DSM-IV Structure
EDUC 345/645
Multiaxial Assessment
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Facilitates comprehensive diagnostic picture.
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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
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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
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All of the various disorders except Personality
Disorders and Mental Retardation
If more than one Axis I diagnosis, all should be
reported
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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
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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.
Note: 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
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For Axis I and Axis II, can code severity either in some
diagnostic categories (e.g., mental retardation) or using specifiers:
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Mild: meets criteria for the diagnosis; however, few additional symptoms
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.
Can also note the following for Axis I or Axis II:
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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.
Prior History: patient no longer meets criteria for this diagnosis;
however, it is clinically prudent to include this diagnosis.
Rule - Outs
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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:
R/O in place of the actual diagnosis.
Axis III
General Medical Conditions
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These should be “potentially relevant to the
understanding or management of the individual’s
mental disorder.”
Primary purpose of Axis III:
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“to encourage thoroughness in evaluation”
“to enhance communication among health care providers”
Differential diagnostic issue:
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If a general medical condition is a direct physiologic cause of
a mental disorder, it is coded on Axis I and Axis III.
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Axis I: Mood Disorder Due to Hypothyroidism
Axis III: Hypothyroidism
Axis III
General Medical Conditions
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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”.
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Notes:
Numerical codes for Axis III come from the ICD-9 (or
ICD-10)
 No numerical code for “None”.
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Axis IV
Psychosocial and Environmental Problems
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Biopsychosocial model:
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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
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Examples:
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Problems with the primary support group
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Problems related to the social environment
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Difficulty with acculturation
Educational problems
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Death of a family member
Discord with teachers
Occupational problems
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Unemployment
Axis IV
Psychosocial and Environmental Problems
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Examples:
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Housing problems
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Economic problems
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Inadequate health insurance
Problems related to interaction with the legal system
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Insufficient welfare support
Problems with access to health care services
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Homelessness
Incarceration
Other psychosocial and environmental problems
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War, natural disasters
Axis V
Global Assessment of Functioning
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Clinical judgment involved in Axis V
“How is the patient doing, overall.”
100-point scale, divided into 10 ranges
GAF – adult scale
CGAS (Children’s Global Assessment Scale) –
GAF adapted for children
Can also report the time period that the rating
encompasses:
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Current, highest over past year, at admission, at
discharge
Multiaxial Evaluation Report Form
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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.
Example form is located here (reproduced from
the DSM-IV-TR).