Gangguan Jiwa Kondisi Medis Umum Masalah Psikososial Masalah Lingkungan Level Fungsi (Level of Functioning) Sebagian besar dapat terlewat karena “single” diagnosis Memberikan suatu model biopsikososial untuk konseptualisasi gangguan mental DSM (Diagnostic and Statistical Manual of Mental Disorder) oleh American Psychiatric Association (APA) Indonesia, PPDGJ III(Pedoman Penggolongan dan Diagnostik Gangguan Jiwa) berdasarkan ICD-10 (International Classification of Diseases) oleh WHO DSM-IV-TR (2000) includes five axes = multiaxial classification system, by requiring judgements on each of the five axes, forces the diagnostician to consider a broad range of information DSM-V (2013): nonaxial documentation of diagnosis (formerly Axes I, II, III), with separate notions for important psychosocial and contextual factors (formerly Axes IV) and disability (formerly Axes V) Contoh 1 296.42 Bipolar I Disorder, current episode manic, moderate severity, with mixed features 301.83 Borderline Personality Disorder Contoh 2 300.4 Persistent Depressive Disorder, mild severity, with early onset, with pure dysthymic syndrome V61.03 Disruption of family by separation 278.00 Overweight or Obesity WHODAS: Score of 53 Multiaksial Axis I: Gangguan Klinis Kondisi lainnya sebagai fokus klinis Axis II: Gangguan kepribadian Retardasi mental Axis III Kondisi Medis Umum Axis IV Masalah psikososoal dan lingkungan Axis V Global Assesment of Functioning (GAF) Scale Tujuan Pembedaan Aksis I, II, III: Untuk evaluasi yang menyeluruh Untuk meningkatkan komunikasi yang baik antar klinisi
Tidak mengimplikasikan bahwa ada perbedaan
fundamental dalam konseptualisasinya tidak ingin mengatakan bahwa gangguan mental tidak berhubungan dengan proses atau faktor fisik, biologis atau psikososial Axis I Clinical Disorders and Other Conditions That May Be a Focus of Clinical Attention All of the various disorders except Personality Disorders and Mental Retardation If more than one Axis I diagnosis, all should be reported Best to also label the “principal diagnosis” or “reason for visit” If more info is needed to make an Axis I diagnosis, code: Deferred (799.9) If no Axis I diagnosis is warranted, code: None (V71.09) AXIS I All mental disorders from block F0 to F9, except F6 F6 is Personality Disorder which is classified in axis II Block F7, F8 & F9 are mental disorders which its onset start during childhood or adolescent It can be found in adult if the condition continues during the adult years Block F0-F6 can be manifested in children & adolescent too, if the diagnostic criteria is fulfill Z code Life problems which are not fulfill diagnostic criterias but make a person seek for help or medical conditions that need attention or therapy. Axis II Personality Disorders and Mental Retardation Axis II notes “prominent maladaptive personality features and defense mechanisms”. Having a separate axis for these concerns “ensures that consideration will be given to the possible presence of Personality Disorders and Mental Retardation” that would otherwise be overlooked in a single-axis diagnostic schema. Note: Borderline Intellectual Functioning is also coded on Axis II Even if Axis I diagnoses are “more florid” Axis II diagnoses are equally important. If more info is needed to make an Axis I diagnosis, code: Deferred (799.9) If no Axis I diagnosis is warranted, code: None (V71.09) Severity For Axis I and Axis II, can code severity either in some diagnostic categories (e.g., mental retardation) or using specifiers: Mild: meets criteria for the diagnosis; however, few additional symptoms Moderate: “between Mild and Severe” Severe: either has many more symptoms than required for a diagnosis, some of the symptoms are particularly severe (e.g., suicide attempt), or daily functioning (school, work, family) is severely affected. Can also note the following for Axis I or Axis II: In Partial Remission: patient no longer meets full diagnostic criteria; some symptoms may still remain. In Full Remission: patient has been free of symptoms for an extended period of time. Prior History: patient no longer meets criteria for this diagnosis; however, it is clinically prudent to include this diagnosis Rule-out Suppose you assess a patient and believe a diagnosis is warranted; however, you do not have enough assessment data to confirm the diagnosis. However, to not diagnose this “hunch” would not communicate the clinical picture of the patient effectively. You may consider using a “rule-out” diagnosis: R/O in place of the actual diagnosis Axis III General Medical Condition Current general medical conditions that are potentially relevant to the understanding or management of the individual’s mental disorder. Differential diagnostic issue: If a general medical condition is a direct physiologic cause of a mental disorder, it is coded on Axis I and Axis III. Axis I: Mood Disorder Due to Hypothyroidism Axis III: Hypothyroidism Axis III Medical conditions can influence choice in pharmacotherapy. If multiple diagnoses are present on Axis III, code them all. If no diagnosis is present, code “None”. Notes: Numerical codes for Axis III come from the ICD-9 (or ICD-10) No numerical code for “None”. Axis IV Psychosocial and Environmental Problems Biopsychosocial model: Axis III + Axis I + Axis II + Axis IV These are typically a negative life event, an environmental difficulty or deficiency, familial or interpersonal stress, poor social support or personal resources. Axis IV Examples: Examples: Problems with the Housing problems primary support group Homelessness Death of a family member Economic problems Insufficient welfare support Problems related to the social environment Problems with access to health care services Difficulty with Inadequate health insurance acculturation Problems related to Educational problems interaction with the legal Discord with teachers system Occupational problems Incarceration Unemployment Other psychosocial and environmental problems War, natural disasters Axis V Global Assessment of Functioning (GAF) Scale in current and past one year “How is the patient doing, overall.” 100-point scale, divided into 10 ranges GAF – adult scale CGAS (Children’s Global Assessment Scale) – GAF adapted for children Can also report the time period that the rating encompasses: Current, highest over past year, at admission, at discharge Consider psychological, social, and occupational functioning on a hypothetical continuum of mental heal/illness. Do not include impairment in functioning due to physical (or environment) limitations. The information of GAF: Is useful in planning treatment, measuring its impact & predicting outcome GAF SCALE 0 Inadequate information 1-10 Persistent danger of severely hurting self or others/persistent inability to maintain minimal personal hygiene OR serious suicidal act with clear expectation of death 11-20 Some danger or hurting self or others OR occasionally fails to maintain minimal personal hygiene OR gross impairment in communication 21-30 Behavior is considered influenced by delusions or hallucinations OR serious impairment in communication or judgment OR inability to function in all areas 31-40 Some impairment in reality testing or communication OR major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood 41-50 Serious symptoms OR any serious impairment in social, occupational, or school functioning 51-60 Moderate symptoms OR moderate difficulty in social, occupational, or school functioning 61-70 Some mild symptoms OR some difficulty in social, occupational, or school functioning, but generally functioning pretty well, has some meaningful interpersonal relationship 71-80 If symptoms are present they are transient and expectable reaction to psychosocial stresses, no more than slight impairment in social, occupational, or school functioning 81-90 Absent or minimal symptoms, good functioning in all areas, interested and involved in a wide range or activities, socially effective, generally satisfied with life, no more than everyday 91-100 No symptoms, superior functioning in a wide range of activities, life’s problem never seem to get out of hand, is sought by others because of his/her many qualities.