How To Write A Diagnosis According To The DSM-5 For MSW Stud ✓ Solved

How to write a diagnosis according to the DSM-5 for MSW stud

How to write a diagnosis according to the DSM-5 for MSW students. Use ICD-10-CM codes, list diagnoses in order of priority to current treatment, place principal diagnosis first, include relevant comorbid mental disorders, medical conditions, and Z-codes for psychosocial factors. Use 'provisional' when criteria likely but insufficient info. Use 'Other Specified' when symptoms cause distress but don't meet full criteria and specify presentation. Always verify coding details and severity specifiers per DSM-5. Using the provided case of Ivander (19-year-old male with one month of auditory hallucinations, delusions, disorganized behavior, social withdrawal, no substance use, and fluctuating mood), write a DSM-5 diagnosis list with appropriate ICD-10-CM codes, order, and brief justification based on the case.

Paper For Above Instructions

Overview and Diagnostic Approach

This report applies DSM-5 diagnostic conventions and ICD-10-CM coding guidance to the clinical case of Ivander, a 19-year-old male presenting with psychotic symptoms. Per DSM-5 and ICD-10-CM practice, diagnoses are listed in order of priority to current treatment, with appropriate ICD-10-CM codes preceding each diagnostic label, and psychosocial Z-codes included as relevant (American Psychiatric Association [APA], 2013; CDC, 2017). Because the case description contains some ambiguities about exact symptom duration and medical rule-outs, provisional language and differential diagnostics are used where appropriate (APA, 2013).

Diagnostic List (Principal to Ancillary)

  • F20.81 Schizophreniform disorder, provisional — prominent psychotic symptoms (auditory hallucinations, delusions, disorganized thought/behavior) consistent with DSM-5 criteria for a schizophrenia spectrum disorder but with uncertain total duration; provisional designation used pending longitudinal confirmatory assessment (APA, 2013).
  • R44.0 Auditory hallucinations — as a symptom code to document the prominent hallucinations presenting in the clinical picture (WHO/ICD coding conventions; CDC, 2017).
  • R41.0 Disorientation and cognitive disturbance — documented transient incoherence and impaired organization on mental status examination; used here as an ancillary symptom descriptor until more detailed cognitive testing rules in/out neurocognitive disorder secondary to medical causes (CDC, 2017).
  • Z03.89 Rule out medical condition(s) as cause of psychiatric symptoms — to note the clinical need to exclude medical etiologies and to guide further medical assessment (CMS/CDC coding guidance).
  • Z60.3 Acculturation difficulty (if clinically relevant) or Z65.8 Other specified problems related to psychosocial circumstances — include psychosocial Z-codes when social stressors or acculturation issues materially affect treatment priorities; include exact Z-code following psychosocial assessment (APA, 2013; CDC, 2017).

Justification and Clinical Reasoning

Ivander presents with core positive psychotic symptoms: reported auditory hallucinations (voices calling his name and commenting), fixed persecutory delusions (distrust of roommate, beliefs about TV referencing him and food theft), and disorganized behavior and speech (loose associations, incoherence, disorganization of papers) along with social withdrawal and blunted/inappropriate affect on examination. These features meet DSM-5 criterion A symptom domains for a schizophrenia spectrum psychotic disorder (APA, 2013).

DSM-5 distinguishes diagnoses partially by symptom duration. Schizophreniform disorder is applied when schizophrenia spectrum symptoms have been present for at least 1 month but less than 6 months; schizophrenia requires ≥6 months total duration (including prodromal, active, and residual phases) (APA, 2013). The history indicates symptoms began approximately one month after starting school, with ongoing impairment and multiple recent incidents observed by campus police; however, exact total symptom duration is unclear from the intake. Therefore, the provisional label “schizophreniform disorder, provisional” (listed first) appropriately captures the likely clinical syndrome while signaling need for longitudinal follow-up to confirm or revise the diagnosis (APA, 2013).

Symptom-level codes such as R44.0 (auditory hallucinations) are used to document prominent phenomena that guide immediate treatment decisions (e.g., safety, medication selection, monitoring) and ensure clear clinical communication between providers (CDC, 2017). The mental status exam findings (agitation, pressured/inappropriately loud speech, fluctuating mood) raise the need to consider mood disorders with psychotic features and substance- or medication-induced psychosis; however, the patient denies substance use and the presentation lacks a clear primary mood episode predominating over psychosis, making primary schizophrenia-spectrum diagnosis more likely (APA, 2013).

Differential Diagnosis and Rule-Outs

Key differential diagnoses to consider and to rule out include:

  • Substance/medication-induced psychotic disorder — urine toxicology and collateral history recommended to exclude substances (APA, 2013).
  • Psychotic disorder due to another medical condition (e.g., neurologic illness, metabolic disturbances) — medical evaluation and labs recommended; if found, a medical-first ordering (K code listed prior) would take precedence (CDC/CMS guidance).
  • Mood disorder with psychotic features — mood symptoms are described as fluctuating; careful assessment of timeline and mood-psychosis relationship is needed to determine if a primary mood disorder explains the psychosis (APA, 2013).
  • Brief psychotic disorder — if symptom duration ultimately documents under 1 month, a brief psychotic disorder code (F23.x) would be more appropriate (APA, 2013).

Clinical and Coding Recommendations

1) Use provisional coding when duration or information is insufficient; document reason for provisional status in the chart (APA, 2013). 2) Obtain medical and toxicology studies to exclude medical or substance causes (CDC, 2017). 3) Use the DSM-5 diagnostic criteria box to identify any required specifiers (e.g., severity, presence of catatonia) and add additional codes if indicated (APA, 2013). 4) Place principal mental disorder first, followed by relevant medical conditions and then Z-codes that reflect psychosocial problems affecting treatment (CMS/CDC guidelines).

Treatment Implications and Follow-Up

Given the probable schizophrenia-spectrum disorder, initial management priorities include safety assessment (suicide/homicide risk), initiation of antipsychotic treatment as clinically indicated, psychoeducation for the patient and family, coordination with campus supports, and close outpatient or inpatient follow-up depending on risk and functional impairment (APA practice guidance). Reassessment of diagnosis at regular intervals, documentation of symptom duration, and adjustment of ICD-10-CM coding when the longitudinal picture clarifies are essential (APA, 2013; CMS, 2017).

Conclusion

Applying DSM-5 and ICD-10-CM conventions to Ivander’s case yields a prioritized diagnostic list beginning with a provisional schizophrenia-spectrum diagnosis (schizophreniform disorder, provisional) accompanied by symptom and rule-out codes (R44.0, R41.0, Z03.89). This approach follows DSM-5 guidance to use provisional labels when necessary, to list diagnoses in order of treatment priority, and to include psychosocial Z-codes where relevant. Final coding should be confirmed after medical and toxicological rule-outs and after longitudinal observation to determine symptom duration and course (APA, 2013; CDC, 2017).

References

  • American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: Author.
  • American Psychiatric Association. (2018). DSM–5 frequently asked questions. Retrieved from https://www.psychiatry.org/psychiatrists/practice/dsm
  • Centers for Disease Control and Prevention. (2017a). ICD-10-CM official guidelines for coding and reporting: FY 2017. Retrieved from https://www.cdc.gov/nchs/icd/icd10cm.htm
  • Centers for Disease Control and Prevention. (2017b). International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM). Retrieved from https://www.cdc.gov/nchs/icd/icd10cm.htm
  • Centers for Medicare & Medicaid Services. (2017). Provider resources. Retrieved from https://www.cms.gov/
  • World Health Organization. (2019). ICD-11: International classification of diseases 11th revision. Retrieved from https://www.who.int/standards/classifications/classification-of-diseases
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  • Tandon, R., Gaebel, W., Barch, D. M., Bustillo, J., Gur, R. E., Heckers, S., ... & Carpenter, W. (2013). Definition and description of schizophrenia in the DSM-5. Schizophrenia Research, 150(1), 3–10. https://doi.org/10.1016/j.schres.2013.05.028
  • Keepers, G. A., Fochtmann, L. J., Anzia, J. M., et al. (2020). The American Psychiatric Association Practice Guideline for the Treatment of Patients With Schizophrenia. American Journal of Psychiatry, 177(9), 868–872. https://doi.org/10.1176/appi.ajp.2020.19010030

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