Axis III – General Medical Condition (GMC)

Axis III – General Medical Condition (GMC) Axis III is for reporting current general medical conditions that are potentially relevant to the understanding or management of the individual’s mental disorder. The purpose of recording General Medical Conditions on Axis III is to encourage thoroughness in evaluation/assessment and to enhance communication among health care providers. Axis III also ensures that medical or physical conditions that can directly or indirectly influence management and treatment are not forgotten. Most mental health professionals will never have occasion to diagnose a mental disorder due to a General Medical Condition (GMC), because this is the domain of physicians. Diagnoses and codes for Axis III are gleaned from medical records. Diagnosing a general medical condition can only be done ethically and legally by a physician. Because it is outside the scope of expertise for a MFT or other mental health practitioner to assess the presence or absence of a general medical condition, referral to a physician is mandatory for ethical treatment and proper diagnosis. However it is important for MFTs and other mental health professionals working in clinical settings to be familiar with current medical conditions that are potentially relevant to the understanding or management of the client’s mental disorder. General Medical Conditions can be related to mental disorders in a variety of ways. For example, a general medical condition can be directly related to the development or worsening of the symptoms of the mental disorder. In addition, situations occur in which the medical condition is important to the overall understanding or treatment of the mental disorder. For example, if a client with Alcohol Dependence develops signs and symptoms of a Delirium (i.e., an acute confused state), it is likely that the client’s Delirium is caused by the alcohol (e.g., Alcohol Withdrawal). Sometimes the Axis III condition does not directly cause the psychiatric disorder, but knowledge of the medical problem is essential for proper management of the case (e.g., a pregnant woman who is severely depressed, suicidal, and also an insulin-dependent diabetic). Failure to properly manage the medical condition during treatment of the mental disorder could have disastrous consequences. In addition to listing GMCs, the clinician can also list medical-record observations on Axis III, such as "abnormal EEG." If no significant medical or physical disorders are present, state "None" or "None Known." The combination of Axes I, II, and III presents an overview of the client's mental and physical condition. For example: Axis I Axis II Axis III 295.30 305.00 301.20 571.2 Schizophrenia, Paranoid Type Alcohol Abuse Schizoid Personality Disorder (premorbid) Cirrhosis, alcoholic, as per physician report. In this example, we know the client has a diagnosis of chronic paranoid schizophrenia, with a significant problem with alcohol. The client has liver cirrhosis, in all likelihood caused by the alcohol. The ICD-9CM diagnostic code 571.2 ("cirrhosis, alcoholic") was found in DSM-IV-TR Appendix G. This client had a schizoid personality prior to developing Schizophrenia, thus "(premorbid)" is noted. More about General Medical Conditions (GMC) General Medical Conditions are disorders listed outside the Mental Disorders section of the International Classification of Diseases (ICD). General Medical Conditions (GMC) that are most relevant to diagnosis and care in mental health settings can be found in Appendix G of the DSMIV-TR (p. 867 – 882). A physician will consider three criteria to identify a GMC and its relationship to the mental symptoms: 1. Is there evidence from the client’s history, physical examination, or laboratory findings that the disturbance is the direct physiological consequence of a general medical condition? a. For example, is there evidence of a close temporal relationship between the GMC and mental disorder? When did the signs and symptoms of the mental disorder appear in relationship to the biological condition? Did the depressed mood precede the biological condition, or vice versa? b. Are features present that are atypical of the primary mental disorder? For example, did the mental disorder begin at an atypical age or was the course of the symptoms unusual (e.g., an unusual weight gain prior to the mental disorder symptoms). c. Does research evidence suggest a well-established or frequently encountered association between the GMC and the mental disorder? This may suggest a causal link, but it is not sufficient for making a definite determination. (See Morrison table 9.1 for connections between GMC and mental disorders.) 2. Is the disturbance better accounted for by another mental disorder? Perhaps the disorder is due to another mental disorder, such as a substance-induced mental disorder. For example, is a client’s Major Depressive Disorder due to a biological factor or to a situational or current condition? 3. Does the disturbance occur exclusively during the course of the GMC, such as delirium? If symptoms such as psychotic, anxiety, or mood symptoms occur only during periods of delirium, they are considered to be associated features of the delirium and do not warrant a separate diagnosis. A Mood Disorder (or psychotic disorder or anxiety disorder) Due to a General Medical Condition (e.g., a tumor) can only be diagnosed separately if the mood symptoms occur at times other than during the course of the delirium. Coding a General Medical Condition If a client has a general medical condition diagnosed by a physician, how can the GMC best be coded using the DSM-IV-TR multiaxial system? 1. If a general medical condition (GMC) is the biological cause of the mental disorder, then look near the end of a section of the DSM-IV for: “Diagnosis” Due To A General Medical Condition and place the diagnosis on both Axis I and III. For example, if a client has a mood disorder and a qualified physician determines that the mood disorder is due to hypothyroidism, then the diagnosis would be: Axis I Axis III 293.83 Mood Disorder Due to Hypothyroidism, with depressive features (see p. 401) 244.9 Hypothyroidism, acquired (physician report) (see p.872, ICD-9 code). 2. If there is some evidence of a connection between Axis I and III, but the evidence is insufficient to determine a direct cause, then code as follows: Axis I Axis III 296.xx Major Depressive Disorder (See p. 375) 244.9 Hypothyroidism, acquired (physician report) (ICD code used here) (see p.872). 3. If the Axis I disorder is a psychological reaction to an AXIS III GMC, then code the same as example (2) above. Coding on Axis III If there is no diagnosis on Axis III, write “none” or “none known” Axis III None Or, if you think an Axis III diagnosis might be forthcoming after your client has been evaluated by his/her physician, write “deferred. Axis III Deferred When your client’s physician has reported a GMC, you may note the diagnosis, followed by, as per physician report. Axis III: 054.72 Meningitis, herpes zoster, as per physician report When your client has reported that she or he has a GMC, you may note what the client has said on Axis III, followed by, as reported by client. For example: Axis III: Ulcer, as reported by client.