DSM-IV Structure

EDUC 345/645
 Multiaxial Assessment
 Facilitates comprehensive diagnostic picture.
 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
 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

 All of the various disorders except Personality

Disorders and Mental Retardation
 If more than one Axis I diagnosis, all should be
reported
 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

 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
 For Axis I and Axis II, can code severity either in some
diagnostic categories (e.g., mental retardation) or using specifiers:
 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:
 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
 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

 These should be “potentially relevant to the

understanding or management of the individual’s
mental disorder.”
 Primary purpose of Axis III:
 “to encourage thoroughness in evaluation”
 “to enhance communication among health care providers”
 Differential diagnostic issue:
 If a general medical condition is a direct physiologic cause of
a mental disorder, it is coded on Axis I and Axis III.
 Axis I: Mood Disorder Due to Hypothyroidism
 Axis III: Hypothyroidism
 Axis III
General Medical Conditions

 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”.
 Notes:
 Numerical codes for Axis III come from the ICD-9 (or
ICD-10)
 No numerical code for “None”.
 Axis IV
Psychosocial and Environmental Problems

 Biopsychosocial model:
 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

 Examples:
 Problems with the primary support group
 Death of a family member
 Problems related to the social environment
 Difficulty with acculturation
 Educational problems
 Discord with teachers
 Occupational problems
 Unemployment
 Axis IV
Psychosocial and Environmental Problems

 Examples:
 Housing problems
 Homelessness
 Economic problems
 Insufficient welfare support
 Problems with access to health care services
 Inadequate health insurance
 Problems related to interaction with the legal system
 Incarceration
 Other psychosocial and environmental problems
 War, natural disasters
 Axis V
Global Assessment of Functioning

 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:
 Current, highest over past year, at admission, at
discharge
 Multiaxial Evaluation Report Form
 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).