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Introduction to the DSM IV TR and the Multiaxial System

Information and history of the DSM up to but not including the DSM 5 which came after the development of this presentation

Jason Cascone

on 13 December 2013

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Transcript of Introduction to the DSM IV TR and the Multiaxial System

Introduction to the DSM-IV-TR
and the Multiaxial System A brief history of the DSM 1812 Benjamin Rush
The Father of American Psychiatry "Medical Inquiries and Observations upon the Diseases of the Mind"
an attempt to classify mental illnesses, causes and cures.
Started movement to create separate treatment facilities and more humane treatment of mentally ill
Pioneered therapeutic approach to addiction and identified "Savant Syndrome" 1840 U.S. government attempts to collect data about mental illness through the census
"Idiocy/Insanity" appeared on the census 1896 Freud calls his methods "psychotherapy" 1886 Jane Addams founds Hull House in Chicago
Documentation of social illness 1880 Census adds: mania, melancholia, monomania, paresis, dementia, dipsomania, and epilepsy 1917 "Statistical Manual for the Use of Institutions for the Insane" created by the Committee on Statistics of the American Medico-Psychological Association (now the APA) and the National Commission on Mental Hygiene 1942 Final edition of the Statistical Manual for the Use of Institutions for the Insane 1952 DSM I is published with 106 disorders known as "reactions"
Coined by Adolph Meyer, Swiss psychiatrist who felt that mental disorders were reactions to biological, psychological and social factors (suggested the term "mental hygiene")
Had a psychodynamic focus
Variant of ICD-6 2 main categories
Disorders with biological antecedent and those without
The latter was further subdivided 1968 DSM II published with 182 disorders
"Reactions" was eliminated as it referred to psychoanalysis assuming narrow etiology and treatment of disorders 1980 DSM III - First major revision
265 diagnostic categories
Eliminated the psychodynamic approach in favor of the medical model promoted by Kraepelin 100 years earlier
Debut of the multiaxial system
Better correspondence with ICD-9
DSM III - R 1883 Emil Kraepelin - "Compendium der Psychiatrie"
Psychiatry was a medical branch and should be studied empirically like other sciences
Distinguished dementia praecox from bipolar disorder 1972 Feighner Criteria - John Feighner
set of diagnostic criteria with a basis in Kraepelin etiology
Homosexuality listed as a disorder 1994 DSM IV - increase to over 300 disorders continuing the tradition of DSM III of requiring empirical research to backup the diagnosis
DSM IV - TR - edit reflected changes in research 2013? DSM 5 - said to be a MAJOR change The DSM-IV-TR Structure Multiaxial Diagnosis Multicultural Issues
Diagnosing with the DSM Case Study A.L., a 20 year old male, presents to the emergency room of a hospital accompanied by his family. He is combative, smells of alcohol, and is obviously quite intoxicated. Three weeks ago, he was arrested for driving under the influence of alcohol (DUI). A. L.’s wife reports that he has been drinking increasing amounts of alcohol since his marital problems developed 2 months ago.

For 3 days he has been tearful and reported to another family member that he “felt hopeless about the marriage.” His appetite, concentration, interest and energy levels, and sleep patterns are relatively normal. He denies suicidal ideation. Past history is significant for poor academic performance during high school (i.e. he was enrolled in special education classes). There is no previous history of alcohol or drug abuse. Organized by
16 Major Diagnostic Classes Disorders Usually First Dx in Infancy, Childhood, or Adolescence
Delirium, Dementia, and Amnestic 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 Gender Identity Disorders
Eating Disorders
Sleep Disorders
Impulse Control Disorders Not Otherwise Classified
Adjustment Disorders
Personality Disorders
Other Conditions That May Be a Focus of Clinical Attention Coding System The coding system is consistent with the ICD-9-CM (International Classification of Diseases, 9th Revision, Clinical Modification) Codes are for consistent record keeping across treatment facilities, for insurance, and for statistics and research The code is a 4 or 5 digit number (rarely 3) that specifies the type and subtype of the disorder, for instance... Schizophrenia: 295.xx

.30 Paranoid Type
.10 Disorganized Type
.20 Catatonic Type
.90 Undifferentiated Type
.60 Residual Type Specifiers have no code as in... 312.8 Conduct Disorder
Specify type: Childhood Onset Type/ Adolescent Onset Type Appendix A: Decision Trees for Differential Diagnosis Aids in the selection of appropriate diagnosis where more than one may be possible Appendix I: Outline for Cultural Formulation and Glossary of Culture-Bound Syndromes 2 sections
Guidelines for using cultural differences in diagnostics
Glossary of culture-bound syndromes Amok: a period of brooding followed by an outburst of violent, aggressive, or homicidal behavior directed at people and objects. Originally observed in Malaysia. Global Assessment of Functioning Scale (GAF)
Global Assessment of Relational Functioning (GARF)
Social and Occupational Functioning Assessment Scale (SOFAS) The innovation of the DSM-III was the multiaxial diagnostic system developed to aid in treatment planning and prognosis prediction The multiaxial system requires a diagnosis framed in 5 domains, or axes, to explain the condition of the client according to a biopsychosocial model Axis I: Clinical Disorders, Other Conditions That May Be a Focus of Clinical Attention
Axis II: Personality Disorders, Mental Retardation
Axis III: General Medical Conditions
Axis IV: Psychosocial and Environmental Problems
Axis V: Global Assessment of Functioning Axis I All disorders except for Personality Disorders and Mental Retardation are entered into this axis
If more than 1 disorder is present, the principal diagnosis (indicated by the presenting problem) is listed first
If Axis II disorder is primary then "Principal Diagnosis" is listed next to the Axis II disorder
No diagnosis is listed as V71.09
If the dx is deferred pending additional information code 799.9 is entered Axis II Personality Disorders and Mental Retardation are listed on Axis II
Allows focus on these additional disorders which might otherwise be secondary to the primary Axis I dx
Indicates that tx of these disorders is fundamentally different than those disorders on Axis I
Same procedure for multiple Axis II diagnoses, no Axis II and inadequate information
Maladaptive behavior and defense mechanisms can also be added to this axis with no coding Axis III Report general medical conditions that are relevant to the understanding or management of the mental disorder
When the medical condition is the direct cause of an Axis I disorder, the condition should be reported on both Axis I and Axis III. For example... Axis I: 293.83 Mental Disorder Due to Hyperthyroidism, with Depressive Features
Axis II: V71.09
Axis III: Hyperthyroidism (if ICD is available, enter ICD code for medical condition) If evidence is uncertain as to whether the medical condition is the cause of the mental disorder, enter the appropriate disorder on Axis I (not GMC) and the medical condition on Axis III
Listing prominent medical conditions may also be helpful in understanding psychological reactions and assist in determinations of appropriate medical therapies
No Axis III should be listed as "None" and pending dxs should be listed as "Deferred" Axis IV Axis IV is uses to report any psychosocial or environmental problems that might affect the diagnosis, treatment or prognosis
Note as many as necessary and the DSM lists overall categories such as: Problems with primary support group
Educational problems
Occupational problems
Problems with access to health services Axis V Axis V lists the client's Global Assessment of Functioning score according to the scale
An indication of the time period follows the score though in most instances it is the current level of functioning
GARF and SOFAS scores may also be used in this axis
Scores are listed thusly: GAF= <GAF score> Tentative changes in the DSM 5
(scheduled for release in May 2013) Removal of the Multiaxial System...

Dimensional Assessments that will allow the clinician to rate the level of depression, anxiety, cognitive impairment and reality orientation of the client.

Inclusion of "binge eating disorder", Internet Use Gaming Disorder, Hoarding Disorder, Non-suicidal Self Injury

More formal suicide risk assessment

Combination of substance abuse and dependence - Substance Use Disorder

All autism related disorders are aligned in Autism Spectrum Disorders removing Asperger's as a specific diagnosis

Addition of Behavioral Addictions - pathological gambling is the only disorder listed however Internet and Sex Addictions are listed in the 'for further study' section

Expanded definitions of sexual disorders and a renaming/defining of Gender Identity Disorder to Gender Dysphoria

Bereavement is added into Major Depressive symptoms rather than an exclusion

Disruptive Mood Dysregulation Disorder - 'verbal or behavioral outbursts in the form of verbal rages or physical aggression toward people and property' (for those over 5)

Reorganization of Personality Disorders Despite the empirical nature of the DSM,
it is not cross-culturally accurate. The clinician must make a note of:
Cultural identity of the individual
Cultural explanations of the individual's illness
Cultural factors related to psychosocial environment and levels of functioning
Cultural elements of the relationship between the individual and the clinician
Overall cultural assessment for diagnosis and care Assign a GAF, GARF and SOFAS Late 1940's U.S. Army publishes statistics and data about outpatient presentations to better assist servicemen and vets V Codes Relational Problems noted on Axis I if part of principal focus of treatment, if not list on Axis IV. For example... V61.20 Parent-Child Relational Problem
V61.1 Partner Relational Problem
V65.2 Malingering
V62.82 Bereavement
V62.89 Religious or Spiritual Problem Neil deGrasse Tyson quoting Logan Clendening: “No science achieves maturity without first developing a system of measurement.” 1898 1st social work class offered at Columbia University World Health Organization publishes the International Classification of Diseases (ICD) 6th ed. and, for the first time, includes mental disorders Coded as: 312.8 Conduct Disorder, Childhood Onset 1900 First International Classification of Diseases (ICD) published
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