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Dr. Mark
Dr. Mark, Psychotherapist
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Experience:  Dr. Mark is a PhD in psychology in private practice
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what is diagnostic code 300.40 please?

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what is diagnostic code 300.40 please? i supplemented this post with further info, please advise you did get that further info please.
Submitted: 3 years ago.
Category: Mental Health
Expert:  Dr. Mark replied 3 years ago.

Hi! I believe I can be of help with this issue.

300.40 is the diagnostic code (both in ICD-9, which is what insurance companies have us report the diagnoses in, and DSM-IV which is the psychiatric diagnostic coding system) for dysthymic disorder. What is that?

Well, without getting too technical, dysthymic disorder is one of the depressive disorders.

In order to truly understand the diagnosis, though, I will have to explain that a clear difference between Dysthymia and Major Depressive Disorder (MDD) doesn't exist. Functionally, I can tell you that the difference is a matter of how long the problem has manifested. If it's lasted without abating longer than a few months, it's going to be Dysthymic Disorder. Otherwise it will be MDD. Here's how the Diagnostic and Statistical Manual classifies them so you can see for yourself and get a better idea. Let's look at it and then I'll continue. Here's the entry for MDD:

Major Depressive Episode

A. Five (or more) of the following symptoms have been present during the same 2-week period and represent a change from previous functioning; at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure.

Note: Do note include symptoms that are clearly due to a general medical condition, or mood-incongruent delusions or hallucinations.

(1) depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad or empty) or observation made by others (e.g., appears tearful). Note: In children and adolescents, can be irritable mood.

(2) markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by either subjective account or observation made by others)

(3) significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of body weight in a month), or decrease or increase in appetite nearly every day. Note: In children, consider failure to make expected weight gains.

(4) insomnia or hypersomnia nearly every day

(5) psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down)

(6) fatigue or loss of energy nearly every day

(7) feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick)

(8) diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others)

(9) recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide

B. The symptoms do not meet criteria for a Mixed Episode.

C. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

D. The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., hypothyroidism).

E. The symptoms are not better accounted for by Bereavement, i.e., after the loss of a loved one, the symptoms persist for longer than 2 months or are characterized by marked functional impairment, morbid preoccupation with worthlessness, suicidal ideation, psychotic symptoms, or psychomotor retardation.

Major Depressive Disorder


Single Episode

A. Presence of a single Major Depressive Episode

B. The Major Depressive Episode is not better accounted for by Schizoaffective Disorder and is not superimposed on Schizophrenia, Schizophreniform Disorder, Delusional Disorder, or Psychotic Disorder Not Otherwise Specified.

C. There has never been a Manic Episode, a Mixed Episode, or a Hypomanic Episode. Note: This exclusion does not apply if all the manic-like, mixed-like, or hypomanic-like episodes are substance or treatment induced or are due to the direct physiological effects of a general medical condition.

Recurrent

A. Presence of two or more Major Depressive Episodes.

Note: To be considered separate episodes, there must be an interval of at least 2 consecutive months in which criteria are not met for a Major Depressive Episode.

B. The Major Depressive Episodes are not better accounted for by Schizoaffective Disorder and are not superimposed on Schizophrenia, Schizophreniform Disorder, Delusional Disorder, or Psychotic Disorder Not Otherwise Specified.

C. There has never been a Manic Episode, a Mixed Episode, or a Hypomanic Episode. Note: This exclusion does not apply if all the manic-like, mixed-like, or hypomanic-like episodes are substance or treatment induced or are due to the direct physiological effects or a general medical condition.

Now, let’s look at the criteria for Dysthymic disorder:

According to the DSM-IV, dysthymia is characterized by an overwhelming yet chronic state of depression, exhibited by a depressed mood for most of the days, for more days than not, for at least 2 years. (In children and adolescents, mood can be irritable and duration must be at least 1 year.) The person who suffers from this disorder must not have gone for more than 2 months without experiencing two or more of the following symptoms:

  • poor appetite or overeating
  • insomnia or hypersomnia
  • low energy or fatigue
  • low self-esteem
  • poor concentration or difficulty making decisions
  • feelings of hopelessness

In addition, no Major Depressive Episode has been present during the first two years (or one year in children and adolescents) and there has never been a Manic Episode, a Mixed Episode, or a Hypomanic Episode, and criteria have never been met for Cyclothymic Disorder. Further, the symptoms cannot be due to the direct physiological effects of a the use or abuse of a substance such as alcohol, drugs or medication or a general medical condition. The symptoms must also cause significant distress or impairment in social, occupational, educational or other important areas of functioning.

So you see she's been diagnosed with dysthymic disorder probably because the depressive symptoms have been going on for a long while and there wasn't a specific event that triggered them. Your description of her, though, doesn't seem to match the diagnosis very well. So, she may not have told her doctors and psychologists much of what you told me here.

I wish you the very best!


 

Please remember to click the green accept button. Feel free to continue the discussion; my goal is to get you the best answers possible. Bonuses are always appreciated! If I can be of further help with any issue, just put "for Dr. Mark" in the front of your new question, and I'll be the one to answer it. All the best, XXXXX XXXXX

Customer: replied 3 years ago.
it sounds like you did get my description of her that includes the sexual acting out when she drinks while on wellbutrin...is there an express contraindication for -OH and an ssri like wellbutrin? what to make of the sexual acting out?
Expert:  Dr. Mark replied 3 years ago.
Yes, I got it. And I don't blame the Wellbutrin for her acting out sexually while drinking. This is her own permission giving mechanism more than anything else most often.

What do I make from the acting out? There's no definitive statement that can be made. I can, however, share with you my first thoughts:

I would, if she were in my session room, first explore the following if I had this information about her. I would want to know about sexual abuse or molestation when she was young. The behavior, in my experience, is most consistent with that type of childhood situation and is often part of a personality disorder problem or PTSD reaction. After that, I would be looking for dysfunction in the home when she grew up, but this isn't quite the behavior that fits that but sometimes it is seen like this.

So you see my first thought is not just a behavioral issue. Caveat: the drinking is most likely a numbing agent for her. Emotional numbing. Whatever the pain is. Again, you see I'm still thinking in terms of something in her early life that didn't go right. But, my point here is that no treatment is worth much in therapy without her first getting treated for the alcoholism. Yeah, I know, you didn't say that. But in my practice, it's a waste of the client's money and my time unless the person actually admits to herself she's got a problem. And then goes to AA where they know how to give the support she'll need to win over the bottle. Then I would accept her as a client/patient.

So, that's as honest and open as I can be about this that you've presented. I wish you the very best!

Please remember to click the green accept button. Feel free to continue the discussion; my goal is to get you the best answers possible. Bonuses are always appreciated! If I can be of further help with any issue, just put "for Dr. Mark" in the front of your new question, and I'll be the one to answer it. All the best, XXXXX XXXXX

Dr. Mark, Psychotherapist
Category: Mental Health
Satisfied Customers: 5131
Experience: Dr. Mark is a PhD in psychology in private practice
Dr. Mark and 3 other Mental Health Specialists are ready to help you
Customer: replied 2 years ago.

Hello Dr. Mark,

 

Following up on the above, now-former gf.

 

We had a rocky winter, spring and summer. In August, her parents - bitterly divorced since she was 10 and rarely speak - met at mom's behest to discuss my 48 yo gf's behavior. Mom was concerned. Dad is a lawyer. The meeting got back to me, and I learned they had contemplated not only formal intervention but involuntary inpatient tx. [Understand this is a highly functioning doctor.....] The symptoms concerning them were irritability, paranoia, lability, drinking and others.

 

When I learned of it I reported it to her. As an atty myself, I felt it was inappropriate, nws my 18 month concerns about the same symptoms. When the family learned I had disclosed this, they scattered and I became odd man out. She was of course terrified.

 

So with that background, i have new questions. What do borderline PD and narcissistic PD look like? Ive read the DSM. But in the trenches? She's NEVER been married, has that pervasive history of unstable relationships, great feelings of abandonment and emptiness, and random outburts of scary anger that go on for awhile. She's really a difficult person, her family and office staff describe to me years of just being difficult. And her education and family of origin: parents divorced at 10, lived thereafter with very bitter mom, Wellesley undergrad, long series of rel's w/older, married men began in med school, fellowship and practice in MFM, which is all women all the time and her staff is all women. But she is very highly hetero-sexed. Help me understand this woman....

Expert:  Dr. Mark replied 2 years ago.

Hi! It's nice to hear from you. I guess that's a tough thing to say given that it's because she's not doing well and you've had a hard time, but it's nice to know what's going on.

Let's first discuss narcissism vs. Borderline Personality Disorder (BPD). You've seen the DSM criteria so we'll dispense with the broad technical aspects. I already had BPD in my thoughts before you mentioned it. So you know right away my diagnostic bias here. Why BPD?


Narcissists can be controlling, manipulative, have unstable relationships, and be hypersexual like those with BPD. But the defining aspect of narcissism is this: she's the sun and everyone else is a moon that revolves around her. Of course the people around her should want to make her happy and make sure she's satisfied: after all, if she's feeling good, then they already are mostly all the way to feeling good as well. the controlling aspect is paramount: narcissists don't let people go that easily from their orbit. And they're rarely emotionally labile in uncontrolled ways. And NPD forms during the first few years in life.


She seems to have had the BPD childhood of instability and parents who were unstable themselves during the mid childhood. So, you've more likely experienced what BPD is like. Loved ones rarely stay. The turnover rate is very, very high. Because there's always drama, always blaming, always emotional intensity.


Randi Krieger and Paul Mason wrote a book you will find in the library though it's very popular and may be checked out. So you may want to buy it online. It is called Stop Walking on Eggshells. Her is the Amazon page for it:

http://www.amazon.com/Stop-Walking-Eggshells-Borderline-Personality/dp/1572246901/ref=sr_1_1?s=books&ie=UTF8&qid=1284441698&sr=1-1

She also has a wonderful online group called the Oz Online Community for Family Members. If you look through the discussions in her groups you'll more than likely recognize what you've experienced. The book, though, may do that enough now that you're out of it. She's a very nice person, too. Here's the web page:

http://www.bpdcentral.com/support/email.shtml



It was very kind of you to step in and help her like that. BPD more than likely prevented her from being able to deal with that niceness in a normal healthy way. But it was an honorable thing to do. BPD often lands sufferers in the hospital but involuntary hospitalization would have precipitated a crisis and long instability almost certainly.

Okay, I wish you the very best!

Please remember to click the green accept button because: even though you have made a deposit, I do not get paid for my time unless you press ACCEPT. Feel free to continue the discussion as my goal is to get you the best answer possible. You can continue the discussion even after pressing ACCEPT. Bonuses are always appreciated! If I can be of further help with any issue, just put "for Dr. Mark" in the front of your new question, and I'll be the one to answer it. All the best, XXXXX XXXXX

Dr. Mark, Psychotherapist
Category: Mental Health
Satisfied Customers: 5131
Experience: Dr. Mark is a PhD in psychology in private practice
Dr. Mark and 3 other Mental Health Specialists are ready to help you

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