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Neurotic, Psychotic
or Just Plain Nuts?
A Primer of Mental
Health Classification
© Vicky Campagna, PhD
For a pdf copy of this article,
click here
Mental
health clinicians---all of us, psychologists, psychiatrists,
master’s level practitioners---use the same classification system when
diagnosing someone’s mental health. DSM-IV (Diagnostic and Statistical
Manual of Mental Disorders---4th Edition) is our “diagnostic
Bible” intended to provide a global picture of the individual’s
functioning. A thorough mental health evaluation should include a
classification on each of the five axes of DSM-IV: each axis
represents a different aspect of functioning. DSM reflects a
“biopsychosocial model,” i.e. a conception of the individual as
reflecting biological, psychological and sociological influences. And
isn’t that the way things really are? We’re all the product of the
many forces that impinge upon us. (By the way, DSM, although it is
used by all mental health professions to make a diagnosis, is not
universally acclaimed! See my article elsewhere on this website titled
“Is Diagnosis Useless in Litigation?”)
What IS DSM?
Each
of the five axes of DSM is designed specifically to address one part of
the biopsychosocial model:
Axis I is for all clinical (mental) disorders other than Personality
Disorders (which are coded on Axis II). It includes such disorders as
bipolar disorder, schizophrenia, the mood disorders, disorders usually
diagnosed first in childhood, and also includes disorders of eating,
sleeping, sexuality, impulse control, adjustment disorders and “V
Codes.” All these are described below. Axis I conditions generally
occur at a given point in an individual’s life, i.e. they are not
lifelong styles, as are the disorders in Axis II.
Axis II is devoted to conditions that are generally life-long.
These include personality disorders and mental retardation. These are
not considered mental illnesses but may (in the case of personality
disorders, for example) reflect maladaptive functioning that could
have a bearing on the legal case.
Axis III reflects physical factors that affect emotional
well-being. For instance, a diagnosis of cancer might cause someone to
develop major depression.
Axis IV is concerned with any psychosocial stressors that may be
impacting emotional well-being. Such stressors as unemployment, family
problems, homelessness, lack of social support, and so forth, often
co-exist with (and may even partially cause) emotional difficulties.
Axis V is where everything is put together. In other words, all
things considered, how well did this individual function over the past
year? This is known as a Global Assessment of Functioning or
GAF. The score can range anywhere from 1 (indicating “persistent
danger of hurting self or others or persistent inability to maintain
minimal personal hygiene”) to 100 (which is “superior functioning in a
wide range of activities…no symptoms”) to any number in between. There
are descriptions of typical behaviors at each increment of 10, but the
precise number is a matter of clinical judgment.
It’s important to be
aware that an individual may have more than one disorder simultaneously.
Someone may even have multiple diagnoses on each axis. These disorders
are in no way mutually exclusive, and it is not uncommon at all for
someone to have diagnoses on each axis. And DSM recognizes that it
might not always be able to capture the essence of the individual’s
disturbance with one of its ready-made diagnostic categories.
Therefore, most diagnoses include the option to specify it as being
“NOS” which means “not otherwise specified.” This indicates the person
has a general presentation in this category but some details are missing
or different from the usual clinical picture.
AXIS I Disorders
Axis I
is subdivided into specific diagnostic categories. These are:
1)
Substance-related disorders
(which is further subdivided into issues of abuse or dependence of any
substance. Generally, only alcohol and drugs are diagnosed in this
manner, but in fact, DSM considers that one can have a diagnosable
problem with even caffeine or nicotine!) And dependence and abuse
problems are defined differently.
2)
Schizophrenia and other psychotic disorders
A psychosis is a mental illness that
involves a break with reality. There are many kinds of psychoses, and
most have subtypes. For instance, schizophrenia is a psychosis that can
manifest as several different subtypes, each with its own set of
symptoms. These subtypes have symptoms in common, and also have
symptoms that are specific to that subtype. Common symptoms include
problems with social functioning, disturbance in thinking, loss of
emotional expression, delusions or hallucinations and other symptoms.
But schizophrenia is not
the only mental illness characterized by a break with reality. Other
psychotic disorders include schizoaffective disorder (a combination of a
thought disorder and mood problems), delusional disorder (the delusions
here are not bizarre
ones!), brief psychotic
disorder (by definition, less than one month in duration), shared
psychotic disorder (where two people share a delusional system) and
substance-induced psychosis ( a psychosis directly caused by use of a
substance, such as alcohol or drugs).
3)
Mood Disorders
There are several types of
mood disorders, but two are the most frequently encountered: One of
these is bipolar disorder (which used to be called manic
depression) in which the individual experiences alternating periods of
depression and elation, called mania. (There is also a variation of
bipolar disorder that includes depression and a much subtler form of
mania that is not as flamboyant as the usual mania.) The interval
between the moods varies widely, and the shift can be very subtle.
While manic, the person might spend a great deal of money s/he does not
have, do socially inappropriate things, and act self-destructively and
very impulsively. When depressed, that same person might be unable to
get out of bed, lose all appetite (or eat non-stop), have difficulty
sleeping (or sleep constantly). The individual bounces back and forth
between two opposite poles of extreme emotion. And it’s important to
know that bipolar can be so severe (although it certainly is not
always) that it can involve a break with reality. This can be a tricky
diagnosis to make, because in its more subtle forms, the individual may
appear quite “normal.”
Another extremely common mood disorder
is major depression. This illness is different
from the “blues” which has been called the common cold of
mental health. Major depression is incapacitating and can be
life-threatening. The sufferer experiences major changes in appetite
and sleep, becomes socially isolated and may neglect
personal hygiene. Well-meaning friends and family may tell the
individual to “snap out of it” but the individual cannot do so without
professional intervention.
There are other forms of
depression as well. One of the more serious variants is major
depression with psychotic features. This is depression in which the
individual may be hearing voices or having some other sort of experience
that indicates a disconnection from reality.
Anxiety disorders
are yet another kind of mood disorder. They have several variations,
including panic disorder (in which the individual experiences
discrete episodes of panic, accompanied by specific physical symptoms
and may or may not be afraid to leave home for fear another attack will
occur) and phobias of all sorts (defined as “a marked and
persistent fear that is excessive and unreasonable, cued by the presence
or anticipation of a specific object or situation” such as flying, dogs,
fear of small, enclosed spaces, etc. It is theoretically possible
(though uncommon) to develop a phobia about anything.
Generalized anxiety
disorder refers to marked
worry, occurring daily for 6 months or longer, about a variety of
subjects. The individual has at least 3 symptoms from the list provided
in DSM. A separate diagnosis is anxiety disorder due to a medical
condition. Also separate is the diagnosis of substance-induced
anxiety disorder, which is what its name implies.
One anxiety diagnosis that
is probably quite familiar to those of you involved in personal injury
litigation is that of PTSD (Post Traumatic Stress Disorder). Few
diagnoses are cited so frequently and yet are so poorly understood.
PTSD is discussed in depth in my paper elsewhere on this website:
“PTSD: The Misunderstood Diagnosis.”
4)
Impulse Control Disorders
People with these problems have great trouble reining in their impulse
for behaviors that are destructive. Included are behaviors like
fire-setting, stealing, compulsive gambling, explosive temper,
hair-pulling and that old stand-by, Impulse Control NOS.
5)
Disorders Usually First Diagnosed in Infancy, Childhood or Adolescence
Here you will find disorders
like Learning Disabilities, Communications Disorders, and disorders
which affect the individual’s entire functioning, such as autism.
6)
Somatoform Disorders
are
those disorders in which emotional problems are manifested by physical
symptoms. The individual is not consciously aware of the
underlying emotional issue.
7)
Factitious Disorders
are
similar to Somatoform Disorders in that they involve emotional problems
expressed by physical symptoms. The key differentiation is that with a
Factitious Disorder, the individual is intentionally feigning the
illness. S/he wants to assume the role of an ill person, but
there is not any clear benefit (e.g. litigation).
8)
Dissociative Disorders
is
the correct name for the over-used and very poorly-understood term
“multiple personality disorder.” This is an extremely rare
condition that involves some form of disassociation from one’s identity.
9)
Sexual
and Gender Identity Disorders
do not include homosexuality, which is not considered to be any
form of a mental illness. Note, however, that the individual may be
experiencing depression or anxiety due to his/her sexual orientation,
but that diagnosis focuses on the symptoms, not on the homosexuality per
se. The illnesses in this category include various disorders of sexual
functioning (e.g. erectile dysfunction), paraphilias (disturbance re:
the object of one’s sexual desire, such as sadism, exhibitionism,
fetishism, etc.)
10)
Eating
Disorders
include anorexia
and bulimia and, of course, Eating Disorder NOS.
11)
Sleep
Disorders envelope a wide
variety of sleep problems, from garden-variety insomnia to night terrors
and many other diagnoses in between.
12)
Adjustment Disorders are
very important to understand, because not infrequently conditions which
should be given this diagnosis are misdiagnosed as being
something else. An adjustment disorder is the development of emotional
problems in response to an identifiable stressor, occurring within 3
months of the onset of that stressor. If someone, for instance,
becomes depressed because s/he has been fired, a diagnosis of
“adjustment disorder with depressed features” would be the correct
diagnosis unless the individual meets other requirements that would
indicate a diagnosis of Major Depression.
Also
included in Axis I are “other conditions that may be a focus of clinical
attention.” These are things that may cause the individual some
distress, but which are not considered mental illnesses by themselves.
Examples include malingering, antisocial behavior, bereavement and
problems with acculturation. There are many more such examples in
DSM and they’re called “V Codes.”
AXIS II Disorders
Axis II is comprised of two
categories: mental retardation and personality disorders. The first
category is probably familiar to you: it refers to persons whose
intelligence falls below a specific level, referred to as an
Intelligence Quotient or IQ. A personality disorder is an enduring
and pervasive style of interacting with the world that “deviates
markedly from the individual’s culture.” This behavior must lead to
“clinically significant distress or impairment in social, occupational,
or other important areas of functioning.” Typically, persons with
personality disorders do not believe that they themselves have a
psychological problem: they generally think the rest of the world ought
to shape up, however! In other words, they think that all the problems
they encounter in their daily interactions are due solely to the
other person’s behavior. Because they don’t see their own
responsibility for the problem, people with personality disorders are
usually not too amenable to treatment; instead, it generally takes a
crisis of some sort to get them into therapy.
There are 3 main “clusters”
of personality disorders: avoidant/fearful, dramatic/emotional,/erratic,
and odd/eccentric.. And within those clusters, there are several
specific types.
Cluster A (Anxious/fearful):
These
are marked by avoidant or fearful symptoms, and include these disorders:
Paranoid:
pervasive mistrust and suspiciousness of others. This person is always
quick to impute the most sinister motivation to others’ behaviors.
Avoidant:
Like the Schizoid and Schizotypal person, the individual with Avoidant
Personality Disorder feels uncomfortable around other people. But
unlike the other types, the Avoidant personality is hypersensitive to
any criticism, and really wants to interact with others; s/he is just
too worried and inhibited.
Dependent:
This individual is defined by his/her preoccupation with being taken
care of, and thus, clings and is submissive to others. Decisions are
very difficult, disagreements are rare, and being alone leads to
feelings of discomfort.
Obsessive-Compulsive:
Here’s the individual who is preoccupied with order and cleanliness and
control, to the point where all flexibility is lost.
Cluster B (dramatic, emotional,
erratic): In this group are
the more flamboyant personality disorders:
Antisocial:
This individual has no regard for the rights and needs of others and
disregards them in favor of his own wishes. There is a tendency towards
deceitfulness, irresponsibility, nonconforming behavior and a complete
lack of remorse for any problems his behavior may cause
Borderline:
The person with this disorder does not have a solid core sense of
personal identity and often displays wildly fluctuating moods, with
anger and fear of abandonment being among the most prominent.
Narcissistic:
The narcissist is known by his or her excessive need for admiration,
overblown feelings of importance, sense of entitlement and a deficit of
empathy for others’ feelings and needs.
Cluster C (Odd,
eccentric): The people in
this group are more easily spotted
due to their obvious peculiarities.
Schizoid:
detachment from others and a reduced range of feelings. This is the
classic “loner” who really does not enjoy either people or most
activities, and who rarely shows any emotions.
Schizotypal:
Like the Schizoid personality disorder, the Schizotypal person does not
feel comfortable around others and indeed, has a reduced capacity for
human relationships. But the Schizotypal person displays eccentricities
in dress, behavior or thinking and may have some clearly “odd” beliefs.
AXIS III
On this axis, we code any
medical conditions that might be important to the understanding or
management of the individual’s mental health. For example, if a person
has an AIDS-related dementia, the diagnosis of AIDS goes on Axis III.
AXIS IV
We all know that the events
around us help to shape how we feel. For instance, the day you get a
big promotion, you’re likely to be in a pretty good mood. Conversely,
if you’re homeless and have few friends, you’re just as likely to feel
pretty lousy. Those psychosocial or environmental stressors
which have been present during the past year are listed on this axis.
These stressors can be many types, including occupational problems,
economic problems, problems related to the legal system, etc. and have
an impact of unknown strength on the subject's emotional health.
AXIS V
This is the individual’s
GAF score: Global Assessment of Functioning. It is a numerical value
which can range from 0 (Inadequate information) to 50 (“Serious symptoms
or any serious impairment in social, occupational or school
functioning”) to 100 (“Superior functioning in a wide range of
activities, life’s problems never seem to get out of hand, is sought out
by others because of his or her many positive qualities. No symptoms.
Any number in between may be assigned, and while the specific number
chosen is up to the clinician’s opinion of the client’s overall
functioning, the number chosen should reflect what has been learned
from the first 4 axes.
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