 |
Okay, these are not the Axes in the DSM, but this is the kind
of Axes we're talking about; various dimensions that can
describe an object, or person. Axes work best for dimensions
that can be counted, like levels of severity of different
symptoms; doesn't work so well to make a picture based
on diagnostic labels. Another reason to drop "Axes." |
That’s “Ax-eees”, plural of ‘axis,’ not “Ax-iz,” plural of ‘ax.’
Clinicians are faced with using the first major revision to
the diagnostic manual in 19 years. Here’s
a behind the scenes look at the changes in how they’ll manage writing down a
diagnosis. Actually choosing which
diagnosis is correct will be a matter of mastering the new and changed
diagnostic criteria; I’ll be posting about that, category by category.
The most burning question at my last presentation on the DSM
5 was: How do I “diagnose,” which meant
in part, “what do I write on the form now that there won’t be 5 Axes to fill
out?”
Here’s a crosswalk from the old process to the new
process:
Until summer 2014 (or later, depending on when agency
paperwork is updated) “Diagnosing” used to mean filling in information in five “Axes”
on a form:
Axis I: Clinical
disorders and other conditions (“V” codes) that are a focus of clinical
attention
à The primary and secondary conditions being
treated by the person filling out the form, and other diagnoses also present
but not as much the focus of treatment
Axis II: Presence of
personality disorder or cognitive disability/”mental retardation”
à
Conditions that might not necessarily be the subject of treatment, but that affect
how treatment proceeds.
Axis III: Medical
Conditions
à
Especially those which may affect mental health problems and treatment
Axis IV: Psychosocial
Stressors
à A list of conditions
outside the individual which affect mental health problems and treatment
Axis V: Global
Assessment of Functioning (GAF)
à a number from 1-100 (0 used only if there is
no information) describing the impact of the mental health condition on the
person’s ability to successfully manage the tasks of everyday life. This number was used as a comparison point
to show progress in treatment.
BUT THE FIVE AXES ARE GONE!
WHAT DO WE DO NOW?
Basic answer: Just
list the diagnosis you’re focusing on, and others that might be important to
mention.
When I say “basic” I don’t mean “easy”; you do have to use
the revised manual and find out what’s a match for your clients; more guidance
on that for a variety of different conditions in upcoming posts.
First, we have some Axes to mourn.
Where will we put that important information that was in the
Axes?
Axis I: mental health
diagnosis will still be there. There
will be some more writing here than in the past: The
codes will not be enough to clarify all the “specifiers” that must be written
our verbally, such as the course, severity, and associated features that can go
along with a condition. More about
specifiers soon.
Axis II: Personality
Disorders and Intellectual Disabilities (moving on from the old term “mental
retardation”) are just listed like any other diagnosis, though it’s still
likely in many settings that there is some other condition that is the primary
focus of treatment.
Axis III: Medical
conditions are sometimes the direct cause of the mental health symptoms and
should be listed separately as a medical diagnosis, and then listed as part of
the diagnosis, as the example on p. 181 of the DSM-5: 244.9 hypothyroidism; 293.83 Depressive
Disorder due to hypothyroidism.
Axis IV: Psychosocial stressors are included in the expanded
list of V codes, “Other Conditions that may be a Focus of Clinical Attention.”
Axis V: GAF rating scores
for the client as a whole are gone, but we are increasingly rating severity as
part of the diagnostic process. For many
diagnoses there are guidelines for rating severity of symptoms and/or severity
of the impact on functioning.
What has changed most in the process of writing down a
diagnosis: The loss of the Axes. Separating this kind of information into five
Axes has been… given the Ax.
Coming up: how to
search for the right diagnosis,
How to correctly diagnose using the criteria for the brand
new diagnoses found in the DSM-5
Important changes to the criteria for existing diagnoses,
Preventing overdiagnosis and misdiagnosis,
Changes in thinking about some diagnoses reflected in the new
categories and chapters. For example,
OCD and PTSD are moved out of the category of Anxiety Disorders, but Selective
Mutism is moved IN to the category of Anxiety Disorders,
And more, including responses to questions about the DSM or
some of the other realms of Mental Health Knowledge.
