8/12/2019 4. Introduction to DSM-IV

1/3

4. INTRODUCTION TO DSM-IVMichael W . K a h n M . D

1. What is the conceptual orientation of DSM-IV?The Diagnostic and Statistical Man uals DSM ) are handbo oks developed by the AmericanPsychiatric Association. T hey c ontain listings and descriptions of psy chiatric diagnoses, analogousto the International Classification of Diseases m anuals. The DS M s have changed as the prevailingconcepts of mental disorder have changed. DSM -I 1952) reflected Adolf M eyers influence onAmerican psychiatry, and classified me ntal disorders as various reactions to stressors. DSM-I11 968) dropped the reactions co ncept, but maintained a perspective strongly influenced by psycho-dyn am ic theory. DSM-I11 198 0) marked a watershed in the deve lopm ent of the classificationsystem, in that it outlined a research-based, empirical, and phenomenologic approach to diagnosis,

which attempted to be atheo retical with regard to etiology. DSM -IV continues this tradition, whichmay be characterized as the biologic or syndromal approach to diagnosis.2. What is the purpose of the multiaxial system?Th e five-axis classification system w as developed to provide a systematic framewo rk for thethorough, descriptive asse ssm ent of a patients psychiatric condition and overall functioning. Theaxes are:Axis I: Clinical disorders Axis 111: General medical conditionsAxis 11: Personality d isorders, Axis I V Psychosocial and environmental problemsAxis V Global assessment of functioningental retardation3 What are the characteristicsof axis I disorders?Axis I diagnoses comprise those clinical syndromes that generally develop in late adolescenceor adulthood. Sch izophrenia, bipolar disorder, panic disorder, posttraumatic stress disorder, and al-cohol abuse are diagnoses coded on ax is I. One can think of ax is I diagnoses as illnesses, as opposedto the persistently maladaptive behavior patterns that characterize personality disorders.4. How do axis I disorders differ from axis I1 disorders?Axis I1 comprises personality disorders and mental retardation. Maladaptive personality traitsand behavior problems also are noted on axis I1 see Question 7 below).5. Can one make multiple diagnoseson axes I and II?Definitely. A patient with well-controlled schizophrenia may develop a problem with alcoholabuse, and would therefore warrant both diagnoses o n axis I. A patient with mental retardation may

also meet criteria for obsessive-compulsive personality disorder, and would therefore receive bothdiagnoses on axis 11. Several diagnoses can b e included on each axis.6. What if a patients signs and symptoms dont fit neatly into one or more categories?Several ways exist to deal w ith this very comm on situation. On axis I, m ost clinical syndromes de-scribed have one variant called [syndrome name] not otherwise specijied NOS ). Psychosis NOS, ad-justment disorder NOS, and bipolar disorder NOS are diagnoses for wh en not all criteria characterizing

a given syndrome are met, but that syndrome seems closest to describing the patients difficulties.If the clinical picture is even less clear, you ca n def er the diagnosis on either ax is I or I1 untilyou are able to gather the information fo r a more definitive diagnosis. The co de for a deferred diag-nosis on either axis I or I1 is 799.90.8

8/12/2019 4. Introduction to DSM-IV

2/3

Introduction to DSM-IV 9Finally, you can make a provisional diagnosis if enough information is available to make a rea-sonable formulation, hut some doubt or uncertainty remains. Simply write provisional after thesuspected diagnosis.

7 Do these issues apply to personality disorders as well?Yes. If a patient seems to have several of the characteristics of, for example, antisocial personal-ity disorder, but does not meet all criteria for that diagnosis, you can record that the patient has anti-social traits. Likewise, a patient may have traits of more than one personality disorder; in thissituation, you would make a diagnosis of, for example, mixed personality disorder with borderlineand histrionic traits.8. How does axis I11 function?Axis I11 primarily records medical problems relevant to the ongoing treatment of the patient.Examples are glaucoma in a patient requiring antidepressants, asthma in a patient with anxiety whois taking theophylline, AIDS in a patient with new-onset psychosis, and cirrhosis of the liver in a pa-

tient with alcohol dependence.9. What about axes IV and V?Axis IV records psychosocial stressors encountered by the patient within the previous 12months that have contributed to 1) the development of a new mental disorder; 2) the recurrence ofa previous mental disorder; or 3) the exacerbation of an ongoing mental disorder. The stressorshould be described in as much detail as needed to indicate how it affects the patients functioning.Even mild stressors should be noted if they figure into the clinical presentation.Axis V records the patients global level of functioning both at the time of evaluation and duringthe past year. The clinician consults the Global Assessment of Functioning GAF) scale in the

manual and determines the patients current GAF score as well as the highest one obtained during arelatively prolonged period within the past year.Global Assessment o Functioning Scale

Consider psychological, social, and occupational functioning on a hypothetical continuum of mentalhealth-illness. Do not include impairment in functioning due to physical or environmental limitations.Code Note: Use intermediate codes when appropriate, e.g., 45,68, 72.10091 No symptoms90

Superior functioning in a wide range of activities, lifes problems never seem to get out ofhand, is sought out by others because of his or her many positive qualities.Absent or minimal symptoms e.g., mild anxiety before an exam), good functioning in all areas,interested and involved in a wide range of activities, socially effective, generally satisfied withlife, no more than everyday problems or concerns e.g., an occasional argument with familyIf symptoms are present, they are transient and expectable reactions to psychosocial stressorse.g., difficulty concentrating after family argument); no more than slight impairment in social,occupational, or school functioning e.g., temporary falling behind in schoolwork).Some mild symptoms e.g., depressed mood and mild insomnia) OR some difficulty in social,occupational, or school functioning e.g., occasional truancy, or theft within the household), butgenerally functioning pretty well, has some meaningful interpersonal relationships.Moderate symptoms e.g., flat affect and circumstantial speech, occasional panic attacks) ORmoderate difficulty in social, occupational, o r school functioning e.g., few friends, conflictsSerious symptoms e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) ORany serious impairment in social, occupational, or school functioning e.g., no friends, unable

Table continued o ollowing page.

81 members.)8077

616051 with peers or co-workers).5041 to keep a job).

8/12/2019 4. Introduction to DSM-IV

3/3

20 Introduction to DSM-IVGlobal Assessment of Functioning Scale Cont.)

121201110

Some impairment in reality testing or communication e.g., speech is at times illogical, ob-scure, or irrelevant)OR major impairment in several areas such as work or school familyrelations judgment thinking or mood e.g,. depressed man avoids friends, neglects family, and isunable to work; child frequently beats up younger children, is defiant at home, and is failing at school).Behavior is considerably influenced by delusions or hallucinations OR serious impairment incommunication r judgment e.g., sometimes inchoherent, acts grossly inappropriately, suicidalpreoccupation)OR inability to function in almost all areas e.g., stays in bed all day; no job,home, or friends).Some danger of hurting self or others e.g., suicide attempts without clear expectation of death;frequently violent; manic excitement)OR occasionally fails to maintain minimal personal hy-giene e.g., smears feces)OR gross impairment in communication e.g., largely incoherent or mute).Persistent danger of severely hurting self or others e.g., recurrent violence)OR persistent in-ability to maintain minimal personal hygiene OR serious suicidal act with clear expectationof death.Inadequate information.

The rating of overall psychological functioningon a scale of 0-100 was operationalized by Luborsky in theHealth-SicknessRating Scale Luborsky L: Clinicians udgments of mental health. Arch Gen Psychiatry 7:407417, 1962).Spitzer and colleagues developed a revision of the Health-Sickness Rating Scale called theGlobal Assessment Scale GAS) EndicottJ SpitzerRL, Fleiss JL, Cohen J: The global assessment scale: Aprocedure for measuring overall severity of psychiatric disturbance.Arch Gen Psychiatry 33:766-77 1, 1976).A modified version of the GAS was included in the DSM-111-R as the Global Assessment of FunctioningGAF) Scale.10. Does the DSM system provide a good way to diagnose psychiatric disorders?Compared to what? This is a thorny question. So long as psychiatry lacks definitive tests to di-agnose illness, arguments about which criteria should form the basis of the diagnostic system willcontinue to flourish. The publication of DSM-I11 in 1980 was widely hailed both inside and outsidethe field for at last providing diagnoses that relied on what people obse we d rather than what theybelieved on the basis of theory. A wide variety of mental health and general medical) practitionersfound that DSM-I11 provided a straightforward, comprehensible, and user-friendly tool for makingsense of or at least classifying) psychopathology.The DSM system has some clear shortcomings, however, and some well-regarded clinicianshave called it parochial, reductionistic, adynamic i.e., not sensitive to the dynamic hypothesis men-tioned above), and clumsy in its difficulty distinguishing between state and trait behaviors. TheDSM system was designed to have high reliability among different raters; that is, it was fashioned sothat two different clinicians would likely arrive at the same diagnosis for a given patient. Yet it isclear that reliability and validity of diagnosis remain distinct. Some would say that the DSM systemfavors the former at the expense of the latter; others would reply that so long as validity remains elu-sive, we should do our best to at least improve reliability, which can be empirically tested in fieldtrials. DSM-IV creates some problems and helps to solve others. A nondogmatic, open-minded, andpragmatic approach to this complicated issue probably serves patients best.

BIBLIOGRAPHY1 American Psychiatric Association: Diagnostic and Statistical Manual-IV. Washington, D.C., American2. Klerman GL, Vaillant GE, SpitzerRL Michels R: A debate on DSM-111. Am J Psychiatry 141:4 1984.Psychiatric Association, 1994.