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Chapter: Medicine Study Notes : Psychological Medicine

DSM IV Classification

Published 1994, replaces Diagnostic and Statistical Manual of Mental Disorders III and III-R

DSM IV Classification


·        Published 1994, replaces Diagnostic and Statistical Manual of Mental Disorders III and III-R


Diagnostic Axises


·        Axis 1: Clinical Disorders eg major depression, adjustment disorder, schizophrenic disorder. Basis in medical model


·        Axis 2: personality disorder or traits and mental retardation. More blurred distinction between person and pathology

·        Axis 3: General Medical Conditions (physical disorders and conditions)


·        Axis 4: Psychosocial and Environmental Problems (eg severity of psychosocial stressors, problems with primary support group, social environment, educational, occupational, housing, economic, access to health care system)


·        Axis 5: global assessment of functioning (eg in the previous year)


Diagnostic Classes



Using DSM Diagnoses*


·        In DSM IIIR, “Delirium, Dementia and Amnestic and Other Cognitive Disorders”, “Mental Disorders Due to a General Medical Condition” and “Substance-Related Disorders” were grouped under the single heading “Organic Mental Syndromes and Disorders”. “Organic mental disorder” is no longer used as it implies other disorders don‟t have a biological basis

·        Qualifiers on Diagnostic codes:


o  Severity and course specifiers: mild, moderate, severe, in partial remission, in full remission, prior history of (ie have had full recovery)


o  Principal diagnosis/Reason for visit: if more than one diagnosis, which one was the principle one leading to admission/contact. Difficult to determine in dual diagnosis (substance related + non-substance related). Multiple diagnoses can re reported in multiaxial fashion


o  Provisional: when strong assumption that criteria will be meet, but insufficient evidence currently available

·        Not-otherwise specified used when:

o  Symptoms below clinical threshold or there is an atypical or mixed presentation

o  Symptom pattern is not included in DSM IV


o  When there is uncertainty about aetiology: eg whether it is due to a general medical condition, is substance induced or is primary

o  There is incomplete or inconsistent information

·        Frequently used criteria – to exclude or suggest differential diagnoses:

o  Criteria have never been/are not meet for…

o  Does not occur exclusively during the course of…


o  Not due to the direct physiological effects or a substance of a general medical condition – ie these have had to have been considered and ruled out

o  Not better accounted for by…

·        These criteria establish a hierarchy:


o  Disorders due to a general medical condition or substance-induced disorder pre-empts diagnoses of primary disorder with the same symptoms (eg Cocaine-induced mood disorder pre-empts Major Depressive Disorder)


o  A more pervasive disorder pre-empts diagnosis of a less pervasive disorder with a subset of the symptoms of the more pervasive disorder (eg Less pervasive disorder will have „Criteria have not been meet for [the more pervasive disorder])


o  When there are very difficult diagnostic boundaries, use „not better accounted for‟ to permit use of clinical judgement

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