Chapters 3-4DSM-IV-TR in Action

Advanced Studies in Mental DisordersEPSY 6395Dr. Sparrow

Multiaxial Assessment

Five axes, three were considered acceptable up until the late 90s.

Axis I: Clinical disorders, everything except personality disorders and mental retardation

Axis II: Personality disorders and mental retardation (also defense mechanisms that can impair functioning and impede progress)

Axis III: General medical problems

Axis IV: Psychosocial and environmental problems (measured by the PIE)

Axis V: Global assessment of functioning (GAF scale)

Multiaxial Assessment

When it may not be necessary

Special populations (troubled youth)

Specialized settings (residential care)

Problem-solving in social work or basic needs settings.

Multiaxial Assessment

Alternative--Nonformal multiaxial assessment, for use in groups, residential settings, etc.

list diagnostic categories (e.g. affective and anxiety)

list principal diagnosis or reason for visit (e.g. moderate depression)

List mental disorders interfering with functioning (e.g. adjustment disorder with depressed mood -- 309.00)

List medical problems possibly interfering with treatment

Two Types of Coding

Diagnostic (what client suffers from) -- the five-digit code

Procedural--Current Procedural Codes (CPT) -- a five digit number. All you need to know are a few that are used to describe outpatient service. For example,

90801--Diagnostic interview

90806-- one hour of therapy

Axis One and Two

All diagnosed mental disorders will be included on either Axis I or II

Axis I: All codeable mental disorders, except personality disorders and mental retardation, including “other conditions that may be a focus of clinical attention”

Axis II: Personality disorders and mental retardation

Axis I diagnoses are not necessarily more severe than Axis II. Axis II disorders generally begin in childhood, and are thus pervasive and longstanding problems

Nature of presenting problems

People usually come into therapy because of a recent problem, so the Axis II diagnosis, which is a longstanding problem, is rarely the reason the client has opted for therapy.

While an Axis II diagnosis is rarely the reason the client is seeking therapy, it may be a “principal diagnosis” if, by chance, it is seen by the clinician as the main source of distress.

Whenever an Axis II disorder is the “principal diagnosis,” it should be placed on Axis II and denoted as the “principal diagnosis.”

Remember

Some type of coding is required for Axis I

V71.09 to denote “no diagnosis)

799.9 to denote “lack of, or inaccurate information”

Clinician should describe

frequency,

intensity, and

duration of symptoms

Remember

Environmental should be considered as possible explanations. (e.g. a family’s house burned down, and father is depressed)

Cultural factors should be considered as well (e.g. Mexican man is unable to work because of injury, and he has become extremely emotionally labile--angry, depressed--when his wife goes to work because his culturally defined manhood is threatened.)

Axis II Documentation: General

Mental Retardation -- Four degrees of mental retardation: mild, moderate, severe, profound

Personality Disorders--three clusters

1) Odd or eccentric -- paranoid, schizoid, schizotypal

2) Dramatic, emotional, erratic -- borderline, anti-social, histrionic, narcissitic, antisocial

3) Anxious -- dependent, avoidant, obssessive-compulsive, NOS

Defense Mechanisms

Axis II Documentation:Personality Disorders

The most important variable in diagnosing a personality disorder is the age of onset. If it’s a lifelong problem, or at least developed before the age of 18, it’s likely to be diagnosed as a personality disorder.

It is also true that mental retardation should be evident from an early age. Otherwise, a medical condition could be causing the symptoms (e.g. lead poisoning, stroke)

Axis II diagnoses should also include frequency, intensity and duration comments.

Axis II Documentation:Defense Mechanisms

Axis II should also include mention of any defense mechanisms

Defensive Functioning Scale divides defense mechanisms into defense levels

high adaptive level

mental inhibitions level

minor image-distorting level

disavowal level

major image-distorting level

action level

Axis II Documentation:Defense Mechanism levels

1) High Adaptive Level includes strategies of which the client is aware of using, which are used to promote well-being (e.g. humor or affiliation)

2) Mental inhibitions -- used to keep potentially threatening content out of awareness (e.g. repression)

3) Minor image distorting -- used to distort image of self or others (e.g. omnnipotence)

4) Disavowal level -- used to keep unacceptable feelings and ideas out of awareness, and may involve misattribution of causes (e.g. projection homosexual feelings onto others and maintaining a judgmental attitude toward them)

Axis II Documentation:Defense Mechanism levels

4) Major image-distorting -- gross distortions or misattribution of the image of self or others (e.g. autistic fantasy, or excessive daydreaming as a substitute for real experiences and relationships)

5) Action level--defenses take the form of actions against or toward others. (e.g. acting out)

Axis III Documentation:Medical Conditions

General Medical Conditions--keeps medical problems in view so that there is less tendency to misattribute problems to mental disorders. (e.g. postpartum depression may accompany pregnancy and birth, and may be harmonal)

Conditions of aging can easily be overlooked as normal.

Important to refer clients to examinations if there is any doubt about the origins of an ostensible mental disorder. Especially if:

the disorder is new

the onset was rapid, or acute

Axis III Documentation:Medical Conditions

(continued) Symptoms developed after the age of 40

symptoms arose before, during, or after the occurrence of a major medical problem

if there is no obvious psychosocial stressor

if the symptoms are exaggerated

if there are distortions of speech of bodily movements

if the client cannot speak, remember, name, or coordinate movements

Axis III Documentation:Medical Conditions

Special considerations that often overlooked

The impact of vision problems, which may lead to suspicion, anxiety, misattribution

The impact of hearing loss, which may lead to apparent defensiveness and anger. People with hearing loss often minimize their problem.

Axis IV Documentation:Severity of Psychosocial Stressors

Originally a simply numerical scale from 1-6, ranging from “low” to “high”

Now there are nine areas of psychosocial stressors, including primary support, social environment, educational, occupational, economic, health care, legal, and “other.”

Axis V Documentation:Global assessment of Functioning

The GAF has 11 breakdowns on a 100-point scale, ranging from highest (range of 91-100) to lowest (1-10), with “0” reserved for inadequate information.

No need to memorize it--keep a copy on your desk

30-50 usually requires inpatient treatment

Axis V Documentation:Supplements

The Global Assessment of Relational Functioning (GARF) -- good to use with clients who may need conjoint, group, or family work

100-point scale used to measure the range of a person’s level of relationship functioning

from competent to dysfunctional

impairment not influenced by psychosocial stressors/symptoms

The Social and Occupational Functioning Assessment Scale (SOFAS)

100-point scale from from excellent to grossly impaired