The Multi-Axial System of DSM-IV
Axis I: Major depressive episode
This axis points out the clinical syndromes that cause significant impairment to the patient (Warelow & Holmes, 2011). Therefore, Joan had a clinical disorder which required immediate attention. Since she had refused to take her anti-depressant medication, the possibility that she would fall in a major depressive episode was inevitable (Warelow & Holmes, 2011).
Axis II: Anti-Social personality disorder
According to Warelow & Holmes, this axis “assesses permanent problems that are often overlooked in the presence of Axis I disorders and it entails disorders such personality disorders” (Warelow & Holmes, 2011, par. 23). Joan’s personality disorder is explained by her social isolation and magical thinking which borders unconventional beliefs.
She sits alone most of the day and never speaks in community meetings. She is also unable to maintain close relationships e.g. divorcing the husband and breaking up with her boyfriend. Joan has a difficult and conflicted relationship with her mother (Warelow & Holmes, 2011).
Axis III: Salysilism (Aspirin Poisoning)
This axis depicts physical and medical that may manipulate or aggravate Axis 1 and Axis II disorders which are noted in the patient (Warelow & Holmes, 2011). Joan had already taken an overdose of aspirin tablets and before she passed out, she called her husband informing him that she was committing suicide (Warelow & Holmes, 2011).
Axis IV: Psycho-social and environmental problems
In this axis, the non-clinical, albeit medically significant, stressors that have the capacity to impact Axis 1 or Axis II disorders are explored. Joan’s husband left her for another woman almost five years ago and they divorced a year later. In addition, her ex-husband is sporadic about child support and visitation. Joan also broke up with her boyfriend recently and her relationship with her mother is one which is difficult and conflicted.
Other environmental problems include the sight of her elder brother diagnosed with schizophrenia and the thought of the death of her father seven years ago. Joan is from a poor back ground and as such, she must attend workfare assignments in order to get public assistance. She also worked as a book keeper. Such psycho-social and environmental problems predispose her to a depressive episode characterized by feelings of wanting to be alone and a tendency towards self destruction (Warelow & Holmes, 2011).
Axis V: Global Assessment of Functioning Scale: 30 (moderately profound symptoms)
This axis serves as a hint of the evaluating psychiatrist’s judgment of the patient’s capacity to function. The scale calibrated on a 100 point and evaluates functioning in psychological, social and occupational spheres (American Psychiatric Association, 2000).
Joan’s score is justified by the fact that she used to work as a book keeper and has one year of college. She also misses work fair assignments which are a must for her to get public assistance, and moves slowly while walking. The presence of stressors predisposes her to her condition. Therefore, she is hospitalized in a psychiatric ward with a suicidal tendency (Warelow & Holmes, 2011).
Reasons for Joan’s Depression From Two Theoretical Perspectives
Psycho-Dynamic Theory
This theory depicts a similarity between the kind of grieving which occurs through the death of a loved one and symptoms of depression (Gray, 2011; Castillo, 1997). Depression is perceived as an excessive and irrational grief as a result of and as a reaction to loss, thus resulting in feelings associated with loss of affection (real or imagined) (American Psychiatric Association, 2000).
In addition, grief is perceived to be caused by a person to whom an individual was most dependent as a child. Actual losses (such as loss of a loved one or death) and symbolic losses (e.g. loss of social prestige or job) leads to parts of an individual’s childhood being re-experienced. Therefore, individuals with depression are over-dependent and may revert to childhood states (American Psychiatric Association, 2000; Gray, 2011).
According to psychoanalysts, the more an individual experiences loss in childhood, the greater he is predisposed to depression. Unresolved and existing hostility towards an individual’s parents (which has been repressed to unconscious levels) is a crucial explanation for depression.
This is due to the belief that anger (outwardly expressed) cannot be accepted by the superego, and as a result, it is masked. Therefore, hostility directed at oneself results to feelings of despair, unworthiness and guilt. This kind of inward directed aggression is thought to be so severe that it can motivate suicidal tendencies (Gray, 2011; Castillo, 1997).
In addition, grief is complicated by mixed feelings which are inevitable. For instance, psychoanalytic accounts by Freud have pointed out that mourners have had (occasionally) feelings of anger towards the deceased. Because such feelings cannot be accepted by the super ego, they end up being self-directed causing low self esteem and feelings of guilt (American Psychiatric Association, 2000).
Cognitive Behavioral Theory
Cognitive behavioral theorists such as Seligan pointed out (through experiments carried out in animals) that an expression of helplessness in individuals is usually generalized to new incidences. This was evident through experiments where dogs were given electric shocks at uncontrollable levels and they failed to have learnt responses either to stop the shock or initiate escape attempts.
The findings of these animal experiments have been thought to depict sound explanations on development of depression. For instance, theorist such as Seligan termed reactive depression in human beings as “a state of learned helplessness” (American Psychiatric Association, 2000, par. 23).
This implies that a person depicts learned expectations of untenable external events rather than events which are crucial. Therefore, the behavioral features of this state can produce the likely features of depression. This can be evident in aspects such as cognitive deficits and difficulties in motivation e.g. retardation in psychomotor dynamics (Gray, 2011; Castillo, 1997).
Impact of Gender, Race, and Class on the Possible Diagnoses
In investigations of correlates of depression where gender was included, interesting differences in the clinical picture of depression has been noted.
For instance, a greater incidence of psychiatric morbidity has been reported to exist in African American females and males compared to their white counterparts. This is coupled with other societal perspectives such as increased severity of somatic symptoms, higher incidences of stress and differences in perception in terms of health beliefs and physical functioning (American Psychiatric Association, 2000; Castillo, 1997).
In this regard, African Americans have less suicidal ideation compared to the whites, and they depict less melancholia compared to the Latinos and the whites. However, research studies have depicted a rising trend of poorer health-related quality of life among the African Americans, which are due to stressful events that emanate from socio-economic challenges (American Psychiatric Association, 2000).
In other studies, African American women have been thought to experience “higher incidences of mood irritability (unlike melancholia), increased appetite and hypersomnia” (American Psychiatric Association, 2000, p. 12). In addition, research findings have pointed out prevalence of depressive symptoms from childhood to adolescence among girls.
However, in the pre-adolescent stage, boys have been found to have higher incidences of depressive symptoms. The depressive symptoms in girls were found to increase rapidly through the early adolescent period, but on their male counterparts, the increase was either insignificant or stable.
In addition, researchers have predicted depressive symptoms and pointed out that low socio-economic status, which is a major causal factor of depression in the african Americans (especially women), is mediated by several other factors such as marital status, internalized racism, physical heath challenges and religious orientation (American Psychiatric Association, 2000 Gray, 2011).
Research has also explored race related stress as an important correlate of mental health, and pointed out that “race related at self-reported and perceived discrimination attempts including both lifetime and day-to-day events is common among African Americans” (American Psychiatric Association, 2000, par. 12). In addition, racism acts as a correlate of poor psychological heath, including depression and this relationship is thought to be mediated by racial identity.
Other studies on mental illnesses and depression have pointed out that the features which are specific to racial identity show existing correlations with other features like low levels of depression. This was depicted in a longitudinal study where self reported levels of depression among male and female American students of African origin were analyzed (American Psychiatric Association, 2000).
References
American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders, fourth edition: DSM-IV-TR. Washington, DC: American Psychiatric Association.
Castillo, R. J. (1997). Culture and mental illness: A client-centered approach. Pacific Grove, Calif., Brooks/Cole Pub. ISBN 13: 978-0-534-34558-7
Gray, S.W. (2011). Competency-based assessments in mental health practice: Cases and practical applications. Hoboken, NJ: Wiley.
Warelow, P., & Holmes, C.A. (2011). Deconstructing the DSM-IV-TR: A critical perspective. International Journal of Mental Health Nursing, 20(6), 383-391.