Understanding Your Mental Health Evaluation: A Guide to Axis IV and Axis V

Axis IV On Axis IV, the clinician lists the psychosocial and environmental stressors encountered by the client during the 12 months prior to evaluation. The clinician can note stressors that occur prior to the previous year if they significantly contribute to the mental disorder. List all relevant psychosocial and environmental problems on Axis IV. Occasionally, this is the primary reason for clinical attention. In such cases, use the appropriate diagnosis and code from the category "Other Conditions That May Be a Focus of Clinical Attention" (DSM-IV-TR, p. 731-742). For example, if a 19year-old college student is evaluated because of failing grades, and no mental disorder was found to account for this problem, "V62.3 Academic Problem" may be entered on Axis I. Stressors that may be considered include, but are not limited to, problems or difficulties in the individual's primary support group; social environment; educational situation; occupational, housing, economic, or financial situation; access to health care services; interaction with the legal system and/or crime related situation; or other psychosocial and environmental factors. Axis V On Axis V, the clinician rates the individual’s overall or global level of functioning. The specific scale used is the Global Assessment of Functioning (GAF) Scale (DSM-IV-TR, p. 34). The GAF Scale is a composite index that considers psychological, social, and occupational functioning. The clinician is warned, “Do not include impairment in functioning due to physical (or environmental) limitations.” GAF Scale ratings are continuous and range from 0 (inadequate information) to 1 (persistent severe difficulties) to 100 (superior functioning). In most instances, the clinician rates the client’s current level of functioning. The period used for rating is recorded in parentheses behind the GAF score, for example, GAF = 41 (current). The current GAF establishes a baseline so that results of therapeutic interventions can be measured. Additional GAF ratings, for example, the highest level of functioning during the year prior to evaluation, can be made on Axis V. The previous example would be listed on Axis V as GAF = 85 (highest level in past year). The highest GAF during the past year may have prognostic significance because the person may return to at least that level of functioning after treatment. Rating the client’s level of functioning according to the GAF Scale is relatively easy if adequate information is available. Simply locate a description that accurately portrays the individual by referring to page 34 of DSM-IV. Each description has an associated range of numbers or codes (e.g., the person with serious impairment is rated from 41 to 50). The clinician selects a number in that range which best represents the client’s level of functioning. For example, a 29-year-old male presents for evaluation in a catatonic state. He is mute and will not follow any commands. According to the GAF Scale, a person who has gross impairment in communication falls into a rating range between 11 and 20. The clinician would rate the client’s current level of functioning within the appropriate range. An individual who is unable to maintain minimal personal hygiene is rated between 1 and 10. 2