DSM IV Organization and Documentation
The Multi-axial system Axis I Axis II Axis III Axis IV Axis V
Axis I Clinical Syndromes – acute mental disorder Causes clinically significant distress or dysfunction V Codes – Areas in need of clinical attn How to record multiple dxs or no dx?
Organic vs functional disorders Subtypes Specifiers Severity Notation for Substance use and General Medical Conditions
Axis II Personality Disorders Personality features Defense mechanisms the coding … on Axis II should not…imply that their pathogenesis or range of appropriate treatment is fundamentally different… Mental Retardation Recording Axis II as primary dx, no dx, deferred dx
Axis I and Axis II Provisional dx NOS
Axis III General medical conditions related to Axis I and/or Axis II Axis I might be result of Axis III; Axis III might be result of Axis I; Axis III should be considered in tx of Axis I Differentiating Axis III as related to Axis I and an Axis I dx of Mental Disorder as caused by General Medical Condition
Mental Disorder d/t General Medical Condition Organized within each Mental Disorder Previous organization in earlier DSMs Hx, lab finding, exam suggest direct physiological consequence of GMC Not better accounted for by another Axis I or II dx Does not occur exclusively during a delirium
Axis IV Psychosocial Stressors (e.g., occupational, social, relationship problems) May be negative or positive May have caused or worsened Axis I/II; be a result of Axis I/II; need attn Note all that apply Timeline Differentiating Axis IV from V-Codes
Axis V Global Assessment of Functioning Rating of symptom severity / psychosocial functioning Record the worse of either Noting time frame Current – worst in past week
Additional proposed Axes or alternatives to Axis V Defensive functioning scale (DFS; p807) Global Assessment of Relational Functioning (GARF; p814) Social and Occupational Functioning Assessment Scale (SOFAS; p817)
Polly, a 33 y/o white female, is referred to you to treat her Panic Disorder. The referring psychologists report indicates that she has been dx with Panic D/O since she was 17 years old, when she left for college. At the time, she went to her PCP for fear that she was having a heart attack. Medical tests revealed that, in fact, Polly had Mitrovalve prolapse, but his efforts to convince her that her panic attacks were not heart attacks were not heard. Polly continues to be treated for MVP and her irrational thoughts of having a deadly heart attack affect all areas of her life. Although she has not had a Panic attack in several months, she does not work and rarely leaves the house to run errands or visit friends. Her bx has become increasingly restrictive that it is causing major problems in her marriage. Her husbands ultimatum to seek tx is what prompted her visit.