DSM-IV™ Multiaxial System

• Axis I:
Clinical Disorders, most V-Codes, and conditions that need Clinical attention.
Diagnosis Flow Charts.
• Axis II:
Personality Disorders and Mental Retardation. Mental terbantut
• Axis III:
General Medical Conditions.
• Axis IV:
Psychosocial and Environmental Problems.-masalah hubungan
• Axis V:
Global Assessment of Functioning Scale.

The Diagnostic and Statistical Manual of Mental Disorders (DSM) is the standard classification
of mental disorders used by mental health professionals in the United States. It is intended to be
applicable in a wide array of contexts and used by clinicians and researchers of many different
orientations (e.g., biological, psychodynamic, cognitive, behavioral, interpersonal,
family/systems). DSM-IV has been designed for use across settings, inpatient, outpatient, partial
hospital, consultation-liaison, clinic, private practice, and primary care, and with community
populations and by psychiatrists, psychologists, social workers, nurses, occupational and
rehabilitation therapists, counselors, and other health and mental health professionals. It is also a
necessary tool for collecting and communicating accurate public health statistics. The DSM
consists of three major components: the diagnostic classification, the diagnostic criteria sets, and
the descriptive text.

The diagnostic classification is the list of the mental disorders that are officially part of the DSM
system. "Making a DSM diagnosis" consists of selecting those disorders from the classification
that best reflect the signs and symptoms that are afflicting the individual being evaluated.
Associated with each diagnostic label is a diagnostic code, which is typically used by institutions
and agencies for data collection and billing purposes. These diagnostic codes are derived from
the coding system used by all health care professionals in the United States, known as the ICD-9-
CM.

For each disorder included in the DSM, a set of diagnostic criteria that indicate what symptoms
must be present (and for how long) in order to qualify for a diagnosis (called inclusion criteria)
as well as those symptoms that must not be present (called exclusion criteria) in order for an
individual to qualify for a particular diagnosis. Many users of the DSM find these diagnostic
criteria particularly useful because they provide a compact encapsulated description of each
disorder. Furthermore, use of diagnostic criteria has been shown to increase diagnostic reliability
(i.e., likelihood that different users will assign the same diagnosis). However, it is important to
remember that these criteria are meant to be used a guidelines to be informed by clinical
judgment and are not meant to be used in a cookbook fashion.

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Finally, the third component of the DSM is the descriptive text that accompanies each disorder.
The text of DSM-IV systematically describes each disorder under the following headings:
"Diagnostic Features"; "Subtypes and/or Specifiers"; "Recording Procedures"; "Associated
Features and Disorders"; "Specific Culture, Age, and Gender Features"; "Prevalence"; "Course";
"Familial Pattern"; and "Differential Diagnosis."

DSM-IV (Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition), published in
1994 was the last major revision of the DSM. It was the culmination of a six-year effort that
involved over 1000 individuals and numerous professional organizations. Much of the effort
involved conducting a comprehensive review of the literature to establish a firm empirical basis
for making modifications. Numerous changes were made to the classification (i.e., disorders
were added, deleted, and reorganized), to the diagnostic criteria sets, and to the descriptive text
based on a careful consideration of the available research about the various mental disorders.

In anticipation of the fact that the next major revision of the DSM (i.e., DSM-V) will not appear
until 2010 or later (i.e., at least 16 years after DSM-IV), a text revision of the DSM-IV called
DSM-IV-TR was published in July 2000. The primary goal of the DSM-IV-TR was to maintain
the currency of the DSM-IV text, which reflected the empirical literature up to 1992. Thus, most
of the major changes in DSM-IV-TR were confined to the descriptive text. Changes were made
to a handful of criteria sets in order to correct errors identified in DSM-IV. In addition, some of
the diagnostic codes were changed to reflect updates to the ICD-9-CM coding system adopted by
the US Government.

AXIS I
CLINICAL DISORDERS, MOST V-CODES, AND CONDITIONS THAT NEED
CLINICAL ATTENTION.

Clinical ( Mental ) Disorders is used to report various disorders or conditions, as well as noting
other conditions that may be a focus of clinical attention. Clinical Disorders are identified into 14
categories, including Anxiety Disorders, Childhood Disorders, Cognitive Disorders, Dissociative
Disorders, Eating Disorders, Factitious Disorders, Impulse Control Disorders, Mood Disorders,
Psychotic Disorders, Sexual and Gender Identity Disorders, Sleep Disorders, Somatoform
Disorders, and Substance-Related Disorders. Other conditions, known as Adjustment Disorders,
may also be a focus of clinical attention include Medication-Induced Movement Disorders,
Relational Problems, Problems Related to Abuse or Neglect, Noncompliance with Treatment,
Malingering, Adult Antisocial Behavior, Child or Adolescent Antisocial Behavior, Age-Related
Cognitive Decline, Bereavement, Academic Problem, Occupational Problem, Identity Problem,
Religious or Spiritual Problem, Acculturation Problem, and Phase of Life Problem.

Report all Axis I disorders.

If no Axis I disorder use code V71.09.
If Axis I diagnosis is deferred or pending more information use code 799.9.

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Clinical Disorders:

i. Adjustment Disorders.
• With Anxiety. • With Mixed Disturbance of
• With Depressed Mood. Emotions and Conduct.
• With Disturbance of Conduct. • Unspecified.
• With Mixed Anxiety and Depressed
Mood.

ii. Anxiety Disorders.

• Acute Stress Disorder. • Obsessive-Compulsive Disorder
• Agoraphobia. ( OCD ).
• Agoraphobia Without History of • Panic Attack.
Panic Disorder. • Panic Disorder With Agoraphobia.
• Anxiety Disorder Due to a General • Panic Disorder Without
Medical Condition. Agoraphobia.
• Anxiety Disorder Not Otherwise • Posttraumatic Stress Disorder.
Specified ( Anxiety Disorder NOS ). • Social Phobia.
• Generalized Anxiety Disorder • Specific Phobia.
( GAD ). • Substance-Induced Anxiety
Disorder.

iii. Cognitive Disorders ( Delirium, Dementia, and Amnestic ).

• Amnestic. • Dementia.
• Delirium.

iv. Dissociative Disorders.

• Depersonalization Disorder. • Dissociative Identity Disorder.

• Dissociative Amnesia. • Dissociative Disorder Not Otherwise
• Dissociative Fugue. Specified. ( NOS )

v. Eating Disorders.

• Anorexia Nervosa. • Eating Disorder Not Otherwise

• Bulimia Nervosa. Specified. ( NOS )

vi. Factitious Disorders.

• With Combined Psychological and Physical Signs and Symptoms.

• With Predominantly Physical Signs and Symptoms.
• With Predominantly Psychological Signs and Symptoms.

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vii. Impulse-Control Disorders ( Not Classified Elsewhere ).

• Impulse-Control Disorder Not • Pathological Gambling.

Otherwise Specified. ( NOS ) • Pyromania.
• Intermittent Explosive Disorder. • Trichotillomania.
• Kleptomania.

Mental Disorders Due To A General Medical Condition.

i. Mood Disorders.

• Bipolar I Disorder. • Dysthymic Disorder.

• Bipolar II Disorder.
• Bipolar Disorder Not Otherwise
Specified ( NOS ).
• Cyclothymic Disorder.
• Depressive Disorder Not Otherwise
Specified ( NOS ).
• Depression ( General Overview ).
• Major Depressive Disorder.
• Mood Disorder Due to a General
Medical Condition.
• Mood Disorder Not Otherwise
Specified ( NOS ).
• Substance-Induced Mood Disorder.

ii. Schizophrenia and other Psychotic Disorders.

• Paranoid Type. • Psychotic Disorder Due to a General

• Disorganized Type. Medical Condition.
• Catatonic Type. • Psychotic Disorder Not Otherwise
• Undifferentiated Type. Specified.
• Residual Type. • Schizoeffective Disorder.
• Brief Psychotic Disorder. • Schizophreniform Disorder.
• Delusional Disorder. • Substance-Induced Psychotic
Disorder.

iii. Sexual and Gender Identity Disorders.

iv. Paraphilias:

• Exhibitionism. • Sexual Sadism.

• Fetishism. • Transvestic Fetishism.
• Frotteurism. • Voyeurism.
• Pedophilia. • Paraphilia Not otherwise Specified. (
• Sexual Masochism. NOS )

v. Sexual Dysfunction:

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• Hypoactive Sexual Desire Disorder.
• Female Orgasmic Disorder.
( Inhibited Female Orgasm )
• Female Sexual Arousal Disorder.
• Male Erectile Disorder.
• Male Orgasmic Disorder. ( Inhibited
Male Orgasm )
• Premature Ejaculation.
• Sexual Aversion Disorder.
• Sexual Dysfunction Due to a General
Medical Condition.
• Substance-Induced Sexual
Dysfunction.
• Sexual Dysfunction Not Otherwise
Specified ( NOS )

vi. Sexual Pain Disorders:

• Dyspareunia. ( Not Due to a General Medical Condition )

• Vaginismus. ( Not Due to a General Medical Condition )

vii. Sleep Disorders.

• Breathing-Related Sleep Disorder.

• Circadian Rhythm Sleep Disorder.
• Dyssomnias Not Otherwise Specified. ( NOS )
• Insomnia Related to Another Mental Disorder.
• Nightmare Disorder ( Dream Anxiety Disorder )
• Primary Sleep Disorders:
o Primary Insomnia.
o Primary Hypersomnia.
o Narcolepsy.
• Sleep Disorder Due to a General Medical Condition.
• Sleep Disorder Related to Another Mental Disorder. Sleep Terror Disorder.
• Sleepwalking Disorder.
• Substance-Induced Sleep Disorder.

viii. Somatoform Disorders.

• Somatization Disorder. • Hypochondriasis.Body Dysmorphic

• Undifferentiated Somatoform Disorder.
Disorder. • Somatoform Disorder not Otherwise
• Conversion Disorder. Specified ( NOS )
• Pain Disorder.

ix. Substance-Related Disorders.

• Substance-Induced Anxiety • Substance-Induced Mood Disorder.

Disorder.
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 • Substance-Induced Psychotic • Substance-Induced Sleep Disorder.
Disorder.

AXIS II
PERSONALITY DISORDERS AND MENTAL RETARDATION.

Personality Disorders and Mental Retardation are recorded so the clinician will give
consideration to additional intervention and treatment choices. Personality is the qualities and
traits of being a specific and unique individual. It is the enduring pattern of our thoughts,
feelings, and behaviors, it is how we think, love, feel, make decisions and take actions.
Personality is determined, in part, by out genetics and also, by out environment. It is the
determining factor in how we live our lives. Individuals with Personality Disorders have more
difficulty in every aspect of their lives. Their individual personality traits reflect ingrained,
inflexible, and maladaptive patterns of behaviors that cause discomfort, distress and impair the
indivdiual's ability to function in the daily activities of living. In Mental Retardation problems in
brain development have usually occurred and virtually will affect all aspects of the indivdiual's
cognitive functioning. Borderline Intellectual Functioning, as well as Learning Disabilities, may
also be a consideration for clinical focus.

Report all Personality Disorders and Mental Retardation.

If no Axis II disorder use code V71.09.
If Axis II diagnosis is deferred or pending more information use code 799.9.
Include prominent maladaptive personality features. ( No code number used )
Include the habitual use of maladaptive defense mechanisms. ( No code number used )
A qualifying phase can be used if the individual has both a Axis I and a Axis II diagnosis as long
as the Axis I is the principal diagnosis or the reason for the visit.

• Principal Diagnosis.
• Reason for Visit.

Personality Disorders / Mental Retardation

General diagnostic criteria is an enduring pattern of inner experience and behavior that deviates
markedly from the expectations of the individual's culture. This pattern is manifested in two (or
more) of the following areas: cognition (i.e., ways of perceiving and interpreting self, other
people, and events); affectivity (i.e., the range, intensity, lability, and inappropriateness of
emotional response); interpersonal functioning; and impulse control. The enduring pattern is
inflexible and pervasive across a broad range of personal and social situations. The individual's
pattern is stable of long duration and its onset can be traced back at least to adolescence or early
adulthood.

• Antisocial Personality Disorder.

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 • Avoidant Personality Disorder.
• Borderline Personality Disorder.
• Dependent Personality Disorder.
• Histrionic Personality Disorder.
• Mental Retardation.
• Narcissistic Personality Disorder.
• Obsessive-Compulsive Personality Disorder.
• Paranoid Personality Disorder.
• Personality Disorder Not Otherwise Specified.
• Schizoid Personality Disorder.
• Schizotypal Personality Disorder.

AXIS III
GENERAL MEDICAL CONDITIONS.

General Medical Conditions is for reporting current medical conditions that are potentially
relevant to the understanding or management of the individual's mental disorder. The purpose of
distinguishing General Medical Conditions is to encourage thoroughness in
evaluation/assessment and to enhance communication among health care providers. General
Medical Conditions can be related to mental disorders in a variety of ways. First, it is clear the
medical condition is directly related to the development or worsening of the symptoms of the
mental disorder. Second, the relationship between the medical condition and mental disorder
symptoms is insufficient. Third, there are situations in which the medical condition is important
to the overall understanding or treatment of the mental disorder.

Report all General Medical Conditions.

If no General Medical Condition indicate. ( Axis III: None )
If Axis III diagnosis is deferred or pending more information indicate. ( Axis III: Deferred. )
Most be outside the ICD-9-CM Mental Disorder chapter and outside of chapter V of the ICD-10.

If a mental disorder is a direct physiological consequence of the general medical condition,

include a Mental Disorder Due to a General Medical Condition in Axis I and a General Medical
Condition should be included in Axis I and Axis III.

General Medical Conditions (With ICD-9-CM codes )

• Infectious and Parasitic Diseases ( 001-139 )

• Neoplasms ( 140-239 )
• Endocrine, Nutritional, and Metabolic Diseases. Immunity Disorders ( 240-279 )
• Diseases of the Blood and Blood-Forming Organs ( 280- 289 )
• Diseases of the Nervous System and Sense Organs ( 320-389 )
• Diseases of the Circulatory System ( 390-459 )
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 • Diseases of the Respiratory System ( 460-519 )
• Diseases of the Digestive System ( 520-579 )
• Diseases of the Genitourinary System ( 580-629 )
• Complications of Pregnancy, Childbirth, and the Puerperium ( 630-676 )
• Diseases of the Skin and Subcutaneous Tissue ( 680-709 )
• Diseases of the Musculoskeletal System and Connective Tissue ( 710-739 )
• Congenital Anomalies ( 740-759 )
• Certain Conditions Originating in the Perinatal Period ( 760-779 )
• Systems, Signs, and Ill-Defined Conditions ( 780-799 )
• Injury and Poisoning ( 800-999 )

AXIS IV
PSYCHOSOCIAL AND ENVIRONMENTAL PROBLEMS.

Psychosocial and Environmental Problems is for reporting psychosocial and environmental

stressors that may affect the diagnosis, treatment, and prognosis of mental disorders. A
psychosocial or environmental problem may be a negative life event, an environmental difficulty
or deficiency, a familial or other interpersonal stressor, an inadequacy of social support of
personal resources, or other problems relating to the context in which an individual's difficulties
have developed. Positive stressors, such as a job promotion, should be listed only if they
constitute or lead to a problem, as when an individual has difficulty adapting to the new
situation. Psychosocial and Environmental Problems fall into nine categories, including primary
support group, problems related to the 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 and environmental
problems that are affecting an individual's ability to function in their daily activities of life.

• Problems with primary support group

• Problems related to the 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/crime
• Other psychosocial and environmental problems

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 AXIS V
GLOBAL ASSESSMENT OF FUNCTIONING SCALE.

• Global Assessment of Functioning is for reporting the clinician's judgment of the

individual's overall level of functioning and carrying out activities of daily living. This
information is useful in planning treatment and measuring its impact, and in predicting
outcome.
• The Global Assessment of Functioning Scale is a 100-point scale that measures a patients
overall level of psychological, social, and occupational functioning on a hypothetical
continuum.
• The GAF Report decision tree is designed to guide clinicians through a methodical and
comprehensive consideration of all aspects of a patients symptoms and functioning to
determine a patients GAF rating in less than 3 minutes.
• The GAF Report addresses the growing need for accuracy and reliability in determining
and reporting on GAF ratings by ensuring all aspects of a patients functioning are
considered. Use the “current” or “past week” rating to indicate current management
needs, the “at discharge” rating to document progress and quality of care, and the
“highest level in past year” rating as a target for termination of treatment.
• The GAF scale is particularly useful for managed care-driven diagnostic evaluations to
determine eligibility for treatment and disability benefits and to delineate the level of care
required for patients. On completion of the GAF Report questions, a 10-point range is
automatically determined. Then, using the sliding rating scale, you can quickly indicate
the specific GAF rating within this 10-point range, using clinical judgment and
hypothetical comparison with other patients in the range. Explanation screens provide
clarification of specific questions throughout the assessment. The report, which
summarizes a patients results, can be produced immediately after an assessment .Global
Assessment of Functioning

Global Assessment of Functioning Scale.

• Scale Consider psychological, social, and occupational functioning on a

hypothetical continuum of mental health-illness.
• Do not include impairment in functioning due to physical or environmental limitations.
• You do not need to know the numbers but rather what the GAF measures and is used for
Code ( Note. Use intermediate codes when appropriate, e.g., 45, 68, 72.)

91-100 Superior functioning in a wide range of activities, life's problems never seem to get out
of hand, is sought out by others because of his or her many positive qualities. No
symptoms
81-90 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,
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 generally satisfied with life, no more than everyday problems or concerns ( e.g., an
occasional argument with family members )
71-80 If symptoms are present, they are transient and expectable reactions to psychosocial.
stressors ( e.g., difficulty concentrating after family argument ); no more than slight
impairment in social occupational, or school functioning ( e.g., temporarily falling
behind in schoolwork ).
61-70 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 ), but generally functioning pretty well, has some meaningful
interpersonal relationships.
51-60 Moderate symptoms ( e.g., flat affect and circumstantial speech, occasional panic
attacks ) OR moderate difficulty in social, occupational, or school functioning ( e.g.,
few friends, conflicts with peers or co-workers ).
41-50 Severe symptoms ( e.g., suicidal ideation, severe obsessional rituals, frequent
shoplifting ) OR any serious impairment in social, occupational or school functioning
( e,g., no friends, unable to keep a job ).
31-40 Some impairment in reality testing or communication ( e.g., speech is at times illogical,
obscure, or irrelevant ) OR major impairment in several areas, such as work or school,
family relations, judgment, thinking, or mood ( e.g., depressed man avoids friends,
neglects family, and is unable to work; child frequently beats up younger children, is
defiant at home, and is failing at school ).
21-30 Behavior is considerably influenced by delusions or hallucinations OR serious
impairment in communication or judgment ( e.g., sometimes incoherent, acts grossly
inappropriately, suicidal preoccupation ) OR inability to function in almost all areas
( e.g., stays in bed all day, no job, home, or friends ).
11-20 Some danger of hurting self or others ( e .g., suicidal attempts without clear expectation
of death; frequently violent; manic excitement ) OR occasionally fails to maintain
minimal personal hygiene ( e.g., smears feces ) OR gross impairment in communication
( e.g., largely incoherent or mute ).
1-10 Persistent danger of severely hurting self or others ( e.g., recurrent violence ) OR
persistent inability to maintain minimal personal hygiene OR serious suicidal act with
clear expectation of death.0 Inadequate information.

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