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the qualifying statement
“Principal Diagnosis” indicated in parentheses.
AXIS III: GENERAL MEDICAL CONDITIONS
This axis permits the clinician to indicate any current physical disorder or condition that is
relevant to the understanding or management of the case. Sometimes these conditions have
clinical significance concerning the mental disorder. For example, a neurological disorder may be
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PSYCHOLOGY AND LIFE
strongly related to a patient’s manifestations of Senile Dementia.
AXIS IV: PSYCHOSOCIAL AND ENVIRONMENTAL PROBLEMS
This axis provides a scale, the “Severity of Psychosocial Stressors Scale,” that enables the clinician
to code the overall severity of psychosocial stressors that have occurred in the client’s life during
the preceding year and to evaluate their contribution to any of the following:
. development of a new mental disorder
. recurrence of a prior mental disorder
. exacerbation of an already existing mental disorder
Stressors often play a precipitating role in the appearance of a disorder, but they may also be a
consequence of the person’s psychopathology. A common situation is to have the Alcohol
Dependence of one partner in a marriage lead to marital discord and eventually divorce. The sum
of the separation and subsequent divorce (with all its attendant traumas) may progress to the
point of a Major Depressive Episode. Types of psychosocial stressors considered for rating on this
axis include:
. Conjugal (marital and nonmarital): engagement, marriage, discord, separation, divorce,
death of a spouse
. Parenting: becoming a parent, friction with a child, illness of a child
. Other Interpersonal: problems with one’s friends, neighbors, associates, nonconjugal
family members, illness of best friend, discordant relationship with one’s boss
. Occupational: work, school, homemaking, unemployment, retirement
. Living Circumstances: change in residence, threat to personal safety, immigration
. Financial: inadequate finances, change in financial status
. Legal: arrest, imprisonment, lawsuit, trial
. Developmental: phases of the life cycle, puberty, transition to adult status, menopause,
“becoming 30/40/50”
. Physical Illness/Injury: illness, accident, surgery, abortion
NOTE: A physical disorder is listed on Axis III whenever it is related to the development
or management of an Axis I or II disorder. A physical disorder can also be a psychosocial
stressor if its impact is due to its meaning (importance) to the individual. In that case, it
will be listed on both Axis III and IV.
. Other Psychosocial Stressors: natural or manmade disaster, persecution, unwanted
pregnancy, out-of-wedlock birth of a child, rape
. Family Factors (children and adolescents): in addition to the above, for children and
adolescents, the following stressors may be considered: cold, hostile, intrusive, abusive,
conflictual, or confusingly inconsistent relationships between parents or toward child;
physical or mental illness of a family member; lack of parental guidance or excessively
harsh or inconsistent parental control; insufficient, excessive, or confusing social
cognitive stimulation; anomalous family situation, complex or inconsistent parental
custody and visitation arrangements; foster family; institutional rearing; loss of nuclear
family members.
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CHAPTER 15: PSYCHOLOGICAL DISORDERS
AXIS V: GLOBAL ASSESSMENT OF FUNCTIONING
This axis allows the clinician to indicate his/her overall judgment of the individual’s
psychological, social, and occupational functioning on a scale (the Global Assessment of
Functioning Scale (GAF) that assesses mental health or illness. Ratings on the GAF are made for
two periods:
· Current: level of functioning at time of evaluation
· Past Year: highest level of functioning for a least at few months during the past year
For children and adolescents, this should include at least one month during the school year. The
ratings of current level of functioning generally reflect the current need for treatment or care.
Ratings of highest level of functioning within the past year are frequently prognostic, because the
individual may be able to return to his or her prior level of functioning, following recovery from
an illness episode.
Eve White and Eve Black
The most extreme form of dissociation is dissociative identity disorder (DID), formerly known as
multiple personality disorder. Until fairly recently, this disorder was thought to be rare.
However, within the past few years, we have reason to believe this disorder to be more pervasive
than originally thought. Ralph Allison, a therapist with extensive experience in treating this DID,
has long believed the actual incidence of this disorder to be much higher, with many cases going
undiagnosed (1
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