njsams.rutgers.edu · web viewany issue with dsm-5 please create help ticket in njsams-tmspage 2 of...

New Jersey

Office of Information Systems (OIS)

User’s Reference Manual

NJSAMS 3.2: DSM-5™

Updated 01/11/2016

Reference:-

DSM-5 Diagnostic and Statistical Manual of Mental Disorders” Fifth Edition”, American Psychiatric Association

New Jersey

This page is intentionally left blank

Any issue with DSM-5 please create help ticket in NJSAMS-TMS of 65

New Jersey

Table of Content

1.0 INTRODUCTION 4

1.0.1 DSM-5™ Overview 4

1.0.2 Changes from DSM IV to DSM-5™ 4

2.0 Getting Started DSM-5™ 5

2.0.1 Counselor/Clinician Information and Credentials 5

3.0 Substance Related and Addictive Disorder 6

3.0.1 ALCOHOL-RELATED DISORDERS 7 to 11

3.0.2 CAFFEINE-RELATED DISORDERS 12 to 15

3.0.3 CANNIBIS-RELATED DISORDERS 15 to 20

3.0.4 HALLUCINOGEN-RELATED DISORDERS 21 to 30

3.0.5 INHALENT-RELATED DISORDERS 30 to 34

3.0.6 OPIOID-RELATED DISORDERS 34 to 39

3.0.7 SEDATIVE, HYPNOTIC OR ANXIOLYTIC-RELATED DISORDERS 40 to 45

3.0.8 STIMULANT-RELATED DISORDERS 46 to 51

3.0.9 TOBACCO-RELATED DISORDERS 52 to 55

3.0.10 OTHER (or Unknown) SUBSTANCE-RELATED DISORDERS 55 to

604.0 NON-SUBSTANCE-RELATED DISORDERS 60

4.0.1 GAMBLING DISORDER 60 to 61

5.0 CO-OCCURRING DISORDERS 62

6.0 DIAGNOSTIC SUMMARY 63

7.0 SAMPLE REPORT 64

8.0 DSM-5 RE-EVALUATION 65


New Jersey


New Jersey

1.0 INTRODUCTION

The purpose of DSM-5™User’s Reference is to provide a training for the part of Substance Related and Addictive Disorder referred from “DSM-5 Diagnostic and Statistical Manual of Mental Disorders” Fifth Edition” and in addition, it includes “Co-occurring Mental Health and Diagnostic Summary.This version of DSM-5™ in NJSAMS is mainly for Addiction Services and does not suffice for overall training on all aspects/covered in “DSM-5 Diagnostic and Statistical Manual of Mental Disorders” Fifth Edition”. This version of DSM-5 is to replace current DSM IV in NJSAMS.

1.0.1 DSM-5™ Overview

DSM is a tool for clinicians intended to serve as a practical, functional, and flexible guide for organizing information that can aid in the accurate diagnosis and treatment of mental and additive disorders. The categories of substance abuse and substance dependence from DSM IV have been eliminated and replaced with an overarching new category of substance use disorders with the specific substance used defining the specific disorders in DSM-5™ ™.

1.0.2 Changes from DSM-IV to DSM-5™

DSM-5 does not separate the diagnoses of substance abuse and dependence as in DSM-IV. Rather, criteria are provided for substance use disorder, accompanied by criteria for intoxication, withdrawal, substance/medication-induced disorders, and unspecified substance-induced disorders, where relevant. The DSM-5 substance use disorder criteria are nearly identical to the DSM-IV substance abuse and dependence criteria combined into a single list, with two exceptions. The DSM-IV recurrent legal problems criterion for substance abuse has been deleted from DSM-5, and a new criterion, craving or a strong desire or urge to use a substance has been added. In addition, the threshold for substance use disorder diagnosis in DSM-5 is set at two or more criteria, in contrast to a threshold of one or more criteria for a diagnosis of DSM-IV substance abuse and three or more for DSM-IV substance dependence. Cannabis withdrawal is new for DSM-5, as is caffeine withdrawal (which was in DSM-IV Appendix B, “Criteria Sets and Axes Provided for Further Study”). Of note, the criteria for DSM-5 tobacco use disorder are the same as those for other substance use disorders. By contrast, DSM-IV did not have a category for tobacco abuse, so the criteria in DSM-5 that are from DSM-IV abuse are new for tobacco in DSM-5.The DSM- IV specifier for a physiological subtype has been eliminated in DSM-5, as has the DSM-IV diagnosis of polysubstance dependence. Early remission from a DSM-5 substance use disorder is defined as at least3 but less than 12 months without substance use disorder criteria (except craving), and sustained remission is defined as at least 12 months without criteria (except craving). Additional new DSM-5 specifiers include “in a controlled environment” and “on maintenance therapy” as the situation warrants.

The phrase “general medical condition” is replaced in DSM-5 with “another medical condition” where relevant across all disorders.


New Jersey

2.0 Getting started DSM-5™

DSM-5™ is mandatory for all clients to continue substance abuse service evaluation (LEVEL OF CARE INDEX – LOCI) for level of care services.

The steps to get the link (or) to continue DSM-5™ in New Jersey Substance Abuse Monitoring System (NJSAMS)

1. DASIE Registration2. Immediate Need Assessment (INP – mandatory for all clients)3. UNCOPE – optional4. Income Eligibility (IE) and Program Eligibility (PE) for those who are consent to collect income information5. Addiction Severity Index (Version 5) – optional unless and otherwise funding entity asks as requirement6. BioPsychoSocial – optional7. DSM-5™ – mandatory

2.0.1 Counselor/Clinician Information and CredentialsScreen S-1

All indicated by red asterisks shown in the screen shot above is required field. Date of Diagnosis is required to enter and date cannot be prior to DASIE Registration date and cannot be future date. Counselor Name is required. Credentials must select from the dropdown list and multiple credentials can be selected. Credentials listed in dropdown are as follows:-

1. APN2. CADC3. CADC intern4. LAC5. LCADC6. LCSW7. Licensed Psychologist8. LMFT9. LPC10. LSW11. MD12. Psychiatrist


New Jersey

If the counselor’s credential is CADC or CADC intern or LSW or LAC, the Supervisor Name text box is appeared to enter supervisor name and credential must select from the dropdown list. Multiple credentials are allowed and credentials listed in the dropdown are as follows:-

1. APN2. LCADC3. LCSW4. Licensed Psychologist5. LMFT6. LPC7. MD8. Psychiatrist

Note: Supervisor Name and Supervisor Credentials are visible only if CADC or CADC intern or LSW or LAC is selected from “Credentials” list.

Regulations check box: is required to check to acknowledge the regulation disclaimer mentioned in the screenshot above, thereby has to check the check box provided. If not check the user cannot proceed any further.

If all required information is entered, the landing page which shows Disorders, Co-occurring and Diagnostic Summary (shown in below screen shot) will be enabled to start. In order to provide diagnose a substance abuse treatment at least one Substance-Related Disorder must be entered.

3.0 Substance-Related and Addictive Disorders

Screen S-2 Landing Page


New Jersey

3.0.1 Alcohol-Related Disorder

Alcohol-Related Disorder consists of five components:-

a. Alcohol Use Disorderb. Alcohol Intoxicationc. Alcohol Withdrawald. Other Alcohol-Induced Disorderse. Unspecified Alcohol-Related Disorders

a. Alcohol Use DisorderScreen S-3

Mouse-over to “green square ” icon for explanation of the label for radio button. Click on “Criteria” button to select the Criteria as shown in screen S-3:-

Pop-up Screen S-4

Click on “Save” button in Screen S-4, after selecting the criteria then click on “Close”.On closing the Criteria pop-up screen S-4, Severity is automatically computed based on the number of symptoms selected.


New Jersey

Basic Rules: 1. If 2-3 symptoms are selected, then Severity is Mild.2. If 4-6 symptoms are selected, then Severity is Medium.3. If more than 6 symptoms are selected, then Severity is Severe4. “Specifiers” section is enabled only if there is a diagnosis.5. Special Notations is always enabled and is optional. Maximum characters to enter are limited to 500.6. None of the options in this section are mandatory

b. Alcohol IntoxicationScreen S-5

Click on “Criteria” button to select Criteria as shown in pop-up screen S-6.Pop-up Screen S-6

Click on “Save” after select the criteria then “Close”.


New Jersey

On closing the Criteria pop-up screen S-6, based on the number of symptoms selected1. Check box " Meets Criteria for Alcohol Intoxication Diagnosis?” is checked, if A, B, one or more of C and D are all selected in pop-up screen S-6.2. “Specifiers” options are automatically computed as given below:

a. Alcohol use disorder is Mild + “Meets Criteria for Alcohol Intoxication Diagnosis?” is checked, then “With use disorder, mild 303.00 (F10.129)”, shown in Screen S-5, will be checked.

b. Alcohol use disorder is Moderate or Severe + “Meets Criteria for Alcohol Intoxication Diagnosis?” is checked, then “With use disorder, moderate or severe 303.00 (F10.229)” , shown in Screen S-5, will be checked.

c. No Alcohol Use disorder diagnosis + “Meets Criteria for Alcohol Intoxication Diagnosis?” is checked, then “Without use disorder 303.00 (F10.929)” , shown in Screen S-5, will be checked.3. Special Notations is always enabled and is optional. Maximum characters to enter are

limited to 5004. None of the options in this section are mandatory.

b. Alcohol Withdrawal

Screen S-7

Click on “Criteria” button to select Criteria as shown in pop-up screen S-8.


New Jersey

Pop-up Screen S-8

Click on “Save” after select the criteria then “Close”.

Basic Rules:1. “Specifiers” can only be manually selected before (or) after selecting the criteria2. Special Notations is always enabled and is optional. Maximum characters to enter are limited to 500.3. None of the options in this section are mandatory

d. Other Alcohol-Induced Disorders

Screen S-9

Basic Rules:

1. This section only has an option to enter the code in “Special Notations” area2. “Special Notation” is always enabled and is optional.

Maximum characters to enter are limited to 500.3. None of the options in this section are mandatory


New Jersey

e. Unspecified Alcohol-Related Disorders

Screen S-10

Pop-up Screen S-11

Click on “Save” then “Close” the pop-up screen

Basic Rules

1. There is only one Criterion and if the user selects, saves and closes the pop up screen S-11, the check box “Unspecified Alcohol-Related Disorder 291.9(F10.99)” shown in Screen S-10 should be checked automatically.

2. Comments can be entered in “Special Notations”. Maximum characters to enter are limited to 500.3. None of the options in this section are mandatory

“Save” button in S-10After entering all valid data, hit “Save” to save the Alcohol -Related Disorder information. If there are no errors, “Saved Successfully” message will be displayed.In case of errors, an appropriate error message will be displayed.


New Jersey

3.0.2 Caffeine Related Disorders

Alcohol-Related Disorder consists of four components:-

a. Caffeine Intoxication b. Caffeine Withdrawal c. Other Caffeine -Induced Disorders d. Unspecified Caffeine -Related Disorders

a. Caffeine Intoxication

Screen S-12

Click on “Criteria” button to select criteria shown in Pop-up screen S-13

Pop-up Screen S-13

Click “Save” after selecting criteria and then “Close”

On closing the Criteria Pop-up Screen S-13, the check box shown in Screen S-12 for "Caffeine Intoxication 305.90 (F15.929)” will be checked if A, five or more of B, C and D are selected.


New Jersey

Basic Rules:1. Comments can be entered in “Special Notations”. Maximum characters to enter are limited to 500.2. None of the options in this section are mandatory

b. Caffeine withdrawal

Screen S-14

Click on “Criteria” button to select criteria shown in Pop-up Screen S-15

Pop-up Screen S-15

Click “Save” after selecting criteria and then “Close”

On closing the Criteria Pop-up Screen S-15, based on the number of symptoms selected the check box shown in Screen S-14 for "Caffeine Intoxication 292.0 (F15.93)” if A, three or more of B, C and D are all selected.

Basic Rules:1. Comments can be entered in “Special Notations”. Maximum characters to enter are limited to 500.2. None of the options in this section are mandatory


New Jersey

c. Other Caffeine -Induced Disorders

Screen S-16

Basic Rules:



d. Unspecified Caffeine -Related Disorders

Screen S-17

Click on “Criteria” button to select criteria shown in Pop-up Screen S-18

Pop-up Screen S-18

Click on “Save” then “Close” the pop-up screen


New Jersey

Basic Rules


2. Comments can be entered in “Special Notations”. Maximum characters to enter are limited to 500.3. None of the options in this section are mandatory

“Save” button in Screen S-17

After entering all valid data, hit “Save” to save the Caffeine -Related Disorder information. If there are no errors, “Saved Successfully” message will be displayed.In case of errors, an appropriate error message will be displayed.

3.0.3 Cannabis Related Disordersa. Cannabis Use Disorder

b. Cannabis Intoxication c. Cannabis Withdrawal d. Other Cannabis -Induced Disorders e. Unspecified Cannabis -Related Disorders

a. Cannabis Use DisorderScreen S-19

Mouse-over to “green square” icon for explanation of the label for radio button. Click on “Criteria” button to select the Criteria as shown in screen S-19.


New Jersey

Pop-up Screen S-20

Click on “Save” button in Pop-up Screen S-20, after selecting the criteria then click on “Close”.

On closing the Criteria pop-up screen, Severity is automatically computed based on the number of symptoms selected.

Basic Rules

1. If 2-3 symptoms are selected, then Severity is Mild.2. If 4-6 symptoms are selected, then Severity is Medium.3. If more than 6 symptoms are selected, then Severity is Severe.4. “Specifiers” section is greyed out initially until the current severity is computed and enable only if there is a diagnosis.5. Special Notations is always enabled and is optional. Maximum characters to enter are limited to 500.6. None of the options in this section are mandatory.


New Jersey

b. Cannabis Intoxication

Screen S-21

Click on “Criteria” button to select Criteria as shown in pop-up screen S-21.

Pop-up Screen S-22



New Jersey

Basic Rules:1. Check box "Meets Criteria for Cannabis Intoxication Diagnosis?” is checked if A, B, Two or more

of C and D are all selected.2. Specifiers:

a. Specify if: Manually select if the client has Perceptual Disturbances or not by selecting the appropriate option.b. If “Without perceptual disturbances 291.81 (F10.239)” is selected, then one of the options under “Without perceptual disturbances” is automatically selected based on the severity of Cannabis use disorder.c. If “With perceptual disturbances 291.81 (F10.232)” is selected, then one of the options under “Without perceptual disturbances” is automatically selected based on the severity of Cannabis use disorder.

3. Special Notations is always enabled and is optional. Maximum characters to enter are limited to 500.

4. None of the options in this section are mandatory.

c. Cannabis WithdrawalScreen S-23

Click on “Criteria” button to select criteria. Select from “Criteria” as shown in pop-up screen S-24

On closing the Criteria pop-up screen S-24 (shown on the next page), based on the number of symptoms selected the check box " Cannabis Withdrawal 292.0 (F12.288)” is checked if A, three or more of B, C and D are all selected.

Basic Rules: 1. Comments can be entered in “Special Notations”. Maximum characters to enter are limited to

500.2. None of the options in this section are mandatory.


New Jersey

Pop-up Screen S-24


d. Other Cannabis -Induced Disorders

Screen S-25

Basic Rules:




New Jersey

e. Unspecified Cannabis -Related Disorders

Screen S-26

Pop-up Screen S-27

Click on “Save” button in Pop-up Screen S-27, then “Close”.

Basic Rules


2. Comments can be entered in “Special Notations”. Maximum characters to enter are limited to 500.

3. None of the options in this section are mandatory


After entering all valid data, hit “Save” to save the Caffeine -Related Disorder information. If there are no errors, “Saved Successfully” message will be displayed.In case of errors, an appropriate error message will be displayed.


New Jersey

3.0.4 Hallucinogen Related Disorders

a. Phencyclidine Use Disorderb. Other Hallucinogen Use Disorderc. Phencyclidine Intoxicationd. Other Hallucinogen Intoxicatione. Hallucinogen Persisting Perception Disorderf. Other Phencyclidine -Induced Disordersg. Other Hallucinogen- Induced Disordersh. Unspecified Phencyclidine -Related Disordersi. Unspecified Hallucinogen -Related Disorders

a. Phencyclidine Use DisorderScreen S-28



New Jersey

Pop-up Screen S-29



Basic Rules:

1. If 2-3 symptoms are selected, then Severity is Mild.2. If 4-6 symptoms are selected, then Severity is Medium.3. If more than 6 symptoms are selected, then Severity is Severe.4. “Specifiers” section is enabled only if there is a diagnosis.5. Special Notations is always enabled and is optional. Maximum characters to enter are limited to 500.6. None of the options in this section are mandatory.


New Jersey

b. Other Hallucinogen Use Disorder

Screen S-30


Pop-up Screen S-31



New Jersey


Basic Rules:

1. If 2-3 symptoms are selected, then Severity is Mild.2. If 4-6 symptoms are selected, then Severity is Medium.3. If more than 6 symptoms are selected, then Severity is Severe.4. Specify or add the Hallucinogen name by typing in the text box provided5. “Specifiers” section is greyed out initially until the current severity is computed and enable only if there is a diagnosis.6. Special Notations is always enabled and is optional. Maximum characters to enter are limited to 500.7. None of the options in this section are mandatory.

c. Phencyclidine Intoxication

Screen S-32

Pop-up Screen S-33



New Jersey

On closing the Criteria pop-up screen S-33, based on the number of symptoms selected, the check box "Meets Criteria for Phencyclidine Intoxication Diagnosis?” is checked if A, B, two or more of C and D are all selected.

Basic Rules1. “Specifiers” options are automatically computed as given below:

a. Hallucinogen use disorder is Mild + “Meets Criteria for Hallucinogen Intoxication Diagnosis?” is checked, then “With use disorder, mild 292.89 (F16.129)” will be checked.

b. Hallucinogen use disorder is Moderate or Severe + “Meets Criteria for Hallucinogen Intoxication Diagnosis?” is checked, then “With use disorder, moderate or severe 292.89 (F16.229)” will be checked.

c. No Hallucinogen Use disorder diagnosis + “Meets Criteria for Hallucinogen Intoxication Diagnosis?” is checked, then “Without use disorder 292.89 (F16.929)” will be checked.



d. Other Hallucinogen Intoxication

Screen S-34

Criteria pop-up will not be display if there is no “Hallucinogen Intoxication Substance” is added. After adding substance name, click on “Criteria” to select symptoms.


New Jersey

Pop-up Screen S-35


On closing the Criteria Pop-up Screen S-33, based on the number of symptoms selected

Basic Rules:1. Check box " Meets Criteria for Hallucinogen Intoxication Diagnosis?” is checked if A, B, two or more of C and D are all selected.2. Specifiers options are automatically computed as given below:

a. Hallucinogen use disorder is Mild + “Meets Criteria for Hallucinogen Intoxication Diagnosis?” is checked, then “With use disorder, mild 292.89 (F16.129)” will be checked.

b. Hallucinogen use disorder is Moderate or Severe + “Meets Criteria for Hallucinogen Intoxication Diagnosis?” is checked, then “With use disorder, moderate or severe 292.89 (F16.229)” will be checked.c. No Hallucinogen Use disorder diagnosis + “Meets Criteria for Hallucinogen Intoxication Diagnosis?” is checked, then “Without use disorder 292.89 (F16.929)” will be checked.

3. Specify the Hallucinogen name in the space provided.4. Special Notations is always enabled and is optional. Maximum characters to enter are limited to 500.5. None of the options in this section are mandatory.


New Jersey

e. Hallucinogen Persisting Perception Disorder

Screen S-36

Click on “Criteria” button from Screen S-36 to select symptoms.

Pop-up Screen S-37


Basic Rules:-1. On closing the “Criteria” Pop-up Screen S-37, if all the Criteria A, B, C are selected,

then the checkbox “Hallucinogen Persisting Perception Disorder 292.89(F16.983)” will be automatically checked.




New Jersey

f. Other Phencyclidine-Induced Disorders

Screen S-38

Basic Rules:

1. This section only has an option to enter the Code in “Special Notations” area. Maximum characters to enter are limited to 500.2. None of the options in this section are mandatory.

g. Other Hallucinogen- Induced Disorders

Screen S-39

Basic Rules:

1. This section only has an option to enter the Code in “Special Notations” area. Maximum characters to enter are limited to 500.2. None of the options in this section are mandatory.

h. Unspecified Phencyclidine-Related Disorder

Screen S-40


New Jersey

Pop-up Screen S-41

Basic Rules



3. None of the options in this section are mandatory

i. Unspecified Hallucinogen -Related Disorders

Screen S-42

Pop-up Screen S-43



New Jersey

Basic Rules:-

1. There is only one Criterion and if the user selects, saves and closes the Pop-up Screen S-43, the check box “Unspecified Hallucinogen -Related Disorder 292.9(F16.99)” should be checked automatically.2. Comments can be entered in “Special Notations”. Maximum characters to enter are limited to 500. 3. None of the options in this section are mandatory.


After entering all valid data, hit “Save” to save the “Hallucinogen-Related Disorder information”. If there are no errors, “Saved Successfully” message will be displayed.In case of errors, an appropriate error message will be displayed.

3.0.5 Inhalant-Related Disorders

a. Inhalant Use Disorderb. Inhalant Intoxicationc. Other Inhalant-Induced Disordersd. Unspecified Inhalant-Related Disorders

a. Inhalant Use DisorderScreen S-44

Mouse-over to “green square ” icon for explanation of the label for radio button. Click on “Criteria” button to select the Criteria as shown in screen S-44. Criteria can be selected only after typing in the “Inhalant Use Substance”.


New Jersey

Pop-up Screen S-45

Click on “Save” button in Pop-up Screen S-45 after selecting the criteria then click on “Close”.


Basic Rules:

1. If 2-3 symptoms are selected, then Severity is Mild.2. If 4-6 symptoms are selected, then Severity is Medium.3. If more than 6 symptoms are selected, then Severity is Severe.4. Specify the Inhalant name in the space provided.5. “Specifiers” section is enabled only if there is a diagnosis.6. Special Notations is always enabled and is optional. Maximum characters to enter are limited

to 500.7. None of the options in this section are mandatory.


New Jersey

b. Inhalant Intoxication

Screen S-46

Criteria can be selected only after typing in the “Inhalant Intoxication Substance”.

Pop-up Screen S-47

Click on “Save” button in Pop-up Screen S-47 after selecting the criteria, and then click on “Close”.

On closing the Criteria Pop-up Screen S-45, based on the number of symptoms selected, the check box for " Meets Criteria for Inhalant Intoxication Diagnosis?” is checked if A, B, two or more of C and D are all selected.


New Jersey

Basic Rules:

1. Specifiers options are automatically computed as given below: a. Inhalant use disorder is Mild + “Meets Criteria for Inhalant Intoxication Diagnosis?” is checked, then “With use disorder, mild 292.89 (F18.129)” will be checked. b. Inhalant use disorder is Moderate or Severe + “Meets Criteria for Inhalant Intoxication

Diagnosis?” is checked, then “With use disorder, moderate or severe 292.89 (F18.229)” will be checked.

c. No Inhalant Use disorder diagnosis + “Meets Criteria for Inhalant Intoxication Diagnosis?” is checked, then “Without use disorder 292.89 (F18.929)” will be checked.

2. Specify the name of the particular Inhalant in the space provided.3. Special Notations is always enabled and is optional. Maximum characters to enter are

limited to 500.4. None of the options in this section are mandatory.

c. Other Inhalant-Induced Disorders

Screen S-48

This section only has an option to enter the Code in “Special Notations” area. Maximum characters to enter are limited to 500.None of the options in this section are mandatory.

d. Unspecified Inhalant-Related Disorders

Screen S-49


New Jersey

Pop-up Screen S-50

Click on “Save” button in Pop-up Screen S-47 after selecting the criteria, and then click on “Close”.

There is only one Criterion in this section. On closing, if the user selects, saves and closes the Pop-up Screen S-50, the check box “Unspecified Inhalant -Related Disorder 292.9(F18.99)” should be checked automatically.

Basic Rules: 1. Comments can be entered in “Special Notations”. Maximum characters to enter are limited to

500.2. None of the options in this section are mandatory.

3.0.6 - Opioid-Related Disorders

Opioid-Related Disorder consists of five components:-

a. Opioid Use Disorderb. Opioid Intoxicationc. Opioid Withdrawald. Other Opioid -Induced Disorderse. Unspecified Opioid -Related Disorders

a. Opioid Use Disorder

Screen S-51

Mouse-over to “green square ” icon for explanation of the label for radio button. Click on “Criteria” button to select the Criteria as shown in screen S-51.


New Jersey

Pop-up Screen S-52

Click on “Save” button in Pop-up Screen S-52, after selecting the criteria, and then click on “Close”.

On closing the Criteria Pop-up Screen S-52, based on the number of symptoms selected, “severity” is automatically computed.

Basic Rules:

1. If 2-3 symptoms are selected, then Severity is Mild.2. If 4-6 symptoms are selected, then Severity is Medium.3. If more than 6 symptoms are selected, then Severity is Severe.4. “Specifiers” section is enabled only if there is a diagnosis.5. Special Notations is always enabled and is optional. Maximum characters to enter are



New Jersey

b. Opioid Intoxication

Screen S-53

Pop-up Screen S-54


On closing the Criteria Pop-up Screen S-54, if A, B, one or more of C and D are all selected the check box for "Meets Criteria for Opioid Intoxication Diagnosis?” will be checked shown in Screen S-53.


New Jersey

Cont’d from Opioid Intoxication…

Basic Rules:

1. Specify if: Select if the client has Perceptual Disturbances or not by selecting the appropriate option.

a. If ‘Without perceptual disturbances” is selected, then one of the options under “Without perceptual disturbances” is selected based on the severity of Opioid use disorder and whether “Meets Criteria for Opioid Intoxication Diagnosis” is selected or not.b. If ‘With perceptual disturbances” is selected, then one of the options under “Without perceptual disturbances” is selected based on the severity of Opioid use disorder and whether “Meets Criteria for Opioid Intoxication Diagnosis” is selected or not.

2. Specify the name of the particular Opioid in the space provided.3. Special Notations is always enabled and is optional. Maximum characters to enter are


c. Opioid Withdrawal

Screen S-55

Click on “Criteria” button will get the symptoms to select shown in Pop-up Screen S-56 at page 38.


New Jersey

Pop-up Screen S-56


On closing the Criteria Pop-up Screen S-56, based on the number of symptoms selected, if A, three or more of B, C and D are all selected the check box in Screen S-55 for "Opioid Withdrawal 292.0 (F11.23)” will be checked.

Basic Rules: 1. Comments can be entered in “Special Notations”. Maximum characters to enter are


d. Other Opioid -Induced Disorders

Screen S-57

Basic Rules:1. This section only has an option to enter the Code in “Special Notations” area. Maximum

characters to enter are limited to 500.2. None of the options in this section are mandatory.


New Jersey

e. Unspecified Opioid -Related Disorder

Screen S-58

Click on “Criteria” button to get the symptoms to select shown in Pop-up Screen S-59.

Pop-up Screen S-59


Basic Rules:

1. There is only one Criterion and if the user selects, saves and closes the pop up, the check box ‘Unspecified Opioid -Related Disorder 292.9(F11.99)’ should be checked automatically.




After entering all valid data, hit “Save” to save the accordion for “Opioid-Related Disorders”. If there are no errors, “Saved Successfully” message will be displayed.In case of errors, an appropriate error message will be displayed.


New Jersey

3.0.7 - Sedative, Hypnotic, or Anxiolytic Related Disorders

a. Sedative, Hypnotic, or Anxiolytic Use Disorderb. Sedative, Hypnotic, or Anxiolytic Intoxicationc. Sedative, Hypnotic, or Anxiolytic Withdrawald. Other Sedative, Hypnotic, or Anxiolytic-Induced Disordere. Unspecified Sedative, Hypnotic, or Anxiolytic-Related Disorder

a. Sedative, Hypnotic, or Anxiolytic Use Disorder

Screen S-60

Mouse-over to “green square ” icon for explanation of the label for radio button. Click on “Criteria” button to select the Criteria as shown in screen S-60. Any additional substance for “Sedative, Hypnotic, or Anxiolytic” can be typed in the text box provided and re-select the “Criteria” for that additional substance.


New Jersey

Pop-up Screen S-61


On closing the Criteria Pop-up Screen S-61, Severity is automatically computed based on the number of symptoms selected.

Basic Rule:1. If 2-3 symptoms are selected, then Severity is Mild.2. If 4-6 symptoms are selected, then Severity is Medium.3. If more than 6 symptoms are selected, then Severity is Severe.4. ‘Specifiers’ section is enabled only if there is a diagnosis.5. Special Notations is always enabled and is optional. Maximum characters to enter are


b. Sedative, Hypnotic, or Anxiolytic Intoxication


New Jersey

Screen S-62

Enter (or) type in the name of “Sedative, Hypnotic, or Anxiolytic” substance to enable “Criteria” button. Criteria button is disable until substance name is entered.

Pop-up Screen S-63


On closing the Criteria Pop-up Screen S-63, based on the number of symptoms selected, if A, B, one or more of C and D are all selected the check box in screen S-62 for "Meets Criteria for Sedative, Hypnotic or Anxiolytic Intoxication Diagnosis?” will be checked.


New Jersey

Basic Rules:

1. Specifiers options are automatically computed as given below:a. Sedative, Hypnotic or Anxiolytic use disorder is Mild + ‘Meets Criteria for Sedative,

Hypnotic or Anxiolytic Intoxication Diagnosis?’ is checked, then ‘With use disorder, mild 292.89 (F13.129)’ will be checked.

b. Sedative, Hypnotic or Anxiolytic use disorder is Moderate or Severe + ‘Meets Criteria for Sedative, Hypnotic or Anxiolytic Intoxication Diagnosis?’ is checked, then ‘With use disorder, moderate or severe 292.89 (F13.229)’ will be checked.

c. No Sedative, Hypnotic or Anxiolytic Use disorder diagnosis + ‘Meets Criteria for Sedative, Hypnotic or Anxiolytic Intoxication Diagnosis?’ is checked, then ‘Without use disorder 292.89 (F13.929)’ will be checked.

2. Specify the name of particular Sedative, Hypnotic or Anxiolytic Intoxication in the text box provided in Screen S-62.



c. Sedative, Hypnotic, or Anxiolytic Withdrawal

Screen S-64

Enter/Type in the name of “Sedative, Hypnotic or Anxiolytic Intoxication” substance in the text box provided in S-64, then click on “Criteria” to select symptoms. Specifiers must select annually.


New Jersey

Cont’d from “Sedative, Hypnotic or Anxiolytic Intoxication” ….

Pop-up Screen S-65


Basic Rules:

1. Specify the particular Sedative, Hypnotic or Anxiolytic name in the text box provided in Screen -64

2. Specifiers have to be manually selected in this case.

d. Other Sedative, Hypnotic, or Anxiolytic-Induced Disorder

Screen S-66

Basic Rules:1. This section only has an option to enter the Code in “Special Notations” area.

Maximum characters to enter are limited to 500.2. None of the options in this section are mandatory.

e. Unspecified Sedative, Hypnotic, or Anxiolytic-Related DisorderAny issue with DSM-5 please create help ticket in NJSAMS-TMS of 65

New Jersey

Screen S-67

Pop-up Screen S-68


Basic Rules:1. There is only one Criterion in this section. If the user selects, saves and closes the Pop

up Screen S-68, the check box “Unspecified Sedative, Hypnotic or Anxiolytic-Related Disorder 292.9(F13.99)” should be checked automatically.




After entering all valid data, hit “Save” to save the accordion for “Sedative, Hypnotic or Anxiolytic-Related Disorders”. If there are no errors, “Saved Successfully” message will be displayed.In case of errors, an appropriate error message will be displayed.


New Jersey

3.0.8 - Stimulant Related Disorders

a. Stimulant Use Disorderb. Stimulant Intoxicationc. Stimulant Withdrawald. Other Stimulant-Induced Disorderse. Unspecified Stimulant-Related Disorders

a. Stimulant Use Disorder

Screen S-69

Mouse-over to “green square ” icon for explanation of the label for radio button. Select Stimulant and click on “Criteria” button to select symptoms as shown in screen S-70. Any additional substance for “Stimulant” can be typed in the text box provided and re-select the “Criteria” for that additional substance.


New Jersey

Pop-up Screen S-71

Click on “Save” button in Pop-up Screen S-71, after selecting the criteria and then click on “Close”.

On closing the Criteria Pop-up Screen S-71, based on the number of symptoms selected. “severity” is automatically computed.

Basic Rule:

1. If 2-3 symptoms are selected, then Severity is Mild.2. If 4-6 symptoms are selected, then Severity is Medium.3. If more than 6 symptoms are selected, then Severity is Severe.4. Select the type of Stimulant from the drop down.5. Based on the Stimulant selected, Current Severity option will be selected automatically

ie., either “Amphetamine or Other Unspecified Stimulant Severity” options or “Cocaine Severity” options are automatically selected.

6. Specify the particular stimulant’s name in the space provided only if the option selected is ‘Amphetamine or Other Unspecified Stimulant’.


New Jersey

7. ‘Specifiers’ section is enabled only if there is a diagnosis.8. Special Notations is always enabled and is optional. Maximum characters to enter are


b. Stimulant Intoxication

Screen S-72


New Jersey

Pop-up Screen S-73


On closing the Criteria Pop-up Screen S-73, the check box on S-72 for "Meets Criteria for Stimulant Intoxication Diagnosis?” will be checked if A, B, two or more of C and D are selected,.

Basic Rules:

1. Select the type of Stimulant from the drop down.2. Specify the particular stimulant’s name in the space provided only if the option

selected in #2 is ‘Amphetamine or Other Unspecified Stimulant’.3. Specify If: This will be manually selected based on whether client has With/Without

perceptual disturbances. 4. Specifiers options are automatically checked based on:

a. Amphetamine or Other OR Cocaine options are checked automatically based on the selection of Stimulant and the severity of Use disorder and if ‘Meets Criteria for Stimulant Intoxication Diagnosis’ is checked or not.

b. If “None” is selected in Stimulant use disorder then “Without use disorder” option is selected.

5. Specify the name of particular Stimulant Intoxication in the space provided. 6. Special Notations is always enabled and is optional. Maximum characters to enter

are limited to 500.7. None of the options in this section are mandatory.


New Jersey

c. Stimulant Withdrawal

Screen S-74

Pop-up Screen S-75


Basic Rules:

1. Specifiers have to be manually selected in this case. (Amphetamine or Other Stimulant 292.0(F15.23) OR Cocaine 292.0 (F14.23).

2. Specify the Stimulant Withdrawal Substance name in the test box provided in Screen S-74.




New Jersey

d. Other Stimulant-Induced Disorders

Screen S-76

Basic Rules:

1. This section only has an option to enter the Code in “Special Notations” area. Maximum characters to enter are limited to 500.


e. Unspecified Stimulant-Related Disorders

Screen S-77

Pop-up Screen S-78

Basic Rules:1. Specifiers must be manually selected.2. Comments can be entered in “Special Notations”. Maximum characters to enter

are limited to 500.3. None of the options in this section are mandatory.


New Jersey

3.0.9 - Tobacco Related Disorders

a. Tobacco Use Disorderb. Tobacco Withdrawalc. Other Tobacco-Induced Disordersd. Unspecified Tobacco-Related Disorders

a. Tobacco Use DisorderScreen S-79

Mouse-over to “green square ” icon for explanation of the label for radio button. Click on “Criteria” button to select symptoms as shown in screen S-80.

Pop-up Screen S-80



New Jersey

On closing the Criteria Pop-up Screen S-80, based on the number of symptoms selected in “Criteria”, severity is automatically computed. Basic Rules:

1. If 2-3 symptoms are selected, then Severity is Mild.2. If 4-6 symptoms are selected, then Severity is Medium.3. If more than 6 symptoms are selected, then Severity is Severe.4. “Specifiers” section is enabled only if there is a diagnosis.5. Special Notations is always enabled and is optional. Maximum characters to enter

are limited to 500.6. None of the options in this section are mandatory

b. Tobacco Withdrawal

Screen S-81

Pop-up Screen S-82



New Jersey

Basic Rules:1. Specifiers have to be manually selected in this case (Tobacco Withdrawal 292.0

(F17.203)).2. Specify the Stimulant name in the space provided.3. Special Notations is always enabled and is optional. Maximum characters to enter are


c. Other Tobacco-Induced Disorders

Screen S-83

Basic Rules:1. This section only has an option to enter the Code in “Special Notations” area. 2. Maximum characters to enter are limited to 500.3. None of the options in this section are mandatory.

d. Unspecified Tobacco-Related Disorders

Screen S-84


After entering all valid data, hit “Save” to save the accordion for “Tobacco--Related Disorders”. If there are no errors, “Saved Successfully” message will be displayed.In case of errors, an appropriate error message will be displayed.


New Jersey

Pop-up Screen S-85


Basic Rules:

1. There is only one Criterion and if the user selects, saves and closes the pop up, the check box ‘Unspecified Tobacco -Related Disorder 292.9(F17.209)’ should be checked automatically.



3.0.10 – Other (or Unknown) Substance -Related Disorders

a. Other (or Unknown) Substance Related Use Disorderb. Other (or Unknown) Substance Related Intoxicationc. Other (or Unknown) Substance Related Withdrawald. Other (or Unknown) Substance Related Induced Disorderse. Unspecified Other (or Unknown) Substance Related Disorders

a. Other (or Unknown) Substance Related Use Disorder

Screen S-86

Mouse-over to “green square ” icon for explanation of the label for radio button. Select Stimulant and click on “Criteria” button to select symptoms as shown in screen S-86.


New Jersey

Pop-up Screen S-87


On closing the Criteria Pop-up Screen S-87, based on the number of symptoms selected in “Criteria”, “severity” is automatically computed.

Basic Rule:1. If 2-3 symptoms are selected, then Severity is Mild.2. If 4-6 symptoms are selected, then Severity is Medium.3. If more than 6 symptoms are selected, then Severity is Severe.4. “Specifiers” section is enabled only if there is a diagnosis.5. Special Notations is always enabled and is optional. Maximum characters to

enter are limited to 500.6. None of the options in this section are mandatory

b. Other (or Unknown) Substance Related Intoxication


New Jersey

Screen S-88

Pop-up Screen S-89


On closing the Criteria Pop-up Screen S-89, based on the number of symptoms selected, if A, B and C are all selected, the check box for S-89 for " Meets Criteria for Other (or Unknown) Substance Intoxication Diagnosis?” will be checked.

Basic Rules:1. “Specifiers” options are automatically computed as given below:

a. Other (or Unknown) Substance use disorder is Mild + ‘Meets Criteria for Other(or Unknown) Substance Intoxication Diagnosis?’ is checked, then ‘With use disorder, mild 292.89 (F19.129)’ will be checked.

b. Other (or Unknown) Substance use disorder is Moderate or Severe + ‘Meets Criteria for Other (or Unknown) Substance Intoxication Diagnosis?’ is checked, then ‘With use disorder, moderate or severe 292.89 (F19.229)’ will be checked.

c. No Other (or Unknown) Substance Use disorder diagnosis + ‘Meets Criteria for Other (or Unknown) Substance Intoxication Diagnosis?’ is checked, then ‘Without use disorder 292.89 (F19.929)’ will be checked.




New Jersey

c. Other (or Unknown) Substance Related Withdrawal

Screen S-90

Pop-up Screen S-91

Click on “Save” button in Pop-up Screen S-91, after selecting the criteria and then click on “Close”.Basic Rules:

1. Specifiers have to be manually selected in this case for “Other (or Unknown) Substance-Related Withdrawal 292.0 (F19.239)”.

2. Specify the Withdrawal Stimulant name in the text box provided in S-90.3. Max Characters to enter are limited to 500.4. None of the options in this section are mandatory.


New Jersey

d. Other (or Unknown) Substance Related Induced Disorders

Screen S-92

Basic Rules:1. This section only has an option to enter the Code in “Special Notations” area.

Maximum characters to enter are limited to 500.2. None of the options in this section are mandatory.

e. Unspecified Other (or Unknown) Substance Related Disorders

Screen S-93


After entering all valid data, hit “Save” to save the accordion for “Other (or Unknown) Substance Related Disorder”. If there are no errors, “Saved Successfully” message will be displayed.In case of errors, an appropriate error message will be displayed.


New Jersey

Pop-up Screen S-94


Basic Rules:

1. There is only one Criterion and if the user selects, saves and closes the pop up, the check box ‘Unspecified Other(or Unknown) Substance-Related Disorder 292.9(F19.99)’ should be checked automatically.



---------------- End of Other (or Unknown) Substance -Related Disorders ---------------

4.0 - Non-Substance Related Disorders

4.0.1 - Gambling DisorderScreen S-95

- Click on “Save” button to save the accordion for “Gambling Disorder”


New Jersey

Pop-up Screen S-96


On closing the Criteria pop-up screen, based on the number of symptoms selected, severity is automatically computed.

Basic Rule:

1. If 4-5 symptoms are selected, then Severity is Mild.2. If 6-7 symptoms are selected, then Severity is Medium.3. If 8-9 symptoms are selected, then Severity is Severe.4. “Specifiers” section is enabled only if there is a diagnosis.5. Special Notations is always enabled and is optional. Maximum characters to

enter are limited to 500.6. None of the options in this section are mandatory


New Jersey

5.0 – Co-occurring Mental Health Disorders

Screen S-97

Basic Rules:

1. Co-occurring Diagnosis check box must be checked if the client has any co-occurring disorders.

2. When it is checked, other controls in this section are enabled, else they are all disabled.3. Choose a Chapter Title to filter the Disorder Name4. Choose a Disorder Name to filter Diagnosis list. 5. Enter comments if any.6. Save after entering all the information.


New Jersey

6.0.1- Diagnosis Information

Screen S-98

This section is mandatory.

Basic Rules:-

1. Click on “Get Diagnostic Codes” to compute the diagnosis information for the client. On clicking this button, the four lists namely “First Diagnosis”, “Second Diagnosis”, “Third Diagnosis”, “Fourth Diagnosis” will be populated with data.

2. Four levels of diagnosis may be selected for the client based on the level of severity of the disorders.

3. “Functional Impairment” section has a list of functional issues that the client may have. These comments/options are mandatory.

4. Save the data after entering all the information.


New Jersey

7.0 - DSM-5™ Report

Sample Summary Report

Report – 1


New Jersey

8.0 - DSM-5 Re-evaluation

DSM-5 Re-evaluation accordion will display when the initial DSM-5 is done and the client is admitted in NJSAMS. When the client is admitted initial DSM-5 (or) DSM-5 which continues to LOCI-3 and admission will be locked. Any re-evaluation for DSM-5 during admission is given as a report. The initial DSM-5 and any re-evaluation DSM-5 will be kept as versioning by the DSM-5 evaluation date. If the client is done more than one DSM-5 during treatment will be shown as in Screens S-99 and S-100.

Screen S-99

Initial and Re-evaluation DSM-5 will be shown as in the sample screen S-100, when click on “Re-Evaluation DSM-5” button.

Screen S-100


njsams.rutgers.edu · web viewany issue with dsm-5 please create help ticket in njsams-tmspage 2 of...

Documents