Examples of How to Record Results of a DSM-IV Multiaxial Evaluation

Example 1:

 

Axis I       

296.23     Major Depressive Disorder, Single Episode, Severe Without Psychotic Features
305.00     Alcohol Abuse

Axis II 301.6   Dependent Personality Disorder Frequent use of denial
Axis III  None
Axis IV    Threat of job loss
Axis V  GAF = 35 (current)

 

Example 2:

 

Axis I       

300.4       Dysthymic Disorder
315.00     Reading Disorder

Axis II V71.09    No diagnosis
Axis III  382.9       Otitis media, recurrent
Axis IV    Victim of child neglect
Axis V  GAF = 53 (current)

  

Example 3:

 

Axis I       

293.83     Mood Disorder Due to Hypothyroidism, With Depressive Features

Axis II V71.09    No diagnosis, histrionic features
Axis III  244.9       Hypothyroidism
365.23     Chronic angle-closure glaucoma
Axis IV    None
Axis V  GAF = 45 (on admission) GAF=65 (current)

       

Example 4:

 

Axis I       

V61.10    Partner Relational Problem

Axis II V71.09    No diagnosis
Axis III  None
Axis IV    Unemployment
Axis V  GAF = 83 (last year)