DSM-IV Structure

1. DSM-IV Structure EDUC 345/645

2. Multiaxial Assessment • Facilitates comprehensive diagnostic picture. • Mental disorders • General medical conditions • Psychosocial problems • Environmental problems • Level of Functioning • Most of which would be missed with a “single” diagnosis. • Also provides for the use of a biopsychosocial model for conceptualizing mental disorders.

3. Multiaxial System • Axis I: Clinical Disorders and Other Conditions That May Be a Focus of Clinical Attention • Axis II: Personality Disorders and Mental Retardation • Axis III: General Medical Conditions • Axis IV: Psychosocial and Environmental Problems • Axis V: Global Assessment of Functioning

4. Axis IClinical DisordersOther Conditions That May Be a Focus of Clinical Attention • All of the various disorders except Personality Disorders and Mental Retardation • If more than one Axis I diagnosis, all should be reported • Best to also label the “principal diagnosis” or “reason for visit” • If more info is needed to make an Axis I diagnosis, code: Deferred (799.9) • If no Axis I diagnosis is warranted, code: None (V71.09)

5. Axis IIPersonality DisordersMental Retardation • Axis II notes “prominent maladaptive personality features and defense mechanisms”. • Having a separate axis for these concerns “ensures that consideration will be given to the possible presence of Personality Disorders and Mental Retardation” that would otherwise be overlooked in a single-axis diagnostic schema. • Note: Borderline Intellectual Functioning is also coded on Axis II • Even if Axis I diagnoses are “more florid” Axis II diagnoses are equally important. • If more info is needed to make an Axis I diagnosis, code: Deferred (799.9) • If no Axis I diagnosis is warranted, code: None (V71.09)

6. Severity • For Axis I and Axis II, can code severity either in some diagnostic categories (e.g., mental retardation) or using specifiers: • Mild: meets criteria for the diagnosis; however, few additional symptoms • Moderate: “between Mild and Severe” • Severe: either has many more symptoms than required for a diagnosis, some of the symptoms are particularly severe (e.g., suicide attempt), or daily functioning (school, work, family) is severely affected. • Can also note the following for Axis I or Axis II: • In Partial Remission: patient no longer meets full diagnostic criteria; some symptoms may still remain. • In Full Remission: patient has been free of symptoms for an extended period of time. • Prior History: patient no longer meets criteria for this diagnosis; however, it is clinically prudent to include this diagnosis.

7. Rule - Outs • Suppose you assess a patient and believe a diagnosis is warranted; however, you do not have enough assessment data to confirm the diagnosis. • However, to not diagnose this “hunch” would not communicate the clinical picture of the patient effectively. • You may consider using a “rule-out” diagnosis: R/O in place of the actual diagnosis.

8. Axis IIIGeneral Medical Conditions • These should be “potentially relevant to the understanding or management of the individual’s mental disorder.” • Primary purpose of Axis III: • “to encourage thoroughness in evaluation” • “to enhance communication among health care providers” • Differential diagnostic issue: • If a general medical condition is a direct physiologic cause of a mental disorder, it is coded on Axis I and Axis III. • Axis I: Mood Disorder Due to Hypothyroidism • Axis III: Hypothyroidism

9. Axis IIIGeneral Medical Conditions • Medical conditions can influence choice in pharmacotherapy. • If multiple diagnoses are present on Axis III, code them all. • If no diagnosis is present, code “None”. • Notes: • Numerical codes for Axis III come from the ICD-9 (or ICD-10) • No numerical code for “None”.

10. Axis IVPsychosocial and Environmental Problems • Biopsychosocial model: • Axis III + Axis I + Axis II + Axis IV • These are typically a negative life event, an environmental difficulty or deficiency, familial or interpersonal stress, poor social support or personal resources.

11. Axis IVPsychosocial and Environmental Problems • Examples: • Problems with the primary support group • Death of a family member • Problems related to the social environment • Difficulty with acculturation • Educational problems • Discord with teachers • Occupational problems • Unemployment

12. Axis IVPsychosocial and Environmental Problems • Examples: • Housing problems • Homelessness • Economic problems • Insufficient welfare support • Problems with access to health care services • Inadequate health insurance • Problems related to interaction with the legal system • Incarceration • Other psychosocial and environmental problems • War, natural disasters

13. Axis VGlobal Assessment of Functioning • Clinical judgment involved in Axis V • “How is the patient doing, overall.” • 100-point scale, divided into 10 ranges • GAF – adult scale • CGAS (Children’s Global Assessment Scale) – GAF adapted for children • Can also report the time period that the rating encompasses: • Current, highest over past year, at admission, at discharge

14. Multiaxial Evaluation Report Form • Used to report all five DSM axes in a systematic, organized way. • Ideally, when you are diagnosing a patient you should include a 5-axis diagnosis. • Example form is located here (reproduced from the DSM-IV-TR).