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September 2013
Kaplan + Old trans  Psychiatric Classification
Science is the systematic classification of experience. And Rating Scales
George Henry Lewes
Read more
OUTLINE at http://www.brainyquote.com/quotes/keywords/classification.html#EZ54yTHR0K DSM-IV-TR
uzLAoK.99 PAGE
 Official psychiatric coding system used in the United States
I. Psychiatric Classification
 BASIC FEATURES:
A. DSM-IV-TR’s Relation to ICD-10 1
o DESCRIPTIVE APPROACH
B. DSM-IV-TR 1
 attempts to describe the manifestations of the
C. Basic Features 1
mental disorders and only rarely attempts to account
D. Multiaxial Evaluation 1
for how the disturbances come about.
E. Non-axial Format 2
 definitions of disorders usually consist of
II. Rating Scales
A. Characteristics 3
DESCRIPTIONS of clinical features
B. Rating scales used in DSM-IV-TR 3
o DIAGNOSTIC CRITERIA
 Specified diagnostic criteria are provided for each
specific mental disorder
CLASSIFICATIONS IN PSYCHIATRY  Include a list of features that must be present for the
 NOSOLOGY – classification of illnesses diagnosis to be made
 Systems of classification for psychiatric diagnoses  Such criteria INCREASES RELIABILITY of diagnostic
process.
 Has several purposes: o SYSTEMATIC DESCRIPTION
o To distinguish one psychiatric diagnosis from  Systematically describes each disorder in terms of its
another, so that clinicians can offer the most effective associated features: specific age-, culture-, and
treatment gender-related features; prevalence, incidence, and
o To provide a common language among health care risk; course; complications; predisposing factors;
professionals familial pattern; and differential diagnosis.
o To explore the still unknown causes of many mental
disorders. MULTIAXIAL EVALUATION
 The DSM-IV-TR is a multiaxial system.
 The two most important psychiatric classifications are the:  Evaluates patients along several variables and contains five
o Diagnostic and Statistical Manual of Mental axes.
Disorders (DSM) – developed mainly by the American AXIS I
Psychiatric Association (APA)
 Consists of clinical disorders and other conditions that
o International Classification of Diseases (ICD) –
may be a focus of clinical attention.
developed by WHO
Include:
 Disorders usually first diagnosed in infancy, childhood, or
HISTORY adolescence (Excluding Mental Retardation)
 Date back to Hippocrates, who introduced the terms  Delirium, dementia, and amnestic and other cognitive
mania and hysteria as forms of mental illness in the fifth disorders
century BC  Mental disorders due to a general medical condition not
 1869 elsewhere classified
o 1st US classification was introduced at the annual  Substance-related disorders
meeting of the American Medico-Psychological  Schizophrenia and other psychotic disorders
Association, which later became the AMERICAN  Mood disorders
PSYCHIATRIC ASSOCIATION (APA).  Anxiety Disorders
 1952  Somatoform disorders
o the APA’s Committee on Nomenclature and Statistics  Factitious disorders
published the first edition of DSM (DSM-I).  Dissociative disorders
o Five editions have been published since then:  Sexual and gender identity disorders
1. DSM-II (1968)  Eating disorders
2. DSM-III (1980)  Sleep disorders
3. DSM-III-R (1987), a revised DSM-III  Impulse-control disorders not elsewhere classified
4. DSM-IV (1994)  Adjustment disorders
5. DSM-IV-TR (TR=Text Revision) (2000)  Other conditions that may be a focus of clinical attention

DSM-IV-TR'S RELATION TO ICD-10 AXIS II

 DSM-IV-TR was designed to correspond to the 10th  consists of personality disorders and mental
revision of ICD (ICD-10), developed in 1992. retardation.
 habitual use of a particular defense mechanism can be
 Done to ensure uniform reporting of national and indicated on Axis II
international health statistics Include:
 Paranoid personality disorder
 Schizoid personality disorder
 ICD-10 is the official classification system used in
 Schizotypal personality disorder
Europe and many other parts of the world  Antisocial personality disorder
 Borderline personality disorder
 All categories used in DSM-IV-TR are found in ICD-  Histrionic personality disorder
10, but not all ICD-10 categories are in DSM-IV-TR.  Narcissistic personality disorder

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 Psychiatric Classification and Rating Scales

Continuation of Axis II….. AXIS V

 Avoidant personality disorder
 Dependent personality disorder
 Obsessive-compulsive personality disorder
 Personality disorder not otherwise specified
 Mental retardation
AXIS III
 any physical disorder or general medical condition
that is present in addition to the mental disorder
 Physical condition may be causative (e.g. kidney failure
causing delirium), the result of mental disorder (e.g.
alcohol gastritis secondary to alcohol dependence), or
unrelated to the mental disorder
 When a medical condition is causative or causally related
to a mental disorder, a mental disorder due to a general
condition is listed on Axis I, and the general medical
condition is listed on both Axis I and Axis III
 Ex. a case in which hypothyroidism is a direct cause of
major depressive disorder–the designation on Axis I is
mood disorder due to hypothyroidism with depressive
features, and hypothyroidism is listed again on Axis III.
Include:
 Infectious and parasitic diseases
 Neoplasms
 Endocrine, nutritional, and metabolic diseases and
immunity disorders
 Diseases of the blood and blood-forming organs
 Diseases of the nervous system and sense organs
 Diseases of the circulatory system
 Diseases of the respiratory system
 Diseases of the digestive system
 Diseases of the genitourinary system
 Complications of pregnancy, childbirth, & the puerperium
 Diseases of the skin and subcutaneous tissue
 Diseases of the musculoskeletal system and connective
tissue
 Congenital anomalies
 Certain conditions originating in the perinatal period
 Symptoms, signs, and ill-defined conditions
 Injury and poisoning
 a global assessment of functioning (GAF) scale in which
clinicians judge patients overall levels of functioning
during a particular time
 functioning is considered a composite of three areas:
a) social functioning
b)psychological
c) occupational functioning
 100 is the highest level of functioning in all areas
GAF Index
(taken from http://depts.washington.edu/washinst/
Resources/CGAS/GAF%20Index.htm)
 SUPERIOR FUNCTIONING in a wide rage of
activities.
91-100  Life's problems never seem to get out of hand,
is sought out by others because of his or her
many qualities.
 No symptoms.
 ABSENT OR MINIMAL SYMPTOMS
 Good functioning in all areas, interested and
90-81 involved in a wide range or activities, socially
effective, generally satisfied with life, no more
than everyday problems or concerns.
 If symptoms are present they are TRANSIENT
AND EXPECTABLE REACTIONS to psychosocial
80-71 stresses
 No more than slight impairment in social,
occupational, or school functioning
 Some MILD SYMPTOMS OR SOME DIFFICULTY
in social, occupational, or school functioning,
70-61
but generally functioning pretty well, has some
meaningful interpersonal relationships.
 MODERATE SYMPTOMS OR ANY MODERATE
60-51
DIFFICULTY in social, occupational, or school
functioning.
 SERIOUS symptoms OR any serious
50-41
impairment in social, occupational, or school
functioning.
 SOME IMPAIRMENT in reality testing or
communication OR major impairment in several
40-31
areas, such as work or school, family relations,
judgment, thinking, or mood.

AXIS IV  Behavior is considered influenced by

 Used to code the psychosocial and environment
problems that contribute significantly to the development
or exacerbation of the current disorder
 Evaluation of stressors is based on a clinicians’ assessment
of the stress that an average person with similar socio-
cultural values and circumstances would experience from
the psychosocial stressors
 JUDGEMENT is based on the amount of change that the
stressor causes in the person’s life, the degree to which the
event is desired and under the person’s control, and the
number of stressors
 Stressors may be positive (job promotion) or negative
(loss of a loved one).
Include:
 Problems with primary support group
 Problems related to the social environment
 Educational problems
 Occupational problems
 Housing problems
 Economic problems
 Problems with access to health care services
 Problems related to interaction with the legal
system/crime
 Other psychosocial and environmental problems
DELUSIONS OR HALLUCINATIONS OR
30-21
SERIOUS IMPAIRMENT in communications or
judgment OR inability to function in all areas.
20-11  Some DANGER OR HURTING SELF OR
OTHERS OR occasionally fails to maintain
minimal personal hygiene OR gross impairment
in communication.
 PERSISTENT DANGER of severely hurting self
or others OR PERSISTENT INABILITY to
10-1
maintain minimum personal hygiene OR serious
suicidal act with clear expectation of death.
NON-AXIAL FORMAT
 Simply list the appropriate diagnoses.
 General rule of recording should be followed as many
coexisting mental disorders, general medical conditions,
and other factors that are relevant to the care and
treatment of the individual.
 PRINCIPAL DIAGNOSIS or THE REASON FOR VISIT
should be listed first.
Sample Exercises for Multiaxial Classification at the end
of this Trans. –courtesy of upper batch trans 

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 Psychiatric Classification and Rating Scales

PSYCHIATRIC RATING SCALES  Most pathological defense mechanisms:

 Questionnaires, interviews, checklists, outcome  Denial
assessments, and other instruments used by psychiatrists  Acting-out
and mental health professionals to aid in treatment  Projection
planning by helping to establish a diagnosis, identify  Projective identification
comorbid conditions, and assess levels of functioning
 Aid clinicians by helping them to confirm their diagnoses or 5. Other Scales
clarify their thinking in ambiguous situations. a. Brief Psychiatric Rating Scale (BPRS)
 Provide a baseline for follow-up of the progress of an illness  Short scale used to measure the severity of
over time or in response to specific interventions. psychiatric symptomotology
 Used for decades as an outcome measure in
treatment studies of schizophrenia
CHARACTERISTICS OF RATING SCALES
 Most useful for patients with fairly significant
 Can be specific or comprehensive impairment (please refer to Table 9.2-5 of Kaplan)
 Can measure both internally experienced variables (e.g.,
mood) and externally observable variables (e.g., behavior) b. Hamilton Rating Scales for Depression and
 Specific scales: measure discrete thoughts, moods, or Anxiety (HAM-D and HAM-A)
behaviours  Used to monitor the severity of depression and
 Comprehensive scales: measure broad abstractions, such anxiety
as depression and anxiety  Scored from 0 to 4 with total scored of above 9
considered the borderline of pathology
OTHER CHARACTERISTICS  Useful to measure the effects of treatment,
1. Time covered particularly with pharmacologic agents (please refer
 Must be specified to Tables 9.2-6,9.2-7 of Kaplan)
 The rate must adhere to this period
2. Level of judgment required c. Scales for the Assessment of Positive Symptoms
3. Method of recording answers (SAPS) and Assessment of Negative Symptoms
 The most reliable rating scales require a limited amount (SANS)
of judgment or inference on the part of the rater.  Measure negative and positive symptoms in
 The actual answer given can be recorded as schizophrenia
 Dichotomous variable: true or false, present or  Primarily used in research to measure change
absent induced by psychopharmacologic agents over the
 Continuous variable: may ask the rater to choose a course of treatment (please refer to Tables 9.2-
term to describe the severity (absent, slight, mild, 8,9.2-9 of Kaplan)
moderate, severe, or extreme) or frequency (never,
rarely, occasionally, often, very often, or always). d. Positive and Negative Syndrome Scale (PANSS)
 Also measures negative and positive symptoms of
RATING SCALES USED IN DSM-IV-TR schizophrenia and other psychotic disorders
1. Global Assessment of Functioning (GAF) Scale  Standard tool of assessing clinical outcome in
 Axis V in DSM-IV-TR uses the GAF scale. treatment studies of schizophrenia
 Used to report a clinician's judgment of a patient's
overall level of functioning
 Information is used to decide on a treatment plan and EXAMPLES FROM THE BOOK
later to measure the plan's effect (Note from upper batch trans: Wala talagang case sa book,
examples lang agad na nakaspecify na by axis, so di ko sure
2. Social and Occupational Functioning Assessment kung tama yung cases hehe :P)
Scale (SOFAS)
 Used to track a patient's progress in social and
occupational areas (please refer to Table 9.2-2 of Case 1:
Kaplan)
 Independent of the psychiatric diagnosis and the Major depressive disorder, severe, no psychotic feautures,
severity of the patient's psychological symptoms single episode
Alcoholic
3. Global Assessment of Relational Functioning (GARF) May possibly lose job
 Measures the overall functioning of a family or other Denies having a problem
ongoing relationship Impaired judgement
 An important measurement because the development Dependent personality disorder
of mental illness is higher in dysfunctional families and
recovery is slower in the absence of a supportive social Axis I Major depressive disorder, single
network (please refer to Table 9.2-3 of Kaplan) episode, severe without psychotic
features
4. Defensive Functioning Scale (DFS) Alcohol abuse
 Covers the defense mechanisms used by the patient to Axis II Dependent personality disorder
cope with stressors Frequent use of denial
 Healthiest defense mechanisms: Axis III None
 Humor
Axis IV Threat of job loss (current)
 Suppression
 Anticipation Axis V GAF = 35
 Sublimation

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 Psychiatric Classification and Rating Scales

Case 2
Case 2: Axis I: Autistic
Axis II: none
A child was brought to the ER due to recurrent otitis media. Axis III: none
Signs of neglect were evident. Psych evaluation noted Axis IV: none
dysthymic disorder and reading difficulties causing some Axis V: below 50
problems in school
Case 3
Axis I Dysthymic disorder Axis I: Bipolar I, MRE manic
Reading disorder Axis II: none
Axis III: none
Axis II No diagnosis
Axis IV: Failed board exam, Insomnia
Axis V: below 50
Axis III Otitis media, recurrent
Axis IV Victim of child neglect (current) Case 4
Axis V GAF = 53 Axis I: Methamphetamine dependence
Axis II: Antisocial personality
Axis III: Hypertension
Case 3: Axis IV: Unemployed, financially dependent on parents,
friends and lovers
A patient with hypothyroidism was admitted for a possible Axis V: ?
mood disorder, with depressive symptoms. The patient also
had chronic angle-closure glaucoma and histrionic personality *****************END OF TRANS********************
disorder causing severe impairments in social functioning
Note: Ung mga may “please refer to Table… in Kaplan”, may
Axis I Mood disorder due to hypothyroidism, sample kasi dun ng bawat scale na masyadong toxic pag
with depressive features sinama dito, but if you want to check it out, then do so.

Axis II No diagnosis, histrionic personality  Sources: Kaplan and Upper Batch Transes. 
features
Axis III Hypothyroidism
Chronic angle-closure glaucoma
Axis IV None
Axis V GAF = 45

SAMPLE EXERCISES
Case 1
Schizoprenic, paranoid type
Diabetes Mellitus
Estranged husband
Irritable, cannot go to work

Case 2
Autistic
Idle, requires full supervision

Case 3
Bipolar I, MRE manic
Failed board exam
Insomnia
Up all night, boisterously disruptive, uncooperative

Case 4
Antisocial personality
Methamphetamine dependence
Hypertension
Unemployed, financially dependent on parents, friends and
lovers

ANSWERS:

Case 1
Axis I: Schizoprenic, paranoid type
Axis II: none
Axis III: Diabetes Mellitus
Axis IV: Estranged husband, irritable, cannot go to work
Axis V: below 50

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