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INTRODUCTION TO DSM-IV
Michael W. Kahn, M.D
1. What is the conceptual orientation of DSM-IV?
The Diagnostic and Statistical Manuals (DSM) are handbooks developed by the American Psychiatric Association. They contain listings and descriptions of psychiatric diagnoses, analogous to the International Classification of Diseases manuals. The DSMs have changed as the prevailing concepts of mental disorder have changed. DSM-I (1952) reflected Adolf Meyers influence on American psychiatry, and classified mental disorders as various reactions to stressors. DSM-I1 (1 968) dropped the reactions concept, but maintained a perspective strongly influenced by psychodynamic theory. DSM-I11 (1980) marked a watershed in the development of the classification system, in that it outlined a research-based, empirical, and phenomenologic approach to diagnosis, which attempted to be atheoretical with regard to etiology. DSM-IV continues this tradition, which may be characterized as the biologic or syndromal approach to diagnosis.

2. What is the purpose of the multiaxial system?

The five-axis classification system was developed to provide a systematic framework for the thorough, descriptive assessment of a patients psychiatric condition and overall functioning. The axes are: Axis I: Clinical disorders Axis 111: General medical conditions Axis I V Psychosocial and environmental problems Axis 11: Personality disorders, Axis V Global assessment of functioning mental retardation

3. What are the characteristics of axis I disorders? Axis I diagnoses comprise those clinical syndromes that generally develop in late adolescence or adulthood. Schizophrenia, bipolar disorder, panic disorder, posttraumatic stress disorder, and alcohol abuse are diagnoses coded on axis I. One can think of axis I diagnoses as illnesses, as opposed to the persistently maladaptive behavior patterns that characterize personality disorders.
4. How do axis I disorders differ from axis I1 disorders? Axis I1 comprises personality disorders and mental retardation. Maladaptive personality traits and behavior problems also are noted on axis I1 (see Question 7 below).

5. Can one make multiple diagnoses on axes I and II?

Definitely. A patient with well-controlled schizophrenia may develop a problem with alcohol abuse, and would therefore warrant both diagnoses on axis I. A patient with mental retardation may also meet criteria for obsessive-compulsive personality disorder, and would therefore receive both diagnoses on axis 11. Several diagnoses can be included on each axis.

6. What if a patients signs and symptoms dont fit neatly into one or more categories? Several ways exist to deal with this very common situation. On axis I, most clinical syndromes described have one variant called [syndrome name] not otherwise specijied (NOS). Psychosis NOS, adjustment disorder NOS, and bipolar disorder NOS are diagnoses for when not all criteria characterizing a given syndrome are met, but that syndrome seems closest to describing the patients difficulties. If the clinical picture is even less clear, you can defer the diagnosis on either axis I or I1 until you are able to gather the information for a more definitive diagnosis. The code for a deferred diagnosis on either axis I or I1 is 799.90.
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Introduction to DSM-IV

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Finally, you can make a provisional diagnosis if enough information is available to make a reasonable formulation, hut some doubt or uncertainty remains. Simply write provisional after the suspected diagnosis.

7 . Do these issues apply to personality disorders as well?

Yes. If a patient seems to have several of the characteristics of, for example, antisocial personality disorder, but does not meet all criteria for that diagnosis, you can record that the patient has antisocial traits. Likewise, a patient may have traits of more than one personality disorder; in this situation, you would make a diagnosis of, for example, mixed personality disorder with borderline and histrionic traits.

8. How does axis I11 function? Axis I11 primarily records medical problems relevant to the ongoing treatment of the patient.
Examples are glaucoma in a patient requiring antidepressants, asthma in a patient with anxiety who is taking theophylline, AIDS in a patient with new-onset psychosis, and cirrhosis of the liver in a patient with alcohol dependence.

9. What about axes IV and V?

Axis IV records psychosocial stressors encountered by the patient within the previous 12 months that have contributed to (1) the development of a new mental disorder; (2) the recurrence of a previous mental disorder; or (3) the exacerbation of an ongoing mental disorder. The stressor should be described in as much detail as needed to indicate how it affects the patients functioning. Even mild stressors should be noted if they figure into the clinical presentation. Axis V records the patients global level of functioning both at the time of evaluation and during the past year. The clinician consults the Global Assessment of Functioning (GAF) scale in the manual and determines the patients current GAF score as well as the highest one obtained during a relatively prolonged period within the past year. Global Assessment of Functioning 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. Code (Note: Use intermediate codes when appropriate, e.g., 45,68, 72.) 100 Superior functioning in a wide range of activities, lifes problems never seem to get out of I hand, is sought out by others because of his or her many positive qualities. 91 No symptoms 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, generally satisfied with life, no more than everyday problems or concerns (e.g., an occasional argument with family 81 members.) 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, 7 1 occupational, or school functioning (e.g., temporary falling behind in schoolwork). 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 6 1 generally functioning pretty well, has some meaningful interpersonal relationships. 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 51 with peers or co-workers). 50 Serious 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 41 to keep a job). Table continued on following page.

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Introduction to DSM-IV
Global Assessment of Functioning Scale (Cont.)

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 31 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). Behavior is considerably influenced by delusions or hallucinations OR serious impairment in communication or judgment (e.g., sometimes inchoherent, acts grossly inappropriately, suicidal 21 preoccupation) OR inability to function in almost all areas (e.g., stays in bed all day; no job, home, or friends). 20 Some danger of hurting self or others (e.g., suicide attempts without clear expectation of death; frequently violent; manic excitement) OR occasionallyfails to maintain minimal personal hy11 giene (e.g., smears feces) OR gross impairment in communication (e.g., largely incoherent or mute). 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 1 of death. 0 Inadequate information. The rating of overall psychological functioning on a scale of 0-100 was operationalizedby Luborsky in the Health-SicknessRating Scale (Luborsky L: Cliniciansjudgments of mental health. Arch Gen Psychiatry 7: 407417, 1962). Spitzer and colleagues developed a revision of the Health-SicknessRating Scale called the Global Assessment Scale (GAS) (Endicott J, Spitzer RL, Fleiss JL, Cohen J: The global assessment scale: A procedure for measuring overall severity of psychiatric disturbance.Arch Gen Psychiatry 33:766-77 1, 1976). A modified version of the GAS was included in the DSM-111-R as the Global Assessment of Functioning (GAF) Scale.

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10. Does the DSM system provide a good way to diagnose psychiatric disorders? Compared to what? This is a thorny question. So long as psychiatry lacks definitive tests to diagnose illness, arguments about which criteria should form the basis of the diagnostic system will continue to flourish. The publication of DSM-I11 in 1980 was widely hailed both inside and outside the field for at last providing diagnoses that relied on what people obsewed rather than what they believed on the basis of theory. A wide variety of mental health (and general medical) practitioners found that DSM-I11 provided a straightforward, comprehensible, and user-friendly tool for making sense of (or at least classifying) psychopathology. The DSM system has some clear shortcomings, however, and some well-regarded clinicians have called it parochial, reductionistic, adynamic (i.e., not sensitive to the dynamic hypothesis mentioned above), and clumsy in its difficulty distinguishing between state and trait behaviors. The DSM system was designed to have high reliability among different raters; that is, it was fashioned so that two different clinicians would likely arrive at the same diagnosis for a given patient. Yet it is clear that reliability and validity of diagnosis remain distinct. Some would say that the DSM system favors the former at the expense of the latter; others would reply that so long as validity remains elusive, we should do our best to at least improve reliability, which can be empirically tested in field trials. DSM-IV creates some problems and helps to solve others. A nondogmatic, open-minded, and pragmatic approach to this complicated issue probably serves patients best. BIBLIOGRAPHY
1. American Psychiatric Association: Diagnostic and Statistical Manual-IV. Washington, D.C., American

Psychiatric Association, 1994. 2. Klerman GL, Vaillant GE, Spitzer RL, Michels R: A debate on DSM-111. Am J Psychiatry 141:4, 1984.