DSMDSM-IV Structure

Psy 610A Gary S. Katz, Ph.D.

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.

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

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 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)

Axis II
Personality Disorders Mental 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. singleNote: 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)

Severity


For Axis I and Axis II, can code severity either in some diagnostic categories (e.g., mental retardation) or using specifiers:
  

Mild: Mild: meets criteria for the diagnosis; however, few additional symptoms Moderate: Moderate: between Mild and Severe 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. In Partial Remission: patient no longer meets full diagnostic criteria; Remission: some symptoms may still remain. In Full Remission: patient has been free of symptoms for an extended Remission: period of time. Prior History: patient no longer meets criteria for this diagnosis; History: however, it is clinically prudent to include this diagnosis.

Can also note the following for Axis I or Axis II:

  

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: ruleR/O in place of the actual diagnosis.

Axis III
General Medical Conditions


These should be potentially relevant to the understanding or management of the individuals mental disorder. Primary purpose of Axis III:
 

to encourage thoroughness in evaluation to enhance communication among health care providers If a general medical condition is a direct physiologic cause of a mental disorder, it is coded on Axis I and Axis III.
 

Differential diagnostic issue:



Axis I: Mood Disorder Due to Hypothyroidism Axis III: Hypothyroidism

Axis III
General 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 ICDICD-10) ICD No numerical code for None.


Axis IV
Psychosocial 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.

Axis IV
Psychosocial and Environmental Problems


Examples:


Problems with the primary support group



Death of a family member Difficulty with acculturation Discord with teachers Unemployment

Problems related to the social environment



Educational problems


Occupational problems


Axis IV
Psychosocial and Environmental Problems


Examples:
    

Housing problems


Homelessness Insufficient welfare support Inadequate health insurance Incarceration War, natural disasters

Economic problems


Problems with access to health care services



Problems related to interaction with the legal system



Other psychosocial and environmental problems



Axis V
Global Assessment of Functioning
     

Clinical judgment involved in Axis V How is the patient doing, overall. 100100-point scale, divided into 10 ranges GAF adult scale CGAS (Childrens 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

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. 5Example form is located here (reproduced from the DSM-IV-TR). DSM-IV-