Abnormal Psychology

Clinical Diagnosis and Assessment 81

4. occupational problems (e.g., unemploy-
   ment or stressful working conditions);


5. housing problems (e.g., homelessness or
   an unsafe neighborhood);


6. economic problems (e.g., extreme poverty);


7. problems with access to health care
   (e.g., inadequate health insurance or lack
   of transportation to health care facilities);
   and


8. legal diffi culties (e.g., being arrested or be-
   ing a victim of a crime).

Axis V requires the clinician or researcher

to provide a numerical estimate (between 1and

100. of the patient’s global functioning within

the past year. As shown in Table 3.3, the num-

ber indicates the highest level of functioning

the patient has achieved in his or her work,

relationships, and leisure time or the patient’s

current level of functioning. This information

can be used to plan treatment and estimate the

level of functioning likely to be attained after

treatment.

Consider a 25-year-old woman, Lia, who

has suffered from delusions and hallucina-

tions from time to time over the last 5 years

and has been diagnosed with schizophrenia.

Lia was briefl y hospitalized because her hal-

lucinations had gotten much worse, but she’s

now out of the hospital and stable. A clinician

would want to know how well Lia had been

doing during the past year as a guide to what

level of functioning might be possible for her.

If her symptoms had been relatively under

control and she had been attending college

part-time, the prognosis would probably be

better than if she had been living at home, not

doing anything during the day, and not always

able to care for herself. Similarly, if Lia had

been able to attend college, treatment might

focus, in part, on identifying factors associ-

ated with the onset of more severe symptoms

and on developing coping strategies and social

support to help her resume her higher level of

functioning. Had she previously been unable

to care for herself, treatment would focus on

helping Lia develop basic self-care abilities—

maintaining hygiene, preparing meals—and

creating some type of daily structure to orga-

nize her time.

Criticisms of DSM-IV-TR

Most mental health professionals agree that DSM-IV-TR is an improvement over

previous editions, but its classification system has been criticized on a number

of grounds. To understand the criticisms, we will focus on the DSM-IV-TR criteria

91–100 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.

81–90 Absent or minimal symptoms (e.g., mild anxiety before an exam), good

functioning in all areas, interested and involved in a wide range of activities,

socially effective, generally satisfi ed with life, no more than everyday

problems or concerns (e.g., an occasional argument with family members).

71–80 If symptoms are present, they are transient and expectable reactions to

psychosocial stressors (e.g., diffi culty concentrating after family argument);

no more than slight impairment in social, occupational, or school functioning

(e.g., temporarily falling behind in schoolwork).

61–70 Some mild symptoms (e.g., depressed mood and mild insomnia) OR some

diffi culty in social, occupational, or school functioning (e.g., occasional

truancy or theft within the household), but generally functioning pretty well,

has some meaningful interpersonal relationships.

51–60 Moderate symptoms (e.g., fl at affect and circumstantial speech, occasional

panic attacks) OR moderate diffi culty in social, occupational, or school

functioning (e.g., few friends, confl icts with peers or coworkers).

41–50 Severe symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent

shoplifting) OR any serious impairment in social, occupational, or school

functioning (e.g., no friends, unable to keep a job).

31–40 Some impairment in reality testing or communication (e.g., speech is at

times illogical, obscure, or irrelevant) OR major impairment in several areas,

such as work or school, family relations, judgment, thinking, or mood (e.g.,

depressed man avoids friends, neglects family, and is unable to work; child

frequently beats up younger children, is defi ant at home, and is failing at

school).

21–30 Behavior is considerably infl uenced by delusions or hallucinations OR serious

impairment in communication or judgment (e.g., sometimes incoherent, acts

grossly inappropriately, suicidal preoccupation) OR inability to function in

almost all areas (e.g., stays in bed all day; no job, home, or friends).

11–20 Some danger of hurting self or others (e.g., suicide attempts without clear

expectation of death, frequently violent, manic excitement) OR occasionally

fails to maintain minimal personal hygiene (e.g., smears feces) OR gross

impairment in communication (e.g., largely incoherent or mute).

1–10 Persistent danger of severely hurting self or others (e.g., recurrent violence)

OR persistent inability to maintain minimal personal hygiene OR serious

suicidal act with clear expectation of death.

0 Inadequate information.

Source: Reprinted with permission from the DSM-IV-TR Casebook: A Learning Companion to the Diagnostic and

Statistical Manual of Mental Disorders, Fourth Edition, Text Revision, (Copyright 2002) American Psychiatric

Association.

Table 3.3 • Axis V: Global Assessment of Functioning Scale

The Global Assessment of Functioning Scale asks the clinician to “consider psychological, social,

and occupational functioning on a hypothetical continuum of mental health—illness. Do not

include impairment in functioning due to physical or environmental limitations” (American

Psychiatric Association, 2000, p. 34).