Case A: Nonaxial Diagnosis Practice

Case
The client is a 48 year old man who came to therapy for a fear of flying. Although he states that he
recognizes that his fear of flying is irrational, excessive and unreasonable, just the thought of being in an
airport provokes intense anxiety. According to the man, he is a geologist who is expected to fly to
various conferences. In the past, he has been able to avoid taking trips that would require him to fly;
however, recently his supervisor has been pressuring him to attend these conferences and this has been
causing him considerable distress. In other aspects of the job his work is adequate and he has received
acceptable yearly evaluations. Interpersonally, he has always been passive and shy. He reported that he
frequently looks to others for guidance and has difficulty making decisions on his own due to a lack of
confidence. He lives with his girlfriend and relies on her to provide support and reassurance. He will
frequently call her from work to seek her opinion or just to get approval for his decisions. As a result, he
often subordinates his needs to those of others and volunteers to do unpleasant tasks to get people to
like him. He reported that he would do anything for his girlfriend and that he is frequently concerned
that she might leave him. Although he has never been married, he has never been alone and quickly
enters a new relationship as soon as a previous relationship has ended. The thought of being on his own
is extremely anxiety-provoking to him, and he worries that he would not be able to function. He
reported that it is the feeling of terror when he thinks of getting into an airplane and the possibility that
it might crash that brought him in for treatment. He denied a history of drug or alcohol use and stated
that he is generally healthy, with the exception of mitral valve prolapse (i.e., mild heart condition).

Case A: Nonaxial Diagnosis Practice

Case
DSM-IV
Axis I

300.29

DSM-5

Specific Phobia,
Situational Type

300.29

Specific Phobia,
Situational

Axis II 301.6

Dependent Personality
Disorder

301.6

Dependent Personality
Disorder

Axis III 924.0

Mitral valve prolapse

(patient report)

924.0

Mitral valve prolapse

(patient report)

Axis IV

work difficulties

Axis V GAF = 65 (current)

CASE B: DSM-IV AND DSM-5 AUTISM

SPECTRUM CASES
Case B.1
John is a 6-year old male referred due to aggressive behavior at school. He
reportedly is aggressive towards peers and occasionally staff at school, hitting
and biting on occasion, mostly when asked to stop one activity to move to
another or when another child takes a toy he is playing with. His mother
reports a normal pregnancy/delivery and did not report any developmental
delays with the exception of a delay in speech; John did not begin talking in
sentences until he was 3 . John displays a great deal of hyperactive and
impulsive behavior both at home and at school. He tends to make minimal
eye contact with others, in part due to his high activity level. Johns mother
reports that he enjoys playing with a range of toys and will often include his
younger brother in imaginary play, however he is often aggressive towards his
younger brother. John is currently receiving speech services at school to help
him to expand his vocabulary and to work on pronunciation difficulties. John
seems to prefer to play by himself at school and other children tend to avoid
him due to his history of aggressive behavior.

CASE B1: AUTISTIC DISORDER

SPECTRUM CASE
DSM-IV
Axis I

299.80

314.01

315.31
Axis II
Axis III
Axis IV

none
none

Axis V

GAF = 65

Pervasive Developmental
Disorder- Not
Otherwise Specified
Attention Deficit/
Hyperactivity
Disorder, Combined
Type (Provisional)
Expressive Language
Disorder (Provisional)

interpersonal
difficulties

DSV-5
315.39

Social (Pragmatic)
Communication Disorder

314.01

Attention Deficit/Hyperactivity
Disorder, Combined
(Provisional)

CASE B: DSM-IV AND DSM-5 AUTISM

SPECTRUM CASES
Case B.2
Anthony is a 6-year old male referred for evaluation due to difficulties adjusting to kindergarten.
His mother reports that Anthony dislikes going to school and will often cry or say he is sick in
order to avoid going to school. Anthonys mother did not report any pregnancy or delivery
complications and reported that Anthony met all developmental milestones at an average or
faster than average rate. She reported that he has always been a very picky eater and is also fussy
about his clothing (e.g., doesnt like to have tags on his clothes, wont wear shirts that arent soft
cotton). She noted that Anthony began speaking at an early age (1 ) and that he is a very verbal
child who likes to talk about his interest in cars. She noted with pride that Anthony can talk for
hours about different types of cars and car engines. She noted that his favorite activity is to play
with matchbox cars at home and that he spends hours lining up his cars and building small cities
and gets upset if his play is disrupted (i.e., his younger brother picks up a car without permission).
Anthonys teacher has noted that Anthony tends to play by himself, seldom engages with other
children, and gets agitated if other children attempt to engage in play with him. She noted that he
is doing well academically but seems disinterested in participating in class activities. For example,
when asked a question in class he will either remain silent or respond with a comment that is
minimally related to the question. Anthonys mother reports that she feels he is bored at
school since he is already starting to read and other children are still learning their numbers and
colors.

CASE B2: AUTISTIC DISORDER

SPECTRUM CASE
DSM-IV
Axis I

299.80

Aspergers Disorder

Axis II

none

Axis III

none

Axis IV

peer interaction difficulties

Axis V

GAF = 65

DSM-5
299.00 Autism Spectrum Disorder,
Level 1, without language
impairment

CASE C: PSYCHOTIC DISORDER CASE

A 23 YO man came to an outpatient clinic for symptoms of psychosis. He has always
been a loner who shows very little emotion and prefers not to become involved with
people. Since high school, he has had no close friends and prefers solitary tasks. He
chose computers as a major in junior college because he feels that "computers are
more rational and easier to deal with than people" and after graduation obtained
employment as a computer programmer. He has no friends or hobbies, except
working on his computer, and has little contact with co-workers or his family. Eight
months ago, his performance at work, which was marginal but adequate, began to
decline. About this same time, he began to believe that his computer was trying to
communicate with him. Several times, he heard a voice that he is convinced was the
computer talking to him. This did not disturb him at first until he began to believe that
the computer was trying to control his thoughts. He was referred for inpatient
admission, was treated with antipsychotic medication, but showed little improvement.
Currently, it has been four months since the onset of his overt psychotic symptoms; he
continues to take antipsychotics on an outpatient basis but still believes that his
computer is trying to communicate with him. He has not returned to work and his
parents have been paying his bills for him. He presents as a quiet, shy, and aloof
young man who shows little if any emotion. Although it was suggested that he also
start individual therapy to work on establishing relationships and learning to express
feelings, he refused. There are no medical problems or history of substance abuse.

CASE C: PSYCHOTIC DISORDER CASE

DSM-IV

DSM-5

Axis I

295.30

Schizophrenia, Paranoid
Type

295.90

Schizophrenia

Axis II

301.20

Schizoid Personality
Disorder (premorbid)

301.20

Schizoid Personality Disorder

(premorbid)

Axis III

None reported

Axis IV

Unemployment,
inadequate social support

Axis V

GAF = 30 (current)

CASE C: DSM-5 SCHIZOPHRENIA

Optional Severity Specifiers

With optional severity specifiers

From Clinician Rated Dimensions of

Psychosis Symptom Severity
Delusions

295.90

Schizophrenia

301.20

Schizoid Personality Disorder

(premorbid)

Hallucinations
Disorganized speech
Abnormal psychomotor behaviors
Negative symptoms

0
1
2
3
4

SCALE: 0 - 4
Not present
Equivocal
Present, but mild
Present and moderate
Present and severe

CASE D: MOOD DISORDER CASE

A 30 year old man was transferred to a long term facility for longstanding feelings of depression.
History reveals that he first experienced a depressive episode at age 23. At that time, he was dysphoric,
hopeless, lost considerable weight due to lack of appetite, withdrew from all social contacts, and heard
voices, which he believed came from God, telling him he was being punished for past sins. His
condition was so severe that he was hospitalized for 2 months. He was tried on various antidepressants
with little success and was eventually given a course of ECT. He showed some partial improvement for 6
months or so, and his psychotic symptoms remitted. However, he became depressed again and has
been depressed on and off ever since. Currently, he has been depressed for at least 3 years without any
periods of remission of his symptoms. He has been experiencing severe depressed mood, insomnia,
poor appetite, fatigue, and feelings of worthlessness almost every day. He feels hopeless, has recurrent
suicidal ideation, although with no specific plan nor intent to act on his ideation, has little interest in
anything, and has no energy. He has not worked since age 23 and is receiving social security disability
benefits. Apparently, the man has never really been happy. History reveals that he felt dysphoric
throughout high school, long before he experienced the more severe depression in adulthood. He has
never had much energy, has always suffered from insomnia, and has had chronic feelings of low selfesteem. As a result, his functioning was always somewhat marginal; he had few friends, rarely dated,
and never established a career. There is no history of periods of elevated or irritable mood or history of
substance abuse. He has no significant medical problems.

CASE D: MOOD DISORDER CASE

DSM-IV
Axis I

296.33

300.4

Major Depressive Disorder,

Recurrent, Severe Without
Psychotic Features, Chronic,
Without Full Interepisode
Recovery
Dysthymic Disorder, Early
Onset

Axis II V71.09

No diagnosis

Axis III

None reported

Axis IV

Unemployment, limited
social support

Axis V GAD = 35 (current)

DSM-5
296.33 Major Depressive Disorder,
Recurrent episode, Severe

300.4 Persistent Depressive Disorder,

Early Onset, With persistent
major depressive episode,
Severe*
*criteria for MDD met throughout past 2
years. If had periods of remission but has
MDD episode now:
With intermittent major depressive
episodes, with current episode

CASE E: TRAUMA-RELATED DISORDER

CASE
A 40 YO man has recently brought by his parents for treatment at a VA hospital. The
man attributes all his problems to serving in the Middle East, where he witnessed
atrocities such as seeing children killed in an explosion. About 2 months ago, after
seeing a car accident, he started having flashbacks and nightmares of some of the
atrocities he witnessed while in the military. However, his family reported that he has
had difficulties since childhood. He was a non-compliant child who had behavioral
problems in early childhood, and was frequently involved in vandalism, stealing,
fighting and truancy in junior high school. In high school, his misbehavior progressed
to auto theft and serious fights, sometimes using weapons. His parents were hopeful
when he enlisted that he would "straighten out." Since his discharge from the
military, he mostly has been a "drifter," never settling down into a long term job or
relationship and usually spending his pay for nonessentials. He has no close friends
and usually winds up back at his parent's home asking for money and a place to live.
He is tense, irritable and hypervigilant, and has an exaggerated startle response and
poor concentration. With his parent's encouragement, he agreed to seek treatment at
the VA hospital. A physical exam performed at the time of admission revealed
hypertension.

CASE E: TRAUMA RELATED DISORDER

CASE
DSM-IV

DSM-5

Axis I

309.81

Posttraumatic Stress
Disorder, Acute, With
Delayed Onset

309.9

Unspecified Trauma- and

Stressor-Related Disorder

Axis II

301.7

Antisocial Personality
Disorder

301.7

Antisocial Personality
Disorder

Axis III

401.9

Hypertension, essential
(medical records)

401.9

Hypertension, essential
(medical records)

History of combat,
unemployment, lack of
stable home or social
support

V62.22 Exposure to Disaster, War or

Other Hostilities
* Not meet the avoidance sx
requirement; if met new criteria:
309.81 Posttraumatic Stress
Disorder, With delayed
expression

Axis IV

Axis V

GAF = 40

(current)

PTSD: DSM-IV vs. DSM-5

DSM-IV
A: stressor: need 2 of 2:
1) experienced, witnessed, or was confronted with
traumatic event and 2) intense fear, helplessness, or
horror.
B. traumatic reexperienced: need 1 of 5:
(1) Recurrent and intrusive distressing recollections;
(2) distressing dreams; (3) flashbacks; 4) Intense
psychological distress at exposure to cues; (5)
Physiological reactivity on exposure to cues
C. persistent avoidance of stimuli associated with
the trauma and numbing: need 3 of 7:
(1) Efforts to avoid thoughts, feelings; (2) Efforts to
avoid activities, places, or people; (3) Inability to
recall an important aspect of the trauma; (4)
Markedly diminished interest; (5) Feeling of
detachment /estrangement; (6) Restricted affect;
(7) Sense of a foreshortened future
D. persistent increased arousal: need 2 of 5:
(1) Difficulty falling /staying asleep; (2) Irritability/
outbursts of anger; (3) Difficulty concentrating; (4)
Hypervigilance; (5) Exaggerated startle response

DSM-5
A: stressor: need 1 of 4:
1) Direct exposure; 2) Witnessing,; 3) Indirectly, by
learning a close relative or close friend was exposed;
4) Repeated/extreme indirect exposure in the course
of professional job (not through media).
B: intrusion symptoms: need 1 of 5:
1) Recurrent, intrusive memories; 2) Traumatic
nightmares; 3) flashbacks; 4) Intense/prolonged
distress after exposure; 5) physiologic reactivity upon
exposure to cues
C: persistent effortful avoidance of distressing
trauma-related stimuli: need 1 of 2:
1) Trauma-related thoughts /feelings; 2) Traumarelated external reminders
D: negative cognitions/ mood: need 2 of 7:
1) Inability to recall key features of the trauma; 2)
negative beliefs about oneself, the world; 3) distorted
blame of self, others; 4) Persistent negative traumarelated emotions; 5) diminished interest; 6) Feeling
alienated, detachment/estrangement; 7) Constricted
affect
E: alterations in arousal and reactivity: need 2 of 6:
1) Irritable or aggressive behavior; 2) Self-destructive/
reckless behavior; 3) Hypervigilance; 4) Exaggerated
startle response; 5) Problems in concentration;
6) Sleep disturbance.

CASE F: SUBSTANCE DISORDER CASE

A 45 year old man sought treatment due to anxiety. He reported that about a year ago, he
had a very frightening episode in which his heart started to race and beat very hard, he
could not breathe, he had chest pains, and thought he was having a heart attack. He called
911 and was taken to the emergency room, but an EKG was normal and there was no
evidence of cardiac disorder hypertension, or respiratory disorders. He was told it was
anxiety, sent home with a prescription for xanax and told to take it when he started to feel
increased anxiety. Since that time, he has had several similar episodes in which he
experiences a sudden onset of intense fear that quickly builds to a peak. His heart pounds
and races, he feels dizzy and short of breathe, and he has terrible feelings of dread, like he
is going to die. He constantly worries about having one of these attacks, but the worry has
not kept him from going to work or leaving his home. However, the man admitted that he
has started drinking much more heavily over the past year, and reported that alcohol calms
his nerves better than the xanax. Although he has not had any legal problems related to his
alcohol use, he has started to frequently miss or be late for work, and his frequent
hangovers have affected the quality of his work. The man is a computer analyst and head
of the department. While he has always been attentive to details, his co-workers have
noticed a significant decline in his performance. Medically, the man is generally healthy,
although medical records indicate that he has carpal tunnel syndrome.

CASE F: SUBSTANCE DISORDER CASE

DSM-IV
Axis I

300.01
305.00

Panic Disorder without

Agoraphobia
Alcohol Abuse, rule out
Alcohol Dependence*

300.01 Panic Disorder

354.0

Axis II

V71.09

No diagnosis

Axis III

354.0

Carpal tunnel (medical

records)

Axis IV
Axis V

DSM-5

Work related problems

GAF = 60 (current)

305.00 Alcohol Use Disorder, Mild**

Carpal tunnel (medical records)

*several symptoms are possibly

present
** would be moderate if at least 4
symptoms were present

Notes. He sought treatment for his anxiety symptoms so it should be listed if you considered the
alcohol problem primary, you could list it first but you would have to put (reason for visit) next to the
Panic Disorder. You could also list the V code: (V62.29 Other Problem Related to Employment) for the
work related problems, especially in DSM-5 since there is no axis IV.

CASE G: NEUROCOGNITIVE DISORDER

CASE
A 55 YO man was brought to see his physician by his wife because of his increasing
difficulty functioning. The man had worked as a librarian in the rare document
department for the past 25 years but was being asked to take an early retirement due
to memory difficulties and inability to keep the documents properly catalogued.
Apparently, he was always an excellent worker because he was so orderly, organized
and perfectionistic; however, in other areas of his life, this preoccupation with details
often resulted in the point of the activity being lost and the task not being completed.
Moreover, he was always so devoted to his work that through the years, he never had
any friends and neglected his wife and all leisure pursuits. His wife had noticed that
during the past year or so he seemed to be having increased difficulty expressing his
thoughts, seemed forgetful and at times, and was confused. In addition, while he had
always dressed meticulously, he no longer seemed to care and was neglecting his
grooming. He became increasingly impaired and acted like he was lost in his own
home. She became very concerned when one day he wandered out of the house in
his pajamas and got lost in his own neighborhood. It was at that point that she
insisted he get checked out by his physician. The physician noted that aside from his
hypertension for which he had been prescribed medication, he was healthy.

CASE F: NEUROCOGNITIVE DISORDER

CASE
DSM-IV

DSM-5

Dementia Not Otherwise

Specified

799.59

Unspecified Neurocognitive
Disorder

Axis II 301.4

Obsessive Compulsive
Personality Disorder
(provisional)

301.4

Obsessive Compulsive
Personality Disorder
(provisional)

Axis III 401.9

Hypertension, Essential
(medical records)

401.9

Hypertension, Essential
(medical records)

Axis IV

Mandated early retirement,

limited social support

Axis I

294.8

Axis V GAF = 30 (current)

*If the etiology was due to a known

medical condition, list that diagnosis first
including the ICD-9-CM code. You could
also choose one of the possible major
cognitive disorders based on history:
Possible Major Neurocognitive Disorder
Due to Alzheimers Disease or Possible
Major Vascular Neurocognitive Disorder