1. Record every mental diagnosis except Personality Disorders and Mental Retardation.
2. Nearly every patient will have one.
3. Indicate severity: Mild, Moderate, Severe, In Partial Remission, In Full Remission, Prior History.
Example: Patient diagnosed with Bipolar I Disorder and Alcohol Dependence.
1. For some patients it is the most important reason for seeking evaluation, as opposed to their Axis I classifications.
Example: From prior example, patient expresses two Axis I disorders, however has a more significant issue with a Mood Disorder (an Axis II disorder).
Axis III: Physical Conditions and Disorders:
1. Physical illness may have a direct effect on the patients Axis I diagnoses; especially true of cognitive disorders. In other cases, physical illness may affect (or be affected by) the management of an Axis I or Axis II disorder.
Example: A patient who is psychotic has a heart condition such as hypertension and consequently believes that the medication has poisoned her.
1. Condition that might affect the diagnosis or management of Axis I and/or Axis II disorder. This environmental problem may be independent of the disorder, or it may have caused the disorder.
2. Possibilities include problems regarding: Economy, Housing, Jobs, Schools, Legal Systems, Access to Health Care Services, Social Environment, Relationships with Primary Support Group, or Other Psychosocial Problems. (Note, see Transactional Ecological Framework)
Example: Patient who has Mood Disorder (Axis II) and Bipolar I Disorder with Alcohol Dependence (Axis I) has lost her drivers license as a result of 2 DUIs (driving under the influence). Because of this, she cannot go to work, and has therefore lost her health benefits.
Axis V: Global Assessment of Functioning (GAF)
1. The GAF score reflects the patient’s current overall occupational, psychological, and social functioning. It is not supposed to reflect the physical limitations or environmental problems. It is recorded as a single number on a 100-point scale. The scale specifies symptoms and behavioral guidelines to help you determine your patient’s GAF score. Perhaps because of the subjectivity inherent in this scale, its greatest usefulness may be in tracking changes in a patient’s level of functioning across time. The GAF scale is reproduced in its entirety on the back.
Source
DSM-IV Made Easy: The Clinician's Guide to Diagnosis. James Morrison.