DSM-IV Structure EDUC 345/645

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

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

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

Axis II Personality Disorders Mental Retardation Axis II notes “prominent maladaptive personality features and defense mechanisms”. 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. 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 Note: Borderline Intellectual Functioning is also coded on Axis II Even if Axis I diagnoses are “more florid” Axis II diagnoses are equally important. 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 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) If no Axis I diagnosis is warranted, code: None (V71.09)

Severity For Axis I and Axis II, can code severity either in some diagnostic categories (e.g., mental retardation) or using specifiers: 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 Mild: meets criteria for the diagnosis; however, few additional symptoms Moderate: “between Mild and Severe” 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. 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: 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 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. 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. Prior History: patient no longer meets criteria for this diagnosis; however, it is clinically prudent to include this diagnosis.

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. 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. 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. You may consider using a “rule-out” diagnosis: R/O in place of the actual diagnosis.

Axis III General Medical Conditions These should be “potentially relevant to the understanding or management of the individual’s mental disorder.” These should be “potentially relevant to the understanding or management of the individual’s mental disorder.” Primary purpose of Axis III: Primary purpose of Axis III: “to encourage thoroughness in evaluation” “to encourage thoroughness in evaluation” “to enhance communication among health care providers” “to enhance communication among health care providers” Differential diagnostic issue: 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. 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 I: Mood Disorder Due to Hypothyroidism Axis III: Hypothyroidism Axis III: Hypothyroidism

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

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

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

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

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

Multiaxial Evaluation Report Form Used to report all five DSM axes in a systematic, organized way. 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. 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). Example form is located here (reproduced from the DSM-IV-TR).here