for another anxiety disorder, consider unspecified anxiety disorder [F41.9, 233]. If you wish to communicate the specific reason a person’s symptoms do not meet the criteria for a specific anxiety disorder, consider other specified anxiety disorder [F41.8, 233]. Examples include generalized anxiety not occurring more days than not and ataque de nervios (attack of nerves).

Obsessive-Compulsive and Related Disorders

DSM-5 pp. 235–264

Screening questions: Do you ever get unwanted thoughts, urges, or pictures stuck in your mind that repeat, and you cannot make them stop? Is there anything you feel you have to check, clean, or organize over and over again in order to feel OK?

If yes, ask: Do these experiences or behaviors ever cause you significant trouble with your friends or family, at work, or in another setting?

If yes, proceed to obsessive-compulsive disorder criteria.
If no, proceed to the body-focused repetitive behavior screening question, which follows the obsessive-compulsive disorder section below.

Obsessive-Compulsive Disorder [F42, 237–242]
1. Inclusion: Requires the presence of obsessive thoughts, compulsive behaviors, or both, as manifested by the following symptoms.
  1. Obsessive thoughts: When you experience these unwanted images, thoughts, or urges, do they make you anxious or distressed? Do you have to work hard to ignore or suppress these kinds of thoughts?
  2. Compulsive behaviors: Some people try to reverse intrusive ideas by repeatedly performing some kind of action such as hand washing or lock checking, or by a mental act such as counting, praying, or silently repeating words. Do you do something like that? Do you think that doing so will reduce your distress or prevent something from occurring?
2. Inclusion: The obsessions or compulsions are time-consuming (e.g., take more than 1 hour per day) or cause clinically significant distress or impairment.
3. Exclusions
  1. If the obsessions or compulsions are better explained by another mental disorder, do not use this diagnosis.
  2. If the obsessive-compulsive symptoms are attributable to the direct physiological effects of a substance, do not use this diagnosis.
  3. If a person reports that her intrusive images, thoughts, or urges are pleasurable, she does not meet the criteria for an obsessive-compulsive disorder.
4. Modifiers
  1. Specifiers
    - Insight
      - — With good or fair insight: Use if a person recognizes that her obsessive-compulsive beliefs are definitely or probably untrue.
      - — With poor insight: Use if a person thinks her obsessive-compulsive beliefs are probably true.
      - — With absent insight/delusional beliefs: Use if a person is completely convinced that her obsessive-compulsive beliefs are true.
  2. Tic-related: Use if a person meets criteria for either a current or lifetime chronic tic disorder.
5. Alternatives
  1. If a person reports intrusive images, thoughts, or urges centered on her body image, consider body dysmorphic disorder [F45.22, 242–247]. The criteria include preoccupation with perceived defects in physical appearance beyond concern about weight or body fat in a person with an eating disorder, repetitive behaviors or mental acts in response to concern about appearance, and clinically significant distress or impairments because of the preoccupation.
  2. If a person reports persistent difficulty in parting with possessions regardless of their value, consider hoarding disorder [F42, 247–251]. The criteria include strong urges to save items, distress associated with discarding items, and the accumulation of a large number of possessions that clutter the home or workplace to the extent that it can no longer be used for its intended function.
  3. If a substance, including a substance prescribed to treat depression, directly causes the condition, consider substance/medication-induced obsessive-compulsive and related disorder [F1x.x88, 257–260].
  4. If another medical condition directly causes the episode, consider obsessive-compulsive and related disorder due to another medical condition [F06.8, 260–263].
  5. If a person reports intrusive images, thoughts, or urges centered on more real-world concerns, consider an anxiety disorder.
  6. If a person experiences symptoms characteristic of an obsessive-compulsive and related disorder that cause clinically significant distress or functional impairment without meeting full criteria for another obsessive-compulsive and related disorder, consider unspecified obsessive-compulsive and related disorder [F42, 264]. If you wish to communicate the specific reason a person’s symptoms do not meet the criteria for a specific obsessive-compulsive and related disorder, consider other specified obsessive-compulsive and related disorder [F42, 263–264]. Examples include body-focused repetitive behavior disorder, obsessional jealousy, and koro (anxiety that the penis or vulva and nipples will recede into the body).
Body-Focused Repetitive Behaviors
1. Inclusion: DSM-5 includes two conditions, trichotillomania (hair-pulling disorder) [F63.3, 251–254] and excoriation (skin-picking) disorder [L98.1, 254–257], with identically structured criteria. Either diagnosis requires the presence of all three of the following symptoms, plus distress or impairment caused by the symptoms.
  1. Behavior: Do you frequently pull your hair or pick at your skin so much that it has caused hair loss or skin lesions?
  2. Repeated attempts to change: Have you repeatedly tried to decrease or stop this behavior?
  3. Impairment: Does this behavior cause you to feel ashamed or out of control? Do you avoid social settings because of this behavior?
2. Alternative: If the behavior is associated with another medical condition or mental disorder or is the result of substance use, the behavior should be diagnostically accounted for with those conditions and you should not diagnose either trichotillomania or excoriation disorder.

Trauma- and Stressor-Related Disorders

DSM-5 pp. 265–290

Screening questions: What is the worst thing that has ever happened to you? Has someone ever touched you in a way you did not want? Have you ever felt that your life was in danger or thought that you were going to be seriously injured? Do you have unhappy memories that make it hard to sleep or to feel OK now?

If yes, ask: Do you think about or relive these events? Does thinking about these experiences ever cause significant trouble with your friends or family, at work, or in another setting?

If yes, proceed to posttraumatic stress disorder criteria.

Posttraumatic Stress Disorder [F43.10, 271–280]
1. Inclusion: Requires exposure to actual or threatened death, serious injury, or sexual violation. The exposure
  can be firsthand or witnessed. The exposure can also be from learning about violent or accidental trauma experienced by a close friend or family member. Finally, the exposure can be repeated or extreme exposure to aversive details of a traumatic event. In addition, a person must experience at least one of the following intrusion symptoms for at least 1 month after the traumatic experience.
  1. Memories: After that experience, did you ever experience intrusive memories when you did not want to think about it?
  2. Dreams: Did you have recurrent, distressing dreams related to the experience?
  3. Flashbacks: After that experience, did you ever feel as if it were happening to you again, as in a flashback?
  4. Exposure distress: When you are around people, places, or objects that remind you of that experience, do you feel intense or prolonged distress?
  5. Physiological reactions: When you are around people, places, or objects that remind you of that experience, do you have distressing physical responses?
2. Inclusion: In addition, a person must experience at least one of the following avoidance symptoms after the traumatic experience.
  1. Internal reminders: Do you work hard to avoid thoughts, feelings, or physical sensations that bring up memories of this experience?
  2. External reminders: Do you work hard to avoid people, places, and objects that bring up memories of this experience?
3. Inclusion: In addition, a person must experience at least two of the following negative symptoms.
  1. Impaired memory: Do you have trouble remembering important parts of the experience?
  2. Negative self-image: Do you frequently think negative thoughts about yourself, other people, or the world?
  3. Blame: Do you frequently blame yourself or others for your experience, even when you know that you or they were not responsible?
  4. Negative emotional state: Do you stay down, angry, ashamed, or fearful most of the time?
  5. Decreased participation: Are you much less interested in activities in which you used to participate?
  6. Detachment: Do you feel detached or estranged from people in your life because of this experience?
  7. Inability to experience positive emotion: Do you find that you cannot feel happy, loved, or satisfied? Do you feel numb, or that you cannot love?
4. Inclusion: In addition, a person must experience at least two of the following arousal behaviors.
  1. Irritability or aggressiveness: Do you often act very grumpy or become aggressive?
  2. Recklessness: Do you often act reckless or self-destructive?
  3. Hypervigilance: Are you always on edge or keyed up?
  4. Exaggerated startle: Do you startle easily?
  5. Impaired concentration: Do you often have trouble concentrating on a task or problem?
  6. Sleep disturbance: Do you often have difficulty falling asleep or staying asleep, or do you often wake up without feeling rested?
5. Exclusion: If the episode is directly caused by the use of a substance or by another medical condition, do not use this diagnosis.
6. Modifiers
  1. Subtypes
    - With dissociative symptoms: depersonalization
    - With dissociative symptoms: derealization
  2. Specifier
    - With delayed expression: Person does not exhibit all the diagnostic criteria until at least 6 months after the traumatic experience.
7. Alternatives
  1. If the episode lasts less than 1 month and the experience occurred within the past month, and the person experiences at least nine of the posttraumatic symptoms enumerated above, consider acute stress disorder [F43.0, 280–286].
  2. If the episode began within 3 months of the experience and a person does not meet the symptomatic and behavioral criteria for posttraumatic stress disorder, consider an adjustment disorder [F43.2x, 286–289]. The criteria include marked distress disproportionate to an acute stressor, either traumatic or nontraumatic, and significant impairment in function.
  3. If a person experiences symptoms characteristic of a trauma- and stressor-related disorder that cause clinically significant distress or functional impairment without meeting full criteria for one of the named disorders, consider unspecified trauma- and stressor-related disorder [F43.9, 290]. If you wish to communicate the specific reason a person’s symptoms do not meet the criteria for a specific disorder, consider other specified trauma- and stressor-related disorder [F43.8, 289]. Examples include adjustment-like disorder with delayed onset of symptoms that occur more than 3 months after the stressor.

Dissociative Disorders

DSM-5 pp. 291–307

Screening questions: Everyone has trouble remembering things sometimes, but do you ever lose time, forget important details about yourself, or find evidence that you took part in events that you cannot recall? Do you ever feel as if people or places that are familiar to you are unreal? Do you ever feel as if you are standing outside your body or watching yourself? Do you lose track of time and feel unsure of what you did during that time?

If yes, ask: Did these experiences ever cause you significant trouble with your friends or family, at work, or in another setting?

If amnesia predominates, proceed to dissociative amnesia criteria.
If depersonalization or derealization predominates, proceed to depersonalization/derealization disorder criteria.

Dissociative Amnesia [F44.0, 298–302]
1. Inclusion: Requires the presence of inability to recall important autobiographical information beyond ordinary forgetting, most often manifested by at least one of the following symptoms.
  1. Localized or selective amnesia: Do you find yourself unable to recall a really important event, especially an event that was very stressful or even traumatic?
  2. Generalized amnesia: Do you find yourself unable to recall really important moments in your life history or details of your very identity?
2. Exclusions
  1. If the disturbance is better accounted for by a major or mild neurocognitive disorder, dissociative identity disorder, posttraumatic stress disorder, acute stress disorder, or somatic symptom disorder, do not use this diagnosis.
  2. If the disturbance is due to the physiological effects of a substance or a neurological or other medical condition, do not use this diagnosis.
3. Modifiers
  1. Specifier
    - With dissociative fugue [F44.1, 298]: Person engages in purposeful travel or bewildered wandering for which she has amnesia.
4. Alternative: If a person reports a disruption of identity, characterized by two or more distinct personality states or an experience of possession that causes clinically significant distress and functional impairment, consider dissociative identity disorder [F44.81, 292–298]. The criteria include recurrent gaps in recall that are inconsistent with ordinary forgetting and dissociative experiences that are not a normal part of a broadly accepted cultural or religious practice and that are not attributable to the physiological effects of a substance or another medical condition.
Depersonalization/Derealization Disorder [F48.1, 302–306]
1. Inclusion: Requires at least one of the following manifestations.
  1. Depersonalization: Do you frequently have experiences of unreality or detachment—as if you are an outside observer of your mind, thoughts, feelings, sensations, body, or whole self?
  2. Derealization: Do you frequently have experiences of unreality or detachment from your surroundings? For example, do you often experience people or places as unreal, dreamlike, foggy, lifeless, or visually distorted?
2. Inclusion: Requires intact reality testing. During these experiences, can you distinguish the experiences from actual events—what is occurring outside of you?
3. Exclusions
  1. If the disturbance is due to the physiological effects of a substance or a neurological or other medical condition, do not use this diagnosis.
  2. If depersonalization or derealization occurs exclusively as symptoms of or during the course of another mental disorder, do not use this diagnosis.
4. Alternatives: If a person is experiencing a disorder whose most prominent symptoms are amnestic but does not meet the criteria for a specific disorder, consider unspecified dissociative disorder [F44.9, 307]. If you wish to communicate the specific reason a person’s symptoms do not meet criteria for a specific disorder, consider other specified dissociative disorder [F44.89, 306–307]. Examples include chronic and recurrent syndromes of mixed dissociative symptoms, identity disturbances in individuals subjected to prolonged periods of intense coercive persuasion, acute reactions to stressful situations, and dissociative trance.

Somatic Symptom and Related Disorders

DSM-5 pp. 309–327

Screening questions: Do you worry about your health more than most people? Do you get sick with aches and pains more often than most people your age?

If yes, ask: Do these experiences significantly affect your daily life?

If yes, ask: Which is worse for you, worrying about the symptoms you experience or worrying about your health and the possibility that you are sick?

If worry about symptoms predominates, proceed to somatic symptom disorder criteria.
If worry about being ill or sick predominates, proceed to illness anxiety disorder criteria.

Somatic Symptom Disorder [F45.1, 311–315]
1. Inclusion: Requires at least one somatic symptom that is distressing. Do you experience symptoms that cause you to feel anxious or distressed? Do these symptoms significantly disrupt your daily life?
2. Inclusion: Requires at least one of the following thoughts, feelings, or behaviors, for at least 6 months.
  1. Disproportionate thoughts: How serious are your health concerns, and do you think about them often?
  2. Persistently high level of anxiety: Do you persistently feel a high level of anxiety or worry about your health concerns?
  3. Excessive investment: Do you find yourself investing a lot more time and energy into your health concerns than you would like to do?
3. Modifiers
  1. Specifiers
    - With predominant pain
    - Persistent
  2. Severity
    - Mild: One of the additional symptoms specified in inclusion criterion b above
    - Moderate: Two or more of the additional symptoms specified in inclusion criterion b above
    - Severe: Two or more of the additional symptoms specified in inclusion criterion b above plus multiple somatic complaints (or one very severe somatic symptom)
4. Alternatives
  1. If a person is focused on the loss of bodily function rather than on the distress a particular symptom causes, consider conversion disorder (functional neurological symptom disorder) [F44.x, 318–321]. The criteria for this disorder include symptoms or deficits affecting voluntary motor or sensory function, clinical evidence that these symptoms or deficits are inconsistent with a recognized medical or neurological disease, and significant impairment in social or occupational functioning.
  2. If a person has a documented medical condition but behavioral or psychological factors adversely affect the course of her medical condition by delaying recovery, decreasing adherence, significantly increasing health risks, or influencing the underlying pathophysiology, consider psychological factors affecting other medical conditions [F54, 322–324].
  3. If a person falsifies physical or psychological signs or symptoms or induces injury or disease to deceptively present herself to others as ill, impaired, or injured, consider factitious disorder imposed on self [F68.10, 324–326]. If a person exhibits these behaviors in pursuit of obvious external rewards, as in malingering, do not use this diagnosis. If a person’s symptoms are better accounted for by another mental disorder, do not use this diagnosis.
  4. If a person falsifies physical or psychological signs or symptoms or induces injury or disease to deceptively present someone else to others as ill, impaired, or injured, consider factitious disorder imposed on another [F68.10, 324–326]. This diagnosis is assigned to the perpetrator rather than the victim. If the perpetrator exhibits these behaviors in pursuit of obvious external rewards, as in malingering, do not use this diagnosis. If the perpetrator’s behavior is better accounted for by another mental disorder, do not use this diagnosis.
Illness Anxiety Disorder [F45.21, 315–318]
1. Inclusion: Requires all of the following symptoms for at least 6 months and the absence of somatic symptoms.
  1. Preoccupation: Do you find yourself unable to stop thinking about having or acquiring a serious illness?
  2. Anxiety: Do you feel a high level of anxiety or worry about having or acquiring a serious illness?
  3. Associated behaviors: How have these worries affected your behavior? Some people find themselves frequently checking their body for signs of illness; reading about illness all the time; or avoiding persons, places, or objects to ward off illness. Are you doing any of those things or other similar things?
2. Exclusion: If a person’s symptoms are better explained by another mental disorder, do not use this diagnosis.
3. Modifiers
  1. Subtypes
    - Care-seeking type
    - Care-avoidant type
4. Alternatives: If a person endorses symptoms characteristic of a somatic symptom and related disorder that cause clinically significant distress or impairment without meeting the full criteria for a specific disorder, consider unspecified somatic symptom and related disorder [F45.9, 327]. If you wish to communicate the specific reason a person’s symptoms do not meet criteria for a specific disorder, consider other specified somatic symptom and related disorder [F45.8, 327]. Examples include brief somatic symptom disorder, brief illness anxiety disorder, and illness anxiety disorder without excessive health-related behaviors.

Feeding and Eating Disorders

DSM-5 pp. 329–354

Screening questions: What do you think of your appearance? Do you ever restrict or avoid particular foods so much that your health or weight is negatively affected?

If yes, ask: When you consider yourself, is the shape or weight of your body one of the most important things about you?

If yes, proceed to anorexia nervosa criteria.
If no, proceed to avoidant/restrictive food intake disorder criteria.

Anorexia Nervosa [F50.0x, 338–345]
1. Inclusion: Requires the presence of all three of the following features.
  1. Energy restriction leading to significantly low body weight adjusted for age, developmental trajectory, physical health, and sex: Have you limited the food you eat to achieve a low body weight? What was the least you ever weighed? What do you weigh now?
  2. Fear of weight gain or behavior interfering with weight gain: Do you have an intense fear of gaining weight or becoming fat? Has there ever been a time when you were already at a low weight and still did things to interfere with gaining weight?
  3. Disturbance in self-perceived weight or shape: How do you experience the weight and shape of your body? How do you think having a significantly low body weight will affect your physical health?
2. Modifiers
  1. Subtypes
    - Restricting type [F50.01, 339]: Use when a person reports no recurrent episodes of binge eating or purging in the last 3 months.
    - Binge-eating/purging type [F50.02, 339]: Use when a person reports recurrent episodes of binge eating or purging in the last 3 months.
  2. Specifiers
    - In partial remission
    - In full remission
  3. Severity
    - Mild: Body mass index (BMI) ≥ 17 kg/m²
    - Moderate: BMI 16–16.99 kg/m²
    - Severe: BMI 15–15.99 kg/m²
    - Extreme: BMI < 15 kg/m²
3. Alternative: If a person reports recurrent binge eating, recurrent inappropriate compensatory behaviors to prevent weight gain (e.g., misuse of laxatives or other medications, self-induced vomiting, excessive exercise), and self-image unduly influenced by body shape or weight, consider bulimia nervosa [F50.2, 345–350]. The diagnosis requires that binge eating and compensatory behaviors both occur, on average, at least once a week for 3 months. If binge eating and compensating behaviors occur only during episodes of anorexia nervosa, do not use this diagnosis.
Avoidant/Restrictive Food Intake Disorder [F50.8, 334–338]
1. Inclusion: Requires significant disturbance in eating or feeding manifested by persistent failure to meet appropriate
  nutritional and/or energy needs associated with at least one of the following sequelae.
  1. Significant weight loss: Do you avoid certain foods or restrict what you eat to the extent that you have experienced a significant weight loss?
  2. Significant nutritional deficiency: Do you avoid or restrict food to the extent that doing so has negatively affected your health, as in causing a significant nutritional deficiency?
  3. Dependence on enteral feeding or oral supplements: Have you avoided or restricted food to the extent that you depend on tube feedings or oral supplements to maintain nutrition?
  4. Marked interference with psychosocial functioning: Can you eat with other people or participate in social activities when food is present? Has avoiding or restricting food impaired your ability to participate in your usual social activities or made it hard to form or sustain relationships?
2. Exclusions
  1. If the eating disturbance is better explained by lack of available food, by an associated culturally sanctioned practice, or by eating practices related to a disturbance in body image, do not use this diagnosis.
  2. If the eating disturbance is due to another medical condition or is better explained by another mental condition, do not use this diagnosis.
3. Alternatives
  1. If a person persistently eats nonfood substances over a period of at least 1 month, consider pica [F50.8, 329–331]. If the eating of nonnutritive, nonfood substances is part of a culturally supported or socially normative practice, do not use this diagnosis.
  2. If a person repeatedly regurgitates food over a period of at least 1 month, consider rumination disorder [F98.21, 332–333]. If the regurgitation occurs as the result of an associated gastrointestinal or other medical condition or occurs exclusively during the course of anorexia nervosa, bulimia nervosa, binge-eating disorder, or avoidant/restrictive food intake disorder, do not use this diagnosis.
  3. If a person has an atypical, mixed, or subthreshold disturbance in eating and feeding or if you lack sufficient information to make a more specific diagnosis, consider unspecified feeding or eating disorder [F50.9, 354]. DSM-5 also allows the use of this category for specific syndromes that are not formally included. If you wish to communicate the specific reason a person’s symptoms do not meet criteria for a specific disorder, consider other specified feeding or eating disorder [F50.8, 353–354]. Examples include atypical anorexia nervosa, binge-eating disorder, and purging disorder.

Sleep-Wake Disorders

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Sep 1, 2019 | Posted by admin in PSYCHOLOGY | Comments Off

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The DSM-5 Older Adult Diagnostic Interview

CHAPTER

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