DSM is the classification system of the American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders (DSM) dsm criteria

System DSM American Psychiatric Association - Diagnostic and Statistical Manual of Mental Disorders(Handbook of diagnosis and statistics of mental disorders) is a classification system for mental disorders that competes with the ICD (Original English version: American Psychiatric Association, 1994; German version: American Psychiatric Association, 1996). Effective recently DSM-IV-Roman numerals indicate the number of revisions - which annulled DSM-III-R(American Psychiatric Association, 1989). DSM-IV compiled from extensive expert reports and field research. DSM-IV is divided into 17 main groups (including the group “Other clinically relevant problems”; see Table 6.2), each main group includes units (disorders). For example, the main group of anxiety disorders includes 12 different forms (for example: panic disorder without agoraphobia; other examples can be found in the chapters on the classification and diagnosis of pattern of functioning disorders). Individual units are described in the form of a systematic, condensed textbook,The text contains, as a rule, the following points: diagnostic signs (general description of the picture of the disorder), subtypes and/or additional codings, coding rules, associated signs and disorders; special cultural, age and gender characteristics; frequency of diseases; flow; family distribution pattern; differential diagnosis (but not indications for treatment). Disorders are identified through operational diagnosis. In the English version (American Psychiatric Association, 1994), disorder units are designated by ICD-9-CM codes and a verbal description (for example, “300.20 Specific Phobia”), in the German version (American Psychiatric Association, 1996) by ICD-9-CM codes, ICD-10 and verbal description (for example, “300.29 (F40.2) Specific phobias”).

DSM-IV corresponds to ICD-10 in the following points (shown in Table 6.1): purpose of classification, logic of classes, properties of classes, classification unit, basis of classification, data sources, formal accuracy. In some points it differs from ICD-10.

- Scope:DSM-IV only mental disorders; ICD-10 - all diseases.

- Selection of units:more focused on empirical research (cf. material in Sourcebooks; Widinger et al., 1994, 1996).

- Definition of units:regarding definitions DSM-IV meets the ICD-10 research criteria: operational diagnostics are consistently implemented here. ICD-10 takes into account less explicitly compared to DSM-IV that symptoms can lead to a decrease in various functions.

- Attribution rules: thanks to operational diagnosis, explicit rules of assignment (in ICD-10 - partly implicit, partly explicit). Additionally in DSM-IV there is a so-called decision tree, which is not in ICD-10. This ensures that the examiner is aware of a graphical diagram that allows individual disorders to be included or excluded (see Chapter 37).

Other differences DSM-IV from ICD-10:

- Number of versions:DSM-IV published in one single version, ICD-10 has several versions (see above).

- Description form:DSM-IV compiled in the form of a textbook text (see above), and ICD-10 contains only general descriptions.

- Multi-axis diagnostics:in ICD-10, multi-axis diagnostics is in preparation, in DSM-IV it is an explicit component. IN DSM-IV The following axes are postulated (overview of categories of axes I and II: see Table 6.2):

Axis I Clinical disorders, other clinically relevant problems (conditions that cannot be attributed to any mental disorder, but give rise to observation or treatment).

Axis II. Personality disorders, mental retardation (in the category of disorders that are diagnosed primarily in infancy, childhood, or adolescence).

Axis III. Somatic diseases.

Axis IV. Psychosocial and environmental problems (9 main areas, such as housing or economic problems).

V axis Global recording of level of functioning (scale with 10 divisions; time period relevant to the current situation, or, for example, the highest level for at least 2 months in the past year).

Axes I, II, III contain official DSM-IV diagnoses; Axes IV and V are additional and are used for specific clinical and research purposes. There can be various gradations along the axes from I to IV. The multi-axis approach makes it possible to carry out a comprehensive diagnosis, which also takes into account psychosocial aspects. From a psychological point of view, however, axes IV and V appear to be too global and one-sided to differentiate psychosocial conditions. For example, factors of overload without taking into account coping are only to a limited extent informative. So far, these axes are not used either in the clinic or in research projects.

- Diagnostic differences:detailed differences appear in some diagnoses: identical in ICD-10 and DSM-IV concepts do not always have identical content. Therefore, it is necessary to indicate exactly which system is used for diagnosis.

Despite all the differences, between ICD-10 and DSM-IV there is clear convergence. The examination methods given in section 2.5 partly make it possible to simultaneously diagnose ICD and DSM-diagnoses, so it becomes possible to compare results in different systems.

Paranoid

Schizoid

Schizotypal

Cluster B (theatrical, emotional or fluctuating disorders):

Antisocial

Border

Hysterical

Narcissistic

Cluster C (anxiety and panic disorders):

Avoidant

Dependent

Obsessive-compulsive

Personality disorders

This section begins with a general definition of personality disorder that applies to each of the 10 specific disorders. All personality disorders are coded on Axis II.

General diagnostic criteria for personality disorder.

A. A long-term pattern of internal experiences and behavior that clearly deviates from cultural expectations. This pattern appears in two (or more) of the following areas:

1 – cognitive sphere (i.e. ways of perceiving or understanding oneself, other people and current events),

2 – affective sphere (i.e. range, intensity, lability, acceptability of emotional reactions),

3 – interpersonal functioning,

4 – impulse control.

B. This long-term pattern is inflexible and pervasive across a wide range of situations of personal and social functioning.

C. This pattern results in overt clinical impairment or impairment in social, occupational, or other important areas of functioning.

D. This pattern is stable and long-lasting, and its establishment can be traced back to at least adolescence or young adulthood.

E. This pattern is not a manifestation or consequence of another mental illness.

F. This pattern is not a direct psychological result of substance use (eg, drugs or medications) or a general health condition (eg, head injury).

Cluster a.

301.0 Paranoid personality disorder

A. Deep distrust and suspicion of others, with an interpretation of the motives of their behavior as malevolent, beginning in youth and present in a variety of contexts, as determined by four (or more) of the following factors:

1- Suspicion, without reasonable grounds, that others are exploiting, harming or deceiving him/her

2- preoccupation with unjustified doubts about the fidelity or reliability of friends or partners

3- reluctance to disclose to others due to unjustified fears that the information received will be maliciously used against him/her

4- looking for hidden meanings or threatening signs in innocuous remarks or events

5- constant hostility, i.e. refusal to forgive insults, insults, ridicule

6- feeling attacks on one's character or reputation that are not visible to others, with an immediate reaction of anger or counterattack

7- repeated suspicions, without sufficient grounds, of the fidelity of a spouse or sexual partner.

B. Does not occur exclusively in association with schizophrenia, mood disorders with psychotic features, other psychotic disorders, and is not a direct physiological result of a medical condition.

Note: If these factors occur before the onset of schizophrenia,” add “premorbid,” for example, “paranoid personality disorder (premorbid).”

The new American classification of mental disorders DSM-5 has been released to the world

Dutch De Psychiater publishes a brief overview of changes in the new version of the American classification of mental disorders DSM-5:

""DSM-5 consists of three sections: it is (1) an introductory part with instructions for use and a warning about the forensic psychiatric use of DSM-5; (2) diagnostic criteria and codes for routine clinical use; and (3) tools and techniques to inform clinical decision making.

Main changes:

Neurodevelopmental Disorders

The severity of the disorder is determined not by IQ, but by level of adaptive functioning. Speech disorders have entered the new category of “social communication disorder,” in which some of the syndromes coincide with “autism spectrum disorder.” The category "Autism Spectrum Disorder" replaces the DSM-4 diagnoses of autism, Asperger's syndrome, childhood disintegrative disorder, and unspecified pervasive developmental disorder, all of which cease to exist as stand-alone diagnoses. ADHD can start later (before 12) and is viewed differently in different areas. Learning disorders and movement disorders are organized differently in this chapter and are somewhat combined.

Schizophrenia spectrum and other psychotic disorders

For the diagnosis of schizophrenia, Schneider's first rank symptoms lose their special weight. Diagnosis henceforth requires one positive symptom. Subtypes have been removed in favor of a dimensional indicator of severity. For schizoaffective disorder, the mood aspect is emphasized, while for delusional disorder, pretentious content is no longer excluded - although it is assessed separately. The “catatonia” section has been expanded: this code can now be entered as a related diagnosis (qualifying indicator) for depressive, bipolar and psychotic disorders.

Bipolar and related disorders

Bipolar and related disorders are now separated from depressive disorders and placed in their own category. A clearer definition of mania is given and clarifying indicators are introduced for mixed episodes, which lowers the threshold for the disorder. A residual subcategory of “other” and a qualifying indicator for anxiety symptoms were added.

Depressive disorders

Added “disruptive mood dysregulation disorder” and premenstrual dysphoric disorder. Chronic depression and dysthymia are combined into one diagnosis, now it is “persistent depressive disorder (dysthymia)” with a number of qualifying indicators. Major depressive disorder remained virtually unchanged, although for “subthreshold” symptoms a clarifying indicator “mixed manifestations” was introduced. A qualifying indicator for anxiety distress was also introduced. The basis for the grief exception has been removed.

Anxiety disorders

Obsessive-compulsive disorder and post-traumatic disorder are presented in separate chapters on neurophysiological and epidemiological grounds (see below). The various phobia criteria have been slightly adapted, and agoraphobia and panic have been separated. Panic attacks can act as a clarifying indicator for other diagnoses. The diagnoses of “separation anxiety disorder” and selective mutism are no longer specific “childhood” diagnoses.

Obsessive-compulsive and related disorders

For obsessions and for “Body Dysmorphic Disorder”, clarifying indicators of severity and criticism have been added, incl. ""delusional character"". The same goes for Hoarding Disorder, a completely new diagnosis in the DSM-5, as does Excoriation (Skin-Picking) Disorder. This also included trichotillomania, and, in addition, exogenous causes of OCD were added, in particular due to the use of psychoactive substances and medications, as well as in connection with other medical conditions.

Trauma- and stressor-related disorders

For both acute trauma and post-traumatic stress disorder, the stressor criterion has been changed to include witnessing and indirect exposure to the stressor when making a diagnosis. The requirement for direct experience of fear, horror or feelings of helplessness is also eliminated. Avoidance and emotional flattening are separated, and at the same time added to emotional flattening, incl. persistent depressed mood. To the already known symptoms of agitation are added recklessness, (auto) destructive behavior, irritability and aggression. For children and adolescents in puberty, lower diagnostic thresholds are used. Adaptation disorder remained unchanged. Reactive attachment disorder has been moved to this chapter.

Dissociative Disorders

Various changes have been made to the criteria for dissociative identity disorder, including, for example, the perception of identity transition by third parties. Depersonalization and derealization are combined into one disorder. Dissociative fugues ceased to be a separate diagnosis, and became a qualifying indicator in “dissociative amnesia.”

Somatic symptom and related disorders

These are what were previously called somatoform disorders. Somatization disorder, hypochondriasis, pain disorder, and unspecified somatoform disorder have been removed from the DSM. A diagnosis of "disorder with physical symptoms" can be made on an equal basis with a diagnosis from another medical specialty only if the physical symptoms are combined with abnormal thoughts, feelings and behavior. Unexplained medical symptoms play a decisive role only in cases of false pregnancy and conversion (ie, a functional disorder with neurological symptoms). In other cases, one should look for positive symptoms in this group.

Feeding and Eating Disorders

This includes former "children's" diagnoses such as "pica" (absorption of inedible substances) and "rumination" (i.e. regurgitation of food with repeated chewing), but for them the age criterion was removed. There is also a new diagnosis: “Avoidant/Restrictive Food Intake”. Anorexia no longer requires amenorrhea and binge eating, although bulimia nervosa and the new category of Binge-Eating Disorder require binge eating at least once a week.

Sleep-Wake Disorders

There is no longer a distinction between truly psychiatric and other (“somatic”) sleep disorders in the DSM-5, given the original concept of the related nature of the diagnoses. The chapter presents a large number of sleep disorders described through physical characteristics in relation to circadian rhythms and breathing disorders. This group includes Restless Legs Syndrome and REM Sleep Behavior Disorder. A large diagnostic choice predisposes to move away from the use of “unspecified” diagnoses.

Sexual Dysfunctions

In order to avoid overdiagnosis, the diagnosis thresholds in this group have been raised. Vaginismus is combined with dyspareunia under the category of Genito-Pelvic Pain/Penetration Disorder. Sexual aversion disorder has been removed. All disorders are subtyped based on psychological or combined factors, situation, and achievement.

Gender Dysphoria

Disruptive, impulse control, and conduct disorders

This is also a new chapter, which partially includes the missing chapter "Disorders Usually First Diagnosed in Childhood and Adolescence." In addition to various impulse control disorders, this also includes antisocial personality disorder, duplicated from the chapter on personality disorders. The criteria for oppositional defiant disorder have been revised and strengthened. In Conduct Disorder, the grounds for excluding the diagnosis were removed, but the clarifying indicator “callous-unemotional” was added. Intermittent Explosive Disorder can now be verbal, and the other criteria for the disorder are much more refined.

Substance-related and addictive disorders

This chapter is the first to include a non-substance-induced disorder: gambling addiction. For chemical substances, abuse and dependence are combined under the name Substance Use Disorder. "Traction" appears as a criterion, and problems with the justice authorities are removed. There was a new code for tobacco use disorder, while caffeine was already in the DSM-IV TR. There is a severity criterion, as well as a reference to “under controlled circumstances” or “as maintenance treatment” (for methadone).

This concludes our review. It's far from full. We are dealing only with the first attempts to comprehend the changes that have taken place, taking into account the accumulated knowledge. More detailed information about the relevant sections can be found on the Internet.

Based on materials:

* (i.e., DSM fifth edition), the next generation of the classifier.

According to DSM-IV, the following factors (“axes”) are considered when formulating a full diagnosis:

presence or absence
- mental illness (axis I),
- background psychopathy (axis II),
- somatic disease (axis III),
aggravating psychosocial factors (axis IV),
general level of adaptation (axis V).

The manual uses ICD-9-CM (ICD-9-CM) codes to codify disorders.

Description

First axis(axis I) includes transient, reversible disorders that come and go, such as phobias, generalized anxiety disorder (GAD), depression, addictions, etc. These disorders are “symptomatic”, as patients with disorders on this axis often find themselves the presence of mental disorders (“symptoms”) that bother them and require treatment.

Second axis(axis II) includes personality disorders and other stable, virtually reversible long-term mental disorders such as mental retardation or retardation.

The attitude of patients towards violations of the First Axis is ego-dystonic, that is, alien, not characteristic of the ego, while violations of the Second Axis, including personality disorders, are ego-syntonic and are considered by patients as their inherent characterological characteristics and/or natural reactions to the current situation.

Third axis(axis III) contains a list of physical disorders or conditions that may be observed in a patient with mental disorders, that is, all somatic and psychosomatic diseases (for example, epilepsy, arterial hypertension, gastric ulcer, infectious diseases, etc.). Axis III contains codes borrowed from the International Classification of Diseases (ICD).

Fourth axis(axis IV) includes past psychosocial stress (eg, divorce, trauma, death of someone close to you) related to the disease; are ranked (separately for adults and separately for children and adolescents) on a scale with a continuum from 1 (no stress) to 6 (catastrophic stress).

Fifth axis(axis V) characterizes the highest level of functioning observed in the patient over the past year (for example, in social, professional activities and mental activity); ranking on a scale ranging from 100 (upper limit) to 1 (severe impairment of function).

Story

- DSM-II (7th edition with homosexuality excluded)
- DSM-III-R (third edition, revised)
- DSM-IV-TR (TR - English. text revision; fourth edition, revised)
- DSM-5 (development began in 1999, published May 18, 2013)

The addition or removal of diseases to the DSM is done by vote of psychiatrists.

Criticism

Of the 170 people who contributed to DSM-IV and DSM-IV-TR, ninety-five (56%) had financial ties to pharmaceutical companies, according to a study published in the journal Psychotherapy and Psychosomatics. Of all the psychiatrists who contributed to the development of the DSM Mood Disorders and Schizophrenia and Other Psychotic Disorders categories, 100% had ties to pharmaceutical companies.

Sources

American Psychiatric Association (1987) “Diagnostic and statistical manual of mental disorders” (3rd ed., rev.). Washington. DC: APA.
American Psychiatric Association (1994) Diagnostic and Statistical Manual of Mental Disorders (4th ed.) (DSM-IV). Washington, DC: APA.
American Psychiatric Association.“Diagnostic and statistical manual of mental disorders, Fourth Edition, Text Revision: DSM-IV-TR" - Washington, DC: American Psychiatric Publishing, Inc., 2000. - ISBN 0890420254.

Write a review of the article "DSM-IV"

Literature

Korolenko Ts. P., Dmitrieva N. V. Personality and dissociative disorders: expanding the boundaries of diagnosis and treatment. - Novosibirsk: NGPU Publishing House, 2006. P. 6-7. ISBN 5-85921-548-7
Kaplan G.I., Sadok B.J. Clinical psychiatry (from a synopsis on psychiatry) in 2 volumes, volume 1. - M.: Medicine, 1998, 672 pp.: ill. pp. 30, 31, 53, 54. ISBN 5-225-00533-0
Regier DA, Kuhl EA, Kupfer DJ// World Psychiatry. - June 2013. - T. 12, No. 2. - pp. 88-94.

Notes

Excerpt describing DSM-IV

“You come in if you need anything, everyone at headquarters will help...” said Zherkov.
Dolokhov grinned.
- You better not worry. I won’t ask for anything I need, I’ll take it myself.
- Well, I’m so...
- Well, so am I.
- Goodbye.
- Be healthy...
... and high and far,
On the home side...
Zherkov touched his spurs to the horse, which, getting excited, kicked three times, not knowing which one to start with, managed and galloped off, overtaking the company and catching up with the carriage, also to the beat of the song.

Returning from the review, Kutuzov, accompanied by the Austrian general, went into his office and, calling the adjutant, ordered to be given some papers relating to the state of the arriving troops, and letters received from Archduke Ferdinand, who commanded the advanced army. Prince Andrei Bolkonsky entered the commander-in-chief's office with the required papers. Kutuzov and an Austrian member of the Gofkriegsrat sat in front of the plan laid out on the table.
“Ah...” said Kutuzov, looking back at Bolkonsky, as if with this word he was inviting the adjutant to wait, and continued the conversation he had begun in French.
“I’m just saying one thing, General,” Kutuzov said with a pleasant grace of expression and intonation, which forced you to listen carefully to every leisurely spoken word. It was clear that Kutuzov himself enjoyed listening to himself. “I only say one thing, General, that if the matter depended on my personal desire, then the will of His Majesty Emperor Franz would have been fulfilled long ago.” I would have joined the Archduke long ago. And believe my honor, it would be a joy for me personally to hand over the highest command of the army to a more knowledgeable and skilled general than I am, of which Austria is so abundant, and to relinquish all this heavy responsibility. But circumstances are stronger than us, General.
And Kutuzov smiled with an expression as if he was saying: “You have every right not to believe me, and even I don’t care at all whether you believe me or not, but you have no reason to tell me this. And that’s the whole point.”
The Austrian general looked dissatisfied, but could not help but respond to Kutuzov in the same tone.
“On the contrary,” he said in a grumpy and angry tone, so contrary to the flattering meaning of the words he was saying, “on the contrary, your Excellency’s participation in the common cause is highly valued by His Majesty; but we believe that the present slowdown deprives the glorious Russian troops and their commanders-in-chief of the laurels that they are accustomed to reaping in battles,” he finished his apparently prepared phrase.
Kutuzov bowed without changing his smile.
“And I am so convinced and, based on the last letter with which His Highness Archduke Ferdinand honored me, I assume that the Austrian troops, under the command of such a skillful assistant as General Mack, have now won a decisive victory and no longer need our help,” said Kutuzov.
The general frowned. Although there was no positive news about the defeat of the Austrians, there were too many circumstances that confirmed the general unfavorable rumors; and therefore Kutuzov’s assumption about the victory of the Austrians was very similar to ridicule. But Kutuzov smiled meekly, still with the same expression, which said that he had the right to assume this. Indeed, the last letter he received from Mac's army informed him of the victory and the most advantageous strategic position of the army.
“Give me this letter here,” said Kutuzov, turning to Prince Andrei. - If you please see. - And Kutuzov, with a mocking smile at the ends of his lips, read in German to the Austrian general the following passage from a letter from Archduke Ferdinand: “Wir haben vollkommen zusammengehaltene Krafte, nahe an 70,000 Mann, um den Feind, wenn er den Lech passirte, angreifen und schlagen zu konnen. Wir konnen, da wir Meister von Ulm sind, den Vortheil, auch von beiden Uferien der Donau Meister zu bleiben, nicht verlieren; mithin auch jeden Augenblick, wenn der Feind den Lech nicht passirte, die Donau ubersetzen, uns auf seine Communikations Linie werfen, die Donau unterhalb repassiren und dem Feinde, wenn er sich gegen unsere treue Allirte mit ganzer Macht wenden wollte, seine Absicht alabald vereitelien. Wir werden auf solche Weise den Zeitpunkt, wo die Kaiserlich Ruseische Armee ausgerustet sein wird, muthig entgegenharren, und sodann leicht gemeinschaftlich die Moglichkeit finden, dem Feinde das Schicksal zuzubereiten, so er verdient.” [We have quite concentrated forces, about 70,000 people, so that we can attack and defeat the enemy if he crosses Lech. Since we already own Ulm, we can retain the advantage of command of both banks of the Danube, therefore, every minute, if the enemy does not cross the Lech, cross the Danube, rush to his communication line, below cross the Danube back to the enemy, if he decides to turn all his power on our faithful allies, prevent his intention from being fulfilled. Thus, we will cheerfully await the time when the imperial Russian army is completely ready, and then together we will easily find the opportunity to prepare for the enemy the fate he deserves.”]
Kutuzov sighed heavily, ending this period, and looked attentively and affectionately at the member of the Gofkriegsrat.
“But you know, Your Excellency, the wise rule is to assume the worst,” said the Austrian general, apparently wanting to end the jokes and get down to business.
He involuntarily looked back at the adjutant.
“Excuse me, General,” Kutuzov interrupted him and also turned to Prince Andrei. - That's it, my dear, take all the reports from our spies from Kozlovsky. Here are two letters from Count Nostitz, here is a letter from His Highness Archduke Ferdinand, here is another,” he said, handing him several papers. - And from all this, neatly, in French, compose a memorandum, a note, for the sake of visibility of all the news that we had about the actions of the Austrian army. Well, then, introduce him to his Excellency.
Prince Andrei bowed his head as a sign that he understood from the first words not only what was said, but also what Kutuzov wanted to tell him. He collected the papers, and, making a general bow, quietly walking along the carpet, went out into the reception room.
Despite the fact that not much time has passed since Prince Andrei left Russia, he has changed a lot during this time. In the expression of his face, in his movements, in his gait, the former pretense, fatigue and laziness were almost not noticeable; he had the appearance of a man who does not have time to think about the impression he makes on others, and is busy doing something pleasant and interesting. His face expressed more satisfaction with himself and those around him; his smile and gaze were more cheerful and attractive.
Kutuzov, whom he caught up with in Poland, received him very kindly, promised him not to forget him, distinguished him from other adjutants, took him with him to Vienna and gave him more serious assignments. From Vienna, Kutuzov wrote to his old comrade, the father of Prince Andrei:
“Your son,” he wrote, “shows hope of becoming an officer, out of the ordinary in his studies, firmness and diligence. I consider myself lucky to have such a subordinate at hand.”
At Kutuzov's headquarters, among his comrades and colleagues, and in the army in general, Prince Andrei, as well as in St. Petersburg society, had two completely opposite reputations.
Some, a minority, recognized Prince Andrei as something special from themselves and from all other people, expected great success from him, listened to him, admired him and imitated him; and with these people Prince Andrei was simple and pleasant. Others, the majority, did not like Prince Andrei, considered him a pompous, cold and unpleasant person. But with these people, Prince Andrei knew how to position himself in such a way that he was respected and even feared.
Coming out of Kutuzov’s office into the reception area, Prince Andrei with papers approached his comrade, the adjutant on duty Kozlovsky, who was sitting by the window with a book.
- Well, what, prince? – asked Kozlovsky.
“We were ordered to write a note explaining why we shouldn’t go ahead.”
- Why?
Prince Andrey shrugged his shoulders.
- No news from Mac? – asked Kozlovsky.
- No.
“If it were true that he was defeated, then the news would come.”
“Probably,” said Prince Andrei and headed towards the exit door; but at the same time, a tall, obviously visiting, Austrian general in a frock coat, with a black scarf tied around his head and with the Order of Maria Theresa around his neck, quickly entered the reception room, slamming the door. Prince Andrei stopped.
- General Chief Kutuzov? – the visiting general quickly said with a sharp German accent, looking around on both sides and walking without stopping to the office door.
“The general in chief is busy,” said Kozlovsky, hastily approaching the unknown general and blocking his path from the door. - How would you like to report?
The unknown general looked contemptuously down at the short Kozlovsky, as if surprised that he might not be known.
“The general in chief is busy,” Kozlovsky repeated calmly.
The general's face frowned, his lips twitched and trembled. He took out a notebook, quickly drew something with a pencil, tore out a piece of paper, gave it to him, walked quickly to the window, threw his body on a chair and looked around at those in the room, as if asking: why are they looking at him? Then the general raised his head, craned his neck, as if intending to say something, but immediately, as if casually starting to hum to himself, he made a strange sound, which immediately stopped. The door to the office opened, and Kutuzov appeared on the threshold. The general with his head bandaged, as if running away from danger, bent down and approached Kutuzov with large, fast steps of his thin legs.

The Diagnostic and Statistical Manual of Mental Disorders, 4th edition, revised, was published by the American Psychiatric Association in 2000. This paper attempts to evaluate psychiatric illness along five axes.

Axis I includes most mental disorders except personality disorders and mental retardation.
Axis II includes personality disorders and varying degrees of mental retardation.
Axis III consists of all concomitant general health disorders that may be observed in a patient with mental disorders (eg, epilepsy, hypertension, gastric ulcers, infectious diseases, etc.).
Axis IV covers psychosocial and environmental problems that may complicate diagnosis and treatment (eg, divorce, trauma, death of a loved one).
V-axis describes clinicians' assessments of patients' overall activity level using the Global Assessment of Functional Status (GAF) Scale, where level of functionality is scored from 0 to 100.