Psychological medicine

DSM IV Classification

  • Published 1994, replaces Diagnostic and Statistical Manual of Mental Disorders III and III-R

Diagnostic Axises

  • Axis 1: Clinical Disorders eg major depression, adjustment disorder, schizophrenic disorder. Basis in medical model
  • Axis 2: personality disorder or traits and mental retardation. More blurred distinction between person and pathology
  • Axis 3: General Medical Conditions (physical disorders and conditions)
  • Axis 4: Psychosocial and Environmental Problems (eg severity of psychosocial stressors, problems with primary support group, social environment, educational, occupational, housing, economic, access to health care system)
  • Axis 5: global assessment of functioning (eg in the previous year)

Diagnostic Classes

Using DSM Diagnoses*

  • In DSM IIIR, “Delirium, Dementia and Amnestic and Other Cognitive Disorders”, “Mental Disorders Due to a General Medical Condition” and “Substance-Related Disorders” were grouped under the single heading “Organic Mental Syndromes and Disorders”. “Organic mental disorder” is no longer used as it implies other disorders don‟t have a biological basis
  • Qualifiers on Diagnostic codes:
  • Severity and course specifiers: mild, moderate, severe, in partial remission, in full remission, prior history of (ie have had full recovery)
  • Principal diagnosis/Reason for visit: if more than one diagnosis, which one was the principle one leading to admission/contact. Difficult to determine in dual diagnosis (substance related + non-substance related). Multiple diagnoses can re reported in multiaxial fashion
  • Provisional: when strong assumption that criteria will be meet, but insufficient evidence currently available
  • Not-otherwise specified used when:
  • Symptoms below clinical threshold or there is an atypical or mixed presentation
  • Symptom pattern is not included in DSM IV
  • When there is uncertainty about aetiology: eg whether it is due to a general medical condition, is substance induced or is primary
  • There is incomplete or inconsistent information
  • Frequently used criteria – to exclude or suggest differential diagnoses:
    • Criteria have never been/are not meet for…
  • Does not occur exclusively during the course of…
  • Not due to the direct physiological effects or a substance of a general medical condition – ie these have had to have been considered and ruled out
  • Not better accounted for by…
  • These criteria establish a hierarchy:
  • Disorders due to a general medical condition or substance-induced disorder pre-empts diagnoses of primary disorder with the same symptoms (eg Cocaine-induced mood disorder pre-empts Major Depressive Disorder)
  • A more pervasive disorder pre-empts diagnosis of a less pervasive disorder with a subset of the symptoms of the more pervasive disorder (eg Less pervasive disorder will have „Criteria have not been meet for [the more pervasive disorder])
  • When there are very difficult diagnostic boundaries, use „not better accounted for‟ to permit use of clinical judgement