EPSY 544
Session 10
Schedule
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DSM-IV-TR
DSM-IV-TR
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Multiaxial System
Axis I:
Clinical Disorders, most V-Codes, and conditions that need
Clinical attention.
Diagnosis Flow Charts.
Axis II:
Personality Disorders and Mental Retardation.
Axis III:
General Medical Conditions.
Axis IV:
Psychosocial and Environmental Problems.
Axis V:
Global Assessment of Functioning Scale.
Axis I
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Egodystonic
14 categories
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Clinical Disorders
Anxiety Disorders,
Childhood Disorders,
Cognitive Disorders,
Dissociative Disorders,
Eating Disorders,
Factitious Disorders,
Impulse Control Disorders,
Mood Disorders,
Psychotic Disorders,
Sexual and Gender Identity Disorders,
Sleep Disorders,
Somatoform Disorders, and
Substance-Related Disorders.
Other conditions, known as Adjustment Disorders, may also be a focus of clinical attention include MedicationInduced Movement Disorders, Relational Problems, Problems Related to Abuse or Neglect, Noncompliance with
Treatment, Malingering, Adult Antisocial Behavior, Child or Adolescent Antisocial Behavior, Age-Related Cognitive
Decline, Bereavement, Academic Problem, Occupational Problem, Identity Problem, Religious or Spiritual Problem,
Acculturation Problem, and Phase of Life Problem.
Report all Axis I disorders.
If no Axis I disorder use code V71.09.
If Axis I diagnosis is deferred or pending more information use code 799.9.
V-Codes example
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These identify conditions that are not considered a disorder
Relational Problems
– V61.9 relational problems related to a mental disorder or general medical
condition
– V61.20 parent-child relational problem
– V61.10 partner relational problem
– V 61.8 sibling relational problem
– V62.81 relational problem not otherwise specified
Axis II – Personality disorders and
Mental Retardation
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an enduring pattern of inner experience and behavior that
deviates markedly from the expectations of the individual's
culture. This pattern is manifested in two (or more) of the
following areas: cognition (i.e., ways of perceiving and
interpreting self, other people, and events); affectivity (i.e., the
range, intensity, lability, and inappropriateness of emotional
response); interpersonal functioning; and impulse control.
The enduring pattern is inflexible and pervasive across a broad
range of personal and social situations. The individual's pattern
is stable of long duration and its onset can be traced back at
least to adolescence or early adulthood.
egosyntonic
Axis II – Personality Disorders
Cluster A:
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paranoid
schizoid
Schizotypal
Cluster B:
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Mood
Lack of insight, impulsive, erratic, unstable behaviors, labile and
heightened affect, wants some kind of intense interaction with the
counselor
antisocial
borderline
histrionic
Narcissitic
Cluster C:
3.
Odd eccentric
Lack of relationships, restricted affect, peculiar ideas, suspicious
Anxious-avoidant
Rigid attempts to meet all demands by enduring, changing self,
withdrawing
avoidant
dependent
obsessive-compulsive
Signs Indicative a Personality Disorder
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The counseling seems to stall after making initial
progress
The client does not seem to be aware of the effect of
his/her behaviors on others
The client seems to accept the problems
The client is underresponsive or noncompliant with
the counseling regimen
The client is often involved with intense conflictual
relationships with institutional systems
Schizoid Personality Disorder
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Pervasive pattern of detachment from social
relationships and restricted range of emotions
Prefer to be alone and little desire for personal
relationships
The appear indifferent to the approval of criticism of
others and are not particularly concerned about what
others think of them
Do not have close friend or confidants, except
possibly first degree relative
Schizotypal Personality Disorder
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Pervasive pattern of peculiar ideation and behavior
with deficits in social and interpersonal relationships
Incorrectly interpret causal incidents as having
particular and unusual meanings to the individual
They have odd beliefs or magical thinking that is
inconsistent with subcultural norms (e.g.,
superstitions, belief in clairvoyance)
Paranoia, unusual perceptions, and odd beliefs are
evident, but they do not reach the level of chronic
delusional proportions
Cluster B
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Very different from Cluster A
These individuals are quite emotional and try
to impress the counselor
Behavior is erratic and unstable
Affect quiet heightened and changeable
(labile)
Cluster B
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Antisocial Personality Disorder
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Pervasive pattern of disregard and violation of others’ rights
Disregard begins in childhood or adolescence and continues into adulthood
Diagnosis cannot be given until person is at least 18 years of age and has
a history of some symptoms of Conduct Disorder before 15
After age 15 the following must be evident
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Repeated involvement in illegal behaviors
Deceitfulness, lying, or conning others
Being impulsive and not planning
Aggressiveness and repeated physical fights or assaults
Reckless disregard for the safety of self and others
Being consistently irresponsible
Lack of remorse
Borderline Personality Disorder
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Pervasive pattern of instability in interpersonal relationships, selfimage, and mood
Instability is accompanied by impulsiveness
Display frantic efforts to avoid real or imagined abandonment
Their relationships are unstable and intense, fluctuating between
idealizing to devaluing the other person (shame, shame, blame,
blame)
Marked and persistent disturbance of identity
May be recurring suicidal gestures or threats or other self-damaging
behaviors
These individuals have tendency to over react with brief but intense
episodes of depression, irritability or anxiety
Tendency to feel chronically empty and have anger control problems
Histrionic Personality Disorder
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Excessive and pervasive emotionality and attention-seeking
behaviors
Dissatisfied unless center of attention
Interactions with other may be inappropriately sexual or
provocative
Emotions change rapidly and their behavior is often considered
inappropriately exaggerated, sometimes to the point of being
theatrical
Their speech is dramatic and impressionistic but also tends to
lack detail
They are often quite suggestible and perceive relationships to
be more intimate than they actually are
Narcissistic Personality Disorder
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Pervasive pattern of grandiosity, need for admiration, and lack
of empathy
Grandiose sense of self-importance and are preoccupied with
their fantasies of success, brilliance, beauty, and ideal love
Expect special regards from others but often devalue others’
achievements and abilities
Require excessive admiration and expect to be catered to
Exploit others and generally have a lack of empathy towards
others
Envious of others and expect that are others are envious of
them in return
Axis II
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Report all Personality Disorders and Mental Retardation
If no Axis II disorder use code V71.09.
If Axis II diagnosis is deferred or pending more information use
code 799.9.
Include prominent maladaptive personality features. ( No code
number used )
Include the habitual use of maladaptive defense mechanisms.
( No code number used )
A qualifying phase can be used if the individual has both a Axis
I and a Axis II diagnosis as long as the Axis I is the principal
diagnosis or the reason for the visit.
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Principal Diagnosis.
Reason for Visit.
Cluster C
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Characterized by client’s being anxious and
avoidant
Rigidly respond to demands by passively
enduring, changing self, or withdrawing
Avoidant Personality Disorder
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Pervasive pattern of social inhibition, feelings of
inadequacy and a fear of negative evaluation
Avoid work, school, or even promotion opportunities
because of their fears
Unlikely to enter into relationships without strong
guarantees of unrelenting acceptance
They are preoccupied with being criticized or
rejected, so they a markedly low threshold for
detecting such behaviors
See themselves as being socially inept, personally
unappealing, or inferior
Dependent Personality Disorder
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Pervasive pattern of excessive need to be taken care of
This need leads to submissive and clinging behaviors
accompanied by fear of separation
Have great difficulty making decisions
They want others to take the lead and are fearful of disagreeing
with them
Fearful of being alone and will go to excessive lengths to obtain
nurturance and support from others
If relationship ends, they typically will urgently seek another
relationship
Obsessive-Compulsive Personality Disorder
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Pervasive pattern of preoccupation with orderliness, perfectionism,
interpersonal and mental control
Overly stringent standard continually interfere with his/her ability to
complete tasks or projects
Strive to make every detail perfect and display excessive devotion to
work and productivity
Rarely take time for leisure, and when they do, the focus is on
performing the leisure activity perfectly
Harsh judgments of others and oneself are common
Some have trouble discarding even unimportant objects and may be
frugal in their spending in order to be prepared for a future disaster
Tend to be rigid and stubborn and contend there is only a single “right”
way to perform
Axis III – General Medical Conditions
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Report current medical conditions that are potentially relevant
to the understanding or management of the individual's mental
disorder.
The purpose of distinguishing General Medical Conditions is to
encourage thoroughness in evaluation/assessment and to
enhance communication among health care providers.
General Medical Conditions can be related to mental disorders
in a variety of ways.
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First, it is clear the medical condition is directly related to the
development or worsening of the symptoms of the mental disorder.
Second, the relationship between the medical condition and
mental disorder symptoms is insufficient.
Third, there are situations in which the medical condition is
important to the overall understanding or treatment of the mental
disorder.
Axis III
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Report all General Medical Conditions.
If no General Medical Condition indicate. ( Axis III:
None )
If Axis III diagnosis is deferred or pending more
information indicate. ( Axis III: Deferred. )
Must be outside the ICD-9-CM Mental Disorder
chapter and outside of chapter V of the ICD-10.
If a mental disorder is a direct physiological
consequence of the general medical condition,
include a Mental Disorder Due to a General Medical
Condition in Axis I and a General Medical Condition
should be included in Axis I and Axis III.
Axis IV – Psychosocial and
Environmental Problems
For reporting psychosocial and environmental stressors
that may affect the diagnosis, treatment, and
prognosis of mental disorders.
A psychosocial or environmental problem may be a
negative life event, an environmental difficulty or
deficiency, a familial or other interpersonal stressor,
an inadequacy of social support of personal
resources, or other problems relating to the context
in which an individual's difficulties have developed.
Positive stressors, such as a job promotion, should be
listed only if they constitute or lead to a problem, as
when an individual has difficulty adapting to the new
situation.
Axis IV
Psychosocial and Environmental Problems fall into nine categories
that are affecting an individual's ability to function in their daily
activities of life.
1. Problems with primary support group
2. Problems related to the social environment
3. Educational problems
4. Occupational problems
5. Housing problems
6. Economic problems
7. Problems with access to health care services
8. Problems related to interaction with the legal system/crime
9. Other psychosocial and environmental problems
Axis V- Global Assessment of
Functioning
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For reporting the clinician's judgment of the individual's overall level of
functioning and carrying out activities of daily living.
useful in planning treatment, measuring its impact, and in predicting
outcome.
100-point scale that measures a patients overall level of psychological,
social, and occupational functioning on a hypothetical continuum.
Use the “current” or “past week” rating to indicate current management
needs, the “at discharge” rating to document progress and quality of
care, and the “highest level in past year” rating as a target for
termination of treatment.
The GAF scale is useful for managed care-driven diagnostic
evaluations to determine eligibility for treatment and disability benefits
and to delineate the level of care required for patients. On completion
of the GAF Report questions, a 10-point range is automatically
determined. Then, using the sliding rating scale, you can quickly
indicate the specific GAF rating within this 10-point range, using
clinical judgment and hypothetical comparison with other patients in
the range.
Multiaxial Diagnosis
AXIS I:
AXIS II:
AXIS III:
AXIS IV:
AXIS V:
Clinical Disorders
Other Conditions That May be a Focus of Clinical Attention
Personality Disorders
Mental Retardation
General Medical Conditions
Psychosocial and Environmental Problems
Problems with primary support group
Problems related to the social environment
Educational problems
Occupational problems
Housing problems
Economic problems
Problems with access to health care services
Problems related to interaction with the legal system/crime
Other psychosocial and environmental problems
Global Assessment of Functioning Scale
Score:
Time Frame:
Example: Sarah
Axis I
Axis II
Axis III
Axis IV
Problems related to the social environment
Educational problems
Occupational problems
Housing problems
Economic problems
Problems with access to health care services
Problems related to interaction with the legal
system/crime
Other psychosocial and environmental problems
Axis V
Current