Structure of the DSM IV-TR
5 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
Definition of Mental Disorder
• 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
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