DSM-5: Diagnosing and Report Writing
STEP 8: DETERMINE WHETHER AND HOW “DISABILITY” WILL BE ASSESSED
DSM-IV utilized the Global Assessment of Functioning (GAF) scale to indi- cate the clinician’s judgment of the person’s overall functioning on a scale of 0–100 (with 0 representing an extremely impaired functioning level and 100 representing an extremely high functioning level) [10 (p34)]. DSM-5 notes that the GAF was not included under this new edition because it lacked clar- ity in describing levels of suicide risk and disability and questionable psycho- metrics in clinical practice [1] .
DSM-5 includes one global measure of disability, the World Health Organization Disability Schedule 2.0 (WHODAS 2.0), in Section III titled
Table 3-1. REPORT EX AMPLE FOR DSM-5 DI AGNOSES AND OTHER DI AGNOSTIC CONSIDER ATIONS FOR “GR ANT.”
Current Diagnostic and Statistical Manual of Mental Disorders (DSM-5) Diagnoses:
1. Schizophrenia, multiple episodes, currently in acute episode (principal diagnosis) 2. Hepatitis C
3. Mild alcohol use disorder
Mr. Wilson meets criteria for schizophrenia. In particular, he has experienced delusional beliefs, such as thinking that the cell phones in his work place are beaming poisonous strychnine to employees putting them at risk to die. He also has auditory hallucinations of Edward Snowden commanding him to destroy cell phones. During my interview, Mr. Wilson was incoherent and he exhibited markedly disorganized speech. For example, when asked the role of his attorney, he responded, “Like order of the trees, to judge not lest ye be judged for all mankind is to do better or not do at all.” My review of Mr. Wilson’s jail records indicates that his symptoms have been present most of the time during his three months of incarceration. His outpatient records substantiate that he has had similar symptoms with multiple psychiatric hospitalizations over a 15-year period.
Mr. Wilson also been recently diagnosed with hepatitis C. This medical condition is included on the diagnostic list because he has developed delusional beliefs about the impact of his hepatitis and is requiring additional mental health treatment to address his concerns about his hepatitis.
In addition, I diagnosed Mr. Wilson with mild alcohol use disorder because he reported that often drank more beer than he intended and he had repeated, but failed, efforts to cut down on his alcohol use.
Consideration of other diagnoses:
I carefully considered the possibility that Mr. Wilson met criteria for bipolar disorder because this is the diagnosis noted in his outpatient treatment records. However, a review of his records indicates that he has never had a manic episode that has occurred concurrently with his active symptoms of hallucinations and delusions. His marked agitation when symptomatic is consistent with the paranoia he experiences when psychotic during the active phase of schizophrenia as opposed to increased energy due to mania.
I also considered the possibility that Mr. Wilson could be malingering, particularly as he is facing criminal charges. It is my opinion that Mr. Wilson is not malingering his symptoms. His mental disorder is well established over a 15-year period and multiple observers have documented that his symptoms continue in jail when he is unaware that he is being observed. I administered three tests to assess possible malingering and none of these indicated he was malingering any symptoms. Finally, Mr. Wilson repeatedly demands to be “declared competent” so that he can “fight the beams,” indicating that he is not trying to avoid his trial.
“Emerging Measures and Models.” DSM-5 does not require the use of the WHODAS 2.0 as a replacement for the GAF score and clearly differentiates measures included in Section III from the diagnostic criteria outlined in Section II. In particular, the DSM-5 manual emphasizes that unlike diagno- ses listed in Section II, the WHODAS 2.0 and other scales included in Section III have not undergone sufficient rigorous research to support their routine use in clinical settings [1 (p23)].
Might the WHODAS 2.0 nevertheless be useful in forensic evaluations and reports? As an overview, the WHODAS 2.0 measures the impact of both physical and mental disorders on functioning and disability in the following six life domains:
1. Cognition (understanding and communication); 2. Mobility (ability to move and get around);
3. Self-care (ability to attend to personal hygiene, dress and eat, and live alone);
4. Getting along (ability to interact with other people);
5. Life activities (ability to carry out responsibilities at home, work and school); and
6. Participation in society (ability to engage in community, civil and recre- ational activities) [1 (p745)].
There are limitations in using the WHODAS 2.0 as a measure of disability in forensic psychiatric evaluations. For example, the WHODAS 2.0 includes several questions that address areas of functioning with limited applicability to correc- tional settings and patients involuntarily committed to psychiatric hospitals. To illustrate, consider how inmates or involuntarily detained psychiatric patients would respond to questions asking about their difficulty “moving around inside your home,” “taking care of your household responsibilities,” “or “joining in community activities in the same way as anyone else can.” Evaluators should not manipulate the language of the WHODAS 2.0 questions in an attempt to force this instrument to apply to any unique setting. In fact, the manual specifi- cally states that users of WHODAS 2.0 have no authority to make substantive changes to the assessment instrument unless given explicit permission to do so [11 (p37)]. Furthermore, the WHODAS 2.0 scoring restrictions limit how many items can be missing yet still allow the instrument to be scored. There are limited, if any, studies that involve the use of the WHODAS 2.0 in criminal evaluations, correctional settings, forensic psychiatric hospitals, or civil litigation samples. Finally, the WHODAS 2.0 is a self-report instrument. It is obvious when com- pleting the form that higher scores equate with more disability. Unfortunately, the WHODAS 2.0 has no measure to assess malingering or over-reporting of one’s limitations due to disability. For these reasons, the WHODAS 2.0 is not recommended for use in either criminal or civil forensic evaluations [12].
If the WHODAS 2.0 is not recommended for use, what should an evalu- ator use? There are several important issues to address to help answer this question. First, a quantitative disability measure is not required for all eval- uations. For example, competency to stand trial evaluations focus on the impairment, if any, that results from a defendant’s mental condition on his or her ability to assist the attorney or understand the legal process. A reason- able argument could be made that more detailed assessments of the defen- dant’s disability in various life circumstances (e.g., home, work, school) is not necessary to render a forensic opinion on trial competency. Likewise, crimi- nal responsibility evaluations focus on the individual’s mindset at the time of the crime. The level of their current disability would have minimal, if any, relevance to that specific legal question. Second, disability assessments in civil cases (e.g., workers’ compensation, private disability, and social security disability insurance) may mandate the use of a specified disability assess- ment instrument/s, independent of DSM-5’s recommendations. The evalu- ator will need to comply with their state’s requirement in regard to how disability is assessed. [See Chapter 9 for further discussion of this issue.] Third, evaluators could continue to use the GAF despite its known limita- tions. In her excellent review of the use of the WHODAS 2.0 and the GAF, Gold [12 (p180)] concludes,
Psychiatric evaluations of impairment and disability have generally benefitted from the standardization of practice provided by the multiaxial assessment methodology that included routine assessment of functioning and use of the GAF. Given the problems associated with forensic use of WHODAS 2.0 and the possibility of the proliferation of idiosyncratic methods for evaluations of psychiatric impairment and disability, psychiatric residency programs and forensic fellowships are well advised to continue training young clinicians in the use of the GAF despite its exclusion from DSM-5.
Finally, the evaluator could provide a qualitative (i.e., nonquantitative) description of how the person’s mental health impairment limits their abil- ity in various areas of their life, such as working, going to school, interacting with others, or performing activities of daily living. Because disability rat- ings are not included in the DSM-5 diagnostic list, a separate heading titled “disability” assessment could be included in the report after the list of diag- noses with their accompanying explanations.
SUMMARY
DSM-5 brings many changes in how diagnoses are made and coded. Although this diagnostic overhaul may seem daunting, evaluators can utilize the basic
steps outlined in this chapter as a practical guide to accurately record and describe DSM-5 diagnoses in clinical records and forensic reports. Key sum- mary points from this chapter include the following:
• DSM-5 no longer uses the multiaxial approach to listing diagnoses. Diagnoses that would have been listed on Axis I, II, and III under the DSM-IV system are now provided on one list.
• Diagnoses should be listed in order of treatment priority or reason for the visit.
• DSM-5 has removed the GAF scoring system with no required alternative disability assessment offered. Evaluators have a range of options to now consider when a disability assessment is required.
• Although DSM-5 recommends the WHODAS 2.0 as a possible disability assessment measure, there are serious concerns about the use of this instrument in forensic evaluations.
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