DSM

The DSM  works on a 5 axes diagnoses in order to best show the client’s clinical information

Axis I: Clinical Disorders except Personality and MR (or Intellectual Disabilities as is the new PC term) & other conditions that may be a focus of Clinical attention

Axis II: Personality Disorders and MR (or Intellectual Disabilities as is the new PC term)

Axis III: General Medical Conditions

Axis IV: Psychosocial and Environmental factors

Axis V: GAF – level of functioning in past 12 months – There may also be indications of (at admission) (at discharge) (current) (highest level in past year)

It is also important to note that typically there is a primary diagnosis present and this is the one for which the current intervention is needed. It can also be determined by the age of onset typically with the mental health illness that was first present being primary diagnoses or determined by the one that affects the functioning of the client that most (which will most likely be the one for which the intervention was needed anyway). The principal diagnosis is indicated by listing it first.

Mental Health diagnoses may be in remission, either partial or full, or may be recovered. If it is in remission, an indication of partial remission means that some of the symptoms are still present. In full remission means that none of the symptoms are present but is kept in the diagnoses due to the intervention still taking place. A diagnosis has been recovered if symptoms are not present and intervention is not occurring anymore. Then it is noted as recovered or Prior History but is kept as a notation of the client’s history and records. There can also be a recurrence in which symptoms of the disorder become present again after remission or even after it has been noted as Prior History.

 

Mental health illnesses may also be mild, moderate, or severe depending on the effect on client’s functioning.  Mild indicates that while the criteria is met, there are few if any additional symptoms for the diagnosis. Moderate is the mid ground between mild and severe. Severe means there are many symptoms beyond the minimum that are met for diagnosis. Severe can also mean that the symptoms result in significant impairment of functioning in social or occupational domains. 

Diagnoses may also be provisional if it is thought that the full criteria may be reached but there may not be enough information. This is diagnosed due to history of client.

NOS (Not Otherwise Specified) means that the symptoms are there for general diagnosis but not any of the outlined specific disorders

American Psychiatric Association. (2000). Diagnositc and Statistical Manual of Mental Disorders Text Revision, 4^th ed. Jaypee Brothers Medical Publishers.