Classification of Psychological Disorders: Multiaxial Approach DSM IV- TR

-Dr. Subhash Meena

Why Classify?

​

• We must first define a disturbance before we can begin to understand its' etiology.
• Classification can facilitate the acquisition of new information.
• Classification can assist in the prediction or prognosis.
• Classification can help determine appropriate treatment.
• Classification assists communication within the field--aids in research.
• Classification helps communication with other professionals.
• Classification can be a relief to clients.

​

​

​

​

CLASSIFICATION AND DIAGNOSIS

Background – History

• Greeks – melancholia, senility, alcoholism
• Kraeplin (1896) – first psychiatric classification system
• Pioneered classification of mental illness based on biological causes

​

​

CLASSIFICATION AND DIAGNOSIS

Background – History

• DSM I (1952) & DSM II (1968) – very brief manuals, guided by psychoanalysis, gross categories (e.g., neurosis, psychosis), lack of reliability, no research base
• DSM III (1980), DSM III-R (1987), DSM IV (1994), DSM IV TR (2000) – field trials to improve reliability, better research base, multiaxial classification

CLASSIFICATION AND DIAGNOSIS

Background – The perfect system would:

• classify disorder by presenting signs and symptoms, etiology or history, prognosis, response to treatment
• identify different symptom clusters that accurately signal different disorders with no overlap between symptoms or signs between disorders
• identify precise effective treatments

Major Diagnostic Systems

International Classification of Diseases- 10 (ICD-10)- published by World Health Organization (1993)

​

Diagnostic and Statistical Manual –IV (DSM-IV)- published by the American Psychiatric Association (1994)

DSM-IV-TR�Diagnostic System

• Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR)
• 4^th edition revised
• Published by American Psychiatric Association
• Multiaxial system
• Diagnosis based on 5 axes or dimensions.

​

Definition of “Mental Disorder”

DSM-IV-TR: a clinically significant behavioral or psychological syndrome or pattern that occurs in an individual and that is associated with present distress (e.g., a painful symptom) or disability (i.e., impairment in one or more important areas of functioning) or with a significantly increased risk of suffering death, pain, disability, or an important loss of freedom.

Definition of “Mental Disorder” cont…

In addition, this syndrome or pattern must not be merely an expectable and culturally sanctioned response to a particular event, for example, death of a loved one. Whatever its original cause, it must currently be considered a manifestation of a behavioral, psychological, or biological dysfunction of the individual. Neither deviant behavior (e.g., political, religious, or sexual) nor conflicts that are primarily between the individual and society are mental disorders unless the deviance or conflict is a symptom of a dysfunction in the individual, as described above.

DSM-IV

• Is multiaxial in nature--has five axes or dimensions along which you diagnose any behavior disorder--this forces the clinician to use more information.
• More & more refined compared to previous editions.
• Descriptive rather than theoretical in nature.
• All diagnoses have clear criteria that must be met in order for the diagnosis to be made.
• Includes epidemiological information for each disorder.

DSM-IV Multiaxial System

• AXIS I: Clinical syndromes

​

• AXIS II: Personality disorders & Mental Retardation

​

• AXIS III: General Medical Conditions

​

• AXIS IV: Psychosocial & Environmental Problems (listed)

​

• AXIS V: Global Assessment of Functioning Scale (GAF) 0- 100 (lower is worse)

����Axis I Clinical syndromes �

DSM-IV-TR: Pervasive Developmental Disorders, Learning Disorders, Motor Skills Disorders, Communication Disorders, and Other Conditions that may be Focus of Clinical Attention

​

Generally, all clinical syndromes are coded here (e.g., Mood Disorders, Schizophrenia, Dementia, Anxiety Disorders, Substance Disorders, Disruptive Behavior Disorders, etc.) and all other codes that are not attributed to a mental disorder but are the focus of treatment.

​

AXIS I Disorders

1. Disorders usually first diagnosed in infancy, childhood or adolescence (e.g. learning disorders, attention-deficit/ hyperactivity disorder, conduct disorders, tic disorders.
2. Delirium, dementia, amnestic & other cognitive disorders.
3. Substance related disorders
4. Schizophrenia & other psychotic disorders
5. Mood disorders--depressive disorders, bipolar disorders
6. Anxiety disorders--panic with or without agoraphobia, specific phobia, agoraphobia without panic, social phobia, obsessive compulsive disorder, generalized anxiety disorder, posttraumatic stress disorder
7. Somatoform disorders--somatization disorders, conversion disorder, pain, hypochrondriasis, body dysmorphic disorder

AXIS I Disorders (Continued)

8. Factitious disorders--intentional development of symptoms

9. Dissociative disorders--dissociative amnesia, fugue, Dissociative identity disorder

10.  Sexual & gender identity disorders--sexual dysfunction, paraphilias (exhibitionism, fetishism, voyeurism, etc.), gender identity disorders (e.g. transexuality)

11. Eating disorders--anorexia nervosa, bulimia nervosa

12. Sleep disorders

13. Impulse-control disorders NOS--pathological gambling, trichotillomania, pyromania, kleptomania

14. Adjustment disorders

Axis II Disorders

Personality Disorders:

  - Paranoid, Schizoid, Schizotypal

  - Antisocial, Borderline,Histrionic, Narcissistic

  - Avoidant, Dependent, Obsessive-compulsive

​

Mental Retardation

(specified by severity- mild,moderate, severe, profound)

​

Axis III

General Medical Conditions

​

• Hearing Impairment

​

• Vision Impairment

​

• Mixing Medical and Mental

​

Physical (medical) conditions relevant to the condition being treated are listed here.

​

Axis IV

​

DSM-IV-TR: Psychosocial and Environmental Problems/Stressors

The stressors can be clarified with specifics:

• problems with primary support
• problems related to social environment
• educational problems
• occupational problems
• housing problems
• economic problems
• problems with access to health care services
• problems related to interaction with the legal system and other psychosocial problems

Axis V

Global Assessment of Functioning (GAF)

​

• GAF is a scale of 100 points
• The higher the number the higher the level of functioning
• The GAF still covers both symptomology and level of functioning.
• The highest level of functioning is determined and rated.

​

CLASSIFICATION AND DIAGNOSIS –

DSM IV

CLASSIFICATION AND DIAGNOSIS –

DSM IV

Types of Information in DSM-IV TR

1. Diagnostic Features
2. Subtypes and/or Specifiers
3. Recording Procedures
4. Associated Features and Disorders
1. Associated descriptive features and mental disorders
2. Associated laboratory findings
3. Associated physical examination findings and general medical conditions

Types of Information in DSM-IV Text (cont…)

5. Specific Culture, Age and Gender Features
6. Prevalence
7. Course
8. Familial Pattern
9. Differential Diagnosis

Thank You for learning diagnostic system to save your client’s life