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Diagnoses based on DSM-IV-TR Axes

To complete a DSM-IV-TR diagnosis by the end of the second session you will need to begin collecting relevant information during the first appointment with this client. A counselor working in a community mental health clinic.

List each of the five DSM-IV-TR axes (no formal DSM-IV-TR diagnosis needed)

What is the purpose of this axis? What type of information will it include?
What are examples of three or four specific questions you will ask Ricardo to gather the information you will need to fill in this axis?
(when thinking about Axis I, what information would you need to find out about Ricardo in order to begin sorting through the possible diagnoses you may want to list on this Axis? When thinking about Axis IV, what will you need to ask him in order to collect information that you may need to list on that axis?)
What are some examples of what you would actually ask Ricardo.
What additional assessment or diagnostic processes would you consider using in addition to your interview with Ricardo in order to gather the information you would need to formulate a DSM-IV-TR diagnosis?

Community Counseling Center: Telephone Intake Report below

Name:
Ricardo S.

Age:
24

Background:
Born in Puerto Rico; moved to the U.S. six months ago. Family still residing in Puerto Rico; client saving money to bring mother and younger brother to U.S. Fluent in both English and Spanish.

Relationships:
Describes self as being gay; one previous long-term relationship (three years); not currently in a relationship. No close friends; reluctant to join in social activities and appears to be somewhat isolated.

Work:
One full-time job and a part-time job on the weekend; reports good attendance at work and good work evaluations.

Living situation:
Describes living in an "unsafe" neighborhood and has been fighting with his landlord to get more locks installed on his windows and doors. Would like to move but does not have a car for transportation to work.

Health:
Headaches; stomach pain (previous ulcers treated by physician in late teens). Has not seen a physician since moving to the U.S.

Life Goals:
Wants to attend college and work in computer field.

Current symptoms/issues:
Fatigue, constant worrying, lonely, feels "jittery."

Reason for seeking therapy:
Supervisor at work recommended he speak with someone about his fears and worries after Ricardo reported late to work three days in a row due to sleeping poorly and having nightmares.

Solution Preview

DSM-IV-TR 5-Axis Diagnosis

To complete a DSM-IV-TR diagnosis by the end of the second session you will need to begin collecting relevant information during the first appointment with this client. A counselor working in a community mental health clinic. (please use APA resources to support answers)

List each of the five DSM-IV-TR axes (no formal DSM-IV-TR diagnosis needed)

What is the purpose of this axis? What type of information will it include?

Axis I: The purpose of this axis is to record conditions that may be the focus of mental attention. All mental disorders with the exception of personality disorders and Mental Retardation are recorded on this axis.

Axis II: Personality Disorders and Mental Retardation

This axis is for recording personality disorders and Mental Retardation. It is also used for reporting maladaptive features and defense mechanisms. Based on a Diagnostic and Statistical Manual of Mental Disorder' explanation, the purposes of placing Personality Disorders and Mental retardation on a separate axis is so that attention will be given to the presence of Personality Disorders that might be overlooked in when reporting Axis I disorders (p. 28).

Axis III: General Medical Conditions

On this axis current general medical conditions are reported that are related to the person's mental disorder, and may contribute to a worsening of the mental condition.

Axis IV: Psychosocial and Environmental problems
This ...

Solution Summary

This solution explains the five axes of the DSM-IV-TR.

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