Psychosocial and environmental problems relevant
to diagnosis, treatment, and prognosis are indicated
onAxis IV. Finally, a quantitative estimate (1 to
100) of an individual’s overall level of functioning
is provided onAxis V. Each of the five axes con-
tributes important information about the patient,
and together they provide a fairly comprehensive
description of the patient’s major problems, stres-
sors, and level of functioning.
The DSM-IV-TR diagnostic evaluation for
Michelle M. is shown in Table 5-3. Several features
of this diagnostic formulation are noteworthy. First,
Michelle has received multiple diagnoses on Axis I.
This is allowed, and even encouraged, in theDSM-
IVsystem because the goal is to describe the client’s
problems comprehensively. Second, note that her
borderline personality disorder (BPD) diagnosis on
Axis II is considered theprincipal diagnosis. This
means that this condition is chiefly responsible for
her admission to the hospital and may be the focus
of treatment. Finally, her Global Assessment of
Functioning(GAF) score on Axis V indicates serious
impairment—in this case, a danger of hurting
herself.General Issues in Classification
We have briefly described theDSM-IV-TRto give
the reader a general idea of what psychiatric classi-
fication entails. However, it is important to exam-
ine a number of broad issues related to classification
in general and to the DSM-IV-TR specifically.The Case of Michelle M.
Michelle M. was a 23-year-old woman admitted to an
inpatient unit at a hospital following her sixth suicide
attempt in 2 years. She told her ex-boyfriend (who had
broken up with her a week earlier) that she had swal-
lowed a bottle of aspirin, and he rushed her to the
local emergency room. Michelle had a 5-year history of
multiple depressive symptoms that never abated;
however, these had not been severe enough to neces-
sitate hospitalization or treatment. They included dys-
phoric mood, poor appetite, low self-esteem, poor
concentration, and feelings of hopelessness.
In addition, Michelle had a history of a number of
rather severe problems that had been present since her
teenage years. First, she had great difficulty controlling
her emotions. She was prone to become intensely dys-
phoric, irritable, or anxious almost at a moment’s
notice. These intense negative affect states were often
unpredictable and, although frequent, rarely lasted
more than 4 or 5 hours. Michelle also reported a long
history of impulsive behaviors, including polysubstanceabuse, excessive promiscuity (an average of about 30
different sexual partners a year), and binge eating. Her
anger was unpredictable and quite intense. For exam-
ple, she once used a hammer to literally smash a wall
to pieces following a bad grade on a test.
Michelle’s relationships with her friends, boy-
friends, and parents were intense and unstable. People
who spent time with her frequently complained that
she would often be angry with them and devalue them
for no apparent reason. She also constantly reported an
intense fear that others (including her parents) might
abandon her. For example, she once clutched a friend’s
leg and was dragged out the door to her friend’scar
while Michelle tried to convince the friend to stay for
dinner. In addition, she had attempted to leave home
and attend college in nearby cities on four occasions.
Each time, she returned home within a few weeks.
Prior to her hospital admission, her words to her ex-
boyfriend over the telephone were,“I want to end it
all. No one loves me.”T A B L E 5-3 Diagnostic Evaluation:
Michelle M.
Axis I: 300.4 Dysthymic Disorder, early onset
305.00 Alcohol Abuse
305.20 Cannabis Abuse
305.60 Cocaine Abuse
305.30 Hallucinogen AbuseAxis II: 301.83 Borderline Personality Disorder
(PRINCIPAL DIAGNOSIS)
Axis III: none
Axis IV: Problems with primary support group
Educational problems
Axis V: GAF 20 (Current)
146 CHAPTER 5