Dsm iv structure
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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.

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DSM-IV Structure

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Dsm iv structure

DSM-IV Structure

EDUC 345/645


Multiaxial assessment

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

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

Axis IClinical DisordersOther 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 IIPersonality DisordersMental 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

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

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

Axis IIIGeneral 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 conditions1

Axis IIIGeneral 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

Axis IVPsychosocial 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 problems1

Axis IVPsychosocial 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 problems2

Axis IVPsychosocial 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

Axis VGlobal 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

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).


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