Table of contents:
- DSM IV Revised
- Medical diseases (with ICD-10 codes)
- Medical diseases (with ICD-10 codes)
- Psychosocial and environmental problems
- Axis V: Evaluation of global activity
In 1952 the first classification appeared, the DSM-I, and it was organized around the concept of reaction of Adolf Meyer, who conceived mental disorders as reactions to vital problems and difficulties. DSM II, for its part, abandons the notion of reaction but preserves psychoanalytic postulates.
The result of this was the absence of a general organizing principle and therefore the inclusion as mental disorders of a series of alterations that had no apparent mutual relationship, such as behaviors, mental phenomena, reactions to substance use, organic brain syndromes, etc.. In the 70s a "neo-krapelian current" begins, with a fundamental contribution such as the Diagnostic Research Criteria (RDC), which give fundamental importance to etiology.
They break with traditional terminology by speaking of "disorders" rather than diseases. DSM III had its origin in German psychiatry and constituted the extension of Feighner's criteria and a deletion of terms in order to develop an "atheist and descriptive" system.
Main characteristics: empirical point of view, inclusion of categories in which to integrate the subjects, multiaxial diagnostic system in order to organize information of various facets. The DSM III-R kept the same format except for some rearrangements of certain categories. In DSM IV the goal is to prioritize research results over other decision criteria in the new classification.
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- Medical diseases (with ICD-10 codes)
- Psychosocial and environmental problems
- Axis V: Evaluation of global activity
DSM IV Revised
A multiaxial system involves an evaluation in several axes, each of which concerns a different area of information that can help the clinician in the planning of the treatment and in the prediction of results.
In the DSM-IV multiaxial classification five axes are included, the use of the multiaxial system facilitates a complete and systematic evaluation of the different mental disorders and medical illnesses, psychosocial and environmental problems, and the level of activity, which could go unnoticed if the The objective of the evaluation will focus on the simple problem that is the object of the consultation. A multiaxial system provides an appropriate format to organize and communicate clinical information, to capture the complexity of clinical situations, and to describe the heterogeneity of individuals presenting the same diagnosis.
In addition, the multiaxial system promotes the application of the biopsychosocial model in clinical, teaching and research. The remainder of this section describes each of the DSM-IV axes. In some centers or situations clinicians may prefer not to use the multiaxial system.
For this reason, certain guidelines are given at the end of the section to report the results of a DSM-IV assessment without applying the formal multiaxial system.
Axis I: Clinical disorders
Other problems that may be the object of clinical attention Axis I describes all disorders included in the classification except for personality disorders and mental retardation (which have been included in Axis II). The main groups of disorders included in Axis I are shown in the table below. Other disorders that may be the subject of clinical attention are also listed on Axis I.
When an individual suffers from more than one Axis I disorder, all of them must be recorded. When more than one Axis I disorder is present, the primary diagnosis or reason for consultation should be indicated first. When a person has an Axis I disorder and an Axis II disorder, it will be assumed that the main diagnosis or the reason for consultation corresponds to Axis I, unless the Axis II diagnosis is followed by the phrase (main diagnosis) or (reason for consultation).
Axis I: Clinical disorders
Other problems that may be the object of clinical attention Disorders of onset in infancy, childhood or adolescence (excluding mental retardation, which is diagnosed on Axis II):
- Delirium, dementia, amnestic disorders, and other cognitive disorders
- Mental disorders due to a general medical condition
- Substance-related disorders
- Schizophrenia and other psychotic disorders
- Mood disorders
- Anxiety disorders
- Somatoform disorders
- Factitious disorders
- Dissociative disorders
- Sexual and sexual identity disorders
- Eating disorder
- Sleep disorders
- Impulse Control Disorders Not Elsewhere Classified
- Adaptive disorders
- Other problems that may be the subject of clinical attention
Axis II: Personality disorders / Mental retardation
Axis II includes personality disorders and mental retardation. It can also be used to record defense mechanisms and maladaptive personality characteristics. Listing personality disorders and mental retardation on a separate axis ensures that the possible presence of personality disorders and mental retardation will be considered, abnormalities that may go unnoticed when direct attention is given to Axis I disorders, usually more flowery.
Coding personality disorders on Axis II does not imply that their pathogenesis or the nature of appropriate therapy are fundamentally different from those implicated in disorders coded on Axis I. Disorders included on Axis II are listed in the box below. When a person has more than one Axis II disorder, a relatively common situation, all diagnoses should be recorded.
When an individual presents simultaneously an Axis I disorder and an Axis II disorder, and the Axis II diagnosis is the main or reason for consultation, this fact should be indicated by adding the phrase (main diagnosis) or (reason for consultation) after the Axis II diagnosis. Axis II can also be used to indicate certain maladaptive personality characteristics that do not meet the minimum necessary to constitute a personality disorder. The habitual use of maladaptive defense mechanisms may also be indicated in Axis II.
Axis II: Personality disorders / Mental retardation
- Paranoid personality disorder
- Dependence personality disorder
- Schizoid personality Disorder
- Obsessive-compulsive personality disorder
- Schizotypal personality disorder
- Antisocial personality disorder
- Nonspecific personality disorder
- Borderline personality disorder
- Histrionic personality disorder
- Narcissistic personality disorder Mental retardation
- Avoidant Personality Disorder
Medical diseases (with ICD-10 codes)
Axis III includes current medical illnesses that are potentially relevant to understanding or addressing the subject's mental disorder. These states are classified outside the chapter
Mental disorders of the ICD-10 (and outside of chapter V of the ICD-9-CM). The table below provides a list of the major categories of medical conditions. As indicated in the Introduction, the multiaxial distinction between Axis I, II and III disorders does not imply that there are fundamental differences in their conceptualization, or that mental disorders are no longer related to physical or biological factors or processes, or that medical illnesses are not related to behavioral or psychological factors or processes. The rationale for distinguishing medical conditions is to encourage thorough evaluation and to improve communication among mental health professionals.
Medical illnesses can be related to mental disorders in different ways. In some cases, it is clear that medical illness is a direct causal factor for the development or worsening of mental symptoms, and that the mechanisms involved in this effect are physiological. When a mental disorder is assumed to be a direct physiological consequence of the medical illness, on Axis I a mental disorder due to medical illness must be diagnosed, and that illness must be recorded on both Axis I and Axis III.
When the etiological relationship between the medical condition and the mental symptoms is insufficiently proven to warrant a diagnosis on Axis I of mental disorder due to a medical condition, the appropriate mental disorder (eg, major depressive disorder) should be coded on Axis I), and the medical condition will only be coded on Axis III. There are other cases in which medical conditions must be recorded on Axis III because of their importance for the general understanding or treatment of the subject with the mental disorder.
An Axis I disorder can be a psychological reaction to an Axis III medical condition in reaction to the diagnosis of breast carcinoma. Some medical conditions may not be directly related to the mental disorder, but they may have important implications for your prognosis or treatment.
Medical diseases (with ICD-10 codes)
- Some infectious and parasitic diseases
- Neoplasms
- Diseases of the blood and hematopoietic organs and some immune diseases Endocrine, nutritional and metabolic diseases Diseases of the nervous system Diseases of the eye and its appendages
- Diseases of the ear and mastoid processes
- Circulatory system diseases
- Diseases of the respiratory system
- Diseases of the digestive system
- Diseases of the skin and subcutaneous tissue
- Musculoskeletal and connective tissue diseases
- Diseases of the genitourinary system
- Pregnancy, childbirth and the puerperium
- Perinatal pathology Malformations, deformations and congenital chromosomal abnormalities
- Symptoms, signs and clinical and laboratory findings not classified elsewhere
- Wounds, poisonings and other processes of external cause
- Morbidity and mortality from external causes
- Factors influencing health status and contact with health centers
Psychosocial and environmental problems
In Axis IV the psychosocial and environmental problems that can affect the diagnosis, treatment and prognosis of mental disorders are recorded (Axes I and II). A psychosocial or environmental problem can be a negative life event, an environmental difficulty or deficiency, a family or interpersonal stress, a lack of social support or personal resources, or another problem related to the context in which alterations experienced by a person.
So-called positive stressors, such as a job promotion, should only be noted if they constitute or lead to a problem, such as when a person has difficulty adjusting to a new situation. In addition to playing a role in the initiation or exacerbation of a mental disorder, psychosocial problems may also appear as a consequence of psychopathology, or they may constitute problems that must be taken into consideration in the planning of general therapeutic intervention.
When a person has multiple psychosocial or environmental problems, the clinician must take note of all those that he deems relevant. In general, the clinician should only record those psychosocial and environmental problems that have been present during the year prior to the current evaluation. However, the clinician may decide to record psychosocial and environmental problems that occurred before the previous year if they clearly contributed to the mental disorder or constituted a therapeutic target (eg, previous combat experiences leading to a stress disorder post-traumatic).
In practice, most of the psychosocial and environmental problems will be indicated in Axis IV. However, when a psychosocial or environmental problem constitutes the center of clinical care, it will also be recorded in Axis I, with a code derived from section
Other problems that may be the subject of clinical attention. For reasons of convenience, the problems have been grouped into the following categories: Problems related to the primary support group: for example, death of a family member, health problems in the family, family disturbance due to separation, divorce or abandonment, change of home, new marriage of one of the parents, sexual or physical abuse, parental overprotection, abandonment of the child, inadequate discipline, conflicts with siblings; birth of a brother.
Problems related to the social environment: for example, death or loss of a friend, inadequate social support, living alone, difficulties adapting to another culture, discrimination, adaptation to the transitions of life cycles (such as retirement). Problems related to teaching: eg illiteracy, academic problems, conflicts with the teacher or classmates, inappropriate school environment.
Work problems: for example, unemployment, threat of job loss, stressful job, difficult working conditions, job dissatisfaction, job change, conflicts with the boss or co-workers. Housing problems: for example, homelessness, inadequate housing, unhealthy neighborhood, conflicts with neighbors or landlords. Economic problems: for example, extreme poverty, insufficient economy, insufficient socioeconomic aid. Problems of access to healthcare services: for example, inadequate medical services, lack of transportation to healthcare services, inadequate health insurance. Problems related to interaction with the legal system or crime: for example, arrests, imprisonment, trials, victim of criminal act. Other psychosocial and environmental problems: for example, exposure to disasters, war or other hostilities, conflicts with unfamiliar caregivers such as counselors, social workers, or doctors, absence of social service centers.
Axis IV:
- Psychosocial and environmental problems
- Primary support group problems
- Problems related to the social environment
- Teaching problems
- Labor problems
- Housing problems
- Economic problems
- Problems of access to healthcare services
- Problems related to interaction with the legal system or with crime
- Other psychosocial and environmental problems
Axis V: Evaluation of global activity
Axis V includes the opinion of the clinician about the general level of activity of the subject. This information is useful for planning treatment and measuring its impact, as well as for predicting evolution. The recording of general activity in Axis V can be done using the Global Activity Assessment Scale (EEAG). The EEAG can be particularly useful in following the evolution of the clinical progress of the subjects in global terms, using a simple measure. The EEAG should only be completed in relation to psychosocial, social and work activity. The instructions specify: do not include activity disturbances due to physical (or environmental) limitations. In most cases EEAG evaluations should refer to the current period (i.e.,activity level at time of assessment) since assessments of current activity will generally reflect the need for treatment or intervention.
In some clinical centers, it may be useful to complete the EEAG both on admission and on discharge. The EEAG can also be completed in other time periods (eg, best activity level achieved in at least a few months during the last year). The EEAG is recorded on Axis V as follows: EEAG =, followed by the EEAG score from 1 to 100, then noting in parentheses the time period reflected in the evaluation, for example, (current), (higher level in the last year), (at discharge).
In some clinical centers, it may be useful to assess social and work disability and verify progress in rehabilitation, regardless of the severity of psychosocial symptoms. With this intention, in appendix B a social and labor activity assessment scale (EEASL) has been included. Two additional scales have been proposed that may also be useful in some centers: the scale of global assessment of relational activity (EEGAR) and the scale of defense mechanisms. Both have been included in Appendix B.
Global Activity Assessment Scale (EEAG)
Psychological, social, and work activity must be considered along a hypothetical health-disease continuum. Do not include activity disturbances due to physical (or environmental) limitations.
- 100 Satisfactory activity in a wide range of activities, never seems overwhelmed by problems in life, is valued by others because of his abundant positive qualities. No symptoms.
- 90 No or minimal symptoms (eg, slight anxiety before an exam), good activity in all areas, interested and involved in a wide range of activities, socially effective, generally satisfied with life, no further worries or problems than everyday ones (eg, an occasional argument with family members).
- 80 If there are symptoms, they are transitory and are expected reactions to psychosocial stressors (eg, difficulty concentrating after a family argument); there is only a slight alteration in social, work or school activity (eg, temporary decline in school performance).
- 70 Some mild symptoms (eg, depressed mood and mild insomnia) or some difficulty in social, work or school activity (eg, playing hooky occasionally or stealing from home), but generally works quite well, has some significant interpersonal relationships.
- 60 Moderate symptoms (eg, flat affect and circumstantial language, occasional panic attacks) or moderate difficulties in social, work or school activity (eg, few friends, conflicts with coworkers or schoolmates).
- 50 Serious symptoms (eg, suicidal ideation, severe obsessive rituals, shoplifting) or any disturbance
- 41 severe from social, work, or school activity (eg, no friends, unable to keep a job).
- 40 An impairment of reality check or communication (eg, language is sometimes illogical, obscure, or irrelevant) or major impairment in various areas such as school work, family relationships, judgment, thinking or mood (eg, a depressed man avoids friends, leaves the family, and is unable to work; a child frequently hits younger children, is defiant at home, and stops going to school).
- 30 Behavior is significantly influenced by delusions or hallucinations, or there is a severe impairment of communication or judgment (eg, sometimes incoherent, acts clearly inappropriate, suicidal preoccupation) or inability to function in almost all situations areas (eg, stays in bed all day; no job, home, or friends).
- 20 Some danger of injuring others or self (eg, suicide attempts without overt expectation of death; often violent; manic arousal) or occasionally failure to maintain minimal personal hygiene (eg, spotting stool) or significant communication impairment (eg, very incoherent or mute).
- 10 Persistent danger of seriously injuring others or self (eg, recurrent violence) or persistent inability to maintain minimal personal hygiene or serious suicidal act with overt expectation of death.
- 0 Inadequate information
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