Diagnosis

 

The Diagnosis page in the assessment is asking us to list the symptoms the member has that support their diagnosis -- not the diagnostic criteria we find in the DSM. In most cases the lists will be similar, but symptoms will vary from member to member, just like the symptoms of a common cold vary from one person to the next.

These are descriptions of supporting symptoms taken from real assessments. Not every diagnosis has an exact match in the list below, but if you use the first 2-3 digits of the code to get to the right area, you'll probably find one that's close. If the illness is in remission, put "Hx of" (or "History of") in front of the description.

F10.1 - Alcohol abuse
Recurrent use of alcohol despite significant social and interpersonal impairments, including increased argumentativeness, altercations with housemates, evictions, and negative interaction with law enforcement

F10.2 - Alcohol dependence
Use of alcohol on a regular basis to avoid withdrawal symptoms; unsuccessful attempts to cut down on drinking; social, occupational, and recreational activities given up due to daily efforts to obtain and consume

F11.2 - Opioid abuse
Recurrent use of opioids despite negative consequences such as confusion, impaired memory, and loss of interest in friends and family

F11.2 - Opioid dependence
Prolonged, regular use of opioids despite negative consequences such as confusion, impaired memory, and loss of interest in friends and family; history of tolerance; use to avoid withdrawal symptoms

F12.1 - Cannabis abuse
Pattern of use resulting in social, interpersonal, and legal problems; use despite negative effects such as reduced motivation and impaired memory

F12.2 - Cannabis dependence
Prolonged, regular use of cannabis despite negative consequences such as impaired judgment and memory, reduced motivation, excessive sedation, lethargy, and marked withdrawal symptoms

F13.1 - Sedative, hypnotic, or anxiolytic abuse
Recurrent abuse of sedating medications despite negative consequences such as confusion, impaired memory, and loss of interest in friends and family

F14.1 - Cocaine abuse
Recurrent use of cocaine despite negative consequences such as increased paranoia, irritability, and aggressiveness; and increased conflict with others

F14.2 - Cocaine dependence
Prolonged, regular use of cocaine despite negative consequences such as increased paranoia, irritability, and aggressiveness; increased dosages due to tolerance; use to avoid withdrawal symptoms

F15.1 - Other stimulant abuse
Recurrent use of stimulants despite negative consequences such as increased irritability, insomnia, anxiety, and conflict with others

F15.2 - Other stimulant dependence
Prolonged, regular use of stimulants despite negative consequences such as increased irritability, insomnia, anxiety, and conflict with others; increased consumption due to tolerance; use to avoid withdrawal symptoms

F17 - Nicotine dependence
Prolonged, regular use of nicotine despite awareness of health risks; use to avoid withdrawal symptoms; unsuccessfully attempts to cut down

F19.1 - Other psychoactive substance abuse: Ask psychiatrist or NP

F19.2 - Other psychoactive substance dependence: Ask psychiatrist or NP

19.99 - Other psychoactive substance use: Ask psychiatrist or NP

 

F20.0 - Paranoid schizophrenia
Paranoia, A/H, delusions, mildly disorganized speech and thinking, impaired memory, anxiety, preoccupation with internal stimuli, argumentativeness, trouble concentrating

F20.3 - Undifferentiated schizophrenia: This means the member's symptoms meet the general conditions for a diagnosis but don't fit any specific subtype. Ask the psychiatrst or NP what the member's symptoms are.

F20.5 - Residual schizophrenia
Prior episode of schizophrenia; continuing evidence of negative symptoms such as flat affect, poverty of speech, and avolition; and attenuated positive symptoms such as occasional A/H, eccentric behavior, and odd beliefs

F20.89 - Other schizophrenia: Same as 20.3 - ask the psychiatrist or NP what the member's symptoms are.

F21 - Schizotypal disorder
Eccentric behavior, unusual preoccupations and fears, unwarranted suspiciousness, great difficulty forming and keeping close relationships
 
F22 - Delusional disorder
Client has unshakable beliefs that are untrue, highly exaggerated, or not based in reality, which negatively impact relationships with others
 
F25.0 - Schizoaffective disorder, bipolar type
Paranoia, A/H, delusions, disorganized thinking & behavior; episodic mood swings ranging from mania (pressured speech, decreased need for sleep, impulsive behavior) to severe depression (lack of motivation, feelings of hopelessness, self-isolation)
 
F25.1 - Schizoaffective disorder, depressive type
Paranoia, A/H, delusions, disorganized thinking & behavior; lack of motivation and energy, feelings of hopelessness, irritability, loss of interest in previously enjoyed activities, trouble concentrating, social withdrawal
 
F25.9 - Schizoaffective disorder, unspecified
A/H and delusional thinking; episodic mood swings ranging from mania to depression; does not meet full diagnostic criteria for a more specific disorder
 
F29 - Unspecified psychosis not due to a substance or known physiological condition
Experiences A/H and delusions but does not meet diagnostic criteria for a more specific psychotic disorder
 
F31.xx - Bipolar disorder - manic without psychotic features
Episodic mood swings ranging from mania to severe depression.  Current symptoms include racing thoughts, pressured speech, impulsive spending, engaging in high-risk behavior, decreased need for sleep, irritability, angry outbursts, and poor judgment
 
F31.xx - Bipolar disorder - manic with psychotic features
Episodic mood swings ranging from mania to severe depression.  Current symptoms include racing thoughts, pressured speech, impulsive spending, engaging in high-risk behavior, decreased need for sleep, irritability, paranoia, A/H, and delusions
 
F31.xx - Bipolar disorder - depressed without psychotic features
Episodic mood swings ranging from mania to severe depression.  Current symptoms include lack of motivation and energy, feelings of hopelessness, irritability, trouble concentrating, and social withdrawal
 
F31.xx - Bipolar disorder - depressed with psychotic features
Episodic mood swings ranging from mania to severe depression.  Current symptoms include lack of motivation and energy, feelings of hopelessness, irritability, trouble concentrating, social withdrawal, paranoia, A/H, and delusions
 
If unspecified (F31.9): Ask psychiatrist or NP

F31.81 - Bipolar II
Alternating episodes of hypomania (increased talkativeness, excessive energy, and trouble sleeping), and depression (lack of motivation and energy, feelings of hopelessness, irritability, trouble concentrating, oversleeping, and social withdrawal)

F33.xx - Major depressive disorder without psychotic features
Lack of motivation and energy, feelings of hopelessness, irritability, loss of interest in previously enjoyed activities, trouble concentrating, feelings of guilt and shame, social withdrawal

F33.xx - Major depressive disorder with psychotic features
Lack of motivation and energy, feelings of hopelessness, irritability, loss of interest in previously enjoyed activities, trouble concentrating, social withdrawal, paranoia, A/H, and delusions

F34.9 - Persistent mood [affective] disorder, unspecifiedAsk psychiatrist or NP

F39 - Unspecified mood [affective] disorderAsk psychiatrist or NP

F40.01 - Agoraphobia with panic disorder
Excessive anxiety in, and avoidance of, situations where escape might be difficult, or where help might not be available in the event of having a panic attack 

F40 - Social phobia
Persistent fear of social or performance situations; fear of being humiliated or embarrassed; avoids groups and social gatherings where behavior might be subject to scrutiny by others

F41 - Panic disorder without agoraphobia
Episodes involving fear of imminent death or going crazy, increased heart rate, feelings of suffocation, sweating, and dizziness

F41.1 - Generalized anxiety disorder
Excessive worry and anxiety making it hard for member to carry out day-to-day activities and responsibilities

F42 - Obsessive compulsive disorder
Persistent thoughts and repetitive behaviors that are time-consuming, cause marked anxiety and distress, and interfere with member's normal routine

F43 - Post-traumatic stress disorder
Intrusive recollections, avoidance of situations associated with past trauma, flashbacks, nightmares, problems sleeping

F44.81 - Dissociative identity disorder
Presence of multiple personality states which recurrently take control of member's behavior; inability to recall important personal information; self-harm (cutting); nightmares, flashbacks, and exaggerated startle responses suggestive of PTSD

F50 - Eating disorders
Engages in self-induced starvation and excessive weight loss and/or binging and purging

F60.2 - Antisocial personality disorder
Long-standing pattern of disregard for the rights of others; lack of empathy and remorse; deceitfulness; impulsivity; frequent law-breaking

F60.3 - Borderline personality disorder
Heightened sensitivity to rejection, frantic efforts to avoid abandonment, difficulty regulating emotional responses, self-mutilation (cutting and burning), unstable relationships, recurrent suicidal threats, and impulsivity

F60.6 - Avoidant personality disorder
Low self-esteem, self isolation, excessive fear of rejection or negative evaluation, avoids activities that involve significant interpersonal contact

F60.7 - Dependent personality disorder
Inability to make decisions without the advice and reassurance of others, fear of abandonment, sensitivity to criticism, lack of self-confidence, fear of disapproval, difficulty being alone, willingness to tolerate mistreatment and abuse from others

F63.81 - Intermittent explosive disorder
Impulsive outbursts of verbal and/or physical aggression that are not premeditated, and are extremely difficult to predict

F70 - Mild intellectual disabilities
Impairments in conceptual, social, and practical life skills due to limitations in intellectual functioning

F79 - Unspecified intellectual disabilitiesAsk psychiatrist or NP

F84.9 - Pervasive developmental disorder, unspecified
Delayed development of basic functions including socialization and communication

F90.1 - Attention-deficit hyperactivity disorder, predominantly hyperactive type
Excessive talking, often interrupts others, difficulty sitting still; impatient, impulsive, has problems with social interactions and in forming/maintaining friendships

F90.9 - Attention-deficit hyperactivity disorder, unspecified type
Trouble concentrating, easily distracted, disorganized, impulsive, excessive talking and movement 

 

All PHI has been de-identified per HIPAA Privacy Rule