All disorders and conditions in the DSM-IV have unique codes
Some codes allow specification of the features and intensity of the disorder using the one or two digits to the right of the decimal.
These codes allow the clinician to specify:
-specific features of the disorder;
-severity of the disorder (mild, moderate, severe); and/or
-status of the disorder (e.g., residual, in remission)
To enter a diagnosis:
-enter the code
-enter the name
-enter the specifics, if any
A differential diagnosis presents those disorders that may explain the client's symptoms and which should be ruled out in order to reach the eventual diagnosis.
The eventual disorder/s that is/are not ruled out consitutes the committed diagnosis.
Differential diagnoses are the product of divergent hypothesis generation and testing.
Differential Diagnosis and Diagnostic Uncertainty
A Differential Diagnosis can reflect varying degrees of uncertainty.
When making a differential diagnosis, one can:
-Make a provisional diagnosis, with or without
specifying disorders to be ruled out;
-Make a broad diagnosis of a category of a
disorder (NOS), with or without specifying
disorder to be ruled out;
-Make a broad diagnosis of a psychotic or
nonpsychotic disorder with or without
specifying disorders to be ruled out;
-Diagnose the simple presence of a mental
disorder with or without specifying disorders to
be ruled out;
-Diagnose a non-mental disorder (i.e., a "V"
code) with or without specifying disorders to be
-Defer a diagnosis (799.90) with or without
specifying disorders to be ruled out; or
-Simply specifying disorders to be ruled out.
Ain't this grand??
Axis I: V799.90, Diagnosis Deferred (R/O 300.4, Dysthymia; 296.22, Major Depression, Single Episode, Moderate
Axis I: 300.4, Dysthymic Disorder (R/O 296.22, Major Depression, Single Episode, Moderate
Axis I: R/O 300.4, Dysthymic Disorder
R/O 296.22, Major Depression, Single Episode,
The Principal Diagnosis
Unless otherwise specified (using the term principal diagnosis):
-the principal diagnosis is the first one listed on
If so specified:
-the principal diagnosis may be on Axis II
Axis I: 300.4, Dysthymic disorder, Early Onset, Secondary Type
Axis II: 301.83, Borderline Personality Disorder
You may have more than one committed diagnosis on Axis I or Axis II
You may have one or more diagnoses on both Axis I and Axis II for a
You must enter something on Axis I and II (i.e., if you are not making a diagnosis, enter V71.09, No Diagnosis, to indicate that you are not diagnosing a disorder or condition)
-some disorders subsume others
-disorders that are subsumed by others should not be
diagnosed as well
A provisional diagnosis is one to which the clinican is not yet committed.
Specify a provisional diagnosis with the term (Provisional)
Axis I: 300.4, Dysthymic disorder (Provisional)
You may choose to specify diagnoses that should be ruled out in order to commit to the provisional diagnosis.
Axis I: 300.4, Dysthymic disorder (Provisional; R/O 296.22, Major Depressive Disorder, Single
Episode, Moderate Severity)
The provisional diagnosis is one means to communicate diagnostic uncertainty
Specifying Features of a Disorder
Features can be specified on Axis I or Axis II
Features are more often specified on Axis II
A client has features of a disorder when s/he exhibits some characteristics of the disorder, but not enough to actually diagnose the disorder
Axis I: 300.4, Dysthymic Disorder, Primary Type
Axis II: V71.09, No Diagnosis, borderline personality
DSM-IV: Multi-Axial Diagnosis
Axes I and II are diagnostic axes
Axes III is for nonpsychiatric medical diagnoses that support diagnoses on Axes I and II
Axes IV and V provide further supporting information
Axis I: Clinical Syndromes (Mental Diseases or Conditions)
Conditions not due to mental disorders
Axis II: Personality Disorders
Axis III: Relevant nonpsychiatric medical conditions
Axis IV: Nature of psychosocial stressors
Axis V: Global assessment of functioning rating (GAF)