Structure of the DSM IV-TR 5 AXES

Structure of the DSM IV-TR5 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

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 Definition of Mental Disorder

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

Structure of the DSM IV-TR 5 AXES