use of the dsm-iv & axis iv in a written assessment of a client

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Use of the DSM-IV (Including Axes I-V) in a Written Assessment of a Client
(Points = 2)
The Diagnostic and Statistical Manual of Mental Disorders (DSM) is the standard
classification of mental disorders and their corresponding diagnostic codes used by mental
health professionals in the United States. It is intended to be applicable in a wide array of
contexts and settings and used by clinicians and researchers of many different theoretical
orientations. The primary purpose of the DSM is to facilitate communication among mental
health professionals. The current version of the DSM is the DSM-IV-TR (Text Revision).
The DSM-IV consists of three major components:
1) The Diagnostic Classification is the list of the mental disorders that are part of the
the DSM-IV system. Each mental disorder is identified by a diagnostic label and
a diagnostic code. These diagnostic codes are derived from the coding system
used by all health care professionals in the United States, known as the ICD-9-CM.
2) The Diagnostic Criteria indicate what symptoms must be present (and for how
long) as well as those symptoms that must not be present in order for a person to
qualify for a specific diagnosis. The diagnoses of the DSM-IV are described
strictly in terms of patterns of observable symptoms that tend to cluster together.
The American Psychiatric Association (publisher of the DSM-IV) states that
appropriate use of the diagnostic criteria requires clinical training and is not
meant to be used in a cookbook fashion.
3) The Descriptive Text systematically describes each disorder under the following
headings: Diagnostic Features; Subtypes; Recording Procedures; Associated
Features and Disorders; Specific Culture, Age, and Gender Specific Features;
Prevalence; Course; Familial Pattern; and Differential Diagnosis. No information
about treatment or presumed etiology is included.
The DSM-IV is a multi-axial system involving an assessment on five axes, each of which
refers to a different domain of information that may help the clinician plan treatment and
predict outcome. The five axes included in the DSM-IV multi-axial classification are:
Axis I:
Clinical Disorders and Other Conditions That Need Clinical Attention.
Axis II: Personality Disorders and Mental Retardation.
Axis III: General Medical Conditions.
Axis IV: Psychosocial and Environmental Problems.
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Problems with primary support group.
Problems related to the social environment.
Educational problems.
Housing problems.
2
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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: Global Assessment of Functioning Scale (GAF).
The Global Assessment of Functioning Scale is a 100-point scale that measures a
person’s overall level of psychological, social, and occupational functioning on a
continuum.
Learning Tool Assignment:
In order to complete this Learning Tool Assignment, the student is to conduct a clinical
assessment of a client utilizing the criteria of the DSM-IV, including Axes I-IV. (This
assignment is for the purpose of gaining experience with this diagnostic tool. Only
licensed mental health professionals are qualified to complete an official diagnosis
of clients.)
Students are required to act in compliance with Health Insurance Portability and
Accountability Act (HIPPA) during all aspects of completing this assignment and in
all Field Education Practicum activities. Note: For the purpose of this assignment
please change the names, DOB’s, addresses, phone numbers, places of
employment, name of agency and any other information that may link this report to
the client. You can use the “find and replace” feature of Word to make these
changes easily.
The agency format for conducting DSM-IV clinical assessments can be used in place of
the following outline:
Outline for Conducting a Clinical Assessment Utilizing the DSM-IV (including
Axes I-IV).
I.
HISTORY.
A. Identifying Information.
B. Chief complaint.
C. History of present illness.
D. Past mental health, substance abuse and developmental history
(including suicidal and homicidal ideation and behavior).
E. Family mental health, substance abuse and medical history (including
suicidal and homicidal Ideation and behavior).
F. Medical history and results of physical examination.
II. MENTAL STATUS EXAMINATION.
A. Appearance.
B. Behavior (including impulse control).
C. Speech.
D. Emotion (including)
3
1. Mood.
2. Affect.
3. Mood congruency.
E. Thought processes and content.
1. Word usage.
2. Stream of thought.
3. Continuity of thought.
4. Content of thought (including suicidal and homicidal thoughts).
F. Perception.
G. Attention.
H. Orientation.
1. Time (date & time of day).
2. Place.
3. Person.
I. Memory.
1. Immediate.
2. Recent.
3. Remote.
J. Judgment.
K. Intelligence, fund of information, and ability to abstract.
L. Insight.
III. AUXILIARY DATA.
A. Information provided by relatives and friends.
B. Results of medical history and physical examination.
C. Results of laboratory tests.
D. Results of psychological testing.
E. Results of neurological evaluation (including brain-imaging studies).
IV. SUMMARY OF PRINCIPAL FINDINGS.
V. DSM-IV-TR DIAGNOSES
A. Axis I: Clinical disorder.
B. Axis II: Personality disorders and mental retardation.
C. Axis III: General medical conditions.
D. Axis IV: Psychosocial and environmental problems.
E. Axis V: Global Assessment of Functioning (GAF).
VI. PROGNOSIS.
VII. BIO-PSYCHOSOCIAL FORMULATION.
VIII. PLAN.
A. Additional data gathering (including interviews, tests, & consultations).
B. Treatment goals.
1. Immediate.
2. Short-term.
3. Long-term.
4
C. Treatment plan.
1. Immediate.
2. Short-term.
3. Long-term.
References:
Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), Fourth Edition,
American Psychiatric Association, 1994 (ISBN 0-89042-061-0).
www.psyweb.com (Then click on DSM-IV Multiaxial System – Made Easy. This site
has information on DSM-IV diagnoses, codes, and Axes I-V).
www.psych.org/psych_pract/treat/pg/pg_adult.cfm? (Practice Guidelines For The
Psychiatric Evaluation of Adults).
Maxim, Jerrold S. & Ward, Nicolas G., Essential Psychopathology and Its Treatment,
2nd Edition, Revised for DSM-IV, Norton, 1995 (ISBN 0-393-70173-5). (This is
an excellent resource for understanding the DSM-IV and conducting clinical
assessments.
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