Sample Multi Axial Diagnosis

CASE REVIEWS COGNITIVE DISORDERS: The Case of the Woman Who Can't Remember

MULTIAXIAL DIAGNOSIS AXIS I. AXIS II. AXIS III.

AXIS IV. IV. AXIS V.

294.11 Dementia due to Grade II Malignant Glioma w/ behavioral disturbance V71.09 No Disorder Present 198.3 Neoplasm, Malignant, brain, secondary 01.59 Transtemporal Excision of Brain Tumor 99.25 Chemotherapy Problems with primary support group: divorce Occupational problems: unemployment GAF Rating: 55 Moderate Symptom (long-term (long-t erm memory and cognitive abilities intact) Moderate difficulty in occupational functioning (unemployed)

JUSTIFICATION JUSTIFICATION OF DIAGNOSIS: 294.11. Dementia due to Grade II Malignant Glioma] Symptoms: Criteria Met by Client

A. Memory Impairment (inability to recall previously learned information) Client forgot appointments and lost objects (e.g. unable to find her car in the parking lot because she forgot its make and where she parked it, forgot orders and repeats them) 

A2d. Disturbance in executive functioning (planning) Client had reduced ability to plan ahead 

Behavioral disturbance manifested in the clients irritability and blaming of others for her problems (e.g. Her secretary for losing her papers again; her children for misplacing things at home; distress over situation) B. Impairment of Social/Occupational Functioning Her forgetting caused her to make many mistakes at work that it eventually led to her inability to continue working. 

C. Computerized Tomography Scan revealed a Grade II out of IV right frontal Glioma. Undergone transtemporal Excision of Brain tumor and 7000 rads of radiotherapy. CI.

ANXIETY DISORDERS: The Case of the Young Man Who Is Scared to Leave the House

MULTIAXIAL DIAGNOSIS: AXIS I AXIS II AXIS III AXIS IV

AXIS V

300.21 Panic Disorder with Agoraphobia (Principal Diagnosis) 309.21 Separation Anxiety, Early Onset 301.6 Dependent Personality Disorder None Problems with primary support group: health problems in family, parental over-protection) Problems related to the social environment (Inadequate social support, difficulty relating due to shyness and sensitivity) GAF Rating: 47 Serious impairment in social functioning (very few friends, unable to relate to others due to embarrassment) Serious impairment of occupational functioning (cannot work/ unemployed due to dependence to parents)

JUSTIFICATION OF DIAGNOSIS 300.21 Panic Disorder with Agoraphobia Symptoms: Criteria met by client: A. 1. Panic attacks Client, at age 28, is unemployed because he is incapacitated by the panic attacks A. 2. b. Worry about the implications of the attack or its consequences He fears that he is losing his mind and experiencing a schizophrenic deterioration. B. Presence of Agoraphobia The client experiences agoraphobia and somatic preoccupations to the point that he cannot be along nor go out alone. 

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309.21 Separation Anxiety Disorder, Early Onset Symptoms: Criteria met by client: A. Developmentally inappropriate and excessive anxiety concerning separation from home or to the individual is attached A.1. Recurrent excessive distress when separated from home or significant figure As observed from his infancy, the client experienced separation anxiety (e.g. went overseas and quitted from his father's firm to look for another job but ended up failing because he ruminates about doing the wrong thing and feels anxious to return to the family routine. ◦

A. 4. Persistent or recurrent refusal to go to school or elsewhere because of fear of separation The client showed mild school refusal in third and fourth grades and attended college and business schools locally to live at home ◦

A.5. Persistently and excessively fearful or reluctant to be alone or without major attachment figures

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He cannot tolerate being along or having no companion when going out, because of this, he is incapacitated and unemployed.

A.6. Repeated complaints of physical symptoms Client experiences panic attacks when away from major attachment figure or from home. 

B. Duration of disturbance is about 3 months. C. Early Onset before age 18. D. Socially and Occupationally impairing to the client.

301.6 Dependent Personality Disorder Symptoms: Criteria met by client: A. 1. Difficulty making everyday decisions without excessive amount of advice or reassurance from others Client depended on his mother to serve as matchmaker when dating. Call and receives calls from his mother several times each day. 

A.2. Needs others to assume responsibility to major areas of his life Client is unemployed because he cannot leave his mother sick. 

A.3. Has difficult expressing disagreement with others He acknowledges his anger for his mother (his parents) for making him dependent to them and yet still stays dependent on themselves 

A.4. Has difficult initiating projects or doing things on his own He tried to be independent from the family but ended up living with his family again because he feels anxious when separated from them. 

A.5. Goes to excessive length to obtain nurturance or support from others He ignores his anger (and knowledge that he is dependent) in exchange for staying and taking care of her mother 

A.6. Feels uncomfortable or helpless when alone Client is afraid to be alone and to go out without company. 

CHILDHOOD DISORDERS: The Case of Sam

MULTIAXIAL DIAGNOSIS: AXIS I AXIS II AXIS III. AXIS IV

AXIS V

299.80 Asperger's Syndrome Case suggestive of 313.81 Oppositional Defiant Disorder V71.09 No Disorder Present None Educational Problems: discord with teachers and classmates Problems with Primary Support Group: estrangement, disruption of family due to temporary separation GAF Rating: 55 Moderate difficulty in social functioning (difficulty empathizing) moderate difficulty in school functioning (conflict with teachers)

JUSTIFICATION OF DIAGNOSIS Symptoms: Criteria met by client: A.1. Marked impairment in the use of multiple non-verbal behaviors He is described by teachers as inattentive and lazy and needed to be taught appropriate social skills (also, he looks outside window while teacher is talking to him) A.2. Failure to develop peer relationships appropriate to developmental level His mother is trying very hard to teach him to share and recognize the feelings of others A.3. Lack of spontaneous seeking to share enjoyment and interests with other people The client's teachers indicate that he needs to be taught appropriate social skills. A. 4. Lack of social or emotional reciprocity Sharing and recognizing feelings of others is one of the emphasis of his mother. 

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*Note: There was no indication in the case whether the client demonstrated repetitive movements. This could mean either Sam is a high-functioning person with Asperger or the issue needs to be explored further. However, the information presented was sufficient for a diagnosis albeit weak.