Structure of the DSM IV-TR 5 AXES

Axis I -- Clinical Disorders (other conditions)

Axis II – Personality Disorders & Mental Retardation

Axis III – General Medical Conditions

Axis IV – Psychosocial & Environmental Problems

Axis V – Global Assessment of Functioning

General

• More pervasive disorders – diagnosed over less pervasive

– if 1st Dx involves symptoms of latter

• List multiple diagnosis– Dx can not overlap

• Axis I (if multiple Dx) considered primary Dx– if primary d/o is on Axis II – note as Principal

Diagnosis

• Multiple diagnosis on same Axis– list in order of treatment priorities

Definition of Mental Disorder

• Unfairly implies distinction between “mental” & “physical”

• Clinically significant behavioral/psychological syndrome or pattern

• Occurs in individual

– Must not be expectable & culturally sanctioned response to event

– Associated with present distress/ disability or with significantly increased risk of

• suffering death,

• pain,

• disability,

• or an important loss of freedom

Clinical Significance

• Disorder must have clinically significant impairment or distress for diagnosis

• Are symptoms pathological?• Difficult clinical judgment• Rely upon info from other sources in addition

to client• Culture-Bound Syndrome

– Recurrent, locality-specific patterns of aberrant behavior & troubling experience

Cautionary Statement

• Diagnosis does not encompass all conditions for which people are treated

• Purpose of DSM-IV TR -- diagnose, communicate about, study, and treat various mental disorders

• Does not imply condition meets legal or other non-medical criteria constituting mental disease, mental disorder, or mental disability

AXIS I

• Clinical disorders

• Other conditions as focus of clinical attention (V-codes)– More than one diagnosis on Axis I

• list principal diagnosis 1st

– usually not 2 diagnosis from same category

• Example -- not usually 2 mood DO

AXIS II

• Personality Disorders & MR• If Axis I also but Axis II Dx primary

– Clarify Axis II Dx as PRINCIPAL DIAGNOSIS or REASON FOR VISIT

– If no clarification– Axis I assumed as principal Dx

• Axis II -- CAN denote personality traits – Example -- with paranoid traits

AXIS III

• General Medical Conditions

• can use ICD numbers here

• List physical DO(s) or relevant conditions– which cause psychological response(s) – (but do not medically cause psychological DO

AXIS IV

• Psychosocial & Environmental – List problems affecting Dx or treatment

• List problems occurring W/ one yr of Dx – (exception PTSD)

• Ratings relate to average person– not individual vulnerability

• Use predominantly acute events – (duration more than 6 months)

• Include predominantly enduring circumstances– (less than 6 months)

AXIS IV (continued)

• Types of psychological stressors – conjugal (engagement etc)– developmental (menopause etc.)– Primary support group– Access to health care services– Educational - Social environment– Economic - Housing– Parenting - Physical illness– Legal - Living circumstances– Occupational - Interpersonal

AXIS V

• GLOBAL ASSESSMENT OF FUNCTIONING (GAF)

• Current

• Past Year– Subjective – At best they are estimates

V-CODES

• V-Codes – other conditions that may be focus of clinical

attention– Code on Axis I

• Codes of conditions not attributable to a medical D/O that are focus of client’s attention or treatment

• Often equal presenting problems of clients

V-Codes Additional Factors

• Problem is focus of Dx, tx, no mental d/o– relational problem but neither partner has d/o -

Code relational problem

• Client has d/o unrelated to problem – relational problem with one partner having

incidental d/o - Code BOTH

• Client has d/o related to problem but “problem” sufficiently severe to warrant independent clinical attention – relational problem focus with attention to major

depression d/o - Code BOTH

ADDITIONAL CODES

• V71.09 - Code indicates:

– No diagnosis or condition on Axis I– may or may not be d/o on axis II

– No diagnosis on Axis II;– may or may not be d/o on Axis

ADDITIONAL CODES (CONTINUED)

• 799.9 - Diagnosis or Condition Deferred - Code indicates:– Inadequate & insufficient information for

accurate diagnostic judgement about d/o on Axis I

– Inadequate & insufficient information for accurate diagnostic judgement about d/o on Axis II

ADDITIONAL CODES (CONTINUED)

• 300.9 - Unspecified Mental Disorder (non psychotic) – Code indicates:– specific d/o not included in DSM-IV

classification– when none of NOT OTHERWISE

SPECIFIED (NOS) appropriate – when nonpsychotic d/o judged as present

but inadequate info available to appropriately diagnose

• change to specific d/o with more information)

SEVERITY

• MILD - few, if any, symptoms beyond needed to confirm diagnosis– only minor interference with social/occupational

function.

• MODERATE - Between Mild & Severe• SEVERE - Many symptoms in excess of

basic diagnostic confirmation requirements– Marked impairment in social/occupational spheres

COURSE SPECIFIERS

• PARTIAL REMISSION – Full diagnostic criteria met previously with only

some symptoms remaining.

• FULL REMISSION – No current signs of disorder though still

clinically relevant to note disorder

• PRIOR HISTORY– clinically useful info about a prior condition,

though client has fully recovered

COURSE SPECIFIERS (continued)

• RECURRENCE – symptoms represent recurrence of

previously diagnosed condition– condition may be diagnosed as current

though formal time requirements not met– Clinically significant symptoms though

unsure whether they indicate a recurrence of original disorder

• Use NOS category

DIFFERENTIAL DIAGNOSIS

• Purpose of DD– aid in making correct diagnosis

• Road to Differential Diagnosis– review basic set of clinical features for

individual diagnosis– when one or more clinical features is

prominent in presenting clinical picture specific features must be ruled out –R/O