Mastering the Kennedy Axis V: A New Psychiatric Assessment of Patient Functioning

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MASTERING THE KENNEDY AXIS V A New Psychiatric Assessment of Patient Functioning

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MASTERING THE KENNEDY AXIS V A New Psychiatric Assessment of Patient Functioning

James A. Kennedy, MD Associate Professor of Psychiatry University of Massachusetts Medical School Worcester, Massachusetts Director Demonstration Unit Westborough State Hospital Westborough, Massachusetts President KennedyMD Consulting Shrewsbury, Massachusetts

Washington, DC London, England

Copyright Copyright © 2003 American Psychiatric Publishing, Inc. The Kennedy Axis V, the Kennedy NOSIE, and the Guide to the Kennedy NOSIE are copyright © 2003 James A. Kennedy, MD. The Kennedy Axis V and the Kennedy NOSIE are not in the public domain. For more details on licensing the use of these instruments and/or obtaining a copy of these instruments, visit www.kennedymd.com. Books published by American Psychiatric Publishing, Inc., represent the views and opinions of the individual authors and do not necessarily represent the policies and opinions of APPI or the American Psychiatric Association. The author has worked to ensure that all information in this book is accurate at the time of publication and consistent with general psychiatric and medical standards, and that information concerning drug dosages, schedules, and routes of administration is accurate at the time of publication and consistent with standards set by the U. S. Food and Drug Administration and the general medical community. As medical research and practice continue to advance, however, therapeutic standards may change. Moreover, specific situations may require a specific therapeutic response not included in this book. For these reasons and because human and mechanical errors sometimes occur, we recommend that readers follow the advice of physicians directly involved in their care or the care of a member of their family. Manufactured in the United States of America on acid-free paper 07 06 05 04 03 5 4 3 2 1 First Edition American Psychiatric Publishing, Inc. 1000 Wilson Boulevard Arlington, VA 22209 www.appi.org

Library of Congress Cataloging-in-Publication Data Kennedy, James A., 1946– Mastering the Kennedy Axis V : a new psychiatric assessment of patient functioning / James A. Kennedy. p. ; cm. Includes bibliographical references. ISBN 1-58562-062-9 (alk. paper) 1. Psychiatric rating scales. 2. Mental illness—Diagnosis. I. Title: Kennedy Axis V. II. Title: Mastering the Kennedy Axis 5. III. Title. [DNLM: 1. Psychiatric Status Rating Scales. 2. Mental Disorders—diagnosis. WM 141 K35m 2002] RC473.P78 K445 2003 616.89′075—dc21 2002027685 British Library Cataloguing in Publication Data A CIP record is available from the British Library.

CONTENTS Foreword........................................................................................................................................ ix Joseph Black, MD, and Michael T. Jumes, PhD

Acknowledgments ......................................................................................................................... xi Cautionary Note .......................................................................................................................... xiii Identifying Patient Data.............................................................................................................. xiii CHAPTER 1

Introduction................................................................................................................................ 1–1 I. Overview .......................................................................................................................................... 1–5 II. Comparison of the K Axis to the GAF ................................................................................................ 1–6 III. Approach to Learning the K Axis ....................................................................................................... 1–9 IV. Development of the K Axis.............................................................................................................. 1–10 V. Population Addressed by the K Axis ................................................................................................ 1–11 VI. K Axis and Diagnoses ...................................................................................................................... 1–13 VII. K Axis and the Clinical Impression ................................................................................................... 1–15 VIII. K Axis and Clinical Decisions ........................................................................................................... 1–15 IX. Evidence-Based Tracking of Medication Changes ............................................................................ 1–16 X. K Axis Within the Correctional System............................................................................................. 1–17 XI. K Axis With a Managed Care Provider ............................................................................................. 1–17 XII. K Axis and the Joint Commission’s ORYX Initiative........................................................................... 1–18 XIII. References ...................................................................................................................................... 1–18 CHAPTER 2

Kennedy Axis V Questionnaire................................................................................................... 2–1 I. Overview .......................................................................................................................................... 2–5 II. Instruction Sheet............................................................................................................................... 2–5 III. Individual Subscales .......................................................................................................................... 2–5 IV. Copy of the K Axis .......................................................................................................................... 2–10 V. Kennedy Axis V Quick Reference ..................................................................................................... 2–22 VI. Scoring Sheets ................................................................................................................................ 2–24 VII. Rounding Off to the Nearest Multiple of 5 ...................................................................................... 2–29 VIII. Reliability and Validity ..................................................................................................................... 2–29 IX. References ...................................................................................................................................... 2–32 CHAPTER 3

Scoring the Kennedy Axis V ....................................................................................................... 3–1 I. Time Periods Being Rated.................................................................................................................. 3–5 II. Necessity of Good Clinical Assessments............................................................................................. 3–6 III. Anchor Points and Best Fit for Capturing the Clinical Impression ....................................................... 3–6 IV. Multiple Factors in Each Subscale ...................................................................................................... 3–6

V. Optional Subscale: Ancillary Impairment ...........................................................................................3–9 VI. Dangerousness..................................................................................................................................3–9 VII. Users of the K Axis ..........................................................................................................................3–10 VIII. Certification on the Use of the K Axis ..............................................................................................3–11 IX. Data Needed to Rate the K Axis ......................................................................................................3–11 X. Familiarity With the K Axis...............................................................................................................3–12 XI. Effects of Symptoms, Treatment, Stress, Physical Limitations, and the Like.......................................3–13 XII. Average Score for the K Axis ...........................................................................................................3–17 XIII. K Axis Scores and Your Multiaxial Diagnoses ...................................................................................3–18 XIV. K Axis Rating and Cultural Factors ...................................................................................................3–20 XV. References.......................................................................................................................................3–20 CHAPTER 4

GAF Equivalent and Dangerousness Level .................................................................................4–1 I. Overview ..........................................................................................................................................4–5 II. GAF Equivalent..................................................................................................................................4–5 III. Dangerousness Level .........................................................................................................................4–6 IV. Dangerousness Level and the GAF Equivalent ....................................................................................4–8 V. Determination of the GAF Equivalent and Dangerousness Level Scores ..............................................4–9 VI. Number of Subscales Needed to Determine the Dangerousness Level .............................................4–13 VII. References.......................................................................................................................................4–13 CHAPTER 5

Problem Description Section of the Scoring Sheet ...................................................................5–1 I. What Is the Problem Description Section of the Scoring Sheet? .........................................................5–5 II. Writing a Problem Description of the Patient’s Functioning ...............................................................5–5 III. Using the Problem Description to Individualize the K Axis..................................................................5–6 IV. Determining the Rate of Change in the Individual Subscale Areas......................................................5–7 V. Using Subscale Scores and Problem Descriptions Together to Track Change .....................................5–8 VI. References.........................................................................................................................................5–9 CHAPTER 6

Scoring Clinical Vignettes (Self-Examination) ...........................................................................6–1 I. Overview ..........................................................................................................................................6–5 II. Process for Rating the Clinical Vignettes in This Book.........................................................................6–5 III. Sample Vignettes Scored Using the K Axis .........................................................................................6–6 Psychological Impairment ..............................................................................................................6–7 Social Skills...................................................................................................................................6–21 Violence.......................................................................................................................................6–35 ADL–Occupational Skills ...............................................................................................................6–51 Substance Abuse ..........................................................................................................................6–65 Medical Impairment.....................................................................................................................6–79 Ancillary Impairment ....................................................................................................................6–95

CHAPTER 7

Completed Kennedy Axis V Scoring Sheets .............................................................................. 7–1 I. Standard-Form Scoring Sheet............................................................................................................ 7–5 II. Long-Form Scoring Sheet................................................................................................................ 7–13 III. Computerized, Variable-Length Scoring Sheet ................................................................................ 7–18 CHAPTER 8

Profiles ........................................................................................................................................ 8–1 I. Conveying Clinical Information Quickly............................................................................................. 8–5 II. Generating Profiles Using the K Axis.................................................................................................. 8–5 III. Profiling Various Treatment Options.................................................................................................. 8–6 IV. Matching Patient Profiles to Profiles of Various Treatment Options .................................................... 8–6 V. Examples of Individual Client Profiles ................................................................................................ 8–7 VI. Examples of Profiles of Groups of Patients in Treatment .................................................................. 8–13 VII. Examples of Matching Patient Profiles to Therapist or Program Profiles............................................ 8–15 VIII. References ...................................................................................................................................... 8–26

Appendix..................................................................................................................................... A–1 I. Spreadsheets for the K Axis Ratings in the Book................................................................................. A–5 II. Problem-Oriented Progress Notes Using the K Axis ......................................................................... A–17 III. Comprehensive Psychiatric Assessment Using the K Axis ................................................................. A–21 IV. Kennedy NOSIE and Guide ............................................................................................................. A–24 V. References ...................................................................................................................................... A–32


Mastering the Kennedy Axis V

ix

Foreword In much the same manner as the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSMIV), and its Text Revision, DSM-IV-TR (American Psychiatric Association 1994, 2000) have given us a nomenclature with which we can convey information about the diagnoses of our patients, James Kennedy, MD, has given us the methodology with which we can convey meaningful information about the functional capacities and deficits of our patients. Similarly, as DSM-IV-TR provides explanations and directions on how to use the diagnostic information contained therein, Mastering the Kennedy Axis V provides explanations and directions on how to use the Kennedy Axis V subscales. Dr. Kennedy has given a description of the use of the Kennedy Axis V (K Axis), its conceptual underpinnings, and guidelines for its clinical application. Therefore, it is reasonable to consider this book a technical training manual. This easy-to-read book introduces the reader to the subscales, provides training for their use, and gives the foundations needed to establish and develop high levels of interrater reliability in research and applied settings. In sum, this manual gives “legs” to the instrument, facilitating its clinical and research applications. Dr. Kennedy’s extension of the Global Assessment of Functioning (GAF) Scale has important implications for treatment planning and outcome measurement. Whereas the GAF can provide only a unidimensional score, the K Axis offers a multidimensional look at a person’s functioning. Where life is multifaceted, a unidimensional score offers a less clear picture of the individual’s relative strengths and weaknesses. With the K Axis, important dimensions are broken out, and those of benefit, as well as those interfering with daily function, are made clear for the user. In taking the GAF to the next level, Dr. Kennedy walks the reader through the conceptual underpinnings of each subscale and provides needed background to more thoroughly utilize the tool for capturing clinical impressions. This is especially useful when the functional anchors provided for each subscale do not precisely describe a particular individual’s skills or deficits. Hence, the user is able to express impressions based on the level of function, using a language more suited to describing the complexities of an individual patient. In so doing, the user also underscores issues important to the treatment planning process, including outlining the usually complex interplay between functional deficits and relevant safety risks. With his presentation, Dr. Kennedy makes finer differentiations, which bring in apparent overlap across functional areas to make the subscales more conceptually distinct. This renders the Kennedy Axis V multidimensional, an important innovation over the GAF. Similarly, profiling the subscale scores, whether computer-generated or plotted by hand, helps the clinician better visualize relative functional strengths and weaknesses and provides rapid integration of critical information for treatment programming and outcome measurement. Dr. Kennedy also includes information relevant to both clinical and forensic settings and helps distinguish behavioral and psychiatric issues in each. We welcome this training manual, which provides a road map by which our colleagues may be introduced to the K Axis. Since 1996, Dr. Black, Chief Psychiatrist for the Competency Program at North Texas State Hospital–Vernon, has had responsibility for training hospital staff on the use of the K Axis. In this duty, he helped establish the K Axis subscales as a basic paradigm for organizing treatment planning. With this work ongoing, we feel sure that this manual—Mastering the Kennedy Axis V—will propel us forward in our efforts to train clinicians to use the subscales and will help establish more uniform subscale ratings across clinicians. Hence, we expect that communication between clinicians will be improved, and information exchange within and without our system will be facilitated. To better study the usefulness of the K Axis as a treatment outcome measure, evaluations are being implemented to analyze the applications of the K Axis as a treatment planning tool in a variety of hospital systems in the Texas Department of Mental Health and Mental Retardation. In our experience, the K Axis, used as a paradigm for treatment planning and as a measure of progress for treatment outcome, has improved our ability to present clinical descriptions of a patient in a manner more rich and meaningful to those requiring the information. In our practice, these have included mental health providers who continue the patient’s treatment in other settings and families who provide needed supports to the persons we serve. Also, in communicating critical information to the courts, a major function in our forensic role at the North Texas State Hospital—Vernon, we have

x


found that the instrument aids us in facilitating communication. In these regards, it has been our experience that use of the K Axis in communicating clinical estimates of patient functioning is a considerable extension of the GAF. Dr. Kennedy’s overview of the instrument, its applications, and utility of information is complemented by the provision of a variety of vignettes. These are provided to guide K Axis users through the process of data collection and integration in order to capture the clinical profile of the individual’s functioning. This readable and thorough review of the K Axis will help clinicians better understand and use it. Likewise, this book is expected to stimulate additional research to clarify and better understand the psychometric properties of the K Axis and expand on its utility as a practical tool for case conceptualization and as a marker of current functioning and treatment outcome. Joseph Black, MD Chief Psychiatrist Competency Program North Texas State Hospital–Vernon Vernon, Texas

Michael T. Jumes, PhD Chief Psychologist Competency Program North Texas State Hospital–Vernon Vernon, Texas

References American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 4th Edition. Washington, DC, American Psychiatric Association, 1994 American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision. Washington, DC, American Psychiatric Association, 2000


xi

Acknowledgments The importance of outcome measurement was established during my graduate education in the Brandeis–Worcester Project. This project included doctoral work at the Florence Heller Graduate School for Advanced Studies in Social Welfare at Brandeis University and psychiatric residency training at Worcester State Hospital. Among the key people who helped to encourage my interest in outcome measurement and to train me in the development of instruments measuring human behavior were Lorraine V. Klerman, DrPH (Project Director), and Joseph P. Morrissey, PhD (Project Research Director). Dr. Klerman is Professor, Department of Maternal and Child Health, School of Public Health, University of Alabama at Birmingham. Dr. Morrissey is Deputy Director of Research, Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill. I would also like to express special thanks to two friends and fellow graduate students from the Heller School: Victor Hoffman and Kent Boynton, PhD. Mr. Hoffman was essential to my early efforts to develop outcome measures and continues to advise me on analytical issues related to the Kennedy Axis V. Mr. Hoffman is Director of Customer Value Management at Tillinghast Towers–Perrin, New York, New York. Because of Dr. Boynton’s early recognition of the clinical usefulness of the Kennedy Axis V, especially in a managed care environment, his support was invaluable to its development. Dr. Boynton is working in managed care as Vice President, Regional and Network Operations, Massachusetts Behavioral Health Partnership, Boston, Massachusetts. I would like to thank Paul S. Appelbaum, MD, President of the American Psychiatric Association, 2002–2003, and Chairman, Department of Psychiatry, University of Massachusetts Medical School, for helping me obtain feedback from colleagues on the Kennedy Axis V. I would like to acknowledge Kenneth Appelbaum, MD, Director, Correctional Mental Health Program, University of Massachusetts Medical School. Dr. Appelbaum helped with my understanding that the type of outcome measure that I was pursuing was an instrument that captured the clinical impression of the clinician, rather than generating the clinician’s clinical impression. For their support with research relating to the validity of the Kennedy Axis V, I would like to acknowledge the contribution of Jeffrey Geller, MD, Professor of Psychiatry and Director of Public Sector Psychiatry, University of Massachusetts Medical School; William H. Fisher, PhD, Associate Director of the Center for Mental Health Services Research, University of Massachusetts Medical School; Susan Skog, RN, BS, CPHQ, Director of Performance Improvement/Utilization Management/Risk Management for the Department of Mental Health, Central Massachusetts Area; Bruce Gaulin, PharmD, Chairman, Research Review Committee, Worcester State Hospital; Carol Persia, RHIA, Director of Accreditation and Medical Records, Worcester State Hospital; and Mary Herman, RHIT, Assistant Director of Medical Records, Worcester State Hospital. For their advice on legal and ethical issues related to the Kennedy Axis V, I would like to acknowledge the help of Thomas Grisso, PhD, Director of Psychology and Coordinator of the Law and Psychiatry Program, University of Massachusetts Medical School; and Matt Zaitchik, PhD, Assistant Professor in the Law and Psychiatry, University of Massachusetts Medical School and Co-Director of the Forensic Service at Worcester State Hospital. Also from the University of Massachusetts Medical School, for his support and guidance with the development of the Kennedy Axis V, I would like to thank Joseph Tonkonogy, MD—a fellow author of an assessment tool. Others from Massachusetts whom I would like to acknowledge for their help and support are Peter Moran, PhD, Director of Psychological Services at the Worcester Medical Center; Michael Rubin, PsyD, Emergency Services Director, Riverside Community Care; Carl Bielack, RN, Nursing Instructor at Worcester State Hospital; Sue M. Lovely, MA, Director, Rehabilitation Services, Worcester State Hospital; Kevin McDonald, MSN, Administrative Director for Psychiatric Services, Psychiatric Treatment Center; John Finneran, EdM, Coordinator of Substance Abuse Services, Psychiatric Treatment Center; Brian Minchoff, Department of Mental Health, Site Director; and Patricia Surette, Department of Mental Health, Case Manager Supervisor. From Texas, I would like to acknowledge Joseph Black, MD, Chief Psychiatrist, Competency Program, North Texas State Hospital–Vernon; and Michael Jumas, PhD, Chair of the Outcome Measures

xii


Committee for the Department of Mental Health in the State of Texas and Chief Psychologist, Competency Program, North Texas State Hospital–Vernon. From the National Association of State Mental Health Program Directors (NASMHPD) in Alexandria, Virginia, I would like to acknowledge the support of Vijay Ganju, PhD. Dr. Ganju’s interest in the Kennedy Axis V began when he was Chair of the Outcome Measures Committee for the Department of Mental Health for the state of Texas. From the California Department of Mental Health, for their work with the Kennedy Axis V, including comparing the Kennedy Axis V with the Global Assessment of Functioning (GAF) scale, I would like to acknowledge the following people: 1) from Central Office, Jim Higgins, EdD, Chief, Systems Planning, Development, and Evaluation, and Karen Purvis, MSW, Research and Performance Outcome Unit; 2) from the Sacramento County Evaluation and Research Unit, Janet Crist-Whitzel, Coordinator of Research and Evaluation; and 3) from San Mateo County Department of Mental Health, Candace Cross-Drew, PhD, Deputy Director for Administration; Sandra Lehman, RN, MS, Adult Unit Chief of the South County Mental Health Clinic and her staff; and David Williams, PhD, Research and Evaluation Analyst. From the California Department of Corrections, I would like to acknowledge Larry H. Dizmang, MD, Chief of Psychiatry at the California Medical Facility, and Gary Collins, PhD, Psychologist at the California Medical Facility. They have been involved with pioneering efforts to integrate the Kennedy Axis V into the ongoing clinical assessment of prison inmates at the California Medical Facility at Vacaville, California. Also, from California, I would like to acknowledge Jim Westphal, MD, for his support of the Kennedy Axis V in presentations at national psychiatric conferences. Dr. Westphal is an expert on outcome measures and past Chief of Psychiatry at the Louisiana State University School of Medicine at Shreveport. Currently, Dr. Westphal is an Associate Clinical Professor at the University of California, San Francisco Medical School, and Director of the Substance Abuse Consultation Service at San Francisco General Hospital. For their early recognition of the clinical usefulness of the Kennedy Axis V, I would like to acknowledge Marjorie Snyder, MD, Clinical Director, Outpatient Services, Bangor Mental Health Institute, Bangor, Maine; Jeff Grace, MD, Medical Director of the Buffalo Psychiatric Center, Buffalo, New York; and Steve Steury, MD, Medical Director for Saint Elizabeth’s Hospital’s Outpatient Services in Washington, D.C. From Princeton, New Jersey, I would like to thank Gilbert Honigfeld, PhD, coauthor of the original NOSIE-30 questionnaire, for his help with the Kennedy NOSIE and his expert advice on the development and promotion of psychiatric outcome measures. I would like to thank Nicolaas Dubbling, PhD, Vice-President of Six County, Inc., Zanesville, Ohio, and Niels Mulder, MD, PhD, from Erasmus University, Rotterdam, the Netherlands, for their help with translating the Kennedy Axis V into Dutch. Finally, I would like to thank the many others not mentioned above who have also helped with the Kennedy Axis V and Kennedy NOSIE over the years of their development.


xiii

Cautionary Note As with most questionnaires in psychiatry, there is no established standard of care for the use of the Kennedy Axis V or the Kennedy NOSIE. You must use reasonable clinical judgment in making clinical decisions related to the Kennedy Axis V and the Kennedy NOSIE. This manual will provide guidelines for the use of the Kennedy Axis V and the Kennedy NOSIE; however, you are responsible for clinical decisions you make in association with your use of the Kennedy Axis V and/or the Kennedy NOSIE. Both the Kennedy Axis V and the Kennedy NOSIE are excellent clinical instruments; however, their accuracy may vary widely depending on a number of factors, including the following:

• • • • • • • • •

The level of training the raters have in the use of the instruments The clinical skills of the raters The time available to do the clinical assessments and ratings The accuracy of the information provided to the raters The ability of the raters to translate their clinical impressions and/or observations into the ratings The raters’ frequency of using the instruments Idiosyncratic factors that may make rating particular patients very difficult Inaccuracies that are inherent in almost any instrument that measures something as complicated and elusive as human symptoms and behaviors Clinical and administrative pressures to give patients particular scores to justify various clinical and administrative decisions

You must be able to defend clinical decisions that you make in conjunction with the use of the Kennedy Axis V and/or the Kennedy NOSIE. You must stand behind your decisions based on your overall clinical assessment of the accuracy of the information gained from using these instruments in your clinical practice. Included in your clinical assessment should be your familiarity with the Kennedy Axis V and/or the Kennedy NOSIE and your assessment of the skills and accuracy of the persons who are making the ratings. If you are unsure of the accuracy of the ratings, you should proceed much more cautiously, including being much more aggressive about gathering additional information to support any clinical decisions that you are making. As with many other instruments measuring human symptoms and behaviors, you are strongly discouraged from mechanically making clinical decisions solely on the basis of the scores generated by the Kennedy Axis V or the Kennedy NOSIE.

Identifying Patient Data The patient and client names and associated treatment facilities used in this book are fictitious. They are intended to provide individual clinical vignettes and patient profiles. Even though patient names are fictitious, the vignettes are based on many years of clinical experience working with psychiatric patients and gathering case material from colleagues and conferences. Although the vignettes are not actual cases, they are usually composites of actual cases. Identifying data has been changed or eliminated. Any resemblance to or association with real individual clients, patients, or staff is purely coincidental.

Notes

CHAPTER 1

INTRODUCTION

1–1


Introduction

1–3

INTRODUCTION CONTENTS I. Overview ......................................................................................................................................... 1–5 II. Comparison of the K Axis to the GAF ............................................................................................. 1–6 III. Approach to Learning the K Axis .................................................................................................... 1–9 IV. Development of the K Axis ........................................................................................................... 1–10 A. Organizing Narrative Clinical Information ................................................................................. 1–10 B. Extracting Subscales From Axis V to Create the K Axis ............................................................... 1–11 V. Population Addressed by the K Axis ............................................................................................. 1–11 VI. K Axis and Diagnoses .................................................................................................................... 1–13 VII. K Axis and the Clinical Impression ................................................................................................ 1–15 VIII. K Axis and Clinical Decisions ......................................................................................................... 1–15 IX. Evidence-Based Tracking of Medication Changes ........................................................................ 1–16 X. K Axis Within the Correctional System ......................................................................................... 1–17 XI. K Axis With a Managed Care Provider.......................................................................................... 1–17 XII. K Axis and the Joint Commission’s ORYX Initiative ...................................................................... 1–18 XIII. References ..................................................................................................................................... 1–18


Introduction

1–5

INTRODUCTION I.

Overview

The search for a universal instrument for use in psychiatry to organize information and to track outcome led to the creation of the Kennedy Axis V (K Axis). One of its main roles is to act as an alternative to the DSM-IV-TR Global Assessment of Functioning (GAF) Scale (American Psychiatric Association 2000); however, as will be presented in this book, its ease of use and powerful features make it much more than just an alternative to the GAF. The K Axis captures all of the major clinical areas, which makes it a truly universal outcome measure for psychiatry. In many clinical situations, all outcome measurement needs can be consolidated into this single instrument. Many examples of its versatility and clinical usefulness are presented in this book, as well as practice exercises to assist you in becoming proficient in the use of the K Axis. Like the GAF, the K Axis generates a global assessment of functioning score and is intended to be practical, quick, and easy to use. Also like the GAF, it is based on information that clinicians routinely collect as an ongoing part of doing good clinical assessments. Unlike the GAF, the K Axis can preserve important clinical information in its seven subscales. These seven subscales distinguish the K Axis from being simply an alternative to the GAF. Everything is boiled down to a single number with the GAF; however, in the process, important elements of a client’s symptoms and functioning are lost. The K Axis also can condense the total clinical picture into a single number in the form of the GAF Equivalent. However, in the process of generating the GAF Equivalent, the K Axis’s seven subscales are created. They act to preserve many critical measures of the client’s symptoms and functioning. The name of each subscale gives clinicians an instant understanding of the information that it is intended to capture: 1. 2. 3. 4. 5. 6. 7.

Psychological Impairment Social Skills Violence Activities of Daily Living (ADL)–Occupational Skills Substance Abuse Medical Impairment Ancillary Impairment

Using these seven subscales, the K Axis can capture vital clinical information that is lost when using the GAF. In addition to capturing this vital clinical information, these seven ratings are used to generate the GAF Equivalent and the Dangerousness Level for each client (see Chapter 4, “GAF Equivalent and Dangerousness Level”). In other words, in addition to a global score, the K Axis provides details on that global score, including the clinical basis for how the global score was generated; therefore, it provides a much richer overview of the client’s general clinical condition. The K Axis, including its subscale scores, can be generated in approximately the same time that it takes to generate the GAF. This is especially true if you consider that the vast majority of the time necessary to perform either rating is the time needed to assess the client. A reasonable clinical assessment is critical to both the K Axis and the GAF. Without a reasonable assessment, the accuracy will be compromised for both the K Axis and the GAF. Once a clinician is familiar with the patient’s clinical presentation and history, the GAF and the K Axis can each be rated in a matter of a few minutes. However, as indicated earlier, the K Axis provides a rich clinical picture by capturing and preserving in its seven subscales an outline of the clinical information gathered during the assessment. To further facilitate its use, the K Axis uses a rating system very similar to that used by the GAF; therefore, clinicians should be able to master the use of the K Axis quickly. This should also allow you to readily interpret the meaning of the scores obtained using the K Axis.

1–6

II.


Comparison of the K Axis to the GAF

The K Axis’s primary function is to serve as an alternative the GAF; therefore, it can be used to measure baseline psychiatric functioning and to track treatment outcome over time. The design of the GAF limits the amount of information that it can convey to clinicians, administrators, and managed care personnel. This lost information can be critical to tracking outcomes in response to various treatments and therapeutic environments and can be vital to decisions related to the management needs of our patients, including staffing levels. This loss of information when using the GAF arises from the GAF’s use of a single number to represent a client’s global functioning, including at least two broad factors: 1) level of functioning and 2) psychiatric symptoms. At the higher function end of the GAF continuum, the GAF mostly measures level of functioning (see Figure 1–1). At the more dysfunctional end of the continuum, the GAF increasingly measures both level of functioning and severe psychiatric symptoms. Therefore, a score at the lower end of the continuum could just as likely reflect either of these factors. This is a major problem for the GAF because which factor is being measured is not clear. This was pointed out by Robert L. Spitzer, MD, et al.: “One limitation of the [GAF] results from combining the level of role functioning and severity of psychopathologic symptoms that, in some cases, may result in low scores for high-functioning patients who present with a single, severe, symptom” (Spitzer et al. 1994, p. 77). Of interest is the fact that the “single, severe, symptom” is often violent behavior toward self or others. Similarly, the Handbook of Psychiatric Measures points out that the GAF has been “criticized for confounding symptoms and functioning. Lack of a clear distinction between the two can make rating difficult when, for example, there are moderate or severe symptoms but functioning that is not very impaired or the reverse. A similar criticism could be made of the SOFAS (Social and Occupational Functioning Assessment Scale) in cases in which, for example, occupational functioning is high but social functioning is impaired” (American Psychiatric Association 2000, p. 99). The expanded functionality of the K Axis over the GAF allows the K Axis to provide a much more complete picture of the patient’s clinical status. This can be done in approximately the same time that it takes to rate the GAF. Besides providing a fuller clinical picture for tracking outcome, the K Axis is helpful in the following ways: •

• •

•

Facilitating the communication of clinical information. The seven subscales can quickly communicate a vast amount of information about an individual client. This can lead to quick exchanges of clinically relevant information among clinicians, administrators, and managed care personnel, which is further facilitated because the K Axis scoring is closely standardized to the GAF. Therefore, this flow of clinical information can be performed with very little additional training because most mental health professionals are already familiar with rating the GAF and interpreting its scores. Generating profiles. Clinicians, administrators, and managed care personnel can use these profiles to get an instant visual overview of individual clinical cases, groups of patients, or programs. Facilitating treatment planning. The K Axis forms the basis for the system used in Fundamentals of Psychiatric Treatment Planning, Second Edition (Kennedy 2003). To facilitate treatment planning, the K Axis captures a patient’s baseline symptoms and skills in the subscale areas. These are used to generate problem lists for psychiatric treatment planning (see Figure 1–2). In doing so, the K Axis can play a central role in organizing clinical thinking and the approach to patients, including organizing clinical information for Master Treatment Plans, comprehensive psychiatric assessments, and problem-oriented progress notes. Helping to set staffing levels. The clinical management demands of our patients can vary markedly from patient to patient. Individual subscales can help quantify for clinicians and administrators a patient’s needs in seven vital clinical areas. In addition, the K Axis profiles can reveal patterns that can be very helpful in determining a patient’s clinical needs. See Chapter 8, “Profiles,” for examples of profiles for patients with difficult-to-manage problems, as well as profiles used to match patients to specific treatment programs or treatment activities.

Introduction

GLOBAL ASSESSMENT OF FUNCTIONING (GAF) SCALE Code

(Note.

Use intermediate codes when appropriate, e.g., 45, 68, 72.)

100–91

Superior functioning in a wide range of activities, life’s problems never seem to get out of hand, is sought out by others because of his or her many positive qualities. No symptoms.

90–81

Absent or minimal symptoms (e.g., mild anxiety before an exam), good functioning in all areas, interested and involved in a wide range of activities, socially effective, generally satisfied with life, no more than everyday problems or concerns (e.g., an occasional argument with family members).

80–71

If symptoms are present, they are transient and expectable reactions to psychosocial stressors (e.g., difficulty concentrating after family argument); no more than slight impairment in social, occupational, or school functioning (e.g., temporarily falling behind in schoolwork).

70–61

Some mild symptoms (e.g., depressed mood and mild insomnia) OR some difficulty in social, occupational, or school functioning (e.g., occasional truancy, or theft within the household), but generally functioning pretty well, has some meaningful interpersonal relationships.

60–51

Moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) OR moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co-workers).

50–41

Serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) OR any serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job).

40–31

Some impairment in reality testing or communication (e.g., speech is at times illogical, obscure, or irrelevant) OR major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood (e.g., depressed man avoids friends, neglects family, and is unable to work; child frequently beats up younger children, is defiant at home, and is failing at school).

30–21

Behavior is considerably influenced by delusions or hallucinations OR serious impairment in communication or judgment (e.g., sometimes incoherent, acts grossly inappropriately, suicidal preoccupation) OR inability to function in almost all areas (e.g., stays in bed all day; no job, home, or friends).

20–11

Some danger of hurting self or others (e.g., suicide attempts without clear expectation of death; frequently violent; manic excitement) OR occasionally fails to maintain minimal personal hygiene (e.g., smears feces) OR gross impairment in communication (e.g., largely incoherent or mute).

10–1

Persistent danger of severely hurting self or others (e.g., recurrent violence) OR persistent inability to maintain minimal personal hygiene OR serious suicidal act with clear expectation of death.

0

Inadequate information.

Figure 1–1. DSM-IV-TR’S Axis V Global Assessment of Functioning (GAF) Scale. Consider psychological, social, and occupational functioning on a hypothetical continuum of mental health illness. Do not include impairment in functioning due to physical (or environmental) limitations. Source. Reprinted from American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision. Washington, DC, American Psychiatric Association, 2000, p. 34. Copyright 2000 American Psychiatric Association. Used with permission.

1–7

1–8


Quick Reference to Problem Categorization by the Kennedy Axis V 1.

Psychological Impairment Psychotic symptoms Poor motivation Mood disturbance Personality disturbance Poor focal attention Eating disturbance

2.

Social Skills Limited interpersonal skills Poor communication skills Lack of awareness of social norms Sexually inappropriate behavior

3.

Violence Threatening and assaultive Suicidal Homicidal Sexually violent Arsonist

4.

ADL–Occupational Skills Poor job skills Lack of skills to care for self Poor workmanship Lack of basic survival skills Poor personal hygiene skills

5.

Substance Abuse Alcohol abuse Cocaine abuse Polysubstance abuse Nicotine addiction

6.

Medical Impairment Hypertension Allergy to penicillin Diabetes Family planning concerns Tardive dyskinesia Dental problems

7.

Ancillary Impairment Homelessness Financial problems Abusive spouse (domestic violence) Legal problems Incarceration Need for guardianship

Figure 1–2. Problem categorization using the K Axis. This classification system serves to simplify problem identification and treatment planning by categorizing problems using the K Axis subscales. The wide range of psychiatric and medical symptoms, syndromes, and issues are divided into the seven subscales. Listed below the subscale titles are some examples of problems from each of the seven areas. Permission granted by American Psychiatric Publishing, Inc., and James A. Kennedy, MD, to copy this page.

Introduction

1–9

The California Outcome Measures Project compared the GAF and the K Axis (Higgins and Purvis 2000, p. 84): In this article, the authors evaluate two brief clinician-scored global assessment instruments used to measure the functioning of adult clients who have a serious mental illness: the Global Assessment of Functioning (GAF) Scale and the relatively new Kennedy Axis V (K Axis). Although both instruments are brief and easy to score, the K Axis provides a multidimensional evaluation, while the GAF provides a single, unidimensional picture of the client’s functioning. Statistical analysis indicated that both instruments have adequate validity and reliability if the clinicians using them are sufficiently trained. Correlations between the two instruments were high where expected. Statistically significant differential functioning was found for various subgroups. The K Axis was better able to pinpoint this specific differential functioning. Table 1–1 summarizes many of the comparisons between the capabilities of the K Axis and the GAF. Table 1–1.

K Axis compared with the GAF Scale GAF

Medical screening

KAx

GAF Eq

X

DL

PSY

SOC

VIO

ADL

SAb

X

MED

ANC

X

Outcome measurement

X

X

X

X

X

X

X

X

X

X

X

Predict outcome

X

X

X

X

X

X

X

X

X

X

X

X

X

X

Patient profile

X

Problem list generator

X

Program profile

X

Psychiatric symptom screening

X

X

Risk for abuse/victimization

X

Skills screening

X

Substance abuse screening Violence screening

X

X

X

X

X

X

X

X

X

X

X

X

X

X X X X

X

Note. This chart brings together many of the comparisons between the capabilities of the K Axis and the GAF, including the fact that the K Axis can be used to help generate problem lists for psychiatric treatment planning. GAF = Global Assessment of Functioning Scale; KAx = K Axis; GAF Eq = GAF Equivalent; DL = Dangerousness Level; PSY = Psychological Impairment; SOC = Social Skills; VIO = Violence; ADL = ADL–Occupational Skills; SAb = Substance Abuse; MED = Medical Impairment; ANC = Ancillary Impairment.

III. Approach to Learning the K Axis This book provides a practical, hands-on approach to learning the use of the K Axis; therefore, the main focus of the book will be rating clinical vignettes. Rating the vignettes will quickly give you an understanding of the K Axis as well as experience using it. Therefore, it is suggested that the best way to approach learning to use the K Axis may be a combination of your usual approach to reading a book or training manual, interspersed with taking breaks to rate some of the vignettes. Another approach may be to begin by familiarizing yourself with the questionnaire by simply browsing through the copy of the K Axis questionnaire provided in Chapter 2, including the instruction sheet, the individual subscales, and the scoring sheet. Then begin rating the vignettes in the book and only refer to specific sections of the book as you uncover difficulties rating the vignettes.

1–10

IV.


Development of the K Axis

The K Axis evolved out of my interest in computers and information management, especially information management issues related to the computerization of the masses of data through which mental health professionals are expected to maneuver. In 1983, I started using a portable computer in my clinical work. At that time, it was clear that demographic information had been successfully computerized (e.g., information that would fit in small fields, such as name, age, diagnosis, medication). However, computerization of narrative information, beyond just word processing, remained elusive. Claims that people were on the verge of automating psychiatric progress notes were everywhere. There was excitement and anticipation that breakthroughs were just around the corner. These breakthroughs would allow the computer to generate progress notes and comprehensive psychiatric assessments with just a few keystrokes. But these breakthroughs continue to be very slow in coming, and it could be far into the future before a truly satisfactory computerized psychiatric record exists. A. Organizing Narrative Clinical Information From 1984 until 1986, I struggled with how to develop a more effective method to organize and track narrative psychiatric information using a computer. The information that I was most interested in computerizing was found in progress notes, comprehensive psychiatric assessment, treatment planning, and the outcome of treatment. In the mid-1980s, paralleling my interest in the computerization of the psychiatric record was the growing popularity of the problem-oriented record. Central to the organization of the problem-oriented record was the problem list; however, in my opinion, there was no system that adequately categorized problem lists. Also, there was no formal, comprehensive system for describing baseline functioning of problems on problem lists and tracking changes in that functioning in response to treatment. I believed that these were essential factors to the organization of clinical information and the computerization of a psychiatric record. Psychiatric questionnaires were good at tracking changes in symptoms; therefore, I began looking at a number of questionnaires to determine whether they could also organize clinical information. However, most of the questionnaires that I could locate at that time were not broad enough (i.e., they often focused on a single factor, such as depression or substance abuse, rather than a wide range of clinical factors). Also, the clinical information they were measuring was usually boiled down to a single number rather than a set of numbers that could be used to track specific clinical areas and to develop a profile of the patient’s total clinical picture. I needed a questionnaire that captured a wide range of psychiatric problems, ideally the universe of psychiatric problems found on problem lists. In summary, the questionnaires that I looked at did not capture the broad clinical picture or they did not adequately divide the information gathered and tracked into clinically useful subscales. Unable to locate a questionnaire that met my needs, I next attempted to force subscales onto a number of questionnaires by grouping their various questions; however, this usually led to very awkward, nonintuitive subscales. Finally, I had some success with a questionnaire that I developed, the Nurses’ Observation Scale for Inpatient Evaluation—Quick Form (NOSIE-QF; Kennedy 1992). It was a modified version of the NOSIE30 (Honigfeld et al. 1966). I recently updated the NOSIE-QF to the Kennedy NOSIE (see the Appendix for a copy of the Kennedy NOSIE). A factor analysis had been done on the NOSIE-30 that allowed me to divide the NOSIE-QF into a manageable number of fairly meaningful clinical subscales. There were three positive subscales: 1) social competence, 2) social interest, and 3) personal neatness. There were three negative subscales: 1) irritability, 2) manifest psychosis, and 3) motor retardation. The NOSIE-QF generated a total “global” score, as well as a score for each of the subscales. It could also be used to generate a profile on individual patients. In the 1986 article “Computerization of the Psychiatric Progress Note: Data Banking and Data Analysis, the Step Beyond Word Processing” (Kennedy 1986), I presented an early attempt to computerize psychiatric progress notes using the subscales of the NOSIE-QF. Figure 1–3 shows an example from that article of possibly the first computerized psychiatric progress notes that went well beyond word processing—indexed fields embedded directly into the narrative note allowed for tracking

Introduction

1–11

of medication, clinical progress, patient’s self-reports, etc. It was organized around the NOSIE-QF; however, I was never satisfied with using the NOSIE-QF to provide the structure for computerizing clinical aspects of the psychiatric record. Its subscales were not very intuitive and there were large gaps in the NOSIE-QF’s ability to capture the broad clinical picture. B. Extracting Subscales From Axis V to Create the K Axis My next attempt was to focus on Axis V (Global Assessment of Functioning) (American Psychiatric Association 2000) (Figure 1–1). I had always been intrigued with Axis V’s ability to quickly capture the total clinical picture; however, it generated only a single number to represent that broad picture. In August 1986, I came up with the idea of breaking Axis V down into the components that it was measuring. As I dissected Axis V, four subscales began to emerge in the K Axis: 1) Psychological Impairment, 2) Social Skills, 3) Violence, and 4) ADL–Occupational Skills. Later, to complete the K Axis, I added three additional subscales: 5) Substance Abuse, 6) Medical Impairment, and 7) Ancillary Impairment. From Axis V, I was able to extract the basic skeleton for each of the subscales; however, most levels along the continuum had few, if any, anchor points. To complete each subscale, I added a large number of anchor points. These anchor points were chosen and placed along the continuum based on my years of clinical experience. In addition, I sought feedback on the choice and placement of the anchor points from literally hundreds of clinicians; however, their feedback was also based on their clinical experience, not a scientific study of the anchor points. Thus far, these anchor points have served the questionnaire well, and expert reviewers of the questionnaire in the California Outcome Measures Project (Higgins and Purvis 2000) have been satisfied with the K Axis’s face validity. Ideally, at some point, studies will be performed to validate the choice and placement of the various anchor points. Subscales for the first four categories formed the very first version of the K Axis in 1986; however, it took more than 10 years before a subscale could be written for each of the last three categories. The final subscale, “Ancillary Impairment,” was completed in early 1998. Since then, subsequent changes in the K Axis have been minimal. The K Axis provided valuable structure for computerization of broad, narrative clinical information, as well as the structure for a systematic approach to psychiatric treatment planning (Kennedy 1992). Clinicians could readily understand this structure, and computers thrive on this kind of structure. Narrative clinical information could be structured, entered into a computer, and associated with information with ratings that quantify that information. Being able to reduce long narrative descriptions of clients, such as the narrative descriptions found in mental status examinations and comprehensive psychiatric assessments, down to a few ratings allows clinicians to more fully use the power of computers, including tracking outcome (Kennedy 1993). The K Axis categories can be used to generate problem lists (Figure 1–2) (Kennedy 2003). Problem lists form the heart of the treatment planning process. All problems on a problem list can be taken directly from one of the K Axis’s seven subscale/problem areas as demonstrated in Figure 1–2.

V.

Population Addressed by the K Axis

The K Axis is intended to rate any individual or group, from the lowest-functioning to the highestfunctioning person. The K Axis has been used successfully with patients ranging in age from 13 to 80 years; however, it is felt to be a reasonable instrument for anyone from about age 5 to older than age 100. At one time or another, everyone is a potential candidate for mental health services. When and if the time arrives, the K Axis should be able to be used to measure that person’s level of functioning in all of the major clinical areas. Because the K Axis measures even healthy or superior functioning, it should be able to capture the completeness of a full recovery. Along the same line, in addition to screening for those who may require mental health services, the K Axis may also be able to screen for “healthy” individuals or groups that may require few, if any, mental health services.

1–12


Type of Record:

Inpatient Record Psychiatric Note

Name:

Doe, John

Staff’s Impression:

According to staff, pt. continues to go thru fairly frequent periods of being very angry, hostile, explosive, confused, and delusional. Between these periods, the symptoms continue at a lower intensity. SI+0X-2

Pt.’s Impression:

Pt. states that he is doing fairly well.

Mood Disturbance:

Pt. states that generally he is somewhat sad. Pt. states that no one seems to like him. Pt. states that he feels tense and nervous. Smiling appears to be mostly inappropriate. No signs of tears. Denies insomnia. Appetite is OK. Moderate restlessness. Md-2

Social Competence:

Often refuses to do the ordinary things expected of him. Occasionally has trouble remembering. Often has to be firmly told what to do. Due to lack of motivation and preoccupation with internal stimuli, pt. often has difficulty completing simple tasks on his own. Pt. was fairly uncooperative during the interview. Sc+24

Social Interest:

Always interested in his surroundings; however, he seldom tries to be friendly and he seldom smiles at funny events. He seldom starts up a conversation and he has no interests. Sn+14

Personal Neatness:

Moderate impairment. He is generally sloppy in his dress and only occasionally keeps himself clean. Pn+12

Irritability:

Area of marked impairment. Always impatient. He is easily angered or annoyed. Always irritable and grouchy. He is frequently spontaneously explosive. Pt. states that he realizes that he gets angry; however, he states that he wouldn’t really hurt anyone. At times during the interview, pt. became moderately angry. Ir-38

Manifest Psychosis:

Area of marked impairment. Frequently having auditory hallucinations. Usually talking or laughing to himself. Pt. states that he now hears voices only about once an hour. During the interview, pt. was frequently laughing inappropriately to himself. Mp-20

Motor Retardation:

Often sits or sleeps unless directed into activity. When up, he is not slow moving and sluggish. Denies being tired. Moderate expressive movements. Mr-04

NOSIE Total:

+80

Psych. Med. Status:

Staff members state that of the numerous medications that pt. has been on, the Prolixin Decanoate seems to bring about the best response. In a review of pt.’s past medications, pt. has never been on a beta-blocker. A trial on Corgard may be helpful. Risks and benefits of Corgard discussed with pt. He agrees to a trial on Corgard.

Antipsychotic:

Prolixin Decanoate

prn Psych. Med.:

Ativan 1 mg po q 4 hours (max. qid) prn anxiety

Other Meds:

None

Adverse Med. Effects:

None

Other Medical Issues:

None

Patient #: 00011

Date: 07/21/86

PI+0Y+1

Done by: Jones, RN & Smith, LPN

Antipsychotic mg/day: 2.5 (2.5 cc im q wk)

Beneficial Med. Effects: Minimal response to meds. Lab.: PT-19 due 09/86

Plasma Level: 06/27/86 3.2 Prolixin

Elaboration: Reference range is 0.2–4.0 ng/ml

Impression:

Pt. continues to do moderately poorly.

I+0Z-2

Rec. Nonmed.:

No change

Rec. Med.:

AIMS exam due 06/86. Start Corgard 40 mg po q A.M.

Rec. Lab.:

Daily B/P and pulse

Figure 1–3.

Example of computerized psychiatric progress notes.

Introduction

1–13

VI. K Axis and Diagnoses The diagnosis provides valuable, qualitative information about a patient; however, diagnoses are usually limited in their ability to provide quantitative information about patients. Working in conjunction with the diagnosis, the K Axis can help provide this missing quantitative information. The K Axis can also generate profiles that are fairly specific to various diagnoses; however, at times the K Axis profiles can be identical for patients with very different diagnoses. For example, the profile of a depressed, suicidal patient can appear identical to the profile of an antisocial, assaultive patient. Knowing the client’s primary psychiatric diagnosis can be very helpful when attempting to interpret profiles generated by the K Axis. Figure 1–4 shows an example of a hypothetical, high-functioning prison inmate with antisocial personality disorder. This profile could be identical to a profile of a highfunctioning patient with depression. However, both of these profiles could be distinguished from Figure 1–5, which shows the profile of a hypothetical patient with schizophrenia, disorganized type. The profile in Figure 1–5 is based on data from patients with schizophrenia, disorganized type, from a pilot study of long-term-care patients (Kennedy et al. 1999).

100

Î Functional

90

Dysfunctional

Ï

80 70 60 50 40 30 20 10 0 PSY

Figure 1–4.

SOC

VIO

ADL

Patient 1—Antisocial personality disorder.

SAb

MED

1–14


100

Î Functional

90

Dysfunctional

Ï

80 70 60 50 40 30 20 10 0 PSY

Figure 1–5.

SOC

VIO

ADL

SAb

MED

Patient 2—Schizophrenia, disorganized type.

100

Î Functional

90

Dysfunctional

Ï

80 70 60 50 40 30 20 10 0 PSY

SOC

VIO

Patient 1

ADL

SAb

MED

Patient 2

Figure 1–6. Antisocial personality disorder (Patient 1) versus schizophrenia, disorganized type (Patient 2).

Introduction

1–15

Figure 1–6 illustrates the two patient’s profiles on a single graph. For examples of how to use the K Axis with DSM-IV-TR’s multiaxial system, see Chapter 3, Section XIII: “K Axis Scores and Your Multiaxial Diagnoses” and Appendix, Section III: “Comprehensive Psychiatric Assessment Using the K Axis.”

VII. K Axis and the Clinical Impression Before the K Axis can be rated, the rater should first perform a clinical assessment of the patient, including a review of the patient’s history. Based on that assessment, the clinician should develop a clinical impression of the patient’s level of functioning. The K Axis is then used to capture that impression. The K Axis captures the clinical impression in its scores, as well as in its problem descriptions. See Chapter 5, “Problem Description Section of the Scoring Sheet,” for an explanation of the problem descriptions. Numerous questionnaires are specifically designed as an adjunct to help create the clinical impression. Many of these questionnaires are presented in the Handbook of Psychiatric Measures (American Psychiatric Association 2000), including the Minnesota Multiphasic Personality Inventory (MMPI), Beck Depression Inventory, Hamilton Rating Scale for Depression, Brief Psychiatric Rating Scale, Addiction Severity Index, and tests of intelligence. These instruments can be extremely useful in helping clinicians form their clinical impressions. The K Axis, however, is intended to capture the clinical impression rather than form it. For example, questionnaires that measure depression usually collect data that allow clinicians to measure factors commonly associated with depression. Subsequently, these measurements of depression can be enormously useful in forming the clinician’s clinical impression. That impression can be captured using the K Axis. In another example, the MMPI, which can be completed by the patient and scored by a computer, is certainly not intended to capture the clinician’s clinical impression; however, the MMPI’s findings can be very valuable in assisting clinicians in forming their clinician impression. In other words, the MMPI can obviously help form the clinical impression; however, you certainly could not depend on using the MMPI to capture your clinical impression. The K Axis, however, can be used to capture the clinical impression once it is made. This can be done using the K Axis’s anchor points to assist in expressing and capturing the clinical impression. Most clinical questionnaires will help form the clinician’s clinical impression rather than capture it. Because the results from these other questionnaires can help form the clinical impression, these other questionnaires can indirectly help determine the K Axis scores by their contribution to forming the clinical impression.

VIII. K Axis and Clinical Decisions The K Axis should not be used alone to make clinical decisions, such as admission, transfer, discharge, or medication change. K Axis scores can be useful adjuncts for making these decisions; however, other factors must be taken into consideration. Even if the K Axis scores were 100% accurate in measuring level of functioning, which they are not, many other factors also contribute to most clinical decisions. The K Axis measures level of functioning. This is often only one of a number of factors that go into clinical decisions such as whether or not to admit. If clinicians are forced to use the K Axis scores alone for clinical decisions, there will be a strong incentive to consciously or unconsciously “correct” for a lack of a match between the K Axis score and what the clinician believes is the correct clinical decision. This “fudging” of the score may help the questionnaire to more accurately reflect the clinician’s decision, such as whether or not a patient should be admitted. However, this practice corrupts the K Axis’s ability to measure the clinician’s real impression of the patient’s level of functioning. For example, a Violence subscale score of 40 may be mandated for admission. If the clinician realizes that the patient should be admitted, but the patient’s score is a 50, it is likely that an attempt will be made to fudge the patient’s score to a 40 in an attempt to provide the patient with needed care. If level of functioning were the only factor needed to determine admission and if the K Axis were 100% accurate, then theoretically the score on the K Axis could be used as the only admission criteria. However, because level of functioning is not the only factor and because the K Axis is certainly not

1–16


100% accurate, policies should be developed that allow for these other factors to be taken into consideration when making decisions using the K Axis. In other words, clinicians must be careful not to make the K Axis scores the only criteria for clinical decisions. The K Axis should be used in conjunction with other clinical information when making clinical decisions. Although the K Axis captures the clinical impression of level of functioning, usually many other clinical factors go into a clinical decision such as admission or discharge. When there are discrepancies between the K Axis scores and the need for a particular clinical intervention, the clinician should always have the authority to override the K Axis scores without changing the K Axis scores. A brief explanation may be needed as to why the clinician is making a decision that appears contrary to the K Axis scores. However, often no explanation is necessary because in the process of documenting why a particular clinical decision is being made, there is usually already very adequate supporting documentation that justifies the decision made. The K Axis would often only be a part of the clinical information used to support a particular clinical decision. An example of concerns about using the K Axis scores to determine level of care was presented by Gary Collins, PhD, Staff Psychologist at the California Medical Facility (Collins 1999). He reported that the K Axis was being used to place psychiatric clients at a specific level of care at the California Medical Facility in the California Department of Corrections. Inmates were placed in one of three levels of care: 1. Intensive Outpatient (IOC)—the most restrictive housing and most impaired level of functioning 2. Enhanced Outpatient (EOP)—the middle level of restriction, in which inmates were housed in a dormitory or cell and were allowed to move around the unit 3. Clinical Correction Case Management (CCCMS)—the lowest level of restriction Under the CCCMS designation, it was assumed that psychiatric impairment was limited and that the inmate responded positively to treatment. The inmate was allowed to be housed on a dormitory and to have a job. The inmate might also be at a point at which he could be sent to another prison. Dr. Collins analyzed the K Axis’s GAF Equivalent rating and the prison inmates’ level of care. The summary of that analysis showed the following:

N

Mean

Standard deviation

IOC group

45

37.07

9.89

EOP group

519

47.21

8.55

CCCMS group

244

54.67

9.04

This analysis revealed that the most-restrictive housing had the most-impaired prison inmates (mean = 37.07) and the least-restrictive housing had the least-impaired prison inmates (mean = 54.67). Dr. Collins’s conclusion was as follows: “The K Axis’s GAF Equivalent ratings for inmates/patients at different levels of care support the conclusion that raters can use the K Axis scales to reflect inmate capabilities” (p. 1). However, Dr. Collins pointed out, “When psychiatric staff wish to move an inmate to other housing and to change his ‘level of care,’ a K Axis rating must support the decision to move the inmate. Consequently one cannot be sure whether the K Axis ratings reflect decisions made on the basis of the K Axis rating scales or whether the K Axis ratings were adjusted to reflect administrative requirement for changes in levels of care” (p. 1).

IX. Evidence-Based Tracking of Medication Changes Tracking the effectiveness of psychotropic medications is becoming increasingly complicated because of the growing number of effective medication options that psychiatrists can choose from for treating patients. However, I have seen a tendency in psychiatry toward prescribing additional medications without stopping previous medications. It is not unusual for patients to be taking more than five

Introduction

1–17

medications for their chronic psychiatric illnesses. Without good, standardized methods to measure patients’ functioning on alternative treatments, it may be unclear as to whether a patient has improved after a medication is added. This can lead to very complicated medication regimens with many potential side effects, without good evidence that all the medications are necessary or effective. Baseline and follow-up K Axis measurements easily and effectively assist with tracking medication changes, even if only subscales 1 and 3 (Psychological Impairment and Violence) are used. Such measurements will help to ensure that patients do not continue to take medications that do not significantly increase their functioning when compared with treatment with only one or two psychotropic medications or no medications at all.

X.

K Axis Within the Correctional System

The K Axis can just as easily be used in correctional facilities by qualified clinicians as in mental health facilities. Clearly, inmates in the correctional system frequently have antisocial (psychopathic/ sociopathic) symptoms and behaviors; however, it is becoming increasingly apparent that many mentally ill persons are being incarcerated in correctional facilities. This was substantiated by a Justice Department study that suggests that correctional facilities are becoming America’s new state mental hospitals (Justice Department, Bureau of Justice Statistics, 1999). Increasing numbers of inmates within correctional facilities have mental problems even while many long-term inpatient mental health facilities continue to close. Many mentally ill persons end up in jail before the mental health system can bring them in for needed treatment. Their crime may be a result of their mental illness; however, there is a very real danger that incarcerated mentally ill people will be classified as criminals rather than as people with a mental illness. As a result, they may be treated as criminals rather than as persons with an illness. Therefore, it is important to identify these mentally ill prisoners and to provide them with treatment within the correctional system or to transfer them into the mental health system for treatment and follow-up. It is hoped that the K Axis can help by providing clinicians with a tool to document their clinical impressions as to the severity of mental illness in individual prisoners, as well as in groups of prisoners.

XI. K Axis With a Managed Care Provider The K Axis may be very useful for quickly communicating information mutually helpful for you and your patient’s managed care provider. Unlike the GAF, in addition to a global score the K Axis provides details on the global score, including how the global score was generated. Therefore, the managed care provider should have a much better understanding as to why particular clinical decisions are being recommended. The GAF does not require specific documentation as to how it was generated; therefore, with the GAF it is much easier to “pull scores out of the air.” Pulling scores out of the air is much more difficult with the GAF Equivalent. The GAF Equivalent, by definition, provides details on how it was generated; therefore, a managed care provider may feel much more confident in the K Axis and its GAF Equivalent in knowing that important clinical details on how it was generated are readily available. For straightforward cases, the K Axis scores may be all that is necessary to convince a managed care provider to authorize needed clinical services. However, for many decisions, clinicians may be asked to provide additional information. If additional information is necessary or if a managed care provider wishes to audit your recommendations, completing the problem description sections of the K Axis Scoring Sheet can be a very helpful adjunct when communicating clinical information to your patient’s managed care provider. See Chapter 5, “Problem Description Section of the Scoring Sheet,” for details on this important feature of the K Axis. Finally, because the K Axis is drawn directly from the clinical assessment, if necessary you can refer to the narrative information included in the documentation of the clinical assessment that was used to form the basis for the K Axis scores. This continuity from the K Axis scores to the problem descriptions to the clinical assessment should help to ensure that appropriate clinical decisions are made when working with the managed care provider. Also, because so much relevant information is provided at the top two levels, the need to access the actual clinical assessment should be relatively rare.

1–18


XII. K Axis and the Joint Commission’s ORYX Initiative In 1997, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) introduced the ORYX Initiative (JCAHO 2002). This initiative integrates outcome and performance measures into the accreditation process. As a part of the initiative, accredited health care facilities submit a number of outcome and performance measures to the Joint Commission via the ORYX system. The K Axis can be used to track outcome in many vital areas of psychiatric care. Therefore, if you are working in a JCAHOaccredited facility, you may want to consider the K Axis for use as a part of your outcome reporting to the Joint Commission via the ORYX system. Details concerning the ORYX initiative can be found on the Joint Commission’s website at www.jcaho.org.

XIII. References American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision. Washington, DC, American Psychiatric Association, 2000 American Psychiatric Association: Handbook of Psychiatric Measures. Washington, DC, American Psychiatric Association, 2000 Collins G: Correspondence from Gary Collins, PhD, to James A. Kennedy, MD, June 3, 1999 Higgins J, Purvis K: A comparison of the Kennedy Axis V and the Global Assessment of Functioning Scale. Journal of Psychiatric Practice 6(2):84–90, 2000 Honigfeld G, Gillis RD, Klett JD: NOSIE-30: a treatment sensitive ward behavior scale. Psychol Rep 19:180–182, 1966 JCAHO: Performance Measurement. Available at: http://www.jcaho.org (click “Performance Measurement” or go directly to: http://www.jcaho.org/PMS/Index.htm). Accessed November 5, 2002 Justice Department, Bureau of Justice Statistics: Forensic List: Bureau of Justice Statistics, Report of Mentally Ill Offenders, 1999 Kennedy JA: Computerization of the psychiatric progress note: data banking and data analysis, the step beyond word processing. Computers in Psychiatry/Psychology 8(4):26–32, 1986 Kennedy JA: Computerization of the Mental Status Examination: a practical clinical example. Advances in Medical Psychotherapy 6:113–138, 1993 Kennedy JA: Fundamentals of Psychiatric Treatment Planning, 2nd Edition. Washington, DC, American Psychiatric Publishing, 2003 Kennedy JA, Fisher W, Skog S: Kennedy Axis V in Long-Term-Care Patients (Pilot). Worcester State Hospital, University of Massachusetts Medical Center, Worcester, MA, and the Massachusetts Department of Mental Health, unpublished data, 1999 Spitzer RL, Gibbon M, Williams JB, Endicott JA: Global Assessment of Functioning (GAF) Scale, in Outcomes Assessment in Clinical Practice. Edited by Sederer LI, Dickey B. Baltimore, MD, Williams & Wilkins, 1994, pp 76–78

CHAPTER 2

KENNEDY AXIS V QUESTIONNAIRE

2–1


Kennedy Axis V Questionnaire

2–3

KENNEDY AXIS V QUESTIONNAIRE CONTENTS I. Overview ......................................................................................................................................... 2–5 II. Instruction Sheet ............................................................................................................................. 2–5 III. Individual Subscales ........................................................................................................................ 2–5 A. Psychological Impairment ........................................................................................................... 2–5 B. Social Skills ................................................................................................................................. 2–6 C. Violence ..................................................................................................................................... 2–6 D. ADL–Occupational Skills.............................................................................................................. 2–7 E.

Substance Abuse......................................................................................................................... 2–7

F.

Medical Impairment ................................................................................................................... 2–9

G. Ancillary Impairment................................................................................................................... 2–9 IV. Copy of the K Axis ......................................................................................................................... 2–10 V. Kennedy Axis V Quick Reference................................................................................................... 2–22 VI. Scoring Sheets............................................................................................................................... 2–24 A. Standard-Form Scoring Sheet ................................................................................................... 2–24 B. Long-Form Scoring Sheet ......................................................................................................... 2–24 C. Computerized, Variable-Length Scoring Sheet .......................................................................... 2–27 D. TELEform “Scannable” Scoring Sheet ........................................................................................ 2–27 VII. Rounding Off to the Nearest Multiple of 5................................................................................... 2–29 VIII. Reliability and Validity................................................................................................................... 2–29 IX. References ..................................................................................................................................... 2–32



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KENNEDY AXIS V QUESTIONNAIRE I.

Overview

This chapter provides a brief explanation of the purpose and function of each section of the Kennedy Axis V (K Axis), including the instruction sheet, the individual subscales, and the scoring sheet. A complete copy of the Kennedy Axis V and scoring sheet are provided in this chapter. Refer to the relevant section of the Kennedy Axis V or scoring sheet as each section is explained. The one-page Kennedy Axis V Quick Reference is also included in this chapter.

II.

Instruction Sheet

The instruction sheet gives the rater a brief overview of the Kennedy Axis V and a summary of the instructions for its use. Before using the questionnaire, read the instruction sheet carefully. Later chapters will expand on many of the topics presented on the instruction sheet.

III. Individual Subscales The Kennedy Axis V is intended to quickly and accurately capture the clinician’s impression of the client’s overall level of functioning in seven critical clinical areas: 1) Psychological Impairment, 2) Social Skills, 3) Violence, 4) ADL–Occupational Skills, 5) Substance Abuse, 6) Medical Impairment, and 7) Ancillary Impairment. As many of the anchor points as possible were taken directly from DSM-IV-TR’s Axis V and moved to the corresponding level on the K Axis continuum. This is especially true for the first four subscales because they measure the same factors measured by DSM-IV-TR’s Axis V. Generic anchor points, such as “no symptoms,” “mild symptoms,” “serious problems or impairment,” and “major problems or impairment,” are carried across all seven subscales and remain at their original level from DSM-IV-TR’s Axis V. For example, “moderate symptoms” is at 51–60 on Axis V’s GAF and is at the same level on each of the K Axis subscales. Because anchor points are kept at the same level along the continuum, ratings of the K Axis capture the same level of severity as DSM-IV-TR’s Axis V. Knowing that a score of 50 captures “serious symptoms” on Axis V allows the rater to know that a score of 50 on any of the K Axis subscales will reflect a similar severity on Axis V. Because most clinicians are familiar with rating DSM-IV-TR’s Axis V, very little additional training is needed to understand how to rate the K Axis and the levels of impairment indicated by particular scores. Comments and suggestions about rating each subscale follow. A. Psychological Impairment Of the subscales, Psychological Impairment appears to have the highest correlation with Axis V’s GAF score. This is certainly not surprising; however, this is probably not true for all populations. Clients whose problem is primarily mental retardation may have GAF scores that correlate most highly with ratings on the ADL–Occupational Skills subscale. Clients who are very impaired in the area of violence may have GAF scores that correlate more highly with ratings on the Violence subscale than with ratings on the Psychological Impairment subscale. See Chapter 4, Section II: “GAF Equivalent” for more on the correlation between the K Axis and the GAF. Social withdrawal and shyness are measured here rather than on the Social Skills subscale. Poor motivation is measured here rather than on the ADL–Occupational Skills subscale. When rating Psychological Impairment, you are prompted to indicate the following on the scoring sheet: Primarily (check one):

Not Impaired___

Antisocially Impaired___

Other Impairment___

Both___

This distinction is useful to help separate the mentally ill from the criminally ill. This concept is addressed in Chapter 3, Section IV: “Multiple Factors in Each Subscale.”

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When rating Psychological Impairment, capture the overall impairment, not just the acute symptoms. Because you are rating the past week or even farther back in time, you will usually have to look beyond the simple presence or absence of acute symptoms. Try to capture the patient’s general impairment due to symptoms over the past week or farther back, including the severity and frequency of reoccurrence of acute symptoms. Also, if a patient is not having any acute symptoms, this does not mean that the patient is not extremely impaired by his or her mental illness. For example, when measuring the level of impairment caused by panic disorder, look at more than the presence or absence of acute symptoms at the moment of the rating. Also determine the frequency and severity of the patient’s panic attacks. The overview may be much more relevant to what you are trying to capture than the fact that the person is or is not having a panic attack at the very time of the rating. The patient could be having an acute, isolated panic attack for the first time in 5 years. Or at the time of the rating, the patient could be free of any acute symptoms of a panic disorder; however, the patient has a history of having almost daily panic attacks that have occurred over the last 5 years. Clearly, the overall impairment is much worse for the latter patient, and, because you are trying to capture the global picture, the rating should be worse for the latter. In other words, look beyond just the presence or absence of acute symptoms to what appears to be the patient’s overall functioning in this subscale, not just the acute presentation. This is also true for the other subscales that measure symptoms (Violence, Substance Abuse, Medical Impairment, and Ancillary Impairment). As will be addressed in the following sections, the two subscales that measure skills (Social Skills and ADL–Occupational Skills) can be obscured by acute symptoms; therefore, try to look beyond any acute symptoms to find the patient’s actual skills. B. Social Skills This subscale does not measure symptoms, such as social withdrawal or shyness—it measures social skills. In other words, this subscale measures skills, not the unwillingness to use those skills or other symptoms that may be covering up the patient’s skills. A poor rating in this area suggests that the patient needs training to improve social skills. The treatment here may be very different than for a Psychological Impairment symptom such as social withdrawal or shyness. If symptoms are covering up social skills, attempt to rate the skills that underlie the symptoms. However, if various symptoms have caused an actual loss of social skills or inability to develop social skills, that loss or the effect of the inability to develop social skills should be measured under Social Skills. For example, years of social withdrawal may lead to significant loss of or failure to develop various social skills. These resultant skill deficits are measured under Social Skills. The social withdrawal would be measured under Psychological Impairment. C. Violence The dangerousness measured by this subscale is violence toward oneself, others, or both. This violence is intentional violence, not accidental injuries. As indicated in Chapter 3, Section VI: “Dangerousness,” violence is only one form of dangerousness. For example, the dangerousness associated with a patient with Alzheimer’s disease who wandered into traffic due to a confused state should not be measured on this subscale. It should be measured under ADL–Occupational Skills. Factors driving violence, such as paranoia, depression, or substance abuse, would be rated on their relevant subscales. For example, a very paranoid patient assaults staff because he feels that the staff is trying to harm him. The impairment of paranoia should be rated under Psychological Impairment, and the impairment of the assaultive behavior should be measured under the Violence subscale. On the scoring sheet, when rating the Violence subscale, you are prompted to indicate the following: Primarily (check one):

Nonviolent___

Violent to Self___

Violent to Others___

Violent to Self and Others___

This distinction is used to help separate patients who attempt to hurt themselves from patients who try to hurt others. Clinically, it is not unusual for these groups to markedly overlap; however, these


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groups can often have very important differences. This is addressed in more detail in Chapter 3, Section IV: “Multiple Factors in Each Subscale.” D. ADL–Occupational Skills This subscale measures activities of daily living skills, academic skills, and occupational skills. It does not measure symptoms such as poor motivation or poor focal attention. In other words, this subscale measures skills, not the unwillingness or inability to use those skills or other symptoms that may be covering up these skills. A poor rating in this area may suggest that the patient needs training to improve ADL skills or occupational skills. The treatment here may be very different than for a Psychological Impairment symptom that interferes with a patient’s using his or her skills, such as poor motivation or poor focal attention due to depression or psychosis. If symptoms are covering up the patient’s ADL–occupational skills, attempt to rate the skills that underlie the symptoms. For example, a severely depressed banker may stay in bed and have no motivation to go to work; however, she should be rated on her skills and not the fact that her skills are not being used. Any effect these symptoms have on actual loss of ADL–occupational skills or inability to develop ADL–occupational skills should be measured under ADL–Occupational Skills. In ADL–Occupational Skills, poor motivation can lead to failure to obtain many skills needed for daily functioning and, therefore, impact the ADL–Occupational Skills rating. For example, years of poor motivation may lead to significant loss of or failure to learn various academic skills. These skill deficits are measured under ADL–Occupational Skills. The poor motivation would be measured under Psychological Impairment. E. Substance Abuse This subscale measures impairment from drugs (including cigarettes and coffee), alcohol, or both. It does not measure problems such as compulsive gambling, compulsive stealing, or compulsive drinking of excessive fluids (polydipsia). These are measured on the Psychological Impairment subscale. Focus on the type, quantity, and frequency of use of alcohol or drugs and their effect on functioning, not on whether the patient is currently intoxicated. You are usually measuring the overall impairment over a clinically relevant time period; this can be weeks to years. Whether the patient is intoxicated at the time of the rating may help to confirm the overall rating. In mental health facilities, clients usually present with acute worsening of their psychiatric symptoms. Psychiatric patients are usually not admitted for acute symptoms of substance abuse alone, which may clear after a few hours. If they have a problem with substance abuse, their abuse may be a chronic problem and it may have been a factor in acute psychiatric symptoms. At admission for these psychiatric symptoms and during the hospitalization, the focus can easily be on the acute psychiatric symptoms. Once these symptoms have cleared, there may be tremendous pressure to discharge the patient, even if there has been no significant change in the patient’s problem with substance abuse. The K Axis may help to ensure that substance abuse is addressed and is not ignored in favor of acute psychiatric symptoms. When rating Substance Abuse, you are prompted to indicate the following on the scoring sheet: Primarily (check one):

Nonabuser___

Alcohol Abuser___

Drug Abuser___

Both___

This rating is used to help separate clients who abuse alcohol from clients who abuse drugs, often illegal drugs. Clinically, it is not unusual for these groups to markedly overlap; however, these groups can often have very important differences. This is addressed in more detail in Chapter 3, Section IV: “Multiple Factors in Each Subscale.” A number of other special issues often arise when rating Substance Abuse: 1.

Initial, baseline measurements of Substance Abuse may be inaccurate because clients often deny or minimize their problems with substance abuse. There may be little or no physical or psychological evidence available to contradict the client’s claims; therefore, the clinical assessment could easily miss significant problems with substance abuse. The K Axis, which is

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based on the clinical impression, would also miss the problems with substance abuse. Later, as more information is available, the clinical impression would capture the fact that the patient is much more impaired in the area of Substance Abuse than was previously thought. This worsening of the subscale score may lead to the appearance that the patient’s problem with substance abuse has gotten worse. 2.

If a problem with substance abuse is not detected at admission or during the hospitalization, it would not be unusual for the only significant treatment of the patient’s problem with substance abuse to be locking the person away from drugs, alcohol, or both. Just being off these substances during hospitalization can lead to significant improvements in the patient’s acute psychiatric problems. In such a case, the patient could recompensate and be discharged without the staff having any knowledge of the patient’s problem with substance abuse and without providing any direct treatment for substance abuse. The K Axis ratings would reflect the clinical impression that the patient had no problem with substance abuse at admission or at discharge. Further, the patient’s improvement without any overt substance abuse treatment might be seen as further proof that the client did not have a problem with substance abuse. Improvements might be mistakenly seen as caused by changes in the patient’s medication or other treatment adjustments.

3.

Problems with substance abuse can often be a lifelong ailment. After years of reasonable treatment, the patient may reach a plateau or baseline. When the patient enters treatment for acute psychiatric decompensation, maintaining that baseline may be the most realistic approach while the acute psychiatric symptoms are being addressed. Once the acute symptoms have been controlled, the patient may be discharged with no significant change in his or her baseline for substance abuse (i.e., the K Axis rating for admission and discharge for Substance Abuse would be the same, even though both ratings may reflect a significant impairment from substance abuse). After discharge, the patient would be continued on the treatment for substance abuse that allowed him or her to reach his or her baseline, unless new information indicates that an alternative approach may be more effective. In other words, when problems with substance abuse have been identified and these problems are being treated as effectively as reasonably possible, the realistic treatment and outcome may be to continue the current treatment for substance abuse to maintain the current level of functioning in the area of substance abuse. If the clinician is successful in maintaining the patient’s baseline functioning, the admission and discharge ratings in the area of Substance Abuse will be identical. Other subscales should capture the improvements in the acute symptoms that led to admission.

Sometimes improvements in the area of Substance Abuse are picked up quicker in subscales other than the Substance Abuse subscale. Substance abuse is often a behavior that is the manifestation of an underlying long-term problem. The underlying substance abuse problem can be easily hidden or distorted by the patient. The client can often say the “right” things that may give the clinician the false impression that progress is being made; therefore, the true measure of the effectiveness of treatment is often whether the client can reduce that level of substance abuse or ideally maintain sobriety over a significant period of time. These periods of sobriety are often necessary to affirm that the client is indeed progressing and may necessitate close follow-up, including the use of toxicology screens over long periods. Stated again, other subscales can often detect change, including secondary change due to improvement in substance abuse, much quicker than improvements in the Substance Abuse subscale. For example, 2 weeks of no angry outbursts or no psychotic symptoms can be good evidence of improvement in the relevant subscale areas. These improvements in the other subscales can reflect secondary effects from improvement in the area of substance abuse. However, not abusing drugs or alcohol for 2 weeks may not reflect a significant improvement in the Substance Abuse subscale, especially if the client is simply hospitalized and locked away from drugs and alcohol for those 2 weeks. Much longer periods of demonstrated improvement may be necessary before the clinician is comfortable with capturing that improvement in the Substance Abuse subscale rating.


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Improvements in the area of Substance Abuse alone can lead to significant improvements in the other subscales. This is especially true for Psychological Impairment, Violence, and Medical Impairment. However, impairments in other subscale areas may be one of the root causes of substance abuse in many patients. Therefore, improvements in the other subscales may subsequently lead to improvements in the Substance Abuse subscale. F. Medical Impairment Focus on how much medical illnesses impair functioning, not on the lethality of the illness. However, very lethal illnesses often cause marked impairment in a patient’s functioning because the symptoms of the illness may cause marked impairment in functioning, and the patient often has to participate in burdensome medical treatments that further interfere with the patient’s normal functioning. The effects of or impairment of the stress of an illness, especially a chronic or potentially fatal illness, would be captured under other subscales. For example, if the medical problems led to symptoms of depression and suicidal impulses, these effects would be captured under Psychological Impairment and Violence. Acute, short-term illnesses, such as the flu, should have no more than a minor effect on the rating, even though the patient’s functioning may be markedly impaired at the time of the rating. If an acute medical illness were a chronic symptom of an underlying chronic disease, its effect on the rating would be captured in the rating of that underlying disease (e.g., chronic cellulitis of one’s foot might be a manifestation of diabetes and would be captured in the rating of the severity of the diabetes and associated chronic medical impairment). An isolated, temporary cellulitis should not significantly affect the Medical Impairment rating, even though the patient may be unable to walk unassisted for a few days. G. Ancillary Impairment This subscale addresses many of the psychosocial and environmental stressors that are addressed in Axis IV of DSM-IV-TR. Consider using the Ancillary Impairment subscale as a replacement for Axis IV in your multiaxial diagnosis. For an example of a multiaxial diagnosis using the Ancillary Impairment subscale to replace Axis IV, see Chapter 3, Section XIII: “K Axis Scores and Your Multiaxial Diagnoses.” These environmental, legal, and financial stressors can have a marked impact on a patient’s functioning and safety. This would also include environmental factors that predispose a client to victimization, such as living with an abusive spouse. The Ancillary Impairment subscale also measures factors that are often addressed when quantifying quality of life (e.g., financial resources, housing, safety in the patient’s environment, and social and family supports). The Ancillary Impairment subscale has been found to be useful with discharge planning because of its focus on financial, family, and environmental factors. Once a patient is stabilized, it is critical that the patient have adequate resources to successfully return to the community. The Ancillary Impairment subscale can help to point out difficulties with financial, family, and environmental factors. These factors are often critical to a smooth transition back into the community. For programs that often address high-risk living situations (e.g., a homeless shelter or a shelter for battered women), factors in this subscale area may be the primary focus of treatment and discharge planning. Use the Ancillary Impairment subscale to document the baseline impairment or danger and to track the outcome of treatment intended to reduce the impairment or danger in the client’s environment. Ironically, some homeless shelters and inpatient environments intended to help clients may, instead, bring harm to the clients, as well as to staff, because of the high level of dangers within the environments. As dangerousness is increasingly used as a necessary part of the criteria for admission, our inpatient facilities are treating populations with an ever-increasing level of violence. For example, these dangers would include risk of assault from an assaultive, paranoid patient who fears that others around him or her are going to attempt to harm him or her. In another example, female patients may be at risk of sexual assault if they are in an environment with sexual predators who are having difficulty maintaining control over sexual impulses toward women. The latter is a growing concern due to the trend away from treating patients in programs segregated by gender and the growing numbers of

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sexually dangerous patients in various inpatient facilities. However, in the same environments, sexual predators are at risk of being falsely accused of sexual assault by patients who find secondary gain in making such accusations. This can be a serious problem and can be very disruptive to the treatment process. Another factor to consider when rating dangers within a patient’s treatment environment is liability. Be cautious when quantifying dangers within the patient’s treatment environment. Identifying and then ignoring these dangers may be just as perilous as ignoring suicidal or homicidal impulses within an individual patient. On the one hand, you may not have the resources or authority to address potentially dangerous environmental factors that may be identified with this subscale. On the other hand, failure to recognize these environmental dangers can also expose you to serious liability. Once environmental dangers have been identified and quantified using the Ancillary Impairment subscale, further investigation may reveal that the dangers are indeed present and they may be found to be unacceptable. Clinicians or administrators need to make appropriate changes to reduce the level of dangerousness, explain why needed changes cannot be made, explain why changes may not help, or explain why changes may make things worse, such as interfering with treatment. This subscale is optional; however, if any impairment in this area is being actively treated, especially treatment to reduce factors that are placing a client at an unreasonable risk of harm, it certainly should be rated. There is always a risk of assault within environments that contain violent patients unless the violent patients are totally isolated in their own “cells” or maintained in restraints continuously. It has been my experience that at times it is unclear as to what should be the minimum safety requirements to prevent harm to patients and staff from violent patients who share the same treatment environment. Having a quantifiable method for measuring dangers in a patient’s environment and establishing minimum levels of dangerousness in a patient’s environment could be very helpful. It is suggested that the Ancillary Impairment subscale may be used to help determine those minimum levels of environmental dangers.

IV. Copy of the K Axis The following is a complete copy of the K Axis. At this point, certain elements of the questionnaire or terms in the questionnaire may be unfamiliar to the reader. These will be explained in subsequent chapters; however, the best way to add to your understanding of the K Axis is for you to examine the questionnaire itself.


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Instruction Sheet What Is the Kennedy Axis V (K Axis)? The K Axis consists of seven subscales for Axis V: Psychological Impairment, Social Skills, Violence, ADL– Occupational Skills, Substance Abuse, Medical Impairment, and Ancillary Impairment. These subscales capture the clinician’s impression of the individual’s overall level of functioning during the previous week (longer if significant, e.g., suicidal attempts). In addition to an individual score for each of the subscales, clinicians can generate a patient profile using the K Axis, as well as a score equivalent to the GAF. The K Axis is useful for developing Problem Lists, planning treatment, measuring its impact, and predicting outcome. Note: If needed, each subscale can stand alone and act as an individual questionnaire.

Using the Kennedy Axis V to Create Equivalents to the GAF Scale

•

GAF Equivalent (GAF Eq): Add the first four subscales and divide by four to give a score that is roughly equivalent to a score from the GAF Scale. This score should ensure that the major areas of functioning are not overlooked when rating the patient.

•

Dangerousness Level (DL): The DL is roughly equivalent to the GAF’s measure of dangerousness. The numbers used to derive the DL are on the scoring sheet directly below each subscale score. The lowest of these numbers becomes the DL. If the DL is 50 or less, it is often associated with the need for very high intensity outpatient care, residential care, or even hospitalization.

Choosing Current, Discharge, and Highest Level of Functioning Ratings

•

The current rating should be based on the level of functioning at the time of the evaluation and is most reflective of the current need for treatment or care.

•

The discharge rating should be based on the level of functioning at the time of discharge and, when compared with the admission rating, is most reflective of the impact of treatment.

•

The highest level of functioning should be based on the highest level of functioning that lasted for at least a few months during the last year. This score may be very predictive of outcome.

Using “Best Fit” to Capture the Clinical Impression The rating choice should be guided by the best fit for the client, even though some of the thinking or behaviors at that level may not be characteristic of the client. The anchor points only serve as aids and are not required for a specific rating. Ultimately, the clinical impression is the determinant of the score, and the best fit should guide one to that score rather than a particular anchor point.

Using Each Subscale to Measure Multiple Factors In each subscale, rate the factor that causes the most impairment. On the Violence subscale, the best fit should be based on suicidal factors for the suicidal client and on factors related to assaultiveness for the assaultive client. On the Substance Abuse subscale, the best fit should be based on use of alcohol for the alcoholic patient and use of drugs for the patient who abuses drugs. Impairments in multiple factors should help confirm a lower rating. Factors that relate to being withdrawn or showing lack of interest or poor motivation should be rated under Psychological Impairment rather than under Social Skills or ADL–Occupational Skills.

Measuring the Effects of Treatment, Stress, Physical Limitations, and the Like

•

The presence or absence of support, medication, other treatments, or even severe stress generally should not affect the rating, unless it is covering up skills. The rating should be based on the level of functioning, and no adjustment should be made for the presence or absence of these factors. Do not factor out the effects of treatment, even if the patient may drop out of treatment.

•

The effect of physical/environmental limitations generally should be factored out of the rating. For example, factor out not abusing drugs or not assaulting others due to being incarcerated or physically restrained; factor out not being socially active or employed due to physical constraints of being in a wheelchair or confined to bed. Rate how functional or dysfunctional a client would be if given reasonable opportunity—that is, do not let physical barriers cover up skills or violence.

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Kennedy Axis V—Psychological Impairment

(Problem Area 1)

100 Superior psychological functioning/coping, no psychological impairment; life’s everyday problems never seem to lead to any significant anxiety or depression. No symptoms.

90 Absent or minimal symptoms (e.g., mild anxiety before an exam), good psychological functioning in all areas; interested and involved in a wide range of activities; generally satisfied with life; no more than everyday problems or concerns. 80 If symptoms are present, they are transient and expected reaction to psychosocial stressors (e.g., upset by breakup with girlfriend; difficulty concentrating after a family argument; mild preoccupation with problems; a woman has many friends, functions extremely well at a difficult job, but says “The stress is too much”); not considered to have mental problems by those who know him/her.

70 Some mild symptoms (e.g., depressed mood with mild insomnia, occasional truancy, theft within the household, difficulty trusting others, mild insensitivity to the feelings and needs of others), but generally functioning fairly well; however, those who know him/her well might express some concerns about his/her mental state.

60 Moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks; frequently preoccupied; moderate impairment in attention span); moderate insensitivity to the feelings and needs of others; to those who know him/her well it is clear that he/she has mental problems.

50 Serious symptoms (e.g., moderately depressed mood, moderate lethargy, severe obsessional rituals, severe phobia, severe sexual perversion, moderate problems with anorexia/bulimia, frequent shoplifting, frequent anxiety attacks, moderately guarded, mild but definite manic syndrome).

40 Major psychological impairment; some impairment in reality testing or communication (e.g., speech is at times illogical, obscure, or irrelevant; moderate paranoia; may have hallucinations or delusions; however, probably realizes they are not a part of reality); major impairment in several areas, such as judgment, thinking, or mood (e.g., depressed man avoids friends, neglects family, and is not motivated to work; or, moderate negative symptoms of schizophrenia); even those who do not know him/her well would likely consider him/her to have mental problems.

30 Behavior is considerably influenced by delusions or hallucinations; appears to be responding to hallucinations; serious impairment in communication or judgment (e.g., sometimes incoherent, thinking is occasionally grossly inappropriate); severely depressed mood; withdrawn, with few spontaneous communications; inability to function in almost all areas (e.g., stays in bed all day and does not care for own living space; no job, home, or friends due to paranoia, poor motivation, social withdrawal, extremely poor insight, or being almost totally insensitive to the feelings and needs of others); at times attention span is markedly impaired; severe sociopathic behaviors have led to multiple arrests; severe sexual perversion toward prepubescent children.

20 Thinking and communication are generally grossly impaired; manic excitement or catatonia; largely incoherent or mute; generally markedly impaired attention span; occasionally fails to maintain minimal personal hygiene due to severe lethargy or very disorganized, bizarre thinking (e.g., too lethargic to attempt to wipe food off shirt; smears feces for bizarre, delusional reasons). 10 Thinking is totally disorganized; totally insensitive to the feelings and needs of others; completely incoherent; completely mute, extremely catatonic; persistent inability to maintain minimal personal hygiene or minimal safety due to totally disorganized thinking or very severe lethargy; unable to focus attention for even a few seconds; chronic, self-induced vomiting has led to a very life-threatening situation. NR Not rated


Kennedy Axis V—Social Skills

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(Problem Area 2)

100

Superior social skills, sought out by others because of his/her outstanding social/communication skills, has many friends and no difficulty making new friends. No symptoms.

90 Good social skills, no difficulty being pleasant and engaging, good communication skills, socially effective.

80 No more than slight impairment in social skills, slightly inappropriate social behavior leads to infrequent interpersonal conflicts, no more than slight difficulty maintaining several friendships.

70 Some difficulty with social skills (e.g., mild difficulty knowing how to share with others, show sympathy for others, and/or understand feelings of others), social skills are not obviously impaired, generally functioning fairly well, has some meaningful interpersonal relationships. 60 Moderate difficulty with social skills (e.g., conflicts with peers due to inappropriate teasing or other inappropriate social behavior; attempts to be pleasant and engaging are usually moderately awkward; moderate difficulty knowing what to say even when talking with friends; moderate difficulty knowing how to share with others, show sympathy toward others, and/or understand feelings of others); hardly any friends because of problems with social skills; communications are understandable but vague.

50 Serious impairment in social skills; has no friends because of clearly impaired social skills; however, has some peer relationships, despite social skills being clearly impaired; frequent conflicts with peers or co-workers because of inappropriate social behavior; conversations are often socially inappropriate; great difficulty communicating thoughts and feelings; unable to introduce self and a second person without clear difficulty; frequently intrusive; inappropriate, nonsexual touching. 40 Major impairment in social skills; attempts to approach others quickly lead to embarrassing situations; no friends and virtually no peer relationships because of poor social skills; unable to appropriately engage in almost any social activity; continually intrusive with little understanding of the inappropriateness of the behavior; major acts of socially inappropriate behavior lead to being assaulted, fired from work, or expelled from school; great difficulty recognizing or coping with inappropriate sexual or aggressive advances by others; great difficulty recognizing that his/her sexual advances are not welcome.

30 Acts grossly inappropriately toward others; virtually no understanding of the feelings of others, how to share with others, and/or how to show sympathy toward others; conversations with others are grossly inappropriate; unaware of or ignores most social norms as manifested by open masturbation, inappropriate sexual touching, and the like.

20 Very few social skills; generally unable to communicate in an organized, understandable way; uses short phrases or gestures to get basic needs met; acts with shocking inappropriateness in front of others, such as smearing of feces or making sexual advances toward young children; however, may have some understanding that such behavior is inappropriate.

10 Few if any social skills; unable to communicate in an organized, understandable way; shows no apparent awareness of social norms (e.g., doesn’t realize that it is inappropriate to grab food or cigarettes from others); extremely vulnerable to victimization (e.g., has no understanding of the inappropriateness and/or dangers of approaching strangers or assaulting others, needs constant care and supervision to not get into dangerous social situations). NR Not rated

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Kennedy Axis V—Violence

(Problem Area 3)

100 No evidence of violence to self or others; very satisfied with life; life’s problems never seem to lead to any inappropriate anger, frustration, or conflicts. No symptoms. 90 No significant evidence of violence to self or others; generally satisfied with life, no more than everyday problems or conflicts (e.g., an occasional argument with family members). 80 No more than slight problems with anger and irritability; if symptoms are present, they are transient and expectable reactions to psychosocial stressors (e.g., occasional “blow up” with family members or friends; mild anger after family argument); no suicidal ideation.

70 Mild symptoms (e.g., mild problems with anger and irritability; occasional thoughts of violent behavior; thoughts that life may not be worth living); symptoms are not interfering significantly with his/her functioning; severely assaulted others or serious suicidal attempt over 5 years ago; however, for years, has had no significant problems with violence or self-harm.

60 Moderate difficulty with anger and irritability (e.g., moderate conflicts with peers or co-workers due to anger and hostility; occasional threats of violent behavior); some evidence that self-destructive thoughts may be present. Murdered someone over 10 years ago; however, for many years, has had no significant problems with violence.

50 Serious problems with anger and irritability; moderate threats of violence; becomes verbally threatening when needs/demands are not immediately met or when pushed to do something; occasionally hits someone; occasional, relatively minor, sexual assault; occasional suicidal ideation; nonsuicidal self-abuse, such as burning self with cigarettes or cutting self superficially; not felt to be in real danger of seriously hurting self or others; however, some precautions including close observation may be indicated. 40 Major problems with anger and irritability; some real danger of hurting self or others; violent outbursts toward family and neighbors; frequent threats of violence; hitting or biting someone is not unusual; occasionally difficult to redirect from aggressive behavior; induces much fear of physical assault in others; single suicidal gesture within the last month; moderate suicidal ideation; actively making plans to hurt self or others; set a relatively minor fire within the last 3 months or is having fire-setting impulses with history of setting one or two minor fires.

30 Often hitting or biting others; becomes physically aggressive when needs are not immediately met; suicidal attempt without clear expectation of death during the last month; frequent suicidal preoccupation; actively following through with plans to hurt self or others (e.g., obtaining a gun, pills, rope); at times close observation or restraints may be necessary to prevent serious harm to self or others.

20 Frequently violent; very real danger of hurting self or others; serious thoughts of killing someone; attempted to very violently harm or violently rape someone within the last month; constant suicidal preoccupation; however, he/she is felt to have some control of the suicidal impulses; two or more suicidal attempts without clear expectation of death within the last month; close observation to prevent harm to self or others may be required 1 or 2 days a week.

10 Persistent danger of severely hurting self or others; attempted to kill someone within the last month; attempted to very violently harm or violently rape a child within the last month; set a fire within the last month with intent of hurting others; serious suicidal attempt within the last month with clear expectation of death; little or no control of impulses to hurt self or others; expressing loss of control of command hallucinations to hurt self or others; one-to-one, at-arms-length observation and/or physical restraint for prevention of serious harm to self or others may be required 3 or more days a week; murdered someone within the last 2 years.

NR Not rated


Kennedy Axis V—ADL–Occupational Skills

2–17

(Problem Area 4)

100 Superior ADL–occupational skills in a wide range of activities (e.g., in school, on the job, as a homemaker, pursuing a complicated hobby); superior workmanship; work challenges never seen to get out of hand; is sought out by others because of his/her work skills. No symptoms. Skills are consistent with those expected of a successful college graduate. 90 Good skills in all ADL–occupational activities; no more than average difficulties with any work assignment. Absent or minimal symptoms. Skills are consistent with those expected of a successful high school graduate. 80 No more than slight impairment in occupational skills or skills in school; has slight difficulty performing at an average level; slight difficulties with routine chores, work assignments, or schoolwork assignments; slight impairment in workmanship. 70 Mild difficulty with occupational skills or skills in school (e.g., minor difficulty following instructions, workmanship is somewhat sloppy), but generally functioning fairly well. 60 Moderate difficulty with occupational skills or skills in school (e.g., probably employed; however, has trouble carrying through assignments; some difficulty problem solving or following instructions; some difficulty driving a car; some difficulty knowing how to budget money; some difficulty maintaining a home or apartment).

50 Serious impairment in occupational skills or skills in school (e.g., unable to keep a job for more than a few weeks due to poor occupational skills; almost failing in school; moderate difficulty following instructions; moderately sloppy workmanship); needs supervision when shopping for food; some difficulty using public transportation; some difficulty preparing self a reasonable, family-style meal; some difficulty ordering, eating properly, tipping, etc., in a regular restaurant; some difficulty making a long-distance phone call. 40 Major impairment in occupational skills or skills in school (e.g., unable to work at a job for any significant period or do routine housework due to poor work skills; failing in school due to poor academic skills); needs supervision to use public transportation; mild to moderate difficulty ordering and eating in a fast-food restaurant; poor understanding of how to budget money.

30 No job and unable to independently maintain a home due to serious impairment in skills needed to perform ADLs and tasks at home; serious difficulty following instructions; needs some supervision to prepare simple meals for self, such as a sandwich and beverage; needs supervision to dress self, make a local phone call, follow a very simple self-medication procedure; needs constant supervision to complete more complicated ADLs (e.g., operating a washer and dryer); very sloppy workmanship; some difficulty responding appropriately to a fire alarm; difficulty finding way back from short errands. 20 Gross impairment in skills needed to perform ADLs and tasks at home (e.g., needs some supervision to maintain minimal personal hygiene; is almost totally unable to follow simple instructions; needs supervision to feed self; unable to function independently (e.g., needs constant supervision to complete most simple tasks; does not know the value of money; unable to dial 911 in an emergency; unable to find way back from short errands). 10 Demonstrates almost no ADL skills (e.g., is totally unable to follow instructions; unable to complete most tasks even with constant supervision; may even have to be physically assisted to complete a task, including eating or dressing); persistent inability to maintain minimal personal hygiene; considerable external support (e.g., nursing care and supervision) is needed to prevent him/her from accidentally harming self (e.g., wandering into traffic, danger of seriously burning self when attempting to cook or when smoking); unable to appropriately respond to a fire alarm.

NR Not rated

2–18


Kennedy Axis V—Substance Abuse

(Problem Area 5)

100 No significant problems with drugs or alcohol; no use or almost no use of alcohol; nonsmoker; no use of street drugs; never abuses substances, even when life’s problems get out of hand; is an example of someone who is totally free of problems with substance abuse. No symptoms. 90 No more than the average problems and concerns with alcohol; minimal use of alcohol; social drinker; no use of illegal drugs; history of serious alcohol or drug abuse with over 10 years of sobriety and minimal, if any, treatment needed to maintain sobriety.

80 No more than slight impairment; drinks to mild intoxication about once a month; smokes cigarettes daily; experiments with marijuana less than once a year; some mild abuse of over-the-counter medications and/or caffeine; no more than slight impairment in social, occupational, or school functioning due to substance abuse (e.g., temporarily falling behind in schoolwork); serious alcohol or drug abuser with over 5 years of sobriety with minimal treatment needed to maintain sobriety. 70 Mild impairment in social, occupational, or school functioning due to substance abuse, but generally functioning fairly well; drinks to mild or moderate intoxication 1 or 2 days a week; excessive prescription drug seeking; experiments with drugs such as marijuana, Valium, Ativan, or Librium once or twice a year; heavy smoker; unable to quit cigarettes despite numerous attempts. 60 Moderate difficulty in social, occupational, or school functioning because of substance abuse (e.g., substance abuse results in moderate impairment in job performance and/or conflicts with peers or co-workers); drinks on a regular basis, often to excess; drinks to moderate intoxication more than 2 days a week; occasionally experiments with drugs such as cocaine, Quaaludes, amphetamines (speed), LSD, PCP (angel dust), Ecstasy, inhalants; moderate abuse of over-the-counter medications and/or caffeine; unable to quit cigarettes despite chronic medical complications; serious alcohol or drug abuser with less than 2 years of sobriety.

50 Serious symptoms; behavior and/or lifestyle is considerably influenced by substance abuse; moderate drug-/alcohol-seeking behavior; often intoxicated when driving or when working; abusing substances despite being pregnant; unable to keep a job; marriage failing or failing school due to abuse of alcohol or marijuana; one alcohol- or drug-related arrest; stealing prescription pads and/or altering or forging prescriptions; moderate daily use of drugs such as marijuana, Valium, Ativan, Librium; occasionally injects drugs into skin or muscle; has a morning drug or drink to get going; uses narcotics other than heroin or cocaine on a fairly regular basis; frequently abuses over-the-counter medications and/or caffeine; use of alcohol or drugs (other than cigarettes) is beginning to cause some medical complications.

40 Major impairment in several areas because of substance abuse (e.g., alcoholic man avoids friends, neglects family, and is unable to get a job; student is failing in school and having serious conflicts with his family or roommate due to substance abuse); occasionally injects heroin or cocaine into his/her veins; occasionally has an accidental drug overdose; severe alcohol or drug abuser with less than 1 month of sobriety. 30 Drugs or alcohol pervade his/her thinking and behavior; his/her behavior is considerably impaired by substance abuse; injects heroin or cocaine into his/her veins once or twice a day; abuses substances without regard for personal safety (e.g., some accidental overdoses and/or auto accidents resulting in medical hospitalizations); blackout spells; prostitutes self for drugs/alcohol; multiple alcohol- or drug-related arrests; serious neglect of children due to substance abuse. 20 Functioning is extremely impaired by daily use of drugs such as LSD, PCP, cocaine, heroin, or inhalants; unable to go for more than a few hours without significant physical and/or psychological craving for drugs or alcohol; continued use of alcohol or drugs (other than cigarettes) is beginning to cause very serious medical complications (e.g., liver failure, overt brain damage, AIDS or high risk for AIDS); injects drugs into his/her veins more than twice a day.

10 His/her life is totally controlled by drugs or alcohol; continually in a state of intoxication or withdrawal; at extremely high risk of seizures or DTs (delirium tremens) due to withdrawal; continually seeking drugs or alcohol; numerous alcohol- or drug-related arrests; clear evidence that drugs or alcohol will lead to severe physical harm or death; numerous instances of drug-related accidents or accidental overdoses resulting in frequent medical hospitalizations; life-threatening neglect of children due to substance abuse. NR Not rated


Kennedy Axis V—Medical Impairment

2–19

(Problem Area 6)

100 Superior medical health; physical exam and laboratory tests are normal, including no significant weight problem; illnesses never seem to affect him/her; few if any problems with even common medical problems (e.g., colds, headaches, indigestion, constipation, diarrhea); virtually never has to miss work or school due to medical problems; exercises regularly; on no medication, except may take a prophylactic medication, such as a multivitamin; doesn’t wear glasses/contacts. No significant medical problems or symptoms. 90 Good medical health; has few if any medical problems; physical exam and laboratory test reveal no more than minor abnormalities; illnesses seldom seem to affect him/her; average difficulties with common medical problems (e.g., colds, headaches, indigestion, constipation, diarrhea); wears glasses/contacts that correct minor visual problems; wears dentures; only occasionally misses work or school due to medical problems; occasionally needs over-the-counter medication.

80 If medical problems are present, they are transient and cause minimal impairment in social, occupational, or school functioning; somewhat more than average missing of work or school due to medical problems; impairment in mobility or use of hands or hearing that is totally corrected by the use of a prosthesis, hearing aids, and the like; mild obesity or mild emaciation; occasional urinary incontinence due to organic problems.

70 Mild medical problems which may cause some difficulty in social, occupational, or school functioning; however, generally functioning fairly well; missing no more than about 1 to 2 weeks a year from work or school due to medical problems; mild impairment in mobility, speech, use of hands, vision, or hearing despite use of prosthesis, glasses, hearing aids, and the like; has chronic illness but has few if any overt signs or symptoms of the illness (e.g., mild asthma, mild hypertension, mild diabetes, mild arthritis; mild dysphagia; epilepsy easily controlled with medication; mild tardive dyskinesia); requires medical follow-up several times a year; takes prescription medication on a daily basis.

60 Moderate difficulty in social, occupational, or school functioning due to medical problems; missing no more than about 1 month a year from work or school due to medical problems (e.g., moderate asthma, moderate hypertension, moderate diabetes, moderate COPD, mild to moderate hyponatremia secondary to polydipsia, HIV positive, chronic hepatitis, mild cerebral palsy, mild cystic fibrosis, mild hemophilia, mild angina on exertion); medical problems requiring daily or weekly monitoring and treatments beyond po medications (e.g., injections, blood levels, nebulizer, physical therapy); needs bladder bag.

50 Serious impairment in social, occupational, or school functioning due to medical problems; serious impairment in mobility, speech, use of hands, vision, or hearing despite use of prosthesis, glasses, hearing aids, and the like; considered a serious risk for falling; only partially controlled epilepsy; equipment is needed for mobility (e.g., wheelchair, portable oxygen). Medical problems prevent him/her from driving a car.

40 Major impairment in several areas (such as work or school or family relations) because of medical problems; missing about 2 months a year or more from work or school due to medical problems; medical problems result in major impairment in mobility, speech, use of hands, vision, or hearing despite use of prosthesis, glasses, hearing aids, and the like; frequently confined to bed or wheelchair because of chronic medical problems. 30 Behavior and/or lifestyle is considerably impaired by medical problems; very serious medical problems confine him/her to bed or wheelchair most of the time (e.g., very symptomatic cases of diseases such as metastatic cancer, multiple sclerosis, cerebral palsy, or AIDS); chronic failure of a major body system (e.g., heart, lung, kidney, liver); on dialysis for kidney failure.

20 Major medical problems confine him/her to bed all of the time and intensive, continuous medical treatment is required without which he/she would rapidly progress to death (e.g., late stages of metastatic cancer, multiple sclerosis, AIDS, and the like); chronic, near terminal failure of a major body system (e.g., heart, lung, kidney, liver); quadriplegic.

10 Chronic medical incapacity requiring basic life support (e.g., ventilator); removal of life support would rapidly lead to death; he/she is in chronic vegetative or near vegetative state; persistent delirium or coma. NR Not rated

2–20


Kennedy Axis V—Ancillary Impairment

(Problem Area 7)

100 Superior life situation; currently in or has ready access to ideal living environment (neighborhood, home, school, work, etc.); superior financial resources for his/her needs; no legal problems; extremely safe environment. No significant ancillary problems or symptoms. 90 Good life situation; has few if any ancillary problems; no more than minor problems with living environment, financial resources, and/or legal problems, e.g., occasionally living environment doesn’t fully meet his/her needs, rare late payment on a bill, rare parking or traffic ticket.

80 If ancillary problems are present, they are transient and cause no more than minimal difficulty with his/her living situation, financial resources, or the law; somewhat more than average problems with his/her living environment, financial resources, or legal problems.

70 Mild ancillary problems, e.g., some difficulty with his/her living environment, financial resources, or the law; mild difficulty paying bills/credit cards; mild difficulty with parking or traffic tickets; occasional mild verbal violence in his/her environment; however, generally safe living situation. 60 Moderate difficulty with living situation, finances, or the law; high risk for being in a dangerous homeless or jail situation; criminal charges place him/her at high risk of incarceration; no stable residence and/or income, often having to move from one living situation to another; moderate difficulty paying bills/credit cards; evaluation and/or disposition is being made for nonviolent criminal activity (e.g., trespassing, stealing, defacing/destruction of property, or lewd behavior); evaluation and/or disposition is being made for competency to make decisions concerning person, estate, and/or treatment.

50 Serious problems with living situation, finances, and/or the law; frequent risks or threats of moderate violence in his/her environment; evaluation and/or disposition is being made for relatively minor but violent or dangerous criminal activity (e.g., minor assault, threats to do physical harm, driving while under the influence, sexually touching someone or exposing self); serious placement difficulties, even when ready for placement. 40 Major problems with living situation, finances, and/or the law; some real danger of being physically injured in his/her environment; evaluation and/or disposition is being made for very violent criminal activity (e.g., vicious assault, attempted rape, attempting to molest a child, arson).

30 Lifestyle is considerably influenced by ancillary problems; he/she is in a very dangerous homeless or jail situation most of the time; unable to obtain basic food, shelter and/or clothing; frequent, mild to moderate physical injuries from violence in his/her environment. 20 Major ancillary problems (e.g., he/she is in a very dangerous homeless or jail situation all of the time); at times, his/her life is at serious risk due to lack of resources for basic food, shelter, and/or clothing or because of high level of violence in his/her environment; evaluation and/or disposition is being made for extremely serious criminal charges (e.g., attempted murder, vicious rape, viciously molesting a child).

10 Living/financial situation is totally inadequate; his/her life is continually at serious risk due to lack of basic food, shelter, and/or clothing or because of extremely high level of violence in his/her environment; evaluation and/or disposition is being made for the most extreme charges of violence (e.g., murdering anyone, very viciously harming or very viciously raping a child, arson with intent of hurting others).

NR Not rated


2–21

Kennedy Axis V: Scoring Sheet Name:

© 1986–2003

#:

Age:

Instructions: For each subscale, enter the rating followed by a brief description of the relevant symptoms and behaviors. Round off intermediate codes, e.g., 43, 62, 78, to the nearest multiple of 5, e.g., 45, 60, 80. Enter NR if Not Rated. The numbers for deriving the Dangerousness Level are located directly below the subscale scores and are automatically indicated as one checks each subscale score.

ÄÄ FUNCTIONAL

DYSFUNCTIONAL ÅÅ

1. Psychological Impairment 100 ___95 ___90 ___85 ___80 ___75 ___70 ___65 ___60 ___55 ___50 ___45 ___40 ___35 ___30 ___25 ___20 ___15 ___10 ___5 ___ 100 95 90 90 85 80 75 75 70 70 65 60 55 55 40 35 25 15 5 50 Primarily (check one):

Not Impaired___


Other Impairment___

Both___

2. Social Skills 100 ___95 ___90 ___85 ___80 ___75 ___70 ___65 ___60 ___55 ___50 ___45 ___40 ___35 ___30 ___25 ___20 ___15 ___10 ___5 ___ 100 95 90 90 85 80 75 70 65 65 60 55 45 40 30 25 20 15 5 50

3. Violence 100 ___95 ___90 ___85 ___80 ___75 ___70 ___65 ___60 ___55 ___50 ___45 ___40 ___35 ___30 ___25 ___20 ___15 ___10 ___5 ___ 100 95 90 85 80 75 70 65 60 55 45 40 35 30 25 20 15 10 5 50 Primarily (check one):

Nonviolent___

Violent to Self___



4. ADL–Occupational Skills 100 ___95 ___90 ___85 ___80 ___75 ___70 ___65 ___60 ___55 ___50 ___45 ___40 ___35 ___30 ___25 ___20 ___15 ___10 ___5 ___ 100 95 90 90 85 80 75 75 70 70 65 60 55 55 40 35 25 15 5 50

5. Substance Abuse 100 ___95 ___90 ___85 ___80 ___75 ___70 ___65 ___60 ___55 ___50 ___45 ___40 ___35 ___30 ___25 ___20 ___15 ___10 ___5 ___ 100 95 90 85 80 75 70 65 60 55 45 40 35 30 25 20 15 10 5 50 Primarily (check one):

Nonabuser___

Alcohol Abuser___

Drug Abuser___

Both___

6. Medical Impairment 100 ___95 ___90 ___85 ___80 ___75 ___70 ___65 ___60 ___55 ___50 ___45 ___40 ___35 ___30 ___25 ___20 ___15 ___10 ___5 ___ 100 95 90 90 85 80 75 75 70 70 65 60 55 55 40 35 25 15 5 50

7. Ancillary Impairment (optional) 100 ___95 ___90 ___85 ___80 ___75 ___70 ___65 ___60 ___55 ___50 ___45 ___40 ___35 ___30 ___25 ___20 ___15 ___10 ___5 ___ 100 95 90 85 80 75 70 65 60 55 45 40 35 30 25 20 15 10 5 50

GAF Equivalent:

#1

+ #2

+ #3

+ #4

=

/

4

=

Dangerousness Level (indicate only the most dangerous rating): Signature:

Date:

2–22

V.


Kennedy Axis V Quick Reference

The Kennedy Axis V Quick Reference (found on the next page) condenses the seven subscales on one page. Once you are familiar with the K Axis, the Quick Reference may be the only guide that you will need when rating clients using the K Axis. For convenience, it is recommended that the Kennedy Axis V Quick Reference be placed on the desk or posted on the wall in an area where the K Axis ratings are being made.


Kennedy Axis V Quick Reference ADL– Occupational

Psychological Code Impairment

Social Skills

Violence

Skills

Substance Abuse

2–23

© 1986–2003 Medical Impairment

Ancillary Impairment (optional)

100

Superior functioning

Outstanding social skills

No violence or aggression

Superior work skills

Model for abstinence

Superior medical health

Superior life situation

90

Minimal symptoms; good functioning

Good social skills

No more than everyday conflicts

Good work skills

No more than average problems

Good medical health

Good life situation

80

Transient and expected reaction to stress

No more than slight impairment in social skills

No more than slight problem with anger

No more than slightly impaired work skills

No more than slight impairment; smokes cigarettes

Minimal and transient medical problems

Somewhat more than average life situation problems

Mild psychological symptoms

Some difficulty with social skills

Mild problems with anger and thoughts life may not be worth living

Mild difficulty with work

Mild impairment due to substance abuse; heavy smoker

Mild functional impairment due to medical problems

Mild life situation problems

60

Moderate psychological symptoms; mental problems are clear to those who know him or her well

Moderate difficulty with social skills; moderately awkward socially

Moderate problems with anger and some evidence that self-destructive thoughts may be present

Moderate impairment with work

Moderate difficulty in functioning due to substance abuse

Moderate functional impairment due to medical problems

Moderate difficulty with life situation; high risk for jail or homelessness

50

Serious psychological symptoms; moderately depressed mood, moderate lethargy, severe phobia

Serious impairment in social skills; no friends, but some peer relationships

Serious problems with anger; occasionally hits someone; occasional suicidal ideation

Serious impairment with work; unable to keep a job for more than a few weeks

Behavior or lifestyle is considerably influenced by substance abuse

Serious functional impairment due to medical problems

Serious difficulty with life situation; threats of moderate violence in pt.’s environment

40

May have hallucinations or delusions; however, probably realizes they are not a part of reality

Attempts to approach others quickly lead to embarrassing situations

Real danger of hurting self or others; hitting or biting someone is not unusual; suicidal gesture within the last month

Major impairment with work; unable to work at a job for any significant period

Major impairment in several areas due to substance abuse

Major impairment in several areas due to medical problems

Major problems with life situation; real danger of being injured in pt.’s environment

30

Behavior is considerably influenced by delusions or hallucinations; severely depressed mood

Acts grossly inappropriately toward others, for example, openly masturbates

Often hitting or biting others; suicidal attempt without clear expectation of death during the last month

No job and unable to independently maintain a home

Drugs or alcohol pervade thinking and behavior; injection of heroin or cocaine into veins daily

Behavior or lifestyle is considerably impaired by medical problems

Frequent mild to moderate physical injuries from violence in pt.’s environment

Gross impairment in thinking and communication; largely incoherent or mute; very disorganized, bizarre thinking

Very few social skills; acts shockingly inappropriately in front of others, such as smearing feces

Frequently violent; very real danger or hurting self or others; serious thoughts of killing someone; constant suicidal preoccupation

Gross impairment in skills needed to perform ADLs and tasks at home; almost totally unable to follow simple instructions

Functioning is extremely impaired by daily use of drugs, such as LSD, PCP, cocaine, heroin, or inhalants

Major medical problems confine pt. to bed all of the time and intensive treatment is required to prevent rapid progression to death

Major ancillary problems, for example, in a very dangerous homeless or jail situation all of the time; unable to obtain basic food, shelter, or clothing

Thinking is totally disorganized; completely incoherent or mute; unable to focus attention for even a few seconds

Few if any social skills; extremely vulnerable to victimization

Persistent danger of severely hurting self or others; little or no control of impulses to hurt self or others

Demonstrates almost no ADL skills; totally unable to follow instructions

Life is totally controlled by drugs or alcohol; clear evidence that drugs or alcohol will lead to severe physical harm or death

Chronic medical incapacity requiring basic life support; chronic vegetative or near vegetative state

Life is continually at serious risk due to lack of basic resources or because of extremely high level of violence in pt.’s environment

70

20

10

2–24


VI. Scoring Sheets The scoring sheet allows the clinician to indicate numerical scores, as well as problem descriptions of the relevant symptoms and behaviors for each subscale area. On the scoring sheet, indicate a score between 5 and 100 by rounding off scores to the nearest multiple of 5, for example, 43 is rounded off to 45, 62 is rounded off to 60, and 78 is rounded off to 80. It is likely that the K Axis is not statistically sensitive beyond the nearest multiple of 5; therefore, rounding off to the nearest multiple of 5 should not result in the loss of significant information. By rounding off to the nearest multiple of 5, the questionnaire is essentially changed from a 100-point scale to a 20-point scale. This allows clinicians to more easily gain an intuitive understanding of the points along the scale. With a 100-point scale, clinicians may end up in statistically meaningless, tedious arguments over where a patient should be scored within a 5-point range on a particular subscale, for example, arguing over whether a patient has scored a 39 or 41. For more details see Section VII: “Rounding Off to the Nearest Multiple of 5,” later in this chapter. The problem descriptions are a very powerful feature of the Kennedy Axis V scoring sheet. This feature is a very important adjunct to help validate the numerical scores, to help track changes over time, and to individualize the K Axis to the client being rated. The problem descriptions can also be used as a part of the problem description when writing a Master Treatment Plan (Kennedy 2003). For details on the problem descriptions, see Chapter 5, “Problem Description Section of the Scoring Sheet.” The scoring sheet comes in four different forms, copies of which are found on the following pages: 1. 2. 3. 4.

Standard form Long form Computerized, variable-length form TELEform® “scannable” form

A. Standard-Form Scoring Sheet The standard-form scoring sheet can be attached to the K Axis and its Quick Reference. The standardform scoring sheet has only minimal space for the problem descriptions, which is all that is needed for most clinical situations. In fact, because of time constraints, it is not unusual for the rater to not complete the problem descriptions. However, you are certainly encouraged to complete the problem descriptions. The standard-form scoring sheet is shown earlier in the chapter, on p. 2–21. B. Long-Form Scoring Sheet The long-form scoring sheet is simply a two-page version of the standard form scoring sheet. This twopage version allows for additional space to include more detailed information in the problem description sections of the scoring sheet. The long-form scoring sheet follows on the next page.


2–25

Kennedy Axis V: Scoring Sheet Name:

© 1986–2003

#:

Age:


ÄÄ FUNCTIONAL

DYSFUNCTIONAL ÅÅ

1. Psychological Impairment 100 ___95 ___90 ___85 ___80 ___75 ___70 ___65 ___60 ___55 ___50 ___45 ___40 ___35 ___30 ___25 ___20 ___15 ___10 ___5 ___ 100 95 90 90 85 80 75 75 70 70 65 60 55 55 40 35 25 15 5 50 Primarily (check one):

Not Impaired___


Other Impairment___

Both___

2. Social Skills 100 ___95 ___90 ___85 ___80 ___75 ___70 ___65 ___60 ___55 ___50 ___45 ___40 ___35 ___30 ___25 ___20 ___15 ___10 ___5 ___ 100 95 90 90 85 80 75 70 65 65 60 55 45 40 30 25 20 15 5 50

3. Violence 100 ___95 ___90 ___85 ___80 ___75 ___70 ___65 ___60 ___55 ___50 ___45 ___40 ___35 ___30 ___25 ___20 ___15 ___10 ___5 ___ 100 95 90 85 80 75 70 65 60 55 45 40 35 30 25 20 15 10 5 50 Primarily (check one):

Nonviolent___

Violent to Self___



Continued on next page

2–26


KENNEDY AXIS V: SCORING SHEET © 1986–2003, Continued from previous page Name:

#:

Age:

4. ADL–Occupational Skills 100 ___95 ___90 ___85 ___80 ___75 ___70 ___65 ___60 ___55 ___50 ___45 ___40 ___35 ___30 ___25 ___20 ___15 ___10 ___5 ___ 100 95 90 90 85 80 75 75 70 70 65 60 55 55 40 35 25 15 5 50

5. Substance Abuse 100 ___95 ___90 ___85 ___80 ___75 ___70 ___65 ___60 ___55 ___50 ___45 ___40 ___35 ___30 ___25 ___20 ___15 ___10 ___5 ___ 100 95 90 85 80 75 70 65 60 55 45 40 35 30 25 20 15 10 5 50 Primarily (check one):

Nonabuser___

Alcohol Abuser___

Drug Abuser___

Both___

6. Medical Impairment 100 ___95 ___90 ___85 ___80 ___75 ___70 ___65 ___60 ___55 ___50 ___45 ___40 ___35 ___30 ___25 ___20 ___15 ___10 ___5 ___ 100 95 90 90 85 80 75 75 70 70 65 60 55 55 40 35 25 15 5 50

7. Ancillary Impairment (optional) 100 ___95 ___90 ___85 ___80 ___75 ___70 ___65 ___60 ___55 ___50 ___45 ___40 ___35 ___30 ___25 ___20 ___15 ___10 ___5 ___ 100 95 90 85 80 75 70 65 60 55 45 40 35 30 25 20 15 10 5 50

GAF Equivalent:

#1

+ #2

+ #3

+ #4

=

/

4

=


Date:


2–27

C. Computerized, Variable-Length Scoring Sheet The computerized, variable-length scoring sheet form is simply a short- or long-form scoring sheet that has been entered into a word processor, such as Microsoft Word or Corel WordPerfect. The necessary information is entered directly into the scoring sheet on the computer screen using basic word processor features, including adding additional space where necessary to enter more detailed problem descriptions. The form would start off on the computer screen looking just like the short- or long-form scoring sheet. Then perform the necessary editing on this computerized form. When finished, simply store it in the computer or print out a hard copy. If needed, in a very complicated or high-profile case, this scoring sheet could be several pages long to capture very detailed problem descriptions. Examples of completed computerized, variable-length scoring sheets are included in Chapter 7, “Completed Kennedy Axis V Scoring Sheets.” D. TELEform® “Scannable” Scoring Sheet The scoring sheet in the TELEform® (Cardiff Software 2001) scannable format appears very similar to the scoring sheet in standard format; however, the numerical information on the form can be faxed into a central computerized database. The TELEform format scoring sheet follows on the next page.

2–28



VII.

2–29

Rounding Off to the Nearest Multiple of 5

As indicated on the scoring sheets, you should round off to the nearest multiple of 5. The K Axis scores are unlikely to be meaningful beyond the nearest multiple of 5. Therefore, as mentioned earlier, it is recommended that when scoring the K Axis, you round off to the nearest multiple of 5. This should not result in the loss of any significant information and at the same time should simplify the questionnaire. By rounding off to the nearest multiple of 5, the questionnaire is changed from a 100-point scale to a 20-point scale. In addition to simplifying the questionnaire, this allows clinicians to more easily gain an intuitive understanding of the points along the scale. Also, a 100-point scale conveys the impression that it is sensitive enough to discriminate between changes as small as one or two points along the 100point scale; however, this is very unlikely to be true. However, you do not want to convey the false impression that there has been no change when indeed there has been slight but real improvement or deterioration that cannot be detected by the K Axis scores. If you are trying to focus on small changes over time, either because the patient is changing very slowly or because frequent measurements are being taken, these small changes can be captured in the problem descriptions and later transferred to the K Axis when there is adequate evidence to justify a change to the next 5-point interval. Small changes may be able to indicate a direction of change; however, the K Axis may be unable to accurately quantify these small changes (i.e., changes less than 5 points). Ultimately, many of these small changes will be able to justify a change in the rating (i.e., when there is enough change to justify a change of 5 points or more). When the clinical information accurately indicates the direction of the change, the change may be too small to accurately quantify. Capturing these small changes is possible with the problem descriptions; however, for various reasons, when a patient is making these slight improvements, a clinician may decide to “fudge” the score by moving the patient up 5 points when the clinical changes do not justify the increase. Be aware that inflating the K Axis scores can come back to haunt you. If this is continued in subsequent ratings, it will lead to the patient’s rating slowly going up to an obviously absurd level. At this level, the numerical rating would clearly contradict the problem descriptions and other relevant clinical information. Just like the stock market, a correction will need to occur, and these inflated scores will have to fall back to a more realistic level. The same is also true when inaccurately portraying the patient as more impaired than he or she really is. The use of the problem descriptions as a means of capturing subtle changes in clients is addressed in Chapter 5.

VIII. Reliability and Validity One formal interrater reliability study was performed on the K Axis (Bilezikian 1998). That study revealed that the K Axis has reasonably good reliability. Table 2–1 shows the interrater reliability results of that study. The raters expressed difficulty with rating the Violence subscale area because anchors for extremely violent past behaviors were placed in the same range with mild current violent behaviors or impulses. However, even though it may be difficult to place extremely violent past behaviors and current mild violent behaviors at the same point along a continuum, both are essential for an accurate global assessment of the client’s current potential for violence. I have done informal assessments of interrater reliability during treatment team meetings and during training sessions for the K Axis. These informal assessments of interrater reliability indicated that the interrater reliability is good, usually leading to agreements within a 15-point range on the 100-point scale. It was noted that nonmedical personnel, even after some minimal training, continued to have some difficulty rating the Medical Impairment subscale. Results of a pilot study using the K Axis to track inpatients at Worcester State Hospital from 1987 to 1997 support the validity and, therefore, to some degree may support the reliability of the K Axis (Kennedy et al. 1999). Analysis of the data revealed a highly significant and credible relationship between length of stay in the hospital and level of functioning as measured by the K Axis.

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Table 2–1. Interrater reliability scores for each of the subscales of the K Axis Measure

Interrater reliability scores

Psychological Impairment

0.90

Social Skills

0.89

Violence

0.80

ADL–Occupational Skills

0.87

Substance Abuse

0.83

Medical Impairment

0.91

Ancillary Impairment*

N/A

GAF

0.93

*The Ancillary Impairment subscale was not available at the time of the study. Source. Bilezikian 1998.

Table 2–2 shows the actual results of the correlation coefficients between length of stay in the hospital and the K Axis scores in the pilot study. As expected, the more impaired the patient was on the first four subscales, the GAF Equivalent, and the Dangerousness Level, the longer the length of stay in the hospital was. As expected, because Worcester State Hospital is a psychiatric hospital, not a general medical hospital or a nursing home facility, medical impairment did not determine length of stay.

Table 2–2. Correlation coefficients between length of stay in the hospital and the K Axis scores for 224 long-term-care inpatients (coefficient/cases/two-tailed significance) Correlation coefficient

P


–0.4630

0.000

Social Skills

–0.5251

0.000

Measure

Dangerousness

–0.2348

0.000


–0.5055

0.000

Substance Abuse

+0.2190

0.001

Medical Impairment

–0.0915

0.172

Dangerousness Level

–0.3933

0.000

GAF Equivalent

–0.5714

0.000

Note. A negative correlation coefficient means that the higher the score on a K Axis subscale (i.e., the more functional the score), the shorter the stay in the hospital. A negative correlation coefficient was present for all except Substance Abuse. It appears that lower-functioning chronic inpatients often do not have the necessary social and ADL–occupational skills to get the money or to develop the social connections to be able to abuse drugs and alcohol.


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Somewhat surprising, but apparently reasonable, was the fact that poorer scores in the area of Substance Abuse were associated with shorter stays in the hospital. This appears to be because fairly good social skills and ADL–occupational skills are needed to obtain drugs or alcohol; therefore, patients with very poor functioning are unable to get access to drugs or alcohol. These patients apparently never developed problems with substance abuse or the problems faded away as their functioning deteriorated over time. In an article based on data from the California Outcome Measures Project, a comparison was done between the GAF and the K Axis (Higgins and Purvis 2000). The California Outcome Measures Project was a pilot study of outcome measures by the California Department of Mental Health. As a part of the study, a subgroup of 359 outpatients was rated on both the K Axis and the GAF. Almost 200 of the clients had a diagnosis of schizophrenia and psychotic disorders and the rest had mostly mood disorders. Table 2–3 shows the correlation coefficients between the K Axis and the GAF. The mean scores are shown in the far-right column of Table 2–3.

Table 2–3. Correlation coefficient between the K Axis and GAF (California Outcome Measures Project) Measure

GAF

GAF Equivalent

Mean score

GAF

1.00

0.82

57

GAF Equivalent

0.82

1.00

64


0.86

0.83

56

Social Skills

0.72

0.85

61

Violence

0.50

0.74

78


0.64

0.84

62

Substance Abuse

0.27

0.29

82

Medical Impairment

0.19

0.21

76

Note.

All correlations were statistically significant (P < 0.01).

Neither the GAF nor the GAF Equivalent directly measures factors measured by two subscales: Substance Abuse and Medical Impairment. As expected, these two subscales have the lowest correlation with the GAF and the GAF Equivalent. K Axis GAF Equivalent, as expected, is highly correlated with the GAF; only the subscale Psychological Impairment has a higher correlation with the GAF. In this study, Violence had a fairly low correlation with the GAF; however, these were outpatients who apparently had a very low incidence of violent behavior (K Axis mean score of 78 on the Violence subscale). As expected, this low incidence of violent behaviors had little impact on the GAF rating. This appears to be caused in part by the fact that anchor points related to violence do not show up in the GAF until a level of about 50 is reached. Therefore, scores greater than 50 to 60 are probably not based on any anchor points for violence on the GAF. A rating of 50 or 60 indicates far more impairment than the very high mean score of 78 on the K Axis Violence subscale for this population. This high score of 78 on the Violence subscale indicates that this population was very nonviolent and their scores on the Violence subscale should have very little impact on the GAF rating. This lack of impact on the GAF is reflected in the low correlation between the GAF and the Violence subscale. If the sample population had been very violent, the Violence subscale should have had a much higher correlation with the GAF. Conversely, in such a violent population, as violence becomes a much more important factor in determining the GAF score, the Psychological Impairment score is very likely to have a much lower correlation with the GAF. It could also be speculated that as Violence increases in the population being rated, the correlations between the GAF and GAF Equivalent with Substance Abuse may increase because of the

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connection between violence and substance abuse. In another example, in a population in which depression is secondary to medical problems, the correlations between Medical Impairment and Psychological Impairment, the GAF and the GAF Equivalent, are likely to increase, even though the Psychological Impairment subscale, the GAF, and the GAF Equivalent do not measure Medical Impairment directly.

IX. References Bilezikian JM: Unpublished doctoral dissertation, Illinois School of Professional Psychology, Chicago, IL, 1998 [cited in Higgins and Purvis 2000] Cardiff Software, Inc.: TELEform®. 3220 Executive Ridge Drive, Vista, CA 92083; available at www.cardiff.com; accessed on August 31, 2001 Higgins J, Purvis K: A comparison of the Kennedy Axis V and the Global Assessment of Functioning Scale. Journal of Psychiatric Practice 6(2):84–90, 2000 Kennedy JA: Fundamentals of Psychiatric Treatment Planning, 2nd Edition. Washington, DC, American Psychiatric Publishing, 2003 Kennedy JA, Fisher W, Skog S: Kennedy Axis V in Long-Term-Care Patients (Pilot). Worcester State Hospital, University of Massachusetts Medical Center, Worcester, MA, and the Massachusetts Department of Mental Health, unpublished data, 1999

CHAPTER 3

SCORING THE KENNEDY AXIS V

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3–3

SCORING THE KENNEDY AXIS V CONTENTS I. Time Periods Being Rated............................................................................................................... 3–5 A. Current Rating ............................................................................................................................ 3–5 B. Discharge Rating ........................................................................................................................ 3–5 C. Highest Level of Functioning....................................................................................................... 3–5 II. Necessity of Good Clinical Assessments ......................................................................................... 3–5 III. Anchor Points and Best Fit for Capturing the Clinical Impression................................................. 3–6 IV. Multiple Factors in Each Subscale................................................................................................... 3–6 A. Psychological Impairment ........................................................................................................... 3–7 B. Violence ..................................................................................................................................... 3–7 C. Substance Abuse......................................................................................................................... 3–8 V. Optional Subscale: Ancillary Impairment ....................................................................................... 3–9 VI. Dangerousness ................................................................................................................................ 3–9 VII. Users of the K Axis ....................................................................................................................... 3–10 VIII. Certification on the Use of the K Axis .......................................................................................... 3–11 IX. Data Needed to Rate the K Axis .................................................................................................. 3–11 X. Familiarity With the K Axis............................................................................................................ 3–12 XI. Effects of Symptoms, Treatment, Stress, Physical Limitations, and the Like ............................... 3–13 A. Symptoms Versus Skills ............................................................................................................. 3–13 B. Effects of Symptoms on Rating Skills ......................................................................................... 3–14 C. Effects of Symptoms on Rating Symptoms ................................................................................ 3–14 D. Effects of Physical and Environmental Factors on Ratings of Symptoms ..................................... 3–14 E. F.

Effects of Physical and Environmental Factors on Ratings of Skills .............................................. 3–15 Effects of Chronic Stress, Medication Noncompliance, Chronic Substance Abuse, and the Like on Ratings of Skills ................................................................................................ 3–16

G. Effects of Chronic Stress, Medication Noncompliance, Chronic Substance Abuse, and the Like on Ratings of Symptoms ....................................................................................... 3–16 H. Ancillary Impairment Subscale and Measurement of Stress........................................................ 3–17 XII. Average Score for the K Axis ....................................................................................................... 3–17 XIII. K Axis Scores and Your Multiaxial Diagnoses............................................................................... 3–18 XIV. K Axis Rating and Cultural Factors................................................................................................ 3–20 XV. References ..................................................................................................................................... 3–20


Scoring the Kennedy Axis V

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SCORING THE KENNEDY AXIS V I.

Time Periods Being Rated

The rating should be based on the level of functioning at the time of the evaluation; however, this is determined by looking at the level of functioning over the previous week. In fact, for some factors, you may have to look back years; however, you should look back only to the extent that it is felt to be relevant to the client’s functioning at the time of the evaluation. For example, looking back to no more than the last few days may be adequate for making a rating concerning a patient’s appetite or sleep pattern; however, a murder that occurred many years ago may still affect the current rating. Certainly the fact that an arsonist or murderer has not set a fire or murdered anyone within the last week should not imply that there is no significant potential for serious violence. You may have to go back a lot further for serious or rare events when making a rating. A person who has a history of suicidal gestures or having a seizure about once every 6 months is not felt to be no longer at risk just because these problems have not been present over the past week. As with the GAF, three specific time periods are often rated using the K Axis: 1) current rating, 2) discharge rating, and 3) highest level of functioning rating. A. Current Rating The current rating is most reflective of the need for treatment or care. The current rating should be based on the level of functioning at the time of the evaluation. Past symptoms and behaviors should be taken into consideration only if they affect the current level of functioning. B. Discharge Rating The discharge rating should be based on the level of functioning at the time of discharge. When compared with the admission rating, this rating is the most reflective of the impact of treatment. It may be very helpful in predicting the success after discharge; however, the discharge rating should be based on the patient’s functioning at discharge, not how the patient is predicted to function after discharge (see the next paragraph for exceptions). For example, patients who are likely to stop their medication following discharge will very likely have a much more impaired rating at follow-up after stopping their medication than they had at the time of discharge. This deterioration would be captured in the followup rating, not the discharge rating. The discharge rating should capture poor insight and other factors that would affect the patient’s medication compliance. The discharge plan should address these factors. As indicated in the previous paragraph, the discharge rating is based on how the patient is functioning at discharge, not on how the patient is predicted to function following discharge. Exceptions to this practice include patients who are not abusing substances or not assaulting others because they are locked away from various substances of abuse or potential victims. In these cases, the rating should be based on how the patient would be predicted to function if given the opportunity. Predicted noncompliance with treatment, including medication, is not included in these exceptions because excluding the effects of treatment would not allow the rater to capture the effects of treatment. C. Highest Level of Functioning The highest level of functioning should be based on the highest level of functioning that lasted for at least a few months during the last year. As with the GAF, this score may be very predictive of outcome of treatment.

II.

Necessity of Good Clinical Assessments

Ultimately the client’s level of functioning is derived from the judgment of clinicians. The K Axis is intended to capture the clinical impression derived by clinicians. Therefore, the ability of the clinician to perform good clinical assessments is critical to the K Axis. If the assessment does not accurately capture clinical information used for the ratings, then the K Axis ratings will not accurately reflect the client’s level of functioning. How to perform good clinical assessments should be a part of a rater’s clinical training and expertise. It is not addressed in this book. However, the clinical vignettes and

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completed Kennedy Axis V scoring sheets in this book provide many examples of the clinical information expected to be used to rate the K Axis. These examples are derived and abstracted from clinical assessments, which usually include clinical interviews. The K Axis ratings are generally not based simply on a single clinical interview with the patient only. The clinical interview is important, but it is often only a part of the assessment. The rater will often need to access clinical information from a variety of other sources, including the client’s primary therapist, other significant therapists, and the client’s record and history. The completed assessment should cover a broad range of clinical information, including current and past history of psychiatric symptoms, relationships, suicidal or other violent behaviors, substance abuse, employment, physical illnesses, and the like. The ratings also may be abstracted, with or without a clinical interview, from comprehensive clinical assessments. Clinicians who are skilled in understanding and abstracting the needed clinical information are, of course, best at performing these ratings. If a clinical interview is not performed, it is important for the rater to have some understanding of the accuracy of the clinical information that he or she is using for the rating; otherwise there is real danger of gross errors being incorporated into the ratings. The anchor points help place the clinical judgment along the K Axis continuum. The more information that is available and the better the clinician is at assessing that information, the more likely it is that the clinician will be able to use the K Axis to accurately capture the clinical impression. In other words, with a good assessment, including a good clinical interview by a competent clinician, the K Axis is very likely to easily and accurately capture the clinician’s clinical impression and that clinical impression is more likely to accurately reflect the client’s level of functioning.

III.

Anchor Points and Best Fit for Capturing the Clinical Impression

The rater’s clinical impression of the client’s actual level of functioning should be the determinant of the score. The anchor points and the best fit help place that clinical impression along the continuum; however, the clinical impression can override the anchor points and even the best fit. This is why the K Axis acts more to capture the clinical impression than to create it; however, in most ratings, there should be a lot of overlap between the clinical impression and the anchor points or the best fit. The clinician’s impression of the patient’s overall level of functioning along the continuum determines the rating, not a particular anchor point or points. The anchor points should generally agree with your clinical impression of the patient’s level of functioning. Similarly, the best fit should guide the rating chosen for the client, even though some of the thinking or behaviors at the chosen level may not be characteristic of the client. The various anchor points only serve as aids and are not required for a specific rating. It cannot be overstated that, ultimately, the clinician’s impression of the client’s level of functioning, not the anchor points, should determine the rating. The anchor points and best fit are just guides to help capture the clinician’s impression of the client’s level of functioning.

IV. Multiple Factors in Each Subscale Each subscale may contain multiple factors. A patient’s impairment may involve only one of these factors. For example, under Violence, the suicidal patient may have no problems with assaultiveness; or under Psychological Impairment, the psychotic patient may have no problems with depression. The suicidal patient should be rated only on factors related to his or her suicidal tendencies. The psychotic patient should be rated only on the factors related to psychosis. There should be no “averaging” of the fact that the other factors are absent; however, the presence of these other negative factors, such as depression or severe tension, may act to confirm a lower score. Likewise, the presence of positive factors or absence of these other negative factors may help to confirm a higher score. In other words, rate only the factor that causes the most impairment for the patient. On the Violence subscale, the rating should be based on suicidal factors for the suicidal client and on factors related to assaultiveness for the assaultive client. On the Substance Abuse subscale, the rating should be based on use of alcohol for alcoholic patients and the use of drugs for drug-abusing patients.


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Factors that relate to being withdrawn, showing lack of interest, or exhibiting poor motivation should be rated under the Psychological Impairment subscale rather than under Social Skills or ADL– Occupational Skills. For example, being too depressed to go to work should be rated under the Psychological Impairment subscale rather than under the ADL–Occupational subscale. As shown in Chapter 2 on the scoring sheet, you are asked to specify which factor is primarily being rated in three subscales: Psychological Impairment, Violence, and Substance Abuse. A. Psychological Impairment Under Psychological Impairment, the clinician is prompted to indicate the following: Primarily (check one):

Not Impaired___


Other Impairment___

Both___

This distinction is used to help separate the mentally ill from the criminally ill. If a patient is rated as impaired, the rater should indicate whether the rating is primarily due to antisocial and sociopathic factors, other factors, or strong loading on both antisocial and sociopathic factors and other factors. This is useful when screening for mentally ill versus criminally ill patients in both the mental health system and the criminal justice system. This may also be very useful when rating clients in homeless shelters. Clearly, treatment interventions and dispositions may be very different for the mentally ill versus the criminally ill. The patient’s diagnosis also should be an important factor in separating these two groups. B. Violence Under Violence, the clinician is prompted to indicate the following: Primarily (check one):

Nonviolent___

Violent to Self___



This item is used to help separate clients who are attempting to hurt themselves from clients who are attempting to hurt others. Clinically, this appears to be a very important difference because clients who are violent to themselves are often different in many significant ways from clients who are violent to others. Also, in our society, violence toward others is seen as much more serious than violence toward oneself. For example, cutting oneself with a razor is not seen to be nearly as serious as cutting someone else with a razor. It is not unusual that one may cut oneself with a razor and be back home with a supportive family the same day with few significant consequences. It is unlikely that there would not be very serious consequences for cutting someone else with a razor (e.g., criminal charges with the possibility of confinement for years in a mental health facility or prison). It is also unlikely that the patient would have a supportive family who would see such an attack as justified, unless done in selfdefense. The increased seriousness of violence to others is supported by the fact that long-term inpatients tend to be patients who are violent toward others rather than toward themselves (see Figure 3–1). Figure 3–1 is based on a pilot study that included the level of violence in patients at Worcester State Hospital, Worcester, Massachusetts (Kennedy et al. 1999). Figure 3–1 shows that 50% of the patients were primarily violent to others and only about 5% were primarily violent to themselves. In discussions with outpatient clinicians, suicidal and self-abuse factors appear to be much more prevalent in outpatient facilities. It appears that assaultiveness is increasingly an inpatient phenomenon. In relation to diagnosis, in the Violence subscale, unlike in the Psychological Impairment subscale, the patient’s diagnosis is less likely to clarify which factor is being measured. Violence to self and others is shared by the diagnostic criteria of many diagnoses—that is, there appear to be pathways from many diagnoses that can lead to violence to self or others. Clearly, certain diagnoses are much more associated with violence to self than violence to others, such as diagnoses that have depression as a prominent part of their diagnostic criteria. Similarly, certain diagnoses are much more likely to be associated with violence to others, such as diagnoses that have paranoia as a prominent part of their diagnostic criteria. However, that a person is paranoid does not mean that he or she is not going to act out violently toward himself or herself. Likewise, that a person is

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depressed does not mean that he or she is not going to be violent toward others. For example, murders and suicides by depressed persons clearly point to the potential for violence toward others by those with depression. There are no simple pathways within a diagnosis that clearly lead to only violence toward self or to only violence toward others. Finally, even though there are often very important differences between the suicidal and the assaultive patient, there is often tremendous overlap between what drives violence toward self and violence toward others. This overlap is one of the main reasons for not dividing the Violence subscale into two subscales. 60

50

Percentage of Patients

50

40

30 26

19

20

10 6

0 Nonviolent

Violent to Self

Violent to Others

Violent to Self and Others

Figure 3–1. K Axis Violence subscale. Total inpatient sample, N = 198; nonviolent, n = 51; violent toward self, n = 11; violent toward self and others, n = 37; violent toward others, n = 99.

C. Substance Abuse Under Substance Abuse, the clinician is prompted to indicate the following: Primarily (check one):

Nonabuser___

Alcohol Abuser___

Drug Abuser___

Both___

If the patient is a substance abuser, this measure will separate those whose abuse is mainly alcohol, mainly drugs, or a strong loading of both drugs and alcohol. Clinically, there appear to be very important differences between clients who abuse alcohol and those who abuse drugs. Besides the differences in the direct chemical effect of drugs and alcohol, alcohol is legal and most drugs that are abused are illegal. Also, in my clinical experience, depression is much more prevalent among alcoholics and antisocial personality disorder is much more prevalent among drug abusers. Often very different problems are present, and very different treatment strategies are used when working with alcoholics as opposed to drug abusers. Finally, as with the Violence subscale, even though there are often very important differences between the alcohol abuser and the drug abuser there is often tremendous overlap between what drives a patient to abuse alcohol and what drives a patient to abuse drugs. This overlap is one of the principal reasons for not dividing the Substance Abuse subscale into two subscales.


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V. Optional Subscale: Ancillary Impairment One subscale, Ancillary Impairment, is optional. This subscale should be considered as a substitute for DSM-IV-TR’s Axis IV because it identifies and quantifies most stressors addressed by Axis IV, including legal, financial, and environmental impairments. These impairments are often not quantified or tracked clinically; however, the Ancillary Impairment subscale can be one of the most important subscales in certain clinical situations, such as in a crisis center that intervenes to get people out of abusive environments or homeless situations. Also, increasingly, safety in an inpatient psychiatric program can be a serious concern because of the growing number of inpatients who are dangerous to others, including murderers, stalkers, and sexual offenders. Certainly, stress and danger have been and continue to be a major factor in prison environments. Except in the problem description section of the scoring sheet, the K Axis does not currently allow the rater to indicate whether the rating reflects the current environment or the discharge environment. This subscale may be very helpful in identifying and tracking dangerous environments; however, use caution when rating this subscale because of the unique liability issues that may arise when rating the safety of the environment within your agency. This is addressed in Chapter 2, Section III: “Individual Subscales.”

VI. Dangerousness Dangerousness is a quality or condition of things that are dangerous, harmful, perilous, risky, or unsafe. This situation can result in damage, harm, injury, pain, or loss. Many clinical decisions are based on the patient’s level of dangerousness. In each subscale area, there are dangerous factors; therefore, it is very important for each subscale to capture these potentially dangerous symptoms and behaviors. Measuring the Violence subscale alone fails to detect very important areas of dangerousness. From Psychological Impairment to Ancillary Impairment, each subscale has anchor points that address dangerousness. There is often a high correlation between level of functioning and dangerousness (i.e., as a patient’s functioning becomes more impaired, this functioning is often associated with increasing dangerousness). Examples of dangerousness from each subscale are shown in Table 3–1.

Table 3–1.

Examples of dangerousness from each K Axis subscale

Subscale

Dangerous behavior


Severe loss of appetite; chronic, self-induced vomiting; difficulty staying focused on one’s surroundings; eating nonnutritive substances (pica)

Social Skills

Getting into a car with strangers; making very impaired decisions concerning sexual relationships; not being able to recognize cues that someone is angry, irritable, or threatening

Violence

Suicidal attempts, assaults, arson, rape


Wandering into the street because the dangers associated with going into the street without looking are not understood, accidentally setting fires when smoking or cooking, not understanding how to respond to a fire alarm

Substance Abuse

Accidentally overdosing on drugs; driving while intoxicated; exhibiting dangerous, risky behaviors to get drugs

Medical Impairment

Cancer, diabetes, heart disease (In serious cases, these may have fatal outcomes, even when well treated. The Medical Impairment subscale measures impairment in functioning due to medical problems, not simply the lethality of various medical illnesses; however, there is often a high correlation between the lethality of an illness and its impairment of functioning.)

Ancillary Impairment

Living in a home with a person who is violent toward the client, living in a dangerous homeless situation, vulnerable female on a ward with sexual predators

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The Violence subscale is not intended to capture all aspects of dangerousness. The Violence subscale is intended to measure dangerousness associated with the patient actively and intentionally trying to hurt himself or herself or others. However, there is a tendency to rate some of these other forms of dangerousness under the Violence subscale. In the other subscales, the dangerousness is generally caused by the patient’s impaired functioning. It is a secondary effect, not an active attempt to hurt oneself or others. For example,

•

•

•

In the Substance Abuse subscale, a patient may be shooting drugs into his or her veins. This is very dangerous behavior; however, the person is attempting to get high and may in no way be attempting to harm himself or herself. If the person is trying to harm himself or herself by shooting drugs, this intentional dangerousness should be rated on the Violence subscale. Similarly, the drunk driver is usually not trying to hurt himself or herself or others. Therefore, even though this behavior can lead to a violent accident, it should be rated under Substance Abuse, not Violence, unless the person is actually trying to hurt himself or herself or others. The smoker who accidentally sets the bed on fire is not trying to kill himself or herself; however, smoking in bed is a very dangerous behavior. This should be rated under Psychological Impairment if the patient is too depressed to get out of bed. It should be rated under ADL–Occupational Skills if the patient does not understand the dangers associated with smoking in bed. The suicidal patient may walk into traffic in an attempt to harm himself or herself. This should be rated under the Violence subscale. However, the dementia patient may wander into the street because of a loss of basic survival skills. This should be rated under ADL–Occupational Skills.

The Dangerousness Level brings the dangerousness from all the subscales, including the Violence subscale, together into a single measure that should capture the most dangerous level for all the subscales (see Chapter 4, “GAF Equivalent and Dangerousness Level,” for details on the Dangerousness Level).

VII.

Users of the K Axis

The K Axis is proposed as an alternative to the GAF (i.e., Axis V in DSM-IV-TR); therefore, it is intended to be used by any clinician or researcher currently using the GAF. This includes clinicians who, either directly or collaboratively, are rating global assessment of functioning as a part of multiaxial psychiatric diagnoses or tracking outcome of treatment. Therefore, those rating the K Axis would certainly include psychiatrists, psychologists, nurses, social workers, and other licensed professionals working in the areas of mental health, mental retardation, substance abuse, and corrections. Licensed professionals in medical specialties other than psychiatry should also find the K Axis useful in their clinical practice. The K Axis does not require licensed staff to rate the questionnaire; however, regardless of who rates the K Axis, a licensed professional should always supervise its use. This questionnaire is not intended to be rated by untrained individuals who spot a relevant anchor point and mechanically assign that point as the rating. Formal training is not mandated for use of the K Axis; however, training and practice using the instrument will significantly increase the reliability and validity of the ratings. Without training and practice, results could be inaccurate. This book is intended to be an excellent resource for self-training on the K Axis. Being able to successfully rate the clinical vignettes contained in this book should be a good indicator that you have the basic skills needed to effectively use the K Axis in clinical settings. Of course, it is assumed that the rater has the skills needed to accurately collect the information contained in the vignettes (i.e., it is assumed that the rater has the skills to perform good clinical assessments). This book is not intended to teach clinicians how to perform clinical assessments. It is expected that the skills for performing good clinical assessments were a part of their basic clinical training. Because the K Axis is intended to generate a summary of the client’s functioning in seven major clinical areas, ratings are best done by a skilled clinician or group of skilled clinicians familiar with the


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client’s overall functioning. This should allow the K Axis to provide a comprehensive overview of the client’s level of functioning in all seven subscales. The more familiar the rater or raters are with the patient’s overall case, the better the ratings should be (i.e., the better the clinical judgments and clinical assessment skills are, the more likely the ratings are to be accurate). When a treatment team acts as the rater, having individual subscales rated by those who have the greatest knowledge in the area that a particular subscale addresses may considerably increase the accuracy. For example, the psychiatrist, psychologist, or primary therapist may be responsible for rating Psychological Impairment and Violence. Occupational therapists or nursing staff may be responsible for Social Skills and ADL–Occupational Skills. The psychiatrist, primary care physician, or nurse may best rate Medical Impairment. If someone on the team has expertise in the area of substance abuse, that person may be asked to do the Substance Abuse rating.

VIII. Certification on the Use of the K Axis A procedure for certification on the use of the K Axis is being considered. This would include certification on the use of the instrument in the clinical setting, as well as certification as an instructor qualified to train clinicians on the use of the K Axis. Even if certification becomes available, it will not be required in order to rate the K Axis; however, getting certification will help verify that the rater has demonstrated a certain minimal level of proficiency in the use of the K Axis. Please go to www.kennedymd.com if you are interested in being certified on the use of the K Axis or certified as an instructor.

IX.

Data Needed to Rate the K Axis

Performing a good clinical assessment of the client is critical to rating the K Axis; however, how to perform that assessment should be a part of the training of clinicians. Training and educating clinicians on how to perform good clinical assessments are certainly not within the scope of this book. Therefore, this section will address only a few issues related to collecting data needed to rate the K Axis. As previously indicated, the rater must develop a clinical impression of the case in order to rate the client using the K Axis. In some cases, interviewing the patient is all that is necessary to gather the information needed to form a good clinical impression of the patient’s functioning; however, usually information from other sources is helpful, even when a skilled clinician is doing the interview. This is especially true when interviewing low-functioning patients, patients attempting to hide information, and patients with poor insight into their illness. In some instances, a rater may be asked to gather the information needed to make a rating by abstracting the necessary clinical information from clinical records or by getting the information from clinicians familiar with the case. This rater may be the only one trained in using the K Axis, and he or she may have very little direct knowledge of the client. This rater must get the needed information to make the ratings from the clinicians who work with the client. This method of developing the clinical impression needed for rating the K Axis is thought to be acceptable, especially if a qualified clinician does the ratings. Of course, for an accurate rating, the information provided to the rater must be accurate and extensive enough to allow for an informed rating of the client. However, there will be serious rating errors if the rater is getting much of his or her information from persons who are not experienced in doing clinical assessments (i.e., if the clinical assessments are poor, the ratings will reflect these inaccuracies). The rater also must be concerned that even when good clinicians are providing the information, these clinicians may not make a reasonable effort to provide the rater with accurate, relevant information. They may see this as a low priority and not take the time needed to provide the rater with full and accurate clinical information. This is especially perilous if the rater has little ability to at least spot check the accuracy of some of the information that he or she is using to develop the clinical impression needed for the ratings. The rater may feel that the information that he or she is gathering is not adequate or is inaccurate. If possible, the rater should do a clinical interview with the patient to help validate the information gathered. If the rater is not qualified to do the clinical interview, a qualified and (if necessary) independent clinician should do the interview.

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One major problem with attempting to perform ratings by simply abstracting clinical records is that critical information needed for the rating is often missing or inadequate. This is especially true for the subscales Social Skills, ADL–Occupational Skills, and Ancillary Impairment. In the process of gathering the information needed to form a good clinical impression of the client, the K Axis can help to point out holes in the clinical assessment. This can occur when there is inadequate information for the clinician to have a reasonable clinical impression of the patient’s functioning in one of the subscale areas. Rating the K Axis forces the clinician to consider all major clinical areas, which ensures that these areas are not overlooked. For example, the clinician may have failed to collect information on substance abuse. The clinician would consequently not have a wellformed clinical impression of the patient’s impairment in the area of Substance Abuse; therefore, this deficit should become apparent when the clinician attempts to rate the Substance Abuse subscale. If a clinician inaccurately assesses the patient’s clinical state, the K Axis will at best only minimally assist the clinician with correcting that assessment. The K Axis depends on having a clinician accurately assess the degree of impairment. The clinician cannot depend on the K Axis to generate a score that reflects the level of impairment without the clinician forming an accurate clinical impression. In summary, the K Axis is extremely dependent on clinicians pulling together all the relevant clinical information, including results from psychological tests. Next, the clinician must accurately assess the degree of impairment revealed by that information. Finally, the clinician can use the K Axis to capture that clinical impression by placing that impression along the K Axis’s continuum.

X. Familiarity With the K Axis The K Axis is most accurate if you refer directly to the questionnaire or its Quick Reference as you are performing the rating. However, the K Axis, like the GAF, can be rated without an actual copy of the K Axis, especially after you have gained an intuitive understanding of the scoring continuum. Because that continuum follows the GAF’s scoring continuum, many raters may already have a good working understanding of that continuum. However, it is recommended that a copy of the actual questionnaire always be available for reference, if needed. When rating a particular subscale, first look for prominent clinical features of the patient’s functioning that apply to that subscale area. Pay special attention to aspects of the client’s functioning that indicate lower levels of functioning. These features are often helpful in determining the actual rating. For example, the fact that a patient has a mildly flat affect or is frequently preoccupied may not significantly affect the Psychological Impairment rating if that patient is also floridly delusional in his or her thinking. Once you have identified prominent clinical features, next go to the relevant subscale and attempt to match those features to the anchor points placed along the continuum of that subscale. On the K Axis subscales, key anchor points are in bold to help quickly focus the rater on the two or three levels that are most characteristic of the client. To view how the bold helps to bring out key anchor points, refer back to the K Axis questionnaire itself in Chapter 2, Section IV. Using the key anchor points, you can start from the bottom and quickly work up to a level that seems to fit the client and then move to the top and work down until you again reach a level that seems to fit the client. If the level is the same working up and then down the scale, that level would be the rating to use. If the two ratings are not the same, you may find that you have often narrowed the choices to only two or three levels. You can then compare the client’s clinical features to the anchor points in these two or three selected levels. This should allow you to quickly make the appropriate rating. Again, if your clinical impression differs from the anchor points or best fit, your clinical impression should override these and you should select the point along the continuum that best captures your clinical impression. As you become more familiar with the K Axis, once your clinical impression is formed you may be able to go directly to the point along the continuum where the appropriate rating is found.


XI.

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Effects of Symptoms, Treatment, Stress, Physical Limitations, and the Like

The interplay between the K Axis and the factors addressed in this section is complicated. As a shortcut, the “rule of thumb” shown in Figure 3–2 can be used to guide you when making ratings involving these factors.

RULE OF THUMB Measuring the Effects of Treatment, Stress, Physical Limitations, and the Like

•

•

The presence or absence of support, medication, other treatments, or even severe stress generally should not affect the rating, unless it is covering up skills. The rating should be based on the level of functioning, and no adjustment should be made for the presence or absence of these factors. Do not factor out the effects of treatment, even if the patient may drop out of treatment. The effect of physical/environmental limitations generally should be factored out of the rating. For example, factor out not abusing drugs or not assaulting others due to being incarcerated or physically restrained; factor out not being socially active or employed due to physical constraints of being in a wheelchair or confinement to bed. Rate how functional or dysfunctional a client would be if given reasonable opportunity—that is, do not let physical barriers cover up skills or violence.

Figure 3–2. A rule of thumb for addressing the effects of treatment, stress, physical limitations, and the like on K Axis ratings.

This rule of thumb is also located on the Instruction Sheet for the K Axis. For ratings in which this rule of thumb does not appear to work or if further explanation is needed, please refer to the relevant information provided in one or more of the following subsections. A. Symptoms Versus Skills The intent of the K Axis is to measure mental health status and functioning; however, a large number of external factors can impact or obscure a patient’s mental health status or functioning. These factors can have different effects on individual subscales. Determining the individual effects on the subscales can be simplified if the subscales are divided into two groups on the basis of whether they measure primarily symptoms or skills: 1.

Measures primarily symptoms a. Psychological Impairment b. Violence c. Substance Abuse d. Medical Impairment

2.

Measures primarily skills a. Social Skills b. ADL–Occupational Skills

Note: The Ancillary Impairment subscale is addressed at the end of this section.

When rating individual subscales, consider symptoms that can cover up K Axis ratings of skills and physical or environmental limitations that can prevent the manifestation of both K Axis symptoms and skills.

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B. Effects of Symptoms on Rating Skills Symptoms can cover up skills. Symptoms covering up skills on K Axis subscales that rate skills should be factored out of the ratings of those subscales (Social Skills and ADL–Occupational Skills)—that is, if symptoms cover up the patient’s skills, the rater must attempt to look beyond the symptoms to get at the underlying skills. For example, just because a banker is temporarily in bed with depression or the flu does not mean that he does not have the ADL–occupational skills needed for his job. His mental or physical illness is preventing him from using his skills; therefore, this should not affect his ADL– Occupational Skills rating. In some ways, rating skills is similar to performing an IQ or academic achievement test. When administering such tests, you rate the client’s IQ, not symptoms that may be obscuring the client’s IQ. An IQ test performed when a patient is suffering the effects of an acute medical or acute psychiatric illness may not reflect the patient’s actual IQ. Such IQ scores may be misleading when used as part of an assessment of a patient’s long-term academic or professional potential. For the same reason, acute symptoms covering up skills (social skills or ADL–occupational skills) should be factored out of the rating of those skills. C. Effects of Symptoms on Rating Symptoms Generally, symptoms should not be factored out of the subscales that measure those symptoms, because they are what those subscales are measuring. However, because the K Axis measures symptoms over the last week or more, acute symptoms, such as an acute panic attack, acute intoxication, or a case of the flu, can cover up or exaggerate the overall symptoms that the rater is trying to measure. These acute symptoms must be placed in the context of the overall frequency and intensity of symptoms that the patient has been manifesting over the last week or more. For example, one patient having an acute panic attack may be exhibiting severe symptoms at the time of the rating; however, she may only have a panic attack once every couple of months. Another patient may be having the same severe symptoms at the time of the rating; however, that patient may have panic attacks several times a day. The K Axis rating should reflect the greater impairment of the latter patient, even though their acute episodes at the time of the ratings are identical. If a mental illness, such as a psychosis, is unremitting over a long period and the K Axis skills are thought to be permanently impaired, not just covered up, then the K Axis’s skills ratings should reflect that permanent impairment. For example, a schizophrenic patient may have his first psychotic break when in college and may currently, despite years of treatment, be barely able to function in a very sheltered and supported work environment. The loss of the skills that he had when attending college is not a temporary, acute loss, but probably a permanent loss. The K Axis should reflect that loss. As will be addressed later in this section, stress, medication noncompliance, and chronic substance abuse can result in symptoms that will cover up skills; therefore, these symptoms, as with other symptoms, should be factored out of the K Axis skills ratings. D. Effects of Physical and Environmental Factors on Ratings of Symptoms The effects of physical and environmental limitations and barriers should be factored out of the ratings for symptoms. In the Violence subscale rating, factor out incarceration if it is known or strongly suspected that without the incarceration, the client would act violently against a victim (i.e., just because the client is not violent on the ward may not indicate that the client will not be violent against a potential victim when given the opportunity). For example, if a wife batterer is unable to get at his wife due to incarceration, he should not be rated as safe simply because he has not assaulted his wife during the period of incarceration. He should be rated as if he had the expected access to the potential victim, his wife, if he were released. If the client is expected to be discharged home to his wife, then the expected access is great and this should be included when making the Violence subscale rating (i.e., as long as the client is thought to be a danger to his wife). If the expected access is very low because the client is unable to locate the potential victim (such as the wife who decided to divorce her husband and moved into a shelter for battered women), this should improve the Violence rating. However, if it is thought that the client is going to take aggressive steps to track down his wife and assault her, this should certainly worsen the rating of the Violence subscale.


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In another example related to the Violence subscale, if a patient is not using a weapon to attack others because he currently does not have access to a weapon, when rating Violence the rater should factor out the current lack of access to a weapon. Instead, the rater should factor in what he or she believes would happen if the patient regained his or her expected access to weapons. The expected access should take into account those who will have easy access to a number of lethal weapons to those who will never have the ability or opportunity to get or use a weapon. Currently, inmates leaving correctional facilities are often “well educated” about obtaining weapons. It is also common for patients to have close friends or relatives who have many weapons. This potential access to weapons can markedly worsen the Violence rating. At the other extreme are patients whose thinking is so severely disorganized that they would not be able to obtain a weapon or know what to do with a weapon if they had one, or patients who are extremely unlikely to leave their current environment, which successfully limits access to weapons. These patients’ expected access is probably extremely low, as is their ability to take advantage of any access they may have to weapons. For example, an extremely impaired patient with chronic psychotic thinking may have delusions of shooting people with a handgun; however, he may be rated as being reasonably safe if it is felt that he has no present or future ability to get a gun or to use a gun if he were able to get a gun. Rating him as extremely dangerous because of his delusions would give the false impression that significant resources may be needed to prevent the patient from harming others with a gun. In an example related to the Substance Abuse subscale, if the patient is not abusing drugs or alcohol due to being hospitalized or incarcerated, this should be factored out. Rate the patient based on how he or she would act if given expected opportunity to obtain drugs or alcohol. E. Effects of Physical and Environmental Factors on Ratings of Skills Physical limitations also may prevent the manifestation of skills. As with the blocking of symptoms by physical limitations, you should factor out physical limitations that block the manifestation of skills. Therefore, K Axis skills are rated on how skilled the patient would be if the underlying skills were allowed to manifest themselves. For example, if a client is confined to a wheelchair and unable to get a job because of the physical limitations of the wheelchair, the person should be rated as if he or she were given reasonable and realistic access to a job. This reasonable access to a job can be by increasing mobility to get to jobs, providing aids that increase functioning on the job, and increasing opportunities to have jobs brought to the client at home such as through the use of computers at home. Barriers to reasonable access to opportunities to use one’s skills can be captured in the rating of the Ancillary Impairment subscale. If the person were permanently confined to bed due to physical illness, the physical illness that confines him or her to bed would be measured under the Medical Impairment subscale. Its effect on the K Axis skills ratings would depend on the patient’s functioning if given reasonable opportunity to use his or her skills. For example, a banker who is paralyzed in an auto accident may have his mobility seriously impaired. This may block his access to his job at the bank, as well as to many social situations; however, he would retain many of his social skills and ADL– occupational skills. He can draw on these skills even if he is no longer able to function in his job as a banker or easily visit with his friends. His ability to use his skills, if given reasonable opportunity, would determine the K Axis’s skills ratings. It is certainly likely that his functional skills would be decreased by his permanent injuries; however, the clinician must use caution not to overrate the degree of impairment if he is given a reasonable chance to use his skills. In this example, if the person paralyzed is someone whose life skills are embedded in tasks that required a lot of physical skills, his or her overall skills impairment may be much greater than a person whose skills are focused on activities that are much less dependent on physical activities. For example, a skilled construction worker and a professional dancer may suffer a loss from paralysis that is much more devastating to their functioning than people involved in activities that require fewer physical skills. Their functional loss would be much greater, and they would, therefore, require more resources to integrate them back into their jobs or to retrain them in very different careers. The K Axis should reflect this greater loss of skills. With training and development of new skills, the K Axis should capture these new skills.

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With or without training, the effects of reasonable access to opportunities should be factored into the skills rating; however, training should certainly act to augment a patient’s opportunities and K Axis rating. F. Effects of Chronic Stress, Medication Noncompliance, Chronic Substance Abuse, and the Like on Ratings of Skills Stress, medication noncompliance, and chronic substance abuse can interfere with the manifestation of K Axis skills; therefore, they are factored out of the K Axis’s skills rating. These factors are captured in the subscales that measure symptoms. This will be addressed in the next subsection. G. Effects of Chronic Stress, Medication Noncompliance, Chronic Substance Abuse, and the Like on Ratings of Symptoms The effects of chronic stress and chronic substance abuse should not be factored out of the K Axis symptom subscales. In fact, the effects of stress, compliance or noncompliance with medication, chronic substance abuse, and the like are often what is being rated when rating symptoms. Effects of these factors are very clinically important (e.g., they may lead to anxiety, increased depression, and psychotic symptoms). These are relevant clinical factors that should not be factored out of the symptoms ratings. Developing treatment strategies to decrease a patient’s level of stress, to ensure medication compliance, and the like are major components of the clinical process. The K Axis baseline rating of these symptoms is very important because changes in a patient’s functioning can be tracked by rating the patient at follow-up after various treatment strategies have been implemented. This should help to determine the effectiveness of the treatment strategies. The following examples involve both noncompliance and compliance with medication and its effect on rating the K Axis subscales measuring symptoms. If a patient is not taking his or her medication and is, as a result, grossly psychotic, the patient should be rated on the K Axis symptoms as psychotic, even though the psychosis is well controlled when the patient is taking his or her medication. Similarly, if the patient is doing well in an inpatient setting and is taking his or her medication, but it is expected that the patient is unlikely to take his or her medication after discharge, then the discharge rating should reflect that the symptoms are being well controlled by the patient’s medication. Predicted future changes in symptoms should not be included in current ratings of symptoms. Suspicions that the patient will stop his or her medication should certainly be taken into account when discharging a patient. If possible, steps should be taken to help ensure that the patient continues to take his or her medication following discharge; however, it is not always possible or legal to hold a patient until factors are in place to ensure that the patient will follow through with taking his or her medication after discharge. After a patient has been discharged, has stopped his or her medication, and has decompensated, the follow-up rating of the K Axis symptoms should reflect that decompensation. In a similar example, if a patient is taking his or her medications, has reached a Violence rating of 60, and is thought to be ready for discharge, the patient’s rating should not be changed to 30 or 40 even if it is felt that he or she will not take his or her medication after discharge and will quickly return to a Violence rating of 30 or 40. In such a situation, there should be additional discharge criteria, such as a court order to ensure medication compliance, that would allow the patient to be safely discharged once the criteria have been achieved. The Violence rating alone should not be the determinant of discharge. The Ancillary Impairment subscale could also play a role in this decision. Discharge to an environment that does not have adequate safeguards to ensure that the patient is safe (e.g., taking his or her medications) often falls under the Ancillary Impairment subscale’s rating of environmental factors. Other factors may also be a part of the discharge criteria. This was emphasized in Chapter 1, Section VIII: “K Axis and Clinical Decisions.” As indicated earlier, you should attempt to put together a discharge plan that helps to prevent noncompliance with medication; however, even when there is nothing that can be done to prevent noncompliance and relapse, this should not affect the K Axis discharge rating of symptoms. Because the predicted medication noncompliance is not captured in the K Axis discharge rating of symptoms, this will impair the ability of the K Axis discharge rating of symptoms to predict the outcome of discharging


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a patient who will stop his or her medication. However, factoring in the effect of noncompliance with medication will not allow the K Axis to measure the effect of the patient’s medication on his or her symptoms. The Ancillary Impairment subscale is one safeguard within the K Axis for capturing factors in the patient’s environment that do not adequately protect him or her from relapse. In another example, if stress is causing a patient to be depressed, that patient should be rated as depressed rather than rated as to how he or she would be if the stressor were removed (i.e., the stress should not be factored out). Of course, reducing or removing the stressor should be one of the goals of treatment. If the treatment is successful and the patient improves, then the follow-up K Axis rating should reflect that improvement. The rating of the stressor can be captured in the Ancillary Impairment subscale as indicated in the next subsection. H. Ancillary Impairment Subscale and Measurement of Stress The Ancillary Impairment subscale measures stressors in a patient’s environment, including the environment into which a patient will be discharged; therefore, these stressors should not be factored out of the Ancillary Impairment subscale. Certainly, as a part of the discharge plan, treatment efforts should be directed at helping the patient to better cope with stress or to eliminate stressors in the discharge environment. The effectiveness of “treatments” to eliminate stressors in the discharge environment should be captured in the Ancillary Impairment subscale’s discharge rating. Also, the Ancillary Impairment subscale can measure factors in the patient’s environment that do not adequately protect him or her from relapse, such as needed community supports and court-ordered treatment compliance.

XII.

Average Score for the K Axis

The K Axis can be used to rate a variety of patients, from those who are very healthy to those who are the most dysfunctional in any population. Everyone will fit at some point along the continuum for each of the seven subscales. However, the questionnaire is skewed so that most people in a general population will be rated at the extreme high end of the questionnaire. Therefore, the “average” score is not 50 for the general population, but closer to 80 or 85. Above-average to superior functioning is in the range of 90 to 100. Below average ratings begin around 75. A pilot study of the K Axis at Worcester State Hospital (Kennedy et al. 1999) of mostly schizophrenic patients who had an average hospital stay of about 3 years resulted in the average scores (rounded off to the nearest multiple of 5) shown in Table 3–2.

Table 3–2. Average K Axis scores from pilot study with schizophrenic patients (Kennedy et al. 1999) Measure

Average score

GAF Equivalent

50


40

Social Skills

55

Violence (mostly to others)

55


55

Substance Abuse

65

Medical Impairment

75

Ancillary Impairment*

N/A

Dangerousness Level

45

*The Ancillary Impairment subscale was not available at the time of the study.

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XIII. K Axis Scores and Your Multiaxial Diagnoses The K Axis can be readily integrated into a patient’s multiaxial diagnosis. The following are examples of DSM-IV-TR multiaxial diagnoses using the GAF. These are coupled with multiaxial diagnoses that use the GAF Equivalent instead of the GAF. First is an example of a multiaxial DSM-IV-TR diagnosis using the GAF: Diagnostic Impression: AXIS I:

Schizophrenia, disorganized type, chronic

AXIS II:

None

AXIS III:

None

AXIS IV:

Abandoned by her family

AXIS V:

GAF =

38 (current)

The same DSM-IV-TR diagnosis using the GAF Equivalent would be illustrated by the following: Diagnostic Impression: AXIS I:

Schizophrenia, disorganized type, chronic

AXIS II:

None

AXIS III:

None

AXIS IV:

Abandoned by her family

AXIS V:

GAF Equivalent =

40 (current)

In these examples, the GAF and GAF Equivalent are essentially identical; however, in the next examples, there is a significant difference between the GAF and the GAF Equivalent: Diagnostic Impression: AXIS I:

Major depression, recurrent, severe without psychotic features

AXIS II:

Obsessive-compulsive personality disorder

AXIS III:

Insulin-dependent diabetes mellitus

AXIS IV:

Divorce

AXIS V:

GAF =

42

Diagnostic Impression: AXIS I:


AXIS II:


AXIS III:


AXIS IV:

Divorce

AXIS V:

GAF Equivalent =

55

As can be seen in this example, there is a difference between the GAF score of 42 and the GAF Equivalent score of 55. The GAF Equivalent score of 55 reveals that the patient has skills that are not being captured by the GAF score of 42. The addition of the Dangerousness Level can help to explain differences between the GAF Equivalent and the GAF:


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Diagnostic Impression: AXIS I:


AXIS II:


AXIS III:


AXIS IV:

Divorce

AXIS V:

GAF Equivalent =

55

Dangerousness Level =

40

The Dangerousness Level reveals that the patient is very impaired in at least one of the subscales, and this is what the GAF appears to have been detecting at the expense of detecting skills that the patient may have. A patient’s DSM-IV-TR multiaxial diagnosis can be further refined if the clinician includes the subscale ratings used to generate the GAF Equivalent. This can often reveal which subscale areas account for various strengths or impairments, which is illustrated in the following example: Diagnostic Impression: AXIS I:


AXIS II:


AXIS III:


AXIS IV:

Divorce

AXIS V:

PSY =

40

SOC =

GAF Equivalent =

65

220

VIO = /4=

40

55

ADL =

75

SAb =

MED =


40

The relatively low functioning in the GAF score of 42 covers up relatively high functioning in the Social Skills subscale of 65 and ADL–Occupational Skills subscale of 75. If needed, the total K Axis can be integrated into the multiaxial diagnosis in the following way, including using the Ancillary Impairment subscale for Axis IV: Diagnostic Impression: AXIS I:


AXIS II:


AXIS III:


AXIS IV:

Ancillary impairment =

AXIS V:

PSY =

40

SOC =

GAF Equivalent =

45 65

220

Divorce VIO =

/4=

55

40

ADL =

75

SAb =

90


MED =

60

40

The stressor of divorce is captured in the Ancillary Impairment subscale score of 45. The details as to why divorce warrants a rating of 45 can be expressed in the problem description section of the Kennedy Axis V scoring sheet. You can enter as little as just the GAF Equivalent into the multiaxial diagnosis. However, you can enter all of the K Axis scores, including the GAF Equivalent, Dangerousness Level, and each subscale score. The K Axis, therefore, allows for a lot of flexibility in the amount of information that is entered into your patient’s multiaxial diagnosis.

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XIV. K Axis Rating and Cultural Factors The ratings for the K Axis are based on the rater’s clinical impression. In developing that clinical impression, the rater should have already made any necessary adjustments for cultural factors as a part of the clinical assessment. How to perform good clinical assessments should be a part of a rater’s clinical training and expertise, including incorporating cultural factors into those assessments.

XV. References Kennedy JA, Fisher W, Skog S: Kennedy Axis V in Long-Term-Care Patients (Pilot). Worcester State Hospital, University of Massachusetts Medical Center, Worcester, MA, and the Massachusetts Department of Mental Health, unpublished data, 1999

CHAPTER 4

GAF EQUIVALENT AND DANGEROUSNESS LEVEL

4–1


GAF Equivalent and Dangerousness Level

4–3

GAF EQUIVALENT AND DANGEROUSNESS LEVEL CONTENTS I. Overview ......................................................................................................................................... 4–5 II. GAF Equivalent ................................................................................................................................ 4–5 III. Dangerousness Level ....................................................................................................................... 4–6 A. Weighted Dangerousness Level Scores ........................................................................................ 4–7 B. Using the Dangerousness Level to Screen for Admission.............................................................. 4–7 C. Unweighted Versus Weighted Scores .......................................................................................... 4–8 IV. Dangerousness Level and the GAF Equivalent................................................................................ 4–8 V. Determination of the GAF Equivalent and Dangerousness Level Scores........................................ 4–9 VI. Number of Subscales Needed to Determine the Dangerousness Level ....................................... 4–13 VII. References ..................................................................................................................................... 4–13



4–5

GAF EQUIVALENT AND DANGEROUSNESS LEVEL I.

Overview

As pointed out in Chapter 1, Section II: “Comparison of the K Axis to the GAF,” an equivalent to the GAF should address at least two factors: 1) psychiatric symptoms and 2) level of functioning. This is done with the GAF Equivalent and the Dangerousness Level. Descriptions of the GAF Equivalent and Dangerousness Level and how to derive them follow. Also, this chapter provides an explanation as to how these measures can work together to better reveal the factors that the GAF currently must convey with a single number.

II. GAF Equivalent The Psychological Impairment and Violence subscales address mostly psychiatric symptoms and the Social Skills and ADL–Occupational Skills subscales address mostly level of functioning. Adding these first four subscales and dividing by 4 generates the GAF Equivalent. This method should give a score that is roughly equivalent to the GAF. However, unlike the GAF, the GAF Equivalent can ensure that the major areas of functioning are not overlooked and that some details of its generation are available. Only the first four subscales are used to determine the GAF Equivalent because these are the subscale areas that are addressed by the GAF. The GAF does not measure Substance Abuse, Medical Impairment, or Ancillary Impairment; therefore, these three subscales are not used to determine the GAF Equivalent. By including the first four subscales, the GAF Equivalent provides a comprehensive global assessment of functioning, while at the same time acting as an estimate of the GAF. In the calculation of the GAF Equivalent, it is assumed that the four subscales are equally important. Therefore, each of the four subscales is given equal weight when determining the GAF Equivalent. Some may argue that Psychological Impairment and Violence should be given more weight; however, others argue that the current system works very well because it ensures that level-offunctioning factors are included in a rating that is supposed to capture level of functioning, not just psychiatric symptoms. Clinically, the method used to determine the GAF Equivalent appears to generate a reasonably accurate equivalent to the GAF, and it does so without having to employ a complicated weighting system. Additional support for the GAF Equivalent comes from the California Outcome Measures Project (Higgins and Purvis 2000), which examined the correlation between the GAF and the GAF Equivalent. This project found the correlation to be 0.82. The California Outcome Measures Project also revealed that the GAF and the GAF Equivalent had significant correlations with the individual subscales of the K Axis. See Table 4–1 for details on these findings (this table is also presented in Chapter 2). The mean scores for the clients in the sample are also shown in Table 4–1. Table 4–1. Correlation coefficient between the K Axis and GAF (California Outcome Measures Project) Measure

GAF

GAF Equivalent

Mean score

GAF

1.00

0.82

57

GAF Equivalent

0.82

1.00

64


0.86

0.83

56

Social Skills

0.72

0.85

61

Violence

0.50

0.74

78


0.64

0.84

62

Substance Abuse

0.27

0.29

82

Medical Impairment

0.19

0.21

76

Note.

All correlations were statistically significant (P < 0.01).

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The subjects in the California Outcome Measures Project were outpatients with a fairly low incidence of violent behaviors; therefore, as expected, both the GAF and the GAF Equivalent had a relatively high correlation with Psychological Impairment (0.86 and 0.83, respectively). Because of the low incidence of violence in this population (average rating on the Violence subscale was 78) and the relatively high incidence of psychological impairment (average rating on the Psychological Impairment subscale was 56), the GAF was most likely measuring psychological impairment rather than violence. Therefore, the correlation between the GAF and the Violence subscale is relatively poor (0.50). If the subjects had been very violent, the GAF would have had a higher correlation with the Violence subscale and possibly a much lower correlation with the Psychological Impairment subscale. Because the GAF does not measure substance abuse or medical impairment, there was an expected low correlation between the GAF and both the Substance Abuse and Medical Impairment subscales (0.27 and 0.19, respectively). The same low correlation is true for the GAF Equivalent, which also does not measure substance abuse or medical impairment (correlations of 0.29 and 0.21, respectively). Probably the closest true equivalent to the GAF using the K Axis would be obtained by taking the most impaired score from two subscales: 1) Psychological Impairment and 2) Violence. Of the subscales, Psychological Impairment has been shown to have the highest correlation with the GAF; however, the patient sample used for this determination was composed of patients who had relatively few problems in the subscale area of Violence. A mean rating of 78 on the Violence subscale revealed this. Conversely, it is speculated that in a very violent population, the Violence subscale would probably be more reflective of a true equivalent to the GAF than the Psychological Impairment subscale. Therefore, both measures would be needed to determine the most accurate GAF Equivalent and that equivalent would be determined by selecting the rating that reflects the most dysfunctional score for these two subscales. Such an equivalent to the GAF that uses only the Psychological Impairment and Violence subscales may more accurately capture the GAF. However, this method of determining the GAF Equivalent is not recommended because the GAF Equivalent is intended to improve on the GAF’s ability to capture level of functioning, including capturing a client’s skills. In some situations, for a purer measure of level of functioning, you may want to omit the Violence subscale rating and possibly the Psychological Impairment rating from the calculation of the GAF Equivalent. This would be especially true if the population being measured has very high levels of violence. The high levels of violence could easily obscure skills and other areas of functioning.

III. Dangerousness Level The GAF Equivalent measures average level of functioning across the first four subscales. However, to get a fuller picture of what the GAF is measuring, you also need a measurement that captures specific declines in functioning or the presence of severe psychiatric symptoms. The greater these declines are, the more likely they are to be associated with dangerous levels of functioning or dangerous behaviors. Because these declines are often associated with dangerousness, the measurement that captures these declines is called the Dangerousness Level. As its name indicates, it captures dangerousness, including violence. The addition of this measure gives the K Axis the power to sweep through the subscales to uncover any significant area of dangerousness. These significant areas of dangerousness can also be a key factor in the determination of the GAF. The Dangerousness Level is a measure that can be used to determine the most dangerous rating reached by the K Axis subscales. Chapter 3, Section VI: “Dangerousness,” pointed out that dangerousness is a part of each of the subscales. The Dangerousness Level is a measurement derived from the subscales and represents the maximum severity of dangerousness measured by the subscales (i.e., the most severe psychiatric symptoms or impairment in skills). By helping to indicate how dangerous a patient is, the Dangerousness Level can be a powerful clinical indicator. For example, it could be used as an adjunct to screen for patients who may require high-intensity outpatient care, a residential program, or even hospitalization. The Dangerousness Level must address the first four subscales to capture what the GAF is measuring. Because the Dangerousness Level can go beyond the first four subscales, it can expand the measurement of dangerousness beyond what is measured by the GAF. Some clinicians may find the Dangerousness Level more useful if Medical Impairment and Ancillary Impairment are not included in


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the determination of the Dangerousness Level. This will be addressed later in Section VI: “Number of Subscales Needed to Determine the Dangerousness Level.” In certain clinical situations, the Dangerousness Level may be more representative of the GAF than the GAF Equivalent. This is often seen when a particular GAF rating reflects violence or other dangerous behaviors seen in only one or two of the first four subscales, whereas the client has relatively few problems in the other subscale areas. This would be demonstrated in the example of the severely suicidal college professor who functions very well in the areas of Social Skills and ADL–Occupational Skills; however, these skills would falsely elevate the GAF Equivalent score when compared with the GAF. This GAF Equivalent score would give the impression that the GAF score is better than it actually is; however, the Dangerousness Level would capture the poor score in the Violence subscale and would, therefore, more accurately reflect the GAF. A. Weighted Dangerousness Level Scores Based on years of clinical experience and use of the K Axis, weighted Dangerousness Levels have been set across all of the seven subscales. These are empirical determinations. They were set so that Dangerousness Level scores of 50 or lower could be used as a general guideline to indicate a very significant level of dangerousness for each subscale. These low scores are often associated with the need for high-intensity outpatient care, a residential program, or even hospitalization. The weighted Dangerousness Level scores are automatically determined when rating the K Axis subscales. Details on how this is done are presented later in this chapter in Section V: “Determination of the GAF Equivalent and Dangerousness Level Scores.” The weighted Dangerousness Level scores were not based on statistical correlations of K Axis scores with actual dangerous outcomes. They were empirical determinations; however, it is believed that these empirically determined Dangerousness Level values have significant face validity. Even with a formal study, the final, weighted scores may be at or very close to their current values. In the future, the validity of the Dangerousness Level should be tested in a more scientific manner. B. Using the Dangerousness Level to Screen for Admission Dangerousness Level ratings that reach 50 or lower are often associated with the need for high-intensity outpatient care, residential care, or even hospitalization. Certainly one of the most important decisions concerning dangerousness is whether a patient should be admitted. Whether a patient has reached a Dangerousness Level score of 50 or lower may help determine whether the patient should be admitted. In most high-intensity treatment programs, most patients, if not all, would be expected to have a Dangerousness Level of 50 or lower. You may want to explore the appropriateness of admissions to high-intensity treatment programs of patients with a Dangerousness Level score significantly higher than 50. As stated in the following warning statement, be careful not to put too much emphasis on a single measure when making clinical decisions or when reviewing clinical decisions.

WARNING Clinicians are strongly discouraged from using the K Axis scores alone, including the Dangerousness Level score, to make complicated clinical decisions, such as decisions related to admission or discharge. The ability of the K Axis scores to be used alone for complicated clinical decisions is very hypothetical (i.e., there is little scientific or clinical evidence to support such use). Therefore, K Axis scores should not be used alone, especially for such vital clinical decisions. There should be a narrative description of the patient’s symptoms and behaviors that supports any decision made. Often the clinical information included in the problem description section of the scoring sheet can be used to satisfy this need. The use of similar narrative summaries in such decisions is, of course, common clinical practice. Based on such summaries, the clinician is often able to communicate whether certain decisions should be made or whether additional information is needed. These issues are addressed in Chapter 1, Section VIII: “K Axis and Clinical Decisions,” and in Chapter 5, “Problem Description Section of the Scoring Sheet.” This is also addressed in the “Cautionary Note” at the beginning of this book.

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A Dangerousness Level of 50 or less can be a good rule of thumb to indicate the need for highintensity treatment. However, because various programs are able to handle different levels of functioning in patients, a Dangerousness Level score of 50 may not match the specific admission criteria of every agency. Therefore, use Dangerousness Levels that fit the particular needs of your agency. Again, it cannot be overemphasized that the Dangerousness Levels must only be a part of a more elaborate admission screening process. The concept of the Dangerousness Level as a screening tool for admission is complicated by the fact that a particular Dangerousness Level score can be seen as a justification for admission by some agencies or treatment groups. However, the same Dangerousness Level may be seen as an admission barrier in other agencies or treatment groups. For example, an outpatient support group for patients with mild depression may not be capable of handling patients with a Dangerousness Level of 50 or lower, especially if the Dangerousness Level is due to ratings on Psychological Impairment or Violence. Therefore, such a score may be a barrier to acceptance into that group.

C. Unweighted Versus Weighted Scores The weighted scores used to determine the Dangerousness Level are intended to search across the subscales to locate the most dangerous level within the subscales. In all other uses of the K Axis, you should use the unweighted scores. When you are not comparing dangerousness across subscales, converting to the weighted scores may simply lead to unnecessary complications and confusion. Therefore, when focusing on dangerousness in fewer than the first four subscale scores, it may just complicate the process to convert to the weighted dangerousness scores. The unweighted K Axis scores should work just as well as the weighted scores in such situations. Any advantage that is gained would likely be offset by the added complication of using the weighted scores. Therefore, when you are not screening through at least the first four weighted subscales for the most dangerous rating, an individual K Axis subscale score or combination of the scores should be used. In this situation, the Dangerousness Level would not be used because you would not be screening through at least the first four weighted subscales for the most dangerous rating. Simply use the unweighted subscale score(s) rather than converting them to scores weighted for dangerousness. For example, a program may be designed to specialize in the treatment of socially impaired schizophrenic patients who also have significant problems with occupational skills. The admission criteria may be that the patients have a diagnosis of schizophrenia and a K Axis score of 50 or worse in the subscale area Social Skills and 40 or worse in the subscale area ADL–Occupational Skills. There would be no reason to convert the score to a weighted dangerousness score. Similarly, if this program is unable to manage patients who are very violent, the program’s admission criteria may require that patients not have low scores in the K Axis subscale for Violence. In these cases, you are not simply screening for the most dangerous rating across the subscales. Using the weighted dangerousness scores is unnecessary and may only create confusion; therefore, use the K Axis unweighted scores from the relevant subscales. In summary, the Dangerousness Level is a screening tool, and the individual weighted subscale scores are not intended to replace the individual unweighted K Axis subscale scores. If you are trying to screen for dangerousness across most of the subscales, then it may be best to convert the scores to a Dangerousness Level score. However, you should certainly not use the Dangerousness Level score when the K Axis unweighted score(s) can work just as well or even better.

IV. Dangerousness Level and the GAF Equivalent One of the major roles of the Dangerousness Level is to ensure that a relatively high GAF Equivalent score does not obscure very low functioning in one of the other subscale areas. If the GAF rating is at the high end of the continuum, the GAF Equivalent and Dangerousness Level are probably both highly correlated with the GAF rating. At the lower end of the continuum, if the GAF is continuing to measure level of functioning, the GAF Equivalent should continue to be highly correlated with the GAF. However, if the GAF is measuring violence, then the Dangerousness


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Level may be much more highly correlated with the GAF. In other words, at the more dysfunctional end of the GAF continuum, in addition to measuring level of functioning, the GAF increasingly measures violence to self and others. Therefore, it is unclear whether very dysfunctional GAF scores are due to poor level of functioning or very violent behaviors. Marked violence can obscure true level of functioning at the low end of the GAF (e.g., the seriously suicidal banker may score the same on the GAF as a chronic, inpatient schizophrenia patient who has been unemployable for decades, though obviously they have very different levels of functioning). The K Axis attempts to deal with this problem by allowing the GAF Equivalent and the Dangerousness Level to work together. In the example of the suicidal banker and the patient with chronic schizophrenia, both patients may have the same Dangerousness Level score, that is, the banker may have a 20 due to his very real danger of hurting himself and the schizophrenic patient may have a 20 due to his gross impairment in thinking and communication. However, the GAF Equivalent for the banker may be around 65, which is significantly better than the GAF Equivalent for the chronic, inpatient schizophrenic patient, which may be around 40. Without the Dangerousness Level, the banker’s high scores in the areas of Social Skills and ADL–Occupational Skills can obscure the fact that the banker is extremely suicidal and in much greater need of care than a GAF Equivalent score of 65 would suggest. The GAF Equivalent should give a good overview of the patient’s level of functioning by providing an average of the key clinical areas addressed by the GAF, including violence. The Dangerousness Level screens for a significant drop in functioning in one of the subscale areas, including all of the subscales addressed by the GAF. The GAF Equivalent score should be very helpful in screening for impaired level of functioning and serious psychiatric symptoms. The Dangerousness Level can act in conjunction with the GAF Equivalent score to ensure that areas of high functioning do not cover up an area or areas of significant impairment. These areas of low functioning can be associated with very dangerous outcomes and certainly should not be missed. Therefore, the Dangerousness Level, which captures any declines in functioning, may be just as useful as the GAF Equivalent when attempting to generate an equivalency to the GAF.

V.

Determination of the GAF Equivalent and Dangerousness Level Scores

The GAF Equivalent is based on the first four subscales. The Dangerousness Level can be calculated using all seven subscales; however, some programs may find the Dangerousness Level more useful if specific subscales, such as Medical Impairment and Ancillary Impairment, are not included in the determination of the Dangerousness Level. Regardless of the number of subscales chosen to determine the Dangerousness Level, a similar method is used to calculate the actual Dangerousness Level rating. In the examples given below, the calculations were done on full sets of seven subscales. The GAF Equivalent was usually calculated first, then the Dangerousness Level; however, it does not matter which is calculated first. The GAF Equivalent is the average score for the first four subscales (Psychological Impairment, Social Skills, Violence, and ADL–Occupational Skills). To calculate the GAF Equivalent, simply add these subscale ratings, divide by 4, and then round off to the nearest multiple of 5, as shown in Figure 4–1.

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Subscale score

Score used to derive DL


40

55

Social Skills

55

65

Violence

70

70

Substance Abuse

65

75


80

80

Medical Impairment

70

75


80

80

Subscale

DL = Dangerousness Level. GAF Equivalent Score

#1 40

+ #2 55

Figure 4–1.

+ #3 70

+ #4 65

= 230 / 4

= 57.5 = 60

Example of the determination of the GAF Equivalent.

In the example in Figure 4–1, the 60 represents 57.5 rounded to the nearest multiple of 5. The GAF Equivalent would be 60. This is calculated by adding 40, 55, 70, and 65, which equals 230. Next step is dividing by 4, which equals 57.5. Rounding to the nearest multiple of 5 equals 60. The Dangerousness Level for the K Axis is the lowest weighted score for at least the first four subscales. Once you have the weighted scores, the actual determination of the Dangerousness Level is almost instantaneous; therefore, in the example in Figure 4–1, the Dangerousness Level would be 55 because it is the most dangerous rating of the scores used to calculate the Dangerousness Level. In other words, determining the Dangerousness Level takes only two steps: 1. 2.

First, determine the weighted scores used to calculate the Dangerousness Level. This is determined automatically, as follows in Step 2. Next, simply choose the lowest score determined in the first step. This score becomes the Dangerousness Level.

In Figure 4–1, the weighted score was already calculated for you; however, the calculation of these weighted scores is extremely easy because it is totally automatic. Once you have rated all the subscales on the scoring sheet, the weighted scores used to determine the Dangerousness Level are the scores directly below the corresponding subscale score. This is illustrated as follows for Psychological Impairment: ÄÄ FUNCTIONAL

DYSFUNCTIONAL ÅÅ

1. Psychological Impairment 100 ___95 ___90 ___85 ___80 ___75 ___70 ___65 ___60 ___55 ___50 ___45 ___40 ___35 ___30 ___25 ___20 ___15 ___10 ___5 ___ 100 95 90 90 85 80 75 75 70 70 65 60 55 55 40 35 25 15 5 50

The lower row of numbers are the scores used to determine the Dangerousness Level. As you can see, once the subscale is rated, the scores used to determine the Dangerousness Level are automatically indicated below the subscale ratings. The lowest of these scores becomes the Dangerousness Level. For example, a subscale score of 55 on the Psychological Impairment subscale would be indicated by placing an X in the blank following the subscale score of 55, as follows:

GAF Equivalent and Dangerousness Level ÄÄ FUNCTIONAL

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DYSFUNCTIONAL ÅÅ

1. Psychological Impairment 100 ___95 ___90 ___85 ___80 ___75 ___70 ___65 ___60 ___55 X 50 ___45 ___40 ___35 ___30 ___25 ___20 ___15 ___10 ___5 ___ 100 95 90 90 85 80 75 75 70 70 65 60 55 55 40 35 25 15 5 50

The subscale score for Psychological Impairment, marked by the X, is 55. The Psychological Impairment score used to determine the Dangerousness Level is located just below the subscale score; that score is 70. If the Psychological Impairment subscale score had been 65, the score used to determine the Dangerousness Level score would be 75. If it had been 90, the score to determine the Dangerousness Level would be 90, if 30, the score would be 50, and so on. Next, repeat this for each of the seven subscales or for all the K Axis subscales that you plan to use in your determination of the Dangerousness Level. Once you have completed rating the K Axis subscales, the scores used to derive the Dangerousness Level will be directly below the subscale scores. Simply select the lowest of these scores and it becomes the Dangerousness Level for the K Axis.

Subscale score



55

70

Social Skills

75

80

Subscale

Violence

25

25

Substance Abuse

80

85


90

90

Medical Impairment

80

85


80

80

DL = Dangerousness Level GAF Equivalent Score

#1 55

+ #2 75

Figure 4–2.

+ #3 25

+ #4 80

= 235 / 4

= 58.75 =

60

Example of the determination of Dangerousness Level.

The Dangerousness Level for the K Axis in Figure 4–2 would be the most dangerous rating from the row used to derive the Dangerousness Level (i.e., 25). This Dangerousness Level score of 25 for the K Axis would indicate that this patient is very impaired in at least one subscale area. The GAF Equivalent for this example would be 60. The 60 represents 58.75 rounded off to the nearest multiple of 5. This is calculated by adding 55, 75, 25, and 80, which equals 235. Next divide by 4, which equals 58.75. Rounding to the nearest multiple of 5 equals 60. Without the Dangerousness Level score of 25, the relatively high GAF Equivalent of 60 would hide the fact that the patient had some very serious problems in at least one subscale area.

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In the next example (Figure 4–3), the GAF Equivalent of 85 and Dangerousness Level of 85 reveal that the client should be relatively healthy.

Subscale score



85

90

Social Skills

80

85

Violence

90

90

Substance Abuse

90

90


90

90

Medical Impairment

80

85


85

85

Subscale

DL = Dangerousness Level. GAF Equivalent Score

#1 85

+ #2 80

Figure 4–3.

+ #3 90

+ #4 90

= 345 / 4

= 86.25 = 85

Example of the determination of Dangerousness Level.

The GAF Equivalent of 85 represents 86.25 rounded off to the nearest multiple of 5. This is calculated by adding 85, 80, 90, and 90, which equals 345. Next divide by 4, which equals 86.25. Rounding to the nearest multiple of 5 equals 85. In this case, the GAF Equivalent supports what the Dangerousness Level score of 85 revealed, that is, this person is probably fairly healthy. In this case, the relatively high GAF Equivalent was not hiding any serious problems in any of the subscale areas. The Dangerousness Level for the K Axis in Figure 4–3 would be the most dangerous rating from the column used to derive the Dangerousness Level (i.e., 85). This Dangerousness Level score of 85 for the K Axis indicates that the patient probably has no serious problems in any of the subscale areas. Even without the GAF Equivalent, you know that this person with a Dangerousness Level score of 85 is probably fairly healthy; however, the GAF Equivalent helps to confirm that the person is doing well. For three of the subscales (Violence, Substance Abuse, and Ancillary Impairment), no weighting is necessary to determine the Dangerousness Level. Therefore, scores used to determine the Dangerousness Level are identical to the subscale scores in these three subscales. For example, 3. Violence 100 ___95 ___90 ___85 ___80 ___75 ___70 ___65 ___60 ___55 ___50 ___45 ___40 ___35 ___30 ___25 ___20 ___15 ___10 ___5 ___ 100 95 90 85 80 75 70 65 60 55 45 40 35 30 25 20 15 10 5 50

In the Violence subscale, a score of 55 would indicate a score of 55 for use in determining the Dangerousness Level. A score of 90 would indicate a score of 90 for use in determining the Dangerousness Level, and a score of 65 would indicate a score of 65 for use in determining the Dangerousness Level. In the other four subscales (Psychological Impairment, Social Skills, ADL–Occupational Skills, and Medical Impairment), the scores used to derive the Dangerousness Level have to be weighted so that they better reflect the level of dangerousness along the continuum. The weighted scores reflect the fact that a lower subscale score is needed to represent the equivalent level of dangerousness in the other three subscales. For example, a score of 50 in the Violence subscale is felt to indicate more dangerousness than a score of 50 in Psychological Impairment. Therefore, the score used to derive the


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Dangerousness Level in Psychological Impairment has been weighted. The resulting weighted score is 30 for a Psychological Impairment subscale score of 50 (i.e., a K Axis score of 50 on Violence is felt to indicate as much dangerousness as a K Axis score of 30 on Psychological Impairment). In other words, a patient has to be more impaired in the areas of Psychological Impairment, Social Skills, ADL– Occupational Skills, and Medical Impairment than in the areas of Violence, Substance Abuse, and Ancillary Impairment to be considered at the same level of dangerousness.

VI.

Number of Subscales Needed to Determine the Dangerousness Level

Because rating Ancillary Impairments is optional, consideration should be given to using no more than the first six subscales in the determination of the Dangerousness Level. As the Dangerousness Level evolves through clinical use, it may come to represent only the first five subscales. This would also eliminate Medical Impairment from the determination of the Dangerousness Level. The dangerousness related to Medical Impairment may not be as relevant to clinical psychiatric decisions and the Ancillary Impairment subscale, which is optional, may not even be completed; therefore, their inclusion may just cloud the findings of the other subscales. If subscales 1 through 5 are used to determine the Dangerousness Level, this may be referred to as the Dangerousness Level Basic or the Dangerousness Level 1–5 (DL Basic or DL 1–5). Eventually, Dangerousness Level may become synonymous with the DL Basic. If all seven subscales have been used, this might be referred to as the Dangerousness Level Plus or Dangerousness Level 1–7 (DL Plus or DL 1–7). You may limit the determination of dangerousness to be derived from only the first four subscales (Psychological Impairment, Social Skills, Violence, and ADL–Occupational Skills). These first four subscales are the areas addressed by the GAF. It is strongly recommended that no fewer that the first four subscales be used in your determination of the Dangerousness Level. If the first four subscales are used to determine the Dangerousness Level, this might be indicated as the Dangerousness Level 1–4 (DL 1–4). If the rater fails to rate the required subscales and a Dangerousness Level rating is needed, the rater should rate the Dangerousness Level based on the available subscale scores rather than leaving the Dangerousness Level blank. In such a case, if possible, the rater should indicate exactly which subscales the rating is based on (e.g., Dangerousness Level 1, 3, and 5). If you are not screening for the most dangerous rating across at least the first four subscales, it is recommended that you probably not use the weighted Dangerousness Level scores. When using fewer than the first four subscales, it is best to use the unweighted K Axis scores and to not calculate a Dangerousness Level.

VII. References Higgins J, Purvis K: A Comparison of the Kennedy Axis V and the Global Assessment of Functioning Scale. Journal of Psychiatric Practice 6(2):84–90, 2000

Notes

CHAPTER 5

PROBLEM DESCRIPTION SECTION OF THE SCORING SHEET

5–1


Problem Description Section of the Scoring Sheet

5–3

PROBLEM DESCRIPTION SECTION OF THE SCORING SHEET CONTENTS I. What Is the Problem Description Section of the Scoring Sheet? ................................................... 5–5 II. Writing a Problem Description of the Patient’s Functioning.......................................................... 5–5 III. Using the Problem Description to Individualize the K Axis ............................................................ 5–6 IV. Determining the Rate of Change in the Individual Subscale Areas................................................ 5–7 V. Using Subscale Scores and Problem Descriptions Together to Track Change ............................... 5–8 VI. References ....................................................................................................................................... 5–9



5–5

PROBLEM DESCRIPTION SECTION OF THE SCORING SHEET I.

What Is the Problem Description Section of the Scoring Sheet?

The problem description sections are areas on the scoring sheet in which you can enter an explanation as to why a specific rating was given. Generally, the explanation should be brief and to the point. The problem descriptions can act as a short, narrative report that captures the client’s overall functioning in every one of the major clinical areas. The problem descriptions are similar to a progress note in a problem-oriented record in which the note is divided according to the client’s active problems. By acting as a focused progress note, the problem descriptions also can be helpful for improving the ability of the K Axis to capture subtle changes in patients over time. These changes may be so subtle that they do not justify any changes in the K Axis scores and, therefore, may be lost in the K Axis scores alone. See Section V: “Using Subscale Scores and Problem Descriptions Together to Track Change,” for details on using the K Axis to track subtle changes over time. In addition to the relationship of the problem description to progress notes, in treatment planning the problem description is used to describe each active problem in the Master Treatment Plan (Kennedy 2003). In treatment planning, the problem description can capture relevant clinical information on problems in the seven problem areas of the K Axis subscales. The problem description, therefore, acts to strengthen the relationships among progress notes, treatment planning, and the K Axis. The problem description also can act as a safety check for the validity (accuracy) of the K Axis ratings. Anyone familiar with rating the K Axis should be able to do spot checks of the scores by reading the problem descriptions to determine whether the clinical data justifies the rating. This can quickly point to problems with the K Axis ratings. Any difficulties uncovered can often be corrected in short, focused training sessions. It has been my experience that this can quickly lead to significant improvement in the reliability and validity of individual raters. In managed care, the problem descriptions can be very helpful for communicating the reasons why a patient was given a particular rating. In some cases, the K Axis scores and the problem descriptions may be all that is necessary for the clinician and managed care provider to reach a reasonable clinical decision about a patient’s care.

II.

Writing a Problem Description of the Patient’s Functioning

When writing the description on the scoring sheet, attempt to use objective, measurable terms similar to the terms found on problem descriptions and long- and short-term goals on a Master Treatment Plan (Kennedy 2003). It is also often helpful to take relevant anchor points directly from the subscales. In some cases, it may be very difficult to objectively describe the patient’s level of functioning. This often reflects the difficulty of documenting very subjective qualities of human symptoms and behaviors. Imprecise language may be the only way to quickly convey the reasoning underlying a rating; however, objective, measurable terms are clearly preferable. Details can give the reader an excellent understanding as to why a particular rating was chosen. In addition to providing valuable clinical information, problem descriptions are very important to help keep raters honest with themselves and others. The problem descriptions help prevent raters from simply pulling the ratings out of the air. Knowing that a rating can be easily verified significantly improves the accuracy of the rating, even for conscientious raters. The descriptions are usually only a few words up to a short paragraph; however, if needed in very complicated or high-profile cases, the rater could include very detailed paragraphs or even pages to support the rating. The more details used to support a rating, the more time it takes to document those details. Including lengthy problem descriptions can significantly increase the time needed to complete the K Axis. The descriptions in Table 5–1 capture particular ranges of scores on the Violence subscale for suicidal patients. As you can see from the figure, the more details provided in the problem descriptions, the narrower the range of reasonable scores becomes.

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Table 5–1.

Examples of problem descriptions

Problem description

Rating range

1.

Currently suicidal.

50–5

2.

Suicide attempt.

70–5

3.

Suicide attempt several years ago, no significant problems since then.

70–65

4.

Serious suicide attempt yesterday.

50–5

5.

Serious suicide attempt yesterday and having occasional thoughts of hurting herself today.

40–20

6.

Serious suicide attempt yesterday and having occasional thoughts of hurting herself today. However, she has resolved the conflict with her husband. She has no previous history of suicidal ideation or attempts. She is contracting for safety and is not felt to be in real danger of hurting herself.

50–40

7.

Serious suicide attempt yesterday. She continues to be actively suicidal. She is on constant observation status because she continues to be seen as in acute, real danger of seriously injuring herself.

10–5

8.

Serious suicide attempt yesterday that was the second attempt within the last few days. She continues to be actively suicidal. She is on constant close observation status because she continues to be seen as an acute danger to herself. She had to be placed in restraints for 3 hours earlier this morning following an attempt to smash her head against the wall.

5–5

As you can see, the more relevant details that are given, the narrower the rating range becomes for what may be acceptable ratings. The actual rating given may be very accurate, even though the problem description does not narrow the range down to that exact score. However, the actual score should likely be within the reasonable range implied by the problem description. For example, a score of 60 for problem description #8 would clearly be outside of any reasonable range. A score of 30 would raise far fewer concerns. Without a problem description, the accuracy of specific ratings is not readily apparent unless you are familiar with the patient being rated. The clinical vignettes included in this book provide many more examples of these problem descriptions. Some of the vignettes will allow only a very narrow range of acceptable scores. Other vignettes may be imprecise, leading to a wide range of acceptable ratings. Narrowing the range is certainly ideal; however, in many clinical situations this may not be practical or the needed clinical information may not be available to narrow the range. When scoring the K Axis, you should not enter a range, even though you may have difficulty narrowing the rating down to a particular score. The score entered on the scoring sheet should be an exact score, even though that score may reflect a midpoint in a wide range. The score may appear to be imprecise based on the information the clinician chose to provide in the problem description; however, the clinician may have simply not included a lot of the details that he or she used in making the rating. Conversely, the score may reflect the clinician’s “best guess” given that he or she had very limited clinical information to support the score. This lack of certainty in the score can be written into the problem description. However, generally the degree of uncertainty is not expressed in the problem description unless extremely important clinical decisions are being made using the K Axis.

III. Using the Problem Description to Individualize the K Axis Just like a progress note, the problem description can be used to capture the unique clinical characteristics of a patient and to track those characteristics over time. Other questionnaires are usually identical in the questions that are asked from one patient to the next (i.e., the same questions are asked instead of tailoring the questionnaire to the individual patient). Because the problem description is a description of the individual patient who is being rated, it allows the K Axis to be individualized (i.e.,


5–7

tailored to that patient). Follow-up administrations of the K Axis can then focus on the specific issues contained in the problem descriptions. This tailors the K Axis to that individual patient. Because of this focus, follow-up administrations of the questionnaire are more likely to pick up change, even if it is small, especially if the problem descriptions contain concise, objective, measurable symptoms and behaviors characteristic of the patient. This is a powerful feature for tracking change over time because attention is focused on symptoms and skills possessed by that individual patient rather than a larger universe of possible symptoms and skills. The K Axis can then be used like a structured progress note to track change in an individual patient over time. Use of progress notes to track change over time has been and continues to be the heart of clinical documentation and tracking of patients. Because progress notes are individualized, they can be tailored to track only those symptoms and behaviors relevant to the individual patient. The world of possible symptoms and behaviors can be markedly narrowed to only those relevant to a particular patient. Structuring progress notes helps to narrow the focus and to ensure that relevant information is captured and tracked in the note; however, because there is often no system for structuring progress notes, their effectiveness in tracking change over time is often not realized. One useful method of structuring progress notes is to structure them according to the Problem List of active problems found on a Master Treatment Plan (i.e., writing problem-oriented progress notes). This method fits in perfectly with the K Axis’s seven subscales and the problem-oriented treatment planning system presented in Fundamentals of Psychiatric Treatment Planning (Kennedy 2003), which uses the same seven problem areas: 1. 2. 3. 4. 5. 6. 7.

Psychological Impairment Social Skills Violence ADL–Occupational Skills Substance Abuse Medical Impairment Ancillary Impairment

See Appendix, Section II: “Problem-Oriented Progress Notes Using the K Axis,” for formats of problem-oriented progress notes using the K Axis.

IV.

Determining Rate of Change in the Individual Subscale Areas

Rates of change are different for the seven subscales. The subscale areas most likely to demonstrate rapid change over time are acute episodes involving Psychological Impairment and Violence. This is true for both acute deterioration and acute improvement. Changes in these two subscale areas are especially important on acute-care units. Change in the other subscale areas often occurs gradually over time. They are often much less responsive to rapid-acting treatments, such as medication and electroconvulsive therapy. Treatments such as medication and electroconvulsive therapy can often bring about rapid changes in acute patients; however, these rapid changes will often be reflected more in the Psychological Impairment and Violence subscales. Subscales such as Social Skills, ADL– Occupational Skills, and Substance Abuse often require long-term rehabilitation programs to bring about significant improvements. Once the acute improvements in Psychological Impairment and Violence have occurred and the patient is back to or near his or her baseline level of functioning, then, as on the other subscale areas, further changes may be more difficult to achieve. These changes in chronic symptoms of Psychological Impairment and Violence may be subtle and may extend over long periods of time. As you attempt to move a patient beyond his or her baseline level of functioning that has been established after years of treatments, further improvements in these chronic symptoms that have stabilized over the years are likely to be subtle in all of the subscales. The use of problem descriptions may be especially important when trying to capture these subtle changes. This is addressed in the next section.

5–8

V.


Using Subscale Scores and Problem Descriptions Together to Track Change

Changes in the K Axis scores over time should reflect changes in the patient over time. The problem description should capture these changes also. Both the K Axis scores and the problem descriptions are derived from the same clinical information. The problem descriptions can be much more descriptive of the patient than the actual subscale scores. The problem description, therefore, may be more sensitive to capturing subtle change over time. The K Axis scores may miss some subtle changes; however, these changes can often be captured in the problem description. This is especially true if the problem descriptions contain relevant, objective, measurable details about the patient’s clinical status. The K Axis is not sensitive enough to distinguish between scores that are only a couple of points apart, such as a score of 40 versus 42. If a patient who scores 40 improves only slightly, the K Axis scores cannot capture this improvement because the improvement cannot justify a 5-point improvement in the score. However, even subtle improvement can often be captured in the problem descriptions. If further improvement occurs and a rating of 45 is justified, the K Axis rating of 45 would certainly capture that improvement. For example, a patient who was hallucinating several times a day might now be hallucinating only once or twice a day. If no other changes have occurred, this might not justify a higher score on the K Axis; however, this improvement can be easily captured in the problem description for Psychological Impairment by simply describing the improvement. In some chronic or stable patient populations, maintaining a particular score (i.e., preventing the patient from deteriorating) may be a reasonable goal. In these populations, an improvement of 5 points over a year may reflect an unusually good rate of improvement. Gradual, subtle improvements are extremely unlikely to be reflected in monthly K Axis scores; therefore, the actual monthly ratings would probably not be very useful for a chronic patient at his or her baseline. Even annual ratings may not capture this gradual change. However, the problem description, just like progress notes, can be very helpful in recording any subtle changes that may have occurred over a particular period. Therefore, if the change is not captured in the K Axis scores, it may still be captured in the problem descriptions, or at least the direction of the change may be captured in the problem descriptions. Do not overlook the fact that the problem descriptions may be very helpful in demonstrating or capturing the direction of small changes. These changes can be picked up even when the change does not justify a change in any of the patient’s K Axis scores. In many clinical situations involving subtle change, obtaining the absolute numerical score may be much less important than capturing the direction of change. In such situations, the problem descriptions may be more effective at capturing the direction of subtle change. Including in the problem description items that are individualized, objective, and measurable can be very helpful with tracking these small changes over time. This can be more effective at capturing subtle changes than the actual change in the subscale score. Even though the subscale scores are integrally tied to the problem descriptions, detailed, individualized problem descriptions can be much more sensitive to change than the actual subscale scores. In some situations, it may be reasonable to indicate that a patient has improved the minimal 5 points on the scale when the improvement may have been no more that 1 or 2 points. This may be necessary to prevent the mistaken impression that no improvement has occurred. This may be especially important, if you feel that

• •

Clinical decisions that are harmful to the patient will be made based on the score, such as discontinuing an effective treatment There will be no further probing to help document the fact that subtle but real changes have occurred

In such situations, to maintain credibility of the ratings, indicate in the problem descriptions the fact that even though the patient is improving, the level of improvement may not fully justify the level of improvement indicated by moving the K Axis score a full 5 points. However, if possible, this route should be avoided and the problem descriptions alone should be used to capture subtle changes instead of attempting to “fudge” the K Axis scores. It is important to remember what was stated earlier about inflating the K Axis scores. For various reasons, you may decide to “fudge” the score by moving the patient up 5 points when the clinical


5–9

changes do not justify the score. You need to be aware that inflating the K Axis scores can come back to haunt you. If this practice is continued in subsequent ratings, it will lead to the patient’s rating slowly going up to an obviously absurd level. At this level, the numerical rating will clearly not match the problem descriptions, or the problem descriptions will clearly not match the clinical situation. A “correction” will have to occur and these inflated scores will have to fall back to a more realistic level. The same correction may also occur if you inaccurately portray the patient as more impaired than he or she really is.

VI.

References

Kennedy JA: Fundamentals of Psychiatric Treatment Planning, 2nd Edition. Washington, DC, American Psychiatric Publishing, 2003

Notes

CHAPTER 6

SCORING CLINICAL VIGNETTES (SELF-EXAMINATION)

6–1


Scoring Clinical Vignettes (Self-Examination)

6–3

SCORING CLINICAL VIGNETTES (SELF-EXAMINATION) CONTENTS I. Overview ......................................................................................................................................... 6–5 II. Process for Rating the Clinical Vignettes in This Book ................................................................... 6–5 III. Sample Vignettes Scored Using the K Axis ..................................................................................... 6–6 Psychological Impairment ................................................................................................................. 6–7 Social Skills...................................................................................................................................... 6–21 Violence.......................................................................................................................................... 6–35 ADL–Occupational Skills.................................................................................................................. 6–51 Substance Abuse ............................................................................................................................. 6–65 Medical Impairment........................................................................................................................ 6–79 Ancillary Impairment....................................................................................................................... 6–95


Scoring Clinical Vignettes (Self-Examination)

6–5

SCORING CLINICAL VIGNETTES (SELF-EXAMINATION) I.

Overview

Numerous clinical vignettes are presented in this chapter to allow you to develop and test your skills in rating the K Axis. The vignettes are grouped in this chapter by the seven subscales of the K Axis. Each subscale has between 7 and 13 vignettes. For your convenience, at the beginning of each vignette section is the K Axis subscale that corresponds to that set of vignettes. Practicing doing these ratings should allow you to quickly become familiar with the K Axis. To promote your learning, you are encouraged to make your own rating of each vignette before looking at the rating given by the author. Visit www.kennedymd.com to see what help is available for checking vignettes you have rated on clients in your own clinical practice.

II.

Process for Rating the Clinical Vignettes in This Book

The author has rated each vignette. Following each vignette, the rating is indicated at the bottom of the page. Even though a particular score is given, there is usually no “right” answer for a vignette. Included in these vignettes are varying degrees of detail, subjectivity, and measurability, which lead to varying degrees of uncertainty in the ratings. The vignettes with lots of objective information supporting a particular rating should have a narrower range of reasonable scores. Other vignettes may have a much wider range of acceptable scores. Rating these vignettes should be helpful in increasing the validity of your ratings, as well as interrater reliability at your facility. Rating actual clinical cases also can be useful when trying to gain skills in the use of the K Axis; however, without feedback from someone skilled in the use of the K Axis, your ratings could be consistently inaccurate, and you may not be aware of the inaccuracies. This can lead to a false level of confidence when using the K Axis. Ideally, your rating of actual clinical cases should be monitored for accuracy by someone skilled in rating the K Axis until you have reached an acceptable level of skill in the use of the K Axis. That monitoring can often be achieved by comparing your scores to the brief descriptions you included to justify your ratings. If you do not have someone at your facility qualified to monitor your ratings, it is suggested that you visit www.kennedymd.com to see what help may be available on the Internet. For most vignettes, it is expected that the rater should be within ±10 points of the rating given in the book. If you are consistently off by ±20 points or more, this is an indication of a problem with rating the vignettes. It is suggested that you rate vignettes within each subscale area until you are fairly comfortable with your ability to obtain a rating that is in reasonable agreement with the book. Once you feel there is reasonable agreement between your ratings and the book, you can move to the next subscale section. In addition to the author’s rating, some of the reasons for the selected rating are provided below each vignette. It is suggested that you jot down your rating before looking at the author’s rating. To keep yourself honest, be sure to cover the bottom of the page as you are rating each vignette. Once you have completed your rating, the rest of the page can be uncovered so you can compare your rating to the author’s rating. Warning dots are used to indicate that you are nearing the area of the rating: . . . . . .

. . . . .

. . . .

. . .

. .

.

These warning dots should help prevent accidentally uncovering the rating. If you disagree with any of the author’s ratings, comments and questions are welcomed at www.kennedymd.com.

6–6


III. Sample Vignettes Scored Using the K Axis Go to the next page to begin rating the vignettes. Cover up the space below each vignette and do not uncover the suggested score until you have written down your rating. Once you feel you have mastered a subscale area, it should be reasonable to move on to the next subscale area without reviewing all of the vignettes in each section; however, the more vignettes that you do, the more familiar you should become with rating with the K Axis. In the explanation of the ratings in some of the vignettes, the words “or better” or “or worse” are used to emphasize a range. “Or better” indicates that a score at or better than the score indicated would be acceptable and vice versa for “or worse.” At times, positive and negative factors are also indicated. Positive factors might help to confirm moving to a higher rating, and negative factors might help to confirm moving to a lower rating. Rating the vignettes in this book should provide you with a good foundation for becoming skilled in the use of the K Axis.

ATTENTION: When rating the vignettes, please conceal the book’s rating (perhaps with a piece of paper) until you have written down your rating.

You may also want to conceal the next vignette and rating on the facing page.

Please proceed to the vignettes.

Scoring Clinical Vignettes (Self-Examination)—Psychological Impairment

CLINICAL VIGNETTES

Psychological Impairment (Problem Area 1)

6–7

6–8


Kennedy Axis V—Psychological Impairment

(Problem Area 1)

100 Superior psychological functioning/coping, no psychological impairment; life’s everyday problems never seem to lead to any significant anxiety or depression. No symptoms.

90 Absent or minimal symptoms (e.g., mild anxiety before an exam), good psychological functioning in all areas; interested and involved in a wide range of activities; generally satisfied with life; no more than everyday problems or concerns. 80 If symptoms are present, they are transient and expected reaction to psychosocial stressors (e.g., upset by breakup with girlfriend; difficulty concentrating after a family argument; mild preoccupation with problems; a woman has many friends, functions extremely well at a difficult job, but says “The stress is too much”); not considered to have mental problems by those who know him/her.

70 Some mild symptoms (e.g., depressed mood with mild insomnia, occasional truancy, theft within the household, difficulty trusting others, mild insensitivity to the feelings and needs of others), but generally functioning fairly well; however, those who know him/her well might express some concerns about his/her mental state.

60 Moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks; frequently preoccupied; moderate impairment in attention span); moderate insensitivity to the feelings and needs of others; to those who know him/her well it is clear that he/she has mental problems.

50 Serious symptoms (e.g., moderately depressed mood, moderate lethargy, severe obsessional rituals, severe phobia, severe sexual perversion, moderate problems with anorexia/bulimia, frequent shoplifting, frequent anxiety attacks, moderately guarded, mild but definite manic syndrome).

40 Major psychological impairment; some impairment in reality testing or communication (e.g., speech is at times illogical, obscure, or irrelevant; moderate paranoia; may have hallucinations or delusions; however, probably realizes they are not a part of reality); major impairment in several areas, such as judgment, thinking, or mood (e.g., depressed man avoids friends, neglects family, and is not motivated to work; or, moderate negative symptoms of schizophrenia); even those who do not know him/her well would likely consider him/her to have mental problems.

30 Behavior is considerably influenced by delusions or hallucinations; appears to be responding to hallucinations; serious impairment in communication or judgment (e.g., sometimes incoherent, thinking is occasionally grossly inappropriate); severely depressed mood; withdrawn, with few spontaneous communications; inability to function in almost all areas (e.g., stays in bed all day and does not care for own living space; no job, home, or friends due to paranoia, poor motivation, social withdrawal, extremely poor insight, or being almost totally insensitive to the feelings and needs of others); at times attention span is markedly impaired; severe sociopathic behaviors have led to multiple arrests; severe sexual perversion toward prepubescent children.

20 Thinking and communication are generally grossly impaired; manic excitement or catatonia; largely incoherent or mute; generally markedly impaired attention span; occasionally fails to maintain minimal personal hygiene due to severe lethargy or very disorganized, bizarre thinking (e.g., too lethargic to attempt to wipe food off shirt; smears feces for bizarre, delusional reasons). 10 Thinking is totally disorganized; totally insensitive to the feelings and needs of others; completely incoherent; completely mute, extremely catatonic; persistent inability to maintain minimal personal hygiene or minimal safety due to totally disorganized thinking or very severe lethargy; unable to focus attention for even a few seconds; chronic, self-induced vomiting has led to a very life-threatening situation. NR Not rated


6–9

Psychological Impairment NAME: Abbott, George AGE:

35

Pt. does not appear to have any significant psychological problems. He is very satisfied with life. His coping skills are very good. He is very good about not allowing problems get to him. His spirits are very good. He has handled the stress of losing his job with no significant difficulty. He is very optimistic about the future, and his optimism appears to be well founded. He is sleeping very well. His energy and appetite are very good. . . . . . .

. . . . .

. . . .

. . .

. .

.

Ratings Psychological Impairment = 100 1) PSY = 100

2) SOC = 90

3) VIO = 90

4) ADL = 90

5) SAb = 80

6) MED = 90

GAF Eq = 95 Dangerousness Level = 80 Explanation of Psychological Impairment Rating No significant psychological problems = 100 Very satisfied with life = 100 Very good coping skills = 100 Very good spirits = 100

7) ANC = 90

6–10


Psychological Impairment NAME: Caruso, Janice AGE:

33

Pt. is no longer showing any major manic or depressive features. No delusions or hallucinations. Some problems with anxiety. She is mildly depressed and tends to isolate herself. Pt. states that she has not heard voices for about 6 months. Pt. states that she no longer believes that there is a war coming with the Russians. Pt. states that generally she is somewhat sad and anxious over the loss of her job. No insomnia. Appetite fair. Mild lethargy. Affect generally flat; however, pt. exhibits an occasional, appropriate smile. No signs of tears. Few expressive movements. No restlessness. . . . . . .

. . . . .

. . . .

. . .

. .

.


2) SOC = 70

3) VIO = 90

4) ADL = 80

5) SAb = 80

6) MED = 80

GAF Eq = 75 Dangerousness Level = 75 Explanation of Psychological Impairment Rating No delusions or hallucinations = 50 or better No voices for last 6 months = 50 or better Some problems with anxiety or sadness = 70 No major manic or depressive features = 40 or better Isolates herself = 50 or better Generally flat affect = 60

7) ANC = 90


6–11

Psychological Impairment NAME: Cross, Anthony AGE:

24

Staff states that pt. is continuing to have problems with depression. Pt.’s energy and motivation appear low. Staff states that he often complains of feeling very tense. Staff states that he often worries over almost anything. Staff states that he often has various physical complaints. Generally, pt. appears apathetic. No crying spells. Pt. does not appear to have a thought disorder; however, at times pt.’s thinking seems somewhat disorganized. Staff feels that pt.’s depression would prevent him from working at a competitive job; however, he is able to stay focused on most tasks at his day program. Pt. states that his mood varies a lot. Pt. states that generally he is moderately sad and somewhat tense. Pt. states that his self-worth is often low. Pt. states that his energy is good. Denies insomnia. Appetite good. Few expressive movements. Mild restlessness. . . . . . .

. . . . .

. . . .

. . .

. .

.


2) SOC = 60

3) VIO = 50

4) ADL = 80

5) SAb = 95

6) MED = 70

GAF Eq = 60 Dangerousness Level = 50 Explanation of Psychological Impairment Rating Moderate depression (few vegetative signs is a plus) = 45 Moderate anxiety = 50 Apathetic = 50 Thinking is somewhat disorganized = 40

7) ANC = 80

6–12


Psychological Impairment NAME: Davis, Richard AGE:

45

Pt. is very incoherent. There is marked impairment in his attention span, that is, his attention span is generally less than 10 seconds. Often hears voices. Often talks or giggles to himself. Few significant interests other than clothes, cigarettes, and satisfaction of basic sex drive. Despite his limited interests, pt.’s motivation to be involved in group activities is very good; however, his capacity to engage productively is very limited. He demonstrates ritualized learned patterns for getting by with no involvement or interaction, such as answering questions with the first thing that comes to mind. It appears that he does this with the hope that the answer is satisfactory and the person will go away. Pt. states the he is feeling fine. Pt. states that sometimes he hears voices inside his head. Pt. states that the voices say both good and bad things to him. . . . . . .

. . . . .

. . . .

. . .

. .

.


2) SOC = 35

3) VIO = 50

4) ADL = 25

5) SAb = 80

6) MED = 80

GAF Eq = 35 Dangerousness Level = 35 Explanation of Psychological Impairment Rating Very incoherent = 20 Marked impairment in attention span = 20 Often talks or giggles to himself (appears to be responding to hallucinations) = 30

7) ANC = 70


6–13

Psychological Impairment NAME: Griffin, Paul AGE:

30

Pt.’s thinking is somewhat bizarre at times; however, he is usually able to interact with very little apparent bizarreness. Occasionally pt. is very circumstantial in his speech. His attention span is generally very limited; however, if given an immediate reward, his attention significantly improves. Pt. is very uncooperative and unmotivated to do much of anything. Staff reports that pt. spends most of his time in bed; however, he goes through periods during which he is fairly energetic. Staff feels that pt. is very manipulative. Pt. states that generally he is happy and relaxed. Pt. states that he ignores the voices, and he doesn’t let them bother him because he knows they are just his mind playing tricks on him. No insomnia. Appetite good. Denies lethargy. Moderate expressive movements. Mild restlessness. . . . . . .

. . . . .

. . . .

. . .

. .

.


2) SOC = 50

3) VIO = 40

4) ADL = 55

5) SAb = 30

6) MED = 70

GAF Eq = 45 Dangerousness Level = 30 Explanation of Psychological Impairment Rating Thinking is somewhat bizarre at times = 40 Occasionally very circumstantial in his speech = 40 Very unmotivated and spends most of his time in bed = 40 Reward significantly improves his limited attention span = 40 Realizes the voices are not real = 40

7) ANC = 50

6–14


Psychological Impairment NAME: Mann, William AGE:

47

Pt. continues to demonstrate frequent stereotypical movements and bizarre posturing. Sporadically, pt. will do simple chores around the ward. Persistent inability to maintain personal hygiene. Thinking is almost totally disorganized. Focal attention is markedly impaired. Pt.’s motivation is markedly impaired. He is almost completely incoherent; however, at times he will use a complete sentence. Actively delusional and hallucinating. Pt. continues to do very bizarre things, such as licking the floor on all fours. Pt. states that he is sad but relaxed. Pt. states that he feels sad when people die. Pt. states that his father recently died (pt.’s father is not dead). Pt. states that at the funeral, his father was just sleeping. Mild to moderate restlessness. . . . . . .

. . . . .

. . . .

. . .

. .

.


2) SOC = 10

3) VIO = 50

4) ADL = 20

5) SAb = 50

6) MED = 60

GAF Eq = 25 Dangerousness Level = 15 Explanation of Psychological Impairment Rating Bizarre posturing = 20 Persistent inability to maintain personal hygiene = 10 Thinking is almost totally disorganized = 20 Almost completely incoherent = 20 Licking the floor on all fours = 20 or worse

7) ANC = 80


6–15

Psychological Impairment NAME: Powers, Jennifer AGE:

35

At times, pt. feels that the pace of her life gets to her a little. She states that she works full time and has two young children at home. Her husband also works full time and is often away on business trips. He helps with some of the work at home. A part-time maid and relatives also help with babysitting and housework. She is able to have some time to rest and relax. Pt. denies feeling sad or anxious. Generally, her energy and spirits are very good. She is sleeping well at night. Despite feeling somewhat overwhelmed at times, she is generally satisfied with her life. . . . . . .

. . . . .

. . . .

. . .

. .

.


2) SOC = 100

3) VIO = 100

4) ADL = 100

5) SAb = 100

6) MED = 100 7) ANC = 100

GAF Eq = 100 Dangerousness Level = 90 Explanation of Psychological Impairment Rating At times the pace of life gets to her a little = 90 No sadness or anxiety = 80 or better Generally satisfied with life = 90

6–16


Psychological Impairment NAME: Renaldo, Alice AGE:

24

Due to increasing stress, pt. has been having more trouble with depression, and her bingeing and purging have increased to three times a day. Staff states that pt. is also having increasing difficulty focusing on conversations. Pt. states that generally she is moderately sad and tense. Pt. states that she is sleeping well. Denies lethargy. Mildly spontaneous. Speech not slowed or subdued. Occasional smiling. No signs of tears. Mild restlessness. No evidence of psychotic thinking. . . . . . .

. . . . .

. . . .

. . .

. .

.


2) SOC = 80

3) VIO = 70

4) ADL = 90

5) SAb = 90

6) MED = 70

7) ANC = 90

GAF Eq = 70 Dangerousness Level = 65 Explanation of Psychological Impairment Rating Bingeing and purging have increased to three times a day = 50 or worse (increasing is a negative sign) Moderately sad and tense = 50 No evidence of psychotic thinking = 50 or better


6–17

Psychological Impairment NAME: Rosenthal, William AGE:

51

Gross impairment in thinking and communication. Very impaired attention span. Pt. is felt to be hallucinating. Occasionally noted to be talking to himself. Often laughing to himself. Pt. is actively delusional, and he is cognitively loose and disorganized. Usually has trouble remembering; however, he is able to remember names of other pts. with no difficulty. Extremely withdrawn with few spontaneous communications. Shows little interest in his surroundings or social activities. Rarely tries to be friendly. Pt. states that he is happy and relaxed. No complaints. Pt. states that he is sleeping well. Pt. states that he doesn’t listen to the voices. Appears fairly relaxed. Moderate smiling. No signs of tears. No restlessness. . . . . . .

. . . . .

. . . .

. . .

. .

.


2) SOC = 10

3) VIO = 45

4) ADL = 20

5) SAb = 70

6) MED = 40

GAF Eq = 25 Dangerousness Level = 15 Explanation of Psychological Impairment Rating Gross impairment in thinking and communication = 20 Very impaired attention span = 30 or worse Extremely withdrawn = 20 Appears to be responding to hallucinations = 30 or worse

7) ANC = 70

6–18


Psychological Impairment NAME: Scott, David AGE:

50

Pt. is alert and oriented. Pt. is able to carry on a coherent, focused conversation. Pt. has a long history of fairly fixed delusions of being a great police hero; however, he realizes that these thoughts are probably not real. Currently he denies having any feelings that he needs to save anyone from the Mafia. Pt. states that relaxing seems to get rid of the voices. Pt. states that the voices do not command him to do things. Pt. states that the voices are primarily of people who have passed away, including his deceased mother (he murdered her). Pt. states he believes the voices are probably an internal “malfunction” of his brain; however, he cannot rule out the possibility that they could be real. Pt. shows strong interest in walking, photography, movies, playing pool, pets, visiting with others, and dating. During the interview, pt. was pleasant, cheerful, and cooperative. . . . . . .

. . . . .

. . . .

. . .

. .

.


2) SOC = 75

3) VIO = 50

4) ADL = 75

5) SAb = 60

6) MED = 70

7) ANC = 70

GAF Eq = 60 Dangerousness Level = 50 Explanation of Psychological Impairment Rating Fairly fixed delusion of being a great police hero; however, he realizes that these thoughts probably are not real = 40 Hallucinations; however, he believes that the voices are probably an internal “malfunction” of his brain = 40 History of murdering his mother would be rated under the Violence subscale


6–19

Psychological Impairment NAME: Sellers, Mark AGE:

63

Pt. is actively delusional and only partially oriented. He is often talking or laughing to himself. He has a poor attention span. He is very socially withdrawn with few spontaneous communications. He reports being happy and relaxed. He is sleeping well. He reports having good energy and appetite. . . . . . .

. . . . .

. . . .

. . .

. .

.


2) SOC = 45

3) VIO = 40

4) ADL = 30

5) SAb = 85

6) MED = 40

GAF Eq = 35 Dangerousness Level = 40 Explanation of Psychological Impairment Rating Pt. is actively delusional, often talking or laughing to himself = 30 Poor attention span = 30 Very socially withdrawn with few spontaneous communications = 30 Happy and relaxed (these are positive factors) Sleeping well and has good energy and appetite (these are positive factors)

7) ANC = 80

6–20


Psychological Impairment NAME: Woods, Gilbert AGE:

28

Pt. is actively delusional and is continually hallucinating. Staff feels that pt. is obsessed with politics and violence. Pt.’s behavior is considerably influenced by hallucinations. At times, pt. yells at the hallucinations. There is gross impairment in thinking and communication. Markedly impaired attention span. Pt. is socially withdrawn. Pt. is sexually preoccupied. When on privileges, pt. simply wanders around the canteen and lobby or talks on the phone to the hallucinations. Pt. states that he feels fine. Pt. denies having any confusion in his thinking. During the interview, pt.’s thinking was very disorganized. It was very difficult to make any sense out of what pt. was saying. Pt. states that the date is November 23, 1943. Pt. states that he doesn’t know what day of the week today is. Pt. did know the name of the hospital; however, he did not know what ward he was on. . . . . . .

. . . . .

. . . .

. . .

. .

.


2) SOC = 35

3) VIO = 35

4) ADL = 30

5) SAb = 90

6) MED = 90

GAF Eq = 30 Dangerousness Level = 35 Explanation of Psychological Impairment Rating Actively delusional and continually hallucinating = 30 or worse Considerably influenced by hallucinations = 30 Gross impairment in thinking and behavior = 20 Markedly impaired attention span = 20 Very disorganized thinking, which made little sense = 20

7) ANC = 70

Scoring Clinical Vignettes (Self-Examination)—Social Skills

CLINICAL VIGNETTES

Social Skills (Problem Area 2)

6–21

6–22


Kennedy Axis V—Social Skills

(Problem Area 2)

100

Superior social skills, sought out by others because of his/her outstanding social/communication skills, has many friends and no difficulty making new friends. No symptoms.

90 Good social skills, no difficulty being pleasant and engaging, good communication skills, socially effective.

80 No more than slight impairment in social skills, slightly inappropriate social behavior leads to infrequent interpersonal conflicts, no more than slight difficulty maintaining several friendships.

70 Some difficulty with social skills (e.g., mild difficulty knowing how to share with others, show sympathy for others, and/or understand feelings of others), social skills are not obviously impaired, generally functioning fairly well, has some meaningful interpersonal relationships. 60 Moderate difficulty with social skills (e.g., conflicts with peers due to inappropriate teasing or other inappropriate social behavior; attempts to be pleasant and engaging are usually moderately awkward; moderate difficulty knowing what to say even when talking with friends; moderate difficulty knowing how to share with others, show sympathy toward others, and/or understand feelings of others); hardly any friends because of problems with social skills; communications are understandable but vague.

50 Serious impairment in social skills; has no friends because of clearly impaired social skills; however, has some peer relationships, despite social skills being clearly impaired; frequent conflicts with peers or co-workers because of inappropriate social behavior; conversations are often socially inappropriate; great difficulty communicating thoughts and feelings; unable to introduce self and a second person without clear difficulty; frequently intrusive; inappropriate, nonsexual touching. 40 Major impairment in social skills; attempts to approach others quickly lead to embarrassing situations; no friends and virtually no peer relationships because of poor social skills; unable to appropriately engage in almost any social activity; continually intrusive with little understanding of the inappropriateness of the behavior; major acts of socially inappropriate behavior lead to being assaulted, fired from work, or expelled from school; great difficulty recognizing or coping with inappropriate sexual or aggressive advances by others; great difficulty recognizing that his/her sexual advances are not welcome.

30 Acts grossly inappropriately toward others; virtually no understanding of the feelings of others, how to share with others, and/or how to show sympathy toward others; conversations with others are grossly inappropriate; unaware of or ignores most social norms as manifested by open masturbation, inappropriate sexual touching, and the like.

20 Very few social skills; generally unable to communicate in an organized, understandable way; uses short phrases or gestures to get basic needs met; acts with shocking inappropriateness in front of others, such as smearing of feces or making sexual advances toward young children; however, may have some understanding that such behavior is inappropriate.

10 Few if any social skills; unable to communicate in an organized, understandable way; shows no apparent awareness of social norms (e.g., doesn’t realize that it is inappropriate to grab food or cigarettes from others); extremely vulnerable to victimization (e.g., has no understanding of the inappropriateness and/or dangers of approaching strangers or assaulting others, needs constant care and supervision to not get into dangerous social situations). NR Not rated


6–23

Social Skills NAME: Abbott, George AGE:

35

Pt. has some concerns that he has been a little awkward during job interviews because it has been such a long time since he needed to look for work. Overall, his social skills are fairly good. Generally he has good communication skills and has no significant difficulty being pleasant and engaging. He is married and has many friends. . . . . . .

. . . . .

. . . .

. . .

. .

.

Ratings Social Skills = 90 1) PSY = 100

2) SOC = 90

3) VIO = 90

4) ADL = 90

5) SAb = 80

6) MED = 90

7) ANC = 90

GAF Eq = 95 Dangerousness Level = 80 Explanation of Social Skills Rating Pt. is a little awkward during job interviews. His awkwardness appears stress related; it should, therefore, have no negative effect on his Social Skills rating (if it were unrelated to stress = 70). Fairly good social skills = 90 Good communication skills = 90 or better No significant difficulty being pleasant and engaging = 90 or better Lots of friends = 90 or better

6–24


Social Skills NAME: Davis, Richard AGE:

45

Almost no understanding of the feelings and needs of others. Pt. has no friends or peer relationships. Pt. continues to hug others inappropriately; however, he is easily redirectable. Pt. continues to be sexually preoccupied; however, there has been little or no sexual touching recently. Pt. is no longer openly masturbating. . . . . . .

. . . . .

. . . .

. . .

. .

.


2) SOC = 35

3) VIO = 50

4) ADL = 25

5) SAb = 80

GAF Eq = 35 Dangerousness Level = 35 Explanation of Social Skills Rating Almost no understanding of the feelings and needs of others = 30 No friends or peer relationships = 35 Inappropriate hugging; however, little or no sexual touching recently = 35 No longer openly masturbating = 40

6) MED = 80

7) ANC = 70


6–25

Social Skills NAME: Griffin, Paul AGE:

30

Pt. is often inappropriate in his social interactions with others; however, he does have some peer relationships. Little understanding of the feelings and needs of others. No sharing. Frequent inappropriate nonsexual touching. Often intrusive. . . . . . .

. . . . .

. . . .

. . .

. .

.


2) SOC = 50

3) VIO = 40

4) ADL = 55

5) SAb = 30

GAF Eq = 45 Dangerousness Level = 30 Explanation of Social Skills Rating Often inappropriate in his social interactions with others = 50 Has some peer relationships = 50 Inappropriate, nonsexual touching = 50

6) MED = 70

7) ANC = 50

6–26


Social Skills NAME: Jacobs, Joseph AGE:

27

About once a month, pt. fondles female peers’ breasts without their clear permission. Several times a month, he approaches females with inappropriate requests for sexual favors. He appears to have difficulty understanding when his advances are unwelcome. About once every 6 months, he fondles himself or masturbates in public. He is usually easily redirected from the sexually inappropriate behavior. . . . . . .

. . . . .

. . . .

. . .

. .

.


2) SOC = 35

3) VIO = 70

4) ADL = 50

5) SAb = 80

6) MED = 90

7) ANC = 80

GAF Eq = 50 Dangerousness Level = 45 Explanation of Social Skills Rating Inappropriate sexual touching without clear permission = 35 Inappropriate requests for sexual favors with difficulty understanding that his advances are unwelcome = 40 Masturbating in public every 6 months = 35 or worse Easily redirected (this is a positive factor)


6–27

Social Skills NAME: Mann, William AGE:

47

Few social skills. Demonstrates very little awareness of social norms. Little or no appropriate interactions with others. He has no close friends because of his bizarre and shockingly inappropriate social behavior. Even when in public, pt. holds onto his genitals like holding onto a security blanket. At times, he inadvertently urinates on others. There is no apparent awareness that these behaviors are inappropriate. Pt.’s ability to communicate is very limited; however, he occasionally asks for something in a complete sentence. . . . . . .

. . . . .

. . . .

. . .

. .

.


2) SOC = 10

3) VIO = 50

4) ADL = 20

5) SAb = 50

6) MED = 60

7) ANC = 80

GAF Eq = 25 Dangerousness Level = 15 Explanation of Social Skills Rating Demonstrates little understanding of social norms = 10 Little or no appropriate social interactions with others = 10 Bizarre, shockingly inappropriate social behavior = 20 or worse Holds onto his genitals in public and inadvertently urinates on others with no apparent awareness that these behaviors are inappropriate = 10

6–28


Social Skills NAME: Palmer, John AGE:

44

No friends; however, pt. has some peer relationships. Great difficulty communicating thoughts and feelings. He is able to engage fairly appropriately in supervised social activities within the hospital. He doesn’t act shockingly inappropriately toward others. . . . . . .

. . . . .

. . . .

. . .

. .

.


2) SOC = 50

3) VIO = 70

4) ADL = 50

5) SAb = 50

GAF Eq = 55 Dangerousness Level = 50 Explanation of Social Skills Rating Some peer relationships = 50 Great difficulty communicating thoughts and feelings = 50 Able to engage fairly appropriately in supervised social activities = 50 or better Doesn’t act shockingly inappropriate = 40 or better

6) MED = 80

7) ANC = 70


6–29

Social Skills NAME: Powers, Jennifer AGE:

35

Pt.’s social skills appear to be excellent. She has lots of friends and support both from within and outside her family. She is successfully involved in a close, caring relationship with her husband and family. Her excellent skills working with people are apparent both at home and in her job as a nursing supervisor. They are also apparent in her volunteer duties as vice-president of the local PTA. . . . . . .

. . . . .

. . . .

. . .

. .

.


2) SOC = 100

3) VIO = 100

4) ADL = 100

5) SAb = 100

GAF Eq = 100 Dangerousness Level = 90 Explanation of Social Skills Rating Excellent social skills = 100 Lots of friends = 90 or better Successfully involved in a close, caring relationship = 60 or better Excellent skills working with people = 100

6) MED = 100 7) ANC = 100

6–30


Social Skills NAME: Renaldo, Alice AGE:

24

Staff states that pt. has some meaningful relationships, including having a fairly good relationship with her boyfriend. Pt. works as a secretary and is able to interact with others with no apparent difficulty. Staff states that pt. is sensitive to the feelings and needs of others. Pt.’s social skills are felt to be no more than slightly impaired. . . . . . .

. . . . .

. . . .

. . .

. .

.


2) SOC = 80

3) VIO = 70

4) ADL = 90

5) SAb = 90

GAF Eq = 70 Dangerousness Level = 65 Explanation of Social Skills Rating Has some meaningful relationships = 70 or better Interacts with others with no apparent difficulty = 80 or better Social skills are felt to be no more than slightly impaired = 80

6) MED = 70

7) ANC = 90


6–31

Social Skills NAME: Rosenthal, William AGE:

51

Few social skills, unable to communicate in any organized, understandable way. Shows no significant awareness of social norms. Pt. has no peer relationships. Pt. is unable to get along with anyone. Pt. isolates himself and is very intolerant of anyone getting into his “personal space.” Interactions with others rapidly lead to conflicts due to pt.’s inappropriate behavior. . . . . . .

. . . . .

. . . .

. . .

. .

.


2) SOC = 10

3) VIO = 45

4) ADL = 20

5) SAb = 70

6) MED = 40

7) ANC = 70

GAF Eq = 25 Dangerousness Level = 15 Explanation of Social Skills Rating Unable to communicate in any organized, understandable way = 10 No significant awareness of social norms = 10 Unable to get along with anyone = 30 or worse Interactions with others rapidly lead to conflicts due to pt.’s inappropriate behavior = 50 or worse

6–32


Social Skills NAME: Scott, David AGE:

50

Pt.’s social skills are slightly impaired; however, he generally presents as polite and well mannered. Pt. was able to maintain a good relationship with his wife until she died 2 years ago. Pt. appears to enjoy visiting with others; however, drug abusers have taken advantage of his generosity and loneliness in the past. This has contributed to his avoidance of developing any meaningful relationships. . . . . . .

. . . . .

. . . .

. . .

. .

.


2) SOC = 75

3) VIO = 50

4) ADL = 75

5) SAb = 60

6) MED = 70

7) ANC = 70

GAF Eq = 60 Dangerousness Level = 50 Explanation of Social Skills Rating Social skills are slightly impaired; however, pt. generally presents as well mannered = 70 to 80 Pt. was able to maintain a good relationship with his wife until she died 2 years ago = 70 or better Drugs abusers have taken advantage of his generosity and loneliness = 70 No meaningful relationships; however, due only in part to social skills = 75


6–33

Social Skills NAME: Sellers, Mark AGE:

63

Pt. has significant difficulty functioning socially. Pt.’s verbalizations can be grossly inappropriate; however, he does not act grossly inappropriately toward others. His lack of friends or peer relationships is due more to social withdrawal than grossly inappropriate behavior. When compensated, he participates appropriately in some activities with others. . . . . . .

. . . . .

. . . .

. . .

. .

.


2) SOC = 45

3) VIO = 40

4) ADL = 30

5) SAb = 85

6) MED = 40

7) ANC = 80

GAF Eq = 35 Dangerousness Level = 40 Explanation of Social Skills Rating Significant difficulty functioning socially = 50 or worse Verbalizations can be grossly inappropriate = 30 Does not act grossly inappropriately toward others = 40 Social withdrawal (rate this under Psychological Impairment) Decompensation covers up some of his social skills (i.e., he can participate appropriately in some activities with others) = 45 (this is felt to more accurately rate his actual skills)

6–34


Social Skills NAME: Woods, Gilbert AGE:

28

Staff states that pt. appears to have no friends or significant peer relationships. Attempts to approach others quickly lead to embarrassing situations. Staff feels that pt. has very little understanding of the feelings and needs of others. Staff states that pt. has not been openly masturbating; however, on one recent occasion, pt. touched a staff member on the rear end and attempted to touch other private parts. Staff states that this was a problem in the community. . . . . . .

. . . . .

. . . .

. . .

. .

.


2) SOC = 35

3) VIO = 35

4) ADL = 30

5) SAb = 90

GAF Eq = 30 Dangerousness Level = 35 Explanation of Social Skills Rating No friends or significant peer relationships = 40 Attempts to approach others quickly lead to embarrassing situations = 40 Very little understanding of the feelings and needs of others = 30 to 40 No longer openly masturbating = 40 or better One recent incident of inappropriate sexual touching = 30 to 40

6) MED = 90

7) ANC = 70

Scoring Clinical Vignettes (Self-Examination)—Violence

CLINICAL VIGNETTES

Violence (Problem Area 3)

6–35

6–36


Kennedy Axis V—Violence

(Problem Area 3)

100 No evidence of violence to self or others; very satisfied with life; life’s problems never seem to lead to any inappropriate anger, frustration, or conflicts. No symptoms. 90 No significant evidence of violence to self or others; generally satisfied with life, no more than everyday problems or conflicts (e.g., an occasional argument with family members). 80 No more than slight problems with anger and irritability; if symptoms are present, they are transient and expectable reactions to psychosocial stressors (e.g., occasional “blow up” with family members or friends; mild anger after family argument); no suicidal ideation.

70 Mild symptoms (e.g., mild problems with anger and irritability; occasional thoughts of violent behavior; thoughts that life may not be worth living); symptoms are not interfering significantly with his/her functioning; severely assaulted others or serious suicidal attempt over 5 years ago; however, for years, has had no significant problems with violence or self-harm.

60 Moderate difficulty with anger and irritability (e.g., moderate conflicts with peers or co-workers due to anger and hostility; occasional threats of violent behavior); some evidence that self-destructive thoughts may be present. Murdered someone over 10 years ago; however, for many years, has had no significant problems with violence.

50 Serious problems with anger and irritability; moderate threats of violence; becomes verbally threatening when needs/demands are not immediately met or when pushed to do something; occasionally hits someone; occasional, relatively minor, sexual assault; occasional suicidal ideation; nonsuicidal self-abuse, such as burning self with cigarettes or cutting self superficially; not felt to be in real danger of seriously hurting self or others; however, some precautions including close observation may be indicated. 40 Major problems with anger and irritability; some real danger of hurting self or others; violent outbursts toward family and neighbors; frequent threats of violence; hitting or biting someone is not unusual; occasionally difficult to redirect from aggressive behavior; induces much fear of physical assault in others; single suicidal gesture within the last month; moderate suicidal ideation; actively making plans to hurt self or others; set a relatively minor fire within the last 3 months or is having fire-setting impulses with history of setting one or two minor fires.

30 Often hitting or biting others; becomes physically aggressive when needs are not immediately met; suicidal attempt without clear expectation of death during the last month; frequent suicidal preoccupation; actively following through with plans to hurt self or others (e.g., obtaining a gun, pills, rope); at times close observation or restraints may be necessary to prevent serious harm to self or others.

20 Frequently violent; very real danger of hurting self or others; serious thoughts of killing someone; attempted to very violently harm or violently rape someone within the last month; constant suicidal preoccupation; however, he/she is felt to have some control of the suicidal impulses; two or more suicidal attempts without clear expectation of death within the last month; close observation to prevent harm to self or others may be required 1 or 2 days a week.

10 Persistent danger of severely hurting self or others; attempted to kill someone within the last month; attempted to very violently harm or violently rape a child within the last month; set a fire within the last month with intent of hurting others; serious suicidal attempt within the last month with clear expectation of death; little or no control of impulses to hurt self or others; expressing loss of control of command hallucinations to hurt self or others; one-to-one, at-arms-length observation and/or physical restraint for prevention of serious harm to self or others may be required 3 or more days a week; murdered someone within the last 2 years.

NR Not rated


6–37

Violence NAME: Abbott, George AGE:

35

Because of some financial difficulties, pt. occasionally gets into an argument with his wife; otherwise, he has no significant evidence of violence. The arguments are generally relatively minor, of no real significance, and end quickly. He has no current or past history of being threatening, assaultive, or suicidal. . . . . . .

. . . . .

. . . .

. . .

. .

.

Ratings Violence = 90 1) PSY = 100

2) SOC = 90

3) VIO = 90

4) ADL = 90

5) SAb = 80

GAF Eq = 95 Dangerousness Level = 80 Explanation of Violence Rating Occasional arguments with his wife = 90 No problems with being suicidal, threatening, or assaultive = 80 or better

6) MED = 90

7) ANC = 90

6–38


Violence NAME: Caruso, Janice AGE:

33

No significant evidence of violence. Pt. is not noted to be significantly irritable or angry. Pt. has no history of being threatening or assaultive. During the interview, pt. was friendly and cooperative. Denies history of suicide attempts or significant suicidal ideation. Pt. denies ever assaulting anyone. . . . . . .

. . . . .

. . . .

. . .

. .

.


2) SOC = 70

3) VIO = 90

4) ADL = 80

5) SAb = 80

6) MED = 80

7) ANC = 90

GAF Eq = 75 Dangerousness Level = 75 Explanation of Violence Rating No significant evidence of violence = 90 or better 100 is not given because there are no statements about pt. being unusually free of interpersonal conflicts or unusually satisfied with her life.


6–39

Violence NAME: Cross, Anthony AGE:

24

Staff states that pt. occasionally threatens to sue staff; however, pt. does not make any threats of physical violence to others. Staff states that pt. has mild to moderate problems with anger and irritability. Staff states that at times he expresses suicidal ideation but seems fairly sure that he will not act on the ideation. At times, pt. expresses a lot of hopelessness. Pt. states that at times he has suicidal thoughts; however, he states that he would not act on the thoughts. During the interview, pt. seemed somewhat irritable. . . . . . .

. . . . .

. . . .

. . .

. .

.


2) SOC = 60

3) VIO = 50

4) ADL = 80

5) SAb = 95

6) MED = 70

7) ANC = 80

GAF Eq = 60 Dangerousness Level = 50 Explanation of Violence Rating Mild to moderate problems with anger and irritability = 65 Somewhat irritable during the interview = 70 Occasional suicidal ideation = 50 (60 or better, if rater feels the suicidal ideation is not serious; 40 or worse, if rater feels there is real danger the pt. will hurt himself)

6–40


Violence NAME: Davis, Richard AGE:

45

Generally, pt. is friendly and cooperative. Pt. is at times impatient; however, he is easily redirectable. About once every few weeks, pt. makes threatening remarks toward staff. There have been no recent problems with his being irritable. There is no evidence of suicidal or self-abuse behavior. A couple of years ago, when doing poorly, pt. had been very threatening and sexually assaultive. Pt. continues to be somewhat sexually preoccupied. During the interview, pt. was pleasant and cooperative. . . . . . .

. . . . .

. . . .

. . .

. .

.


2) SOC = 35

3) VIO = 50

4) ADL = 25

5) SAb = 80

6) MED = 80

7) ANC = 70

GAF Eq = 35 Dangerousness Level = 35 Explanation of Violence Rating Occasionally makes threatening remarks toward staff = 60 No recent assaults = 60 or better A couple of years ago, when doing poorly, pt. had been very threatening and sexually assaultive. This history of acting on threats moves the 60 to 50 because his history makes the threats more real.


6–41

Violence NAME: Griffin, Paul AGE:

30

Staff states that generally pt. is uncooperative. Moderate problems with anger and irritability. Pt. is threatening toward staff several times a week; however, it has been a few months since he was assaultive. Pt.’s anger is not directed toward the other pts.; however, it is often directed at the staff or his family. In the past, pt. has been actively threatening and assaultive toward his family, especially his mother. Staff states that the threats and assaults are generally associated with his demands not being met or when staff members attempt to pressure him into some activity. Staff states that there is no evidence of suicidal ideation. During the interview, pt. was mildly irritable but cooperative. . . . . . .

. . . . .

. . . .

. . .

. .

.


2) SOC = 50

3) VIO = 40

4) ADL = 55

5) SAb = 30

6) MED = 70

GAF Eq = 45 Dangerousness Level = 30 Explanation of Violence Rating Moderate problems with anger and irritability = 60 Frequent threats of violence = 40 Significant past history of violence; assaultive a few months ago = 50 or worse The vignette suggests that there is some real danger that he will hurt others = 40

7) ANC = 50

6–42


Violence NAME: Palmer, Brenda AGE:

37

Staff states that pt. tends to misinterpret verbal statements because of her delusional thinking and may become very angry as a result of feeling that others are against her. Staff states that pt. has assaulted others three times over the last 4 months. Pt. has been restricted from visiting home alone because she set a small fire in her home 2 months ago when actively delusional. No previous history of setting fires. It did not appear the pt. was trying to hurt anyone with the fire. She states that there has been no recent return of impulses to set fires or the thoughts that she can control fires. Staff states that pt. often becomes very angry when any limits are set on her use of cigarettes. Pt. was somewhat angry and irritable during the interview. Pt. has no history of being suicidal. . . . . . .

. . . . .

. . . .

. . .

. .

.


2) SOC = 50

3) VIO = 30

4) ADL = 60

5) SAb = 70

6) MED = 80

GAF Eq = 40 Dangerousness Level = 30 Explanation of Violence Rating Has assaulted others three times over the last 4 months = 40 or worse Paranoid and tends to misinterpret statements and become very angry and assaultive = 30 Set a fire 2 months ago and is delusional, angry, and irritable = 30 or worse No history of being suicidal = 80 or better (this should have no effect on the rating)

7) ANC = 70


6–43

Violence NAME: Powers, Jennifer AGE:

35

Pt. has no current or past history of being suicidal or assaultive. Despite having a very busy life, she is very satisfied with her life. She copes with various problems in a very healthy manner. Life’s problems never lead to any inappropriate anger or frustration. She is seen as sensitive and able to compromise when handling problems. . . . . . .

. . . . .

. . . .

. . .

. .

.


2) SOC = 100

3) VIO = 100

4) ADL = 100

5) SAb = 100

6) MED = 100 7) ANC = 100

GAF Eq = 100 Dangerousness Level = 90 Explanation of Violence Rating No history of being suicidal or assaultive = 80 or better Very satisfied with life and copes with problems in a very healthy way = 90 or better Life’s problems never lead to any inappropriate anger or frustration = 100 Seen as sensitive and able to compromise when handling problems = 90 or better

6–44


Violence NAME: Renaldo, Alice AGE:

24

Staff states that pt. self-induces vomiting three times a day; however, staff feels that pt. is not vomiting in any attempt to hurt herself. No suicidal ideation. Staff states that generally pt. is not significantly angry or irritable. Pt. denies having any thoughts of wanting to hurt herself; however, sometimes she feels that life is not worth living. . . . . . .

. . . . .

. . . .

. . .

. .

.


2) SOC = 80

3) VIO = 70

4) ADL = 90

5) SAb = 90

6) MED = 70

7) ANC = 90

GAF Eq = 70 Dangerousness Level = 65 Explanation of Violence Rating Sometimes feels that life is not worth living = 70 Not significantly angry or irritable = 90 or better Factor out the dangerousness of vomiting. This is measured by the Psychological Impairment subscale.


6–45

Violence NAME: Robbins, Clyde AGE:

48

Pt. was admitted from the county jail with charges of strangling a female resident to death 1 week ago at the halfway house where they were living. He had resided at the halfway house for 3 years. While at the halfway house, he had been hospitalized on several occasions. At times, he was reported to have been paranoid, delusional, and threatening. Currently, pt. is actively paranoid and delusional. The alleged murder was done in association with beliefs that if he did not kill someone, he would be killed as a religious martyr. He reported that during his hospitalizations, he had no opportunity to kill anyone. At the halfway house, he had not killed anyone earlier because he had diverted his need to kill someone into active involvement in religious activities and writing. This stopped working following pt.’s being asked to leave the church because of his hostile behavior. Pt. reportedly savagely beat the woman before strangling her. About 15 years earlier, pt. attempted to kill four people because of a belief that it would cleanse his soul; however, he was successful only one of the four times. This was an elderly man whose throat he cut with a knife. He was found not guilty by reason of insanity. He has a long history of nonlethal attacks on other people. He shows callousness and indifference toward people. He shows no remorse and casually talks about the murders. He is felt to be very dangerous to others. He is observed constantly to prevent him from harming others. . . . . . .

. . . . .

. . . .

. . .

. .

.


2) SOC = 50

3) VIO = 5

4) ADL = 50

5) SAb = 80

GAF Eq = 35 Dangerousness Level = 5 Explanation of Violence Rating Murdered someone less than 1 month ago = 5 Continues to be paranoid and delusional (negative factor) Recent murder was a second murder (extremely negative factor) Savage nature of the murders (negative factor) Shows no remorse and is unfeeling toward others (negative factor) Ongoing problems with nonlethal assaultive behavior = 40 or worse Felt to be very dangerous to others = 30 or worse Observed constantly to prevent his harming others = 10 or worse

6) MED = 80

7) ANC = 80

6–46


Violence NAME: Rosenthal, William AGE:

51

Serious problems with anger and irritability; however, at times pt. appears to cycle through periods of being almost pleasant. Frequent threats of violence. Often spontaneously explosive. When questioned, pt. rapidly becomes angry and defensive. Despite his threats, he only occasionally actually strikes out at anyone. No evidence of suicidal ideation. During the interview, pt. was unusually friendly and cooperative. . . . . . .

. . . . .

. . . .

. . .

. .

.


2) SOC = 10

3) VIO = 45

4) ADL = 20

5) SAb = 70

GAF Eq = 25 Dangerousness Level = 15 Explanation of Violence Rating Serious problems with anger and irritability = 50 Frequent threats of violence = 40 Often spontaneously explosive = 40 Only occasionally actually strikes out at anyone = 50

6) MED = 40

7) ANC = 70


6–47

Violence NAME: Scott, David AGE:

50

More than 20 years ago, pt. stabbed his mother and sister to death. He was overtly psychotic at the time. He had paranoid delusions that he was “saving” them from torture by the Mafia. Before the murders, pt. was preoccupied with the glory of being a hero. Pt. reported that at the time of the murders, he cared very much for his mother and sister. About 10 years ago, pt. was released because there appeared to be no current evidence of dangerousness, and he recognized the need for medication, was able to ignore auditory hallucinations, and was not expressing paranoid delusions. However, periodically before and after his release, the delusions would return, he would begin to lose insight into his illness, and at times the impulses to hurt others would also return. There has been no subsequent evidence of his attempting to act on impulses to harm others. Pt. acknowledges ongoing auditory hallucinations; however, these are generally not considered dangerous until he experiences them as commands. About a year ago, there were concerns that pt. might attempt to “help” protect a drug addict from the Mafia. Several months ago, he told people who were confronting him about his delusions that they were going to die soon. However, he made no overt threats or attempts to harm anyone. There has been no recent evidence of any thoughts or impulses to harm anyone. . . . . . .

. . . . .

. . . .

. . .

. .

.


2) SOC = 75

3) VIO = 50

4) ADL = 75

5) SAb = 60

6) MED = 70

7) ANC = 70

GAF Eq = 60 Dangerousness Level = 50 Explanation of Violence Rating More than 20 years ago, he murdered two people; however, no further problems with violence = 60 Periodic delusional thoughts of “helping” people; in the past, “helping” people was by killing them = 50 or worse

6–48


Violence NAME: Sellers, Mark AGE:

63

Periodically, pt. is frequently assaultive to others. He is also self-abusive (hits himself in the head and bangs his head). He is generally angry and verbally abusive. He requires frequent prn medication to control his anger. . . . . . .

. . . . .

. . . .

. . .

. .

.


2) SOC = 45

3) VIO = 40

4) ADL = 30

5) SAb = 85

GAF Eq = 35 Dangerousness Level = 40 Explanation of Violence Rating Periodically, pt. is frequently assaultive = 40 or worse Self-abusive = 50 Generally angry and verbally abusive = 50 Frequent prn medication to control anger = 50 or worse

6) MED = 40

7) ANC = 80


6–49

Violence NAME: Woods, Gilbert AGE:

28

Pt. is very angry and irritable; however, the explosive, loud, angry outbursts have decreased. With verbal prompting, he is able to calm down. Pt. is fairly preoccupied with violence. Pt. has a long history of assaultiveness, including seriously injuring at least one person. Pt. has not been assaultive for a long time. Staff feels that his lack of assaultiveness is because of a combination of better control and the fact that he is not pushed to do things. His anger is treated with prn medication, and he is directed to quiet areas when agitated. Staff feels that if pushed, pt. would be in real danger of hurting others. . . . . . .

. . . . .

. . . .

. . .

. .

.


2) SOC = 35

3) VIO = 35

4) ADL = 30

5) SAb = 90

GAF Eq = 30 Dangerousness Level = 35 Explanation of Violence Rating Very angry and irritable = 40 Calms down with verbal prompting (this is a positive factor) Explosive, loud, angry outbursts = 40 Preoccupied with violence (this is a negative factor) Long history of violence (this is a negative factor) No recent assaults (this is a positive factor) Would be frequently assaultive if not handled very carefully by staff = 30 If pushed, would be a real danger to hurt others = 40 or worse

6) MED = 90

7) ANC = 70

Notes

Scoring Clinical Vignettes (Self-Examination)—ADL–Occupational Skills

CLINICAL VIGNETTES

ADL–Occupational Skills (Problem Area 4)

6–51

6–52


Kennedy Axis V—ADL–Occupational Skills

(Problem Area 4)

100 Superior ADL–occupational skills in a wide range of activities (e.g., in school, on the job, as a homemaker, pursuing a complicated hobby); superior workmanship; work challenges never seen to get out of hand; is sought out by others because of his/her work skills. No symptoms. Skills are consistent with those expected of a successful college graduate. 90 Good skills in all ADL–occupational activities; no more than average difficulties with any work assignment. Absent or minimal symptoms. Skills are consistent with those expected of a successful high school graduate. 80 No more than slight impairment in occupational skills or skills in school; has slight difficulty performing at an average level; slight difficulties with routine chores, work assignments, or schoolwork assignments; slight impairment in workmanship. 70 Mild difficulty with occupational skills or skills in school (e.g., minor difficulty following instructions, workmanship is somewhat sloppy), but generally functioning fairly well. 60 Moderate difficulty with occupational skills or skills in school (e.g., probably employed; however, has trouble carrying through assignments; some difficulty problem solving or following instructions; some difficulty driving a car; some difficulty knowing how to budget money; some difficulty maintaining a home or apartment).

50 Serious impairment in occupational skills or skills in school (e.g., unable to keep a job for more than a few weeks due to poor occupational skills; almost failing in school; moderate difficulty following instructions; moderately sloppy workmanship); needs supervision when shopping for food; some difficulty using public transportation; some difficulty preparing self a reasonable, family-style meal; some difficulty ordering, eating properly, tipping, etc., in a regular restaurant; some difficulty making a long-distance phone call. 40 Major impairment in occupational skills or skills in school (e.g., unable to work at a job for any significant period or do routine housework due to poor work skills; failing in school due to poor academic skills); needs supervision to use public transportation; mild to moderate difficulty ordering and eating in a fast-food restaurant; poor understanding of how to budget money.

30 No job and unable to independently maintain a home due to serious impairment in skills needed to perform ADLs and tasks at home; serious difficulty following instructions; needs some supervision to prepare simple meals for self, such as a sandwich and beverage; needs supervision to dress self, make a local phone call, follow a very simple self-medication procedure; needs constant supervision to complete more complicated ADLs (e.g., operating a washer and dryer); very sloppy workmanship; some difficulty responding appropriately to a fire alarm; difficulty finding way back from short errands. 20 Gross impairment in skills needed to perform ADLs and tasks at home (e.g., needs some supervision to maintain minimal personal hygiene; is almost totally unable to follow simple instructions; needs supervision to feed self; unable to function independently (e.g., needs constant supervision to complete most simple tasks; does not know the value of money; unable to dial 911 in an emergency; unable to find way back from short errands). 10 Demonstrates almost no ADL skills (e.g., is totally unable to follow instructions; unable to complete most tasks even with constant supervision; may even have to be physically assisted to complete a task, including eating or dressing); persistent inability to maintain minimal personal hygiene; considerable external support (e.g., nursing care and supervision) is needed to prevent him/her from accidentally harming self (e.g., wandering into traffic, danger of seriously burning self when attempting to cook or when smoking); unable to appropriately respond to a fire alarm.

NR Not rated


6–53

ADL–Occupational Skills NAME: Abbott, George AGE:

35

Pt. has an above-average IQ. He graduated from high school and had been working full time for many years in a factory repairing equipment, including computers. Recently, pt. was laid off because his job was contracted to an outside company. He feels that he needs some help getting another job and has come in for our job-counseling program. He may also be interested in further job training. He reports getting reasonably good reviews on his job performance. . . . . . .

. . . . .

. . . .

. . .

. .

.

Ratings ADL–Occupational Skills = 90 1) PSY = 100

2) SOC = 90

3) VIO = 90

4) ADL = 90

5) SAb = 80

6) MED = 90

GAF Eq = 95 Dangerousness Level = 80 Explanation of ADL–Occupational Skills Rating High school graduate with above-average IQ = 90 or better Able to do reasonably good full-time work at a high school graduate–level job = 90

7) ANC = 90

6–54


ADL–Occupational Skills NAME: Cross, Anthony AGE:

24

Pt. graduated from high school. He has been driving a delivery van full time for the last 5 years. Pt. was considered a fairly good worker; however, recently his depression lead to his frequently missing work. At times, he even had difficulty driving his van because of his impaired focal attention. Staff states that ADL skills are fairly good; however, because of a lack of motivation, he often does not use his ADL skills (e.g., he often neglects his personal hygiene). His depression appears to interfere with his problem-solving skills. . . . . . .

. . . . .

. . . .

. . .

. .

.


2) SOC = 60

3) VIO = 50

4) ADL = 80

5) SAb = 95

6) MED = 70

GAF Eq = 60 Dangerousness Level = 50 Explanation of ADL–Occupational Skills Rating Fairly good worker in competitive, full-time employment = 80 Factor out depressive symptoms (these are captured under Psychological Impairment):

• Impaired focal attention and problem solving • Lack of motivation • Neglect of personal hygiene

7) ANC = 80


6–55

ADL–Occupational Skills NAME: Davis, Richard AGE:

45

Pt. needs minimal supervision to dress himself; however, he needs almost constant supervision to complete more complicated ADLs. Pt. is unable to make his bed without supervision. Pt. has great difficulty following even simple instructions. Pt. is felt to be unable to find his way back from errands. Workmanship is very sloppy. Focal attention is very poor. Pt. does well with very repetitive tasks. . . . . . .

. . . . .

. . . .

. . .

. .

.


2) SOC = 35

3) VIO = 50

4) ADL = 25

5) SAb = 80

6) MED = 80

7) ANC = 70

GAF Eq = 35 Dangerousness Level = 35 Explanation of ADL–Occupational Skills Rating Needs minimal supervision to dress himself; however, he needs almost constant supervision to complete more complicated ADLs = 30 Great difficulty following even simple instructions = 25 Unable to find his way back from errands = 20

6–56


ADL–Occupational Skills NAME: Griffin, Paul AGE:

30

Staff states that pt.’s personal hygiene is moderately impaired. Staff states that pt. is generally disheveled in his dress. When directed to do so, he can make his bed, prepare simple meals, and do basic housework. Pt. is able to drive a car; however, his license has been suspended for drinking and reckless driving. Pt.’s workmanship is moderately to very sloppy. His lack of motivation makes it very difficult to fully assess his ADL skills. . . . . . .

. . . . .

. . . .

. . .

. .

.


2) SOC = 50

3) VIO = 40

4) ADL = 55

5) SAb = 30

6) MED = 70

7) ANC = 50

GAF Eq = 45 Dangerousness Level = 30 Explanation of ADL–Occupational Skills Rating Can make his bed, prepare simple meals, and do basic housework = 50 or better Able to drive a car (drinking is measured under Substance Abuse) = 60 or better Workmanship is moderately to very sloppy (this is likely to be due in part to poor motivation) = 40 but probably better


6–57

ADL–Occupational Skills NAME: Palmer, John AGE:

44

Pt.’s dress is generally unkempt. Staff states that he uses the washing machine. When motivated, he is able to follow fairly complicated instructions, such as copying a single page on the copier. Able to make his bed and dress himself with prompting. Pt. has some difficulty using public transportation. He was able to drive a stolen car when on escape; however, his driving was reported as poor. Pt. needs supervision when shopping for food. . . . . . .

. . . . .

. . . .

. . .

. .

.


2) SOC = 50

3) VIO = 70

4) ADL = 50

5) SAb = 50

GAF Eq = 55 Dangerousness Level = 50 Explanation of ADL–Occupational Skills Rating Uses washing machine and copier and makes bed = 50 or better Some difficulty using public transportation = 50 Can drive, but has poor driving skills = 50 Needs supervision when shopping for food = 50

6) MED = 80

7) ANC = 70

6–58


ADL–Occupational Skills NAME: Powers, Jennifer AGE:

35

Pt. has an above-average IQ. She was a very good student in nursing school and went on to get her master’s degree in nursing. She is working full time as a nursing supervisor at a local hospital. She appears to be doing very well in her job. She is very skilled with budgeting and keeping her home in excellent shape. Pt. does exceptionally well in her volunteer work with the PTA. . . . . . .

. . . . .

. . . .

. . .

. .

.


2) SOC = 100

3) VIO = 100

4) ADL = 100

5) SAb = 100

6) MED = 100 7) ANC = 100

GAF Eq = 100 Dangerousness Level = 90 Explanation of ADL–Occupational Skills Rating Above-average IQ = 90 or better Very good college-level student = 100 Successfully employed at a college-level job = 100 Very skilled at budgeting and keeping her home in excellent shape = 100 Does exceptionally well in volunteer PTA work = 90 or better


6–59

ADL–Occupational Skills NAME: Renaldo, Alice AGE:

24

Staff states that pt. is doing fairly well in her full-time, competitive employment; however, she is having some difficulty keeping up with her college work. Staff states that she is always well dressed and well groomed. Pt. states that she is doing well at her job; however, she feels that her boss puts too many demands on her. Pt. states that taking a college course has been more difficult than she had expected. . . . . . .

. . . . .

. . . .

. . .

. .

.


2) SOC = 80

3) VIO = 70

4) ADL = 90

5) SAb = 90

6) MED = 70

GAF Eq = 70 Dangerousness Level = 65 Explanation of ADL–Occupational Skills Rating Mild difficulty with full-time competitive employment and part-time college work = 80 to 90

7) ANC = 90

6–60


ADL–Occupational Skills NAME: Rosenthal, William AGE:

51

Pt. demonstrates very few ADL skills. He needs almost constant supervision to maintain minimal personal hygiene. Pt. is able to follow simple instructions with constant supervision. Unable to find his way back to ward. Dependent patient. . . . . . .

. . . . .

. . . .

. . .

. .

.


2) SOC = 10

3) VIO = 45

4) ADL = 20

5) SAb = 70

6) MED = 40

GAF Eq = 25 Dangerousness Level = 15 Explanation of ADL–Occupational Skills Rating Needs almost constant supervision to maintain minimal personal hygiene = 20 Able to follow simple instructions with constant supervision = 20 Unable to find way back to ward = 20 Dependent patient = 20 or worse

7) ANC = 70


6–61

ADL–Occupational Skills NAME: Sawyer, Barbara AGE:

42

Pt. appears to have an IQ around 115 based on IQ testing. Pt.’s basic ADL skills are fairly good; however, she needs assistance with independent ADLs, such as home management and budgeting. Pt. has some difficulty driving a car; however, she has no significant difficulty using public transportation. When motivated, pt. has no significant difficulty preparing a family-style meal, including shopping for the food. During periods of decompensation, pt.’s ADLs are markedly impaired. . . . . . .

. . . . .

. . . .

. . .

. .

.


2) SOC = 80

3) VIO = 50

4) ADL = 60

5) SAb = 80

6) MED = 50

7) ANC = 80

GAF Eq = 60 Dangerousness Level = 50 Explanation of ADL–Occupational Skills Rating Needs assistant with home management and budgeting = 60 Difficulty driving a car = 60 No significant difficulty using public transportation = 60 or better Able to prepare a family-style meal = 60 or better The fact that the client has periods of decompensation should have no significant effect on the ADL– Occupational Skills rating. Once the client has recompensated, these skills should manifest themselves because they were only covered up by the patient’s symptoms. Other subscales, including the Psychological Impairment subscale and Violence subscales, should capture the symptoms of the decompensation.

6–62


ADL–Occupational Skills NAME: Scott, David AGE:

50

Pt. appears to have a normal IQ. Pt. appears to have adequate ADL skills to fairly successfully maintain his apartment in the community. He went to school until the 11th grade; later the pt. obtained his GED. Pt. joined the Navy 20 years ago and earned a honorable discharge after 4 years. Pt.’s work record was sporadic, and he was described as having low ambition. Pt.’s work experience included mill worker, movie projectionist, and waiter. Alcohol was reported to have contributed to his problems at work. . . . . . .

. . . . .

. . . .

. . .

. .

.


2) SOC = 75

3) VIO = 50

4) ADL = 75

5) SAb = 60

6) MED = 70

GAF Eq = 60 Dangerousness Level = 50 Explanation of ADL–Occupational Skills Rating Adequate ADLs to fairly successfully maintain an apartment in the community = 70 or better Honorable discharge from the Navy = 70 or better Some difficulty with high school graduate–level jobs = 70 Factor out low ambition and alcohol

7) ANC = 70


6–63

ADL–Occupational Skills NAME: Sellers, Mark AGE:

63

Pt. has a low-normal IQ. He needs supervision with grooming, bathing, and dressing. Pt. generally refuses to even attempt more complicated tasks. Poor motivation and poor attention span probably cover up pt.’s skills. . . . . . .

. . . . .

. . . .

. . .

. .

.


2) SOC = 45

3) VIO = 40

4) ADL = 30

5) SAb = 85

6) MED = 40

7) ANC = 80

GAF Eq = 35 Dangerousness Level = 40 Explanation of ADL–Occupational Skills Rating Low-normal IQ = 60 Needs supervision with grooming, bathing, and dressing = 30 Refuses to attempt more complicated tasks (covers up possible higher functioning, may justify a higher score) Poor motivation and poor attention span cover up pt.’s ADL skills (difficult to fully factor this out; if fully factored out, this may justify a higher score)

6–64


ADL–Occupational Skills NAME: Woods, Gilbert AGE:

28

With prompts and encouragement, pt. is able to do simple tasks on the ward. Pt. has a high school education; however, he has deteriorated over many years in association with his mental illness. Staff feels that pt.’s ADL skills are concealed by delusional, disorganized thinking and markedly impaired attention span. He has some difficulty finding his way back from short errands. . . . . . .

. . . . .

. . . .

. . .

. .

.


2) SOC = 35

3) VIO = 35

4) ADL = 30

5) SAb = 90

6) MED = 90

7) ANC = 70

GAF Eq = 30 Dangerousness Level = 35 Explanation of ADL–Occupational Skills With prompts, able to do simple tasks on the ward = 30 Has a high school education = 80 or better; however, this is wiped out by his deterioration ADL skills are concealed by his mental illness (this positive factor is negated by the fact that his skills have been concealed for many years) Some difficulty finding his way back from short errands = 30

Scoring Clinical Vignettes (Self-Examination)—Substance Abuse

CLINICAL VIGNETTES

Substance Abuse (Problem Area 5)

6–65

6–66


Kennedy Axis V—Substance Abuse

(Problem Area 5)

100 No significant problems with drugs or alcohol; no use or almost no use of alcohol; nonsmoker; no use of street drugs; never abuses substances, even when life’s problems get out of hand; is an example of someone who is totally free of problems with substance abuse. No symptoms. 90 No more than the average problems and concerns with alcohol; minimal use of alcohol; social drinker; no use of illegal drugs; history of serious alcohol or drug abuse with over 10 years of sobriety and minimal, if any, treatment needed to maintain sobriety.

80 No more than slight impairment; drinks to mild intoxication about once a month; smokes cigarettes daily; experiments with marijuana less than once a year; some mild abuse of over-the-counter medications and/or caffeine; no more than slight impairment in social, occupational, or school functioning due to substance abuse (e.g., temporarily falling behind in schoolwork); serious alcohol or drug abuser with over 5 years of sobriety with minimal treatment needed to maintain sobriety. 70 Mild impairment in social, occupational, or school functioning due to substance abuse, but generally functioning fairly well; drinks to mild or moderate intoxication 1 or 2 days a week; excessive prescription drug seeking; experiments with drugs such as marijuana, Valium, Ativan, or Librium once or twice a year; heavy smoker; unable to quit cigarettes despite numerous attempts. 60 Moderate difficulty in social, occupational, or school functioning because of substance abuse (e.g., substance abuse results in moderate impairment in job performance and/or conflicts with peers or co-workers); drinks on a regular basis, often to excess; drinks to moderate intoxication more than 2 days a week; occasionally experiments with drugs such as cocaine, Quaaludes, amphetamines (speed), LSD, PCP (angel dust), Ecstasy, inhalants; moderate abuse of over-the-counter medications and/or caffeine; unable to quit cigarettes despite chronic medical complications; serious alcohol or drug abuser with less than 2 years of sobriety.

50 Serious symptoms; behavior and/or lifestyle is considerably influenced by substance abuse; moderate drug-/alcohol-seeking behavior; often intoxicated when driving or when working; abusing substances despite being pregnant; unable to keep a job; marriage failing or failing school due to abuse of alcohol or marijuana; one alcohol- or drug-related arrest; stealing prescription pads and/or altering or forging prescriptions; moderate daily use of drugs such as marijuana, Valium, Ativan, Librium; occasionally injects drugs into skin or muscle; has a morning drug or drink to get going; uses narcotics other than heroin or cocaine on a fairly regular basis; frequently abuses over-the-counter medications and/or caffeine; use of alcohol or drugs (other than cigarettes) is beginning to cause some medical complications.

40 Major impairment in several areas because of substance abuse (e.g., alcoholic man avoids friends, neglects family, and is unable to get a job; student is failing in school and having serious conflicts with his family or roommate due to substance abuse); occasionally injects heroin or cocaine into his/her veins; occasionally has an accidental drug overdose; severe alcohol or drug abuser with less than 1 month of sobriety. 30 Drugs or alcohol pervade his/her thinking and behavior; his/her behavior is considerably impaired by substance abuse; injects heroin or cocaine into his/her veins once or twice a day; abuses substances without regard for personal safety (e.g., some accidental overdoses and/or auto accidents resulting in medical hospitalizations); blackout spells; prostitutes self for drugs/alcohol; multiple alcohol- or drug-related arrests; serious neglect of children due to substance abuse. 20 Functioning is extremely impaired by daily use of drugs such as LSD, PCP, cocaine, heroin, or inhalants; unable to go for more than a few hours without significant physical and/or psychological craving for drugs or alcohol; continued use of alcohol or drugs (other than cigarettes) is beginning to cause very serious medical complications (e.g., liver failure, overt brain damage, AIDS or high risk for AIDS); injects drugs into his/her veins more than twice a day.

10 His/her life is totally controlled by drugs or alcohol; continually in a state of intoxication or withdrawal; at extremely high risk of seizures or DTs (delirium tremens) due to withdrawal; continually seeking drugs or alcohol; numerous alcohol- or drug-related arrests; clear evidence that drugs or alcohol will lead to severe physical harm or death; numerous instances of drug-related accidents or accidental overdoses resulting in frequent medical hospitalizations; life-threatening neglect of children due to substance abuse. NR Not rated


6–67

Substance Abuse NAME: Abbott, George AGE:

35

Pt. has no history of substance abuse. He is a social drinker; however, since losing his job, he has been drinking to the point of being mildly intoxicated about once a month. He has a family history of alcoholism; however, he doesn’t think that he is starting to have a problem with alcohol. He states that he in no way craves alcohol. He states that he just has too much free time on his hands. He hopes that getting job counseling will help him get back to work, and he will go back to just being an occasional social drinker. He has never smoked cigarettes. . . . . . .

. . . . .

. . . .

. . .

. .

.

Ratings Substance Abuse = 80 1) PSY = 100

2) SOC = 90

3) VIO = 90

4) ADL = 90

5) SAb = 80

GAF Eq = 95 Dangerousness Level = 80 Explanation of Substance Abuse Rating No history of substance abuse = 90 or better Social drinker = 90 Drinks to mild intoxication once a month = 80 Never smoked cigarettes = 90 or better

6) MED = 90

7) ANC = 90

6–68


Substance Abuse NAME: Cross, Anthony AGE:

24

There are no reports of any history of substance abuse. Pt. states that he used to be a social drinker. Pt. states that he has never had any problems with substance abuse. Doesn’t smoke cigarettes. . . . . . .

. . . . .

. . . .

. . .

. .

.


2) SOC = 60

3) VIO = 50

4) ADL = 80

5) SAb = 95

GAF Eq = 60 Dangerousness Level = 50 Explanation of Substance Abuse Rating No history of problems with substance abuse = 90 or better Doesn’t smoke cigarettes = 90 or better Used to be a social drinker = 90 or better

6) MED = 70

7) ANC = 80


6–69

Substance Abuse NAME: Davis, Richard AGE:

45

Many years ago, pt. had problems with alcohol abuse. Smokes cigarettes. . . . . . .

. . . . .

. . . .

. . .

. .

.


2) SOC = 35

3) VIO = 50

4) ADL = 25

5) SAb = 80

GAF Eq = 35 Dangerousness Level = 35 Explanation of Substance Abuse Rating Many years ago, pt. had problems with alcohol abuse = 90 Smokes cigarettes = 80

6) MED = 80

7) ANC = 70

6–70


Substance Abuse NAME: Griffin, Paul AGE:

30

Pt. has a long history of substance abuse, including IV drug use. Staff feels that pt. would continue to abuse drugs daily if given the opportunity. Staff states that drugs and alcohol pervade pt.’s thinking. Staff states that pt. is suspected of having neurological damage secondary to the drug use. Pt. states that he has had hepatitis in the past from drug use. Pt.’s driver’s license is currently suspended because of drinking while driving. Pt. smokes cigarettes. . . . . . .

. . . . .

. . . .

. . .

. .

.


2) SOC = 50

3) VIO = 40

4) ADL = 55

5) SAb = 30

6) MED = 70

GAF Eq = 45 Dangerousness Level = 30 Explanation of Substance Abuse Rating IV drug use = 40 or worse Drugs and alcohol pervade his thinking = 30 Medical complications (neurological damage suspected) from drug use = 50 to 30 Pt.’s driver’s license is currently suspended because of drinking while driving = 50 or worse Smokes cigarettes = 80

7) ANC = 50


6–71

Substance Abuse NAME: Lane, Barbara AGE:

25

Pt. has a long history of abuse of alcohol, cocaine, and marijuana. Before her hospitalization, pt. was using drugs and alcohol several times a day. Pt. freebases cocaine. At times, the abuse was severe enough to cause blackouts. Pt. continues to demonstrate preoccupation with drugs and frequent drug-seeking behavior. Staff feels that if given the opportunity, pt. would abuse drugs and alcohol on a daily basis. Recently, pt.’s license was again revoked because of driving under the influence of alcohol. Pt. is unemployed because of her problems with substance abuse. Pt. continues to minimize her problems with drugs and alcohol. . . . . . .

. . . . .

. . . .

. . .

. .

.


2) SOC = 50

3) VIO = 30

4) ADL = 60

5) SAb = 30

6) MED = 70

7) ANC = 40

GAF Eq = 50 Dangerousness Level = 30 Explanation of Substance Abuse Rating Before hospitalization, pt. was using drugs and alcohol several times a day; if given the opportunity, pt. would use drugs or alcohol on a daily basis = 50 or worse Blackout spells = 30 Preoccupation with drugs and frequent drug-seeking behavior = 30 License again revoked because of substance abuse = 50 or worse Unemployed because of substance abuse = 40 Poor insight into substance abuse (this is a negative factor)

6–72


Substance Abuse NAME: Palmer, John AGE:

44

Pt. has a history of extensive alcohol and drug abuse. Staff states that he is preoccupied with drinking. However, he is less frequently going AWA (away without authorization) to get alcohol. Staff states that there have been no recent attempts to get other pts. to buy him alcohol. Staff states that if given the opportunity, he would drink to excess or use street drugs on a daily basis. Pt. states that he is not having any problems staying away from alcohol. Pt. states that there have been times when he wanted to escape to drink and he didn’t. Pt. states that he is not having impulses to use street drugs. Pt. states that he does not know why he drinks. Smokes cigarettes. . . . . . .

. . . . .

. . . .

. . .

. .

.


2) SOC = 50

3) VIO = 70

4) ADL = 50

5) SAb = 50

6) MED = 80

GAF Eq = 55 Dangerousness Level = 50 Explanation of Substance Abuse Rating Preoccupied with drinking = 50 If given the opportunity, he would drink to excess or use street drugs on a daily basis = 50 No IV drug use = 50 or better Smokes cigarettes = 80 No mention of drug- or alcohol-related arrests = 60 or better History of extensive alcohol and drug abuse (this is a strongly negative factor)

7) ANC = 70


6–73

Substance Abuse NAME: Powers, Jennifer AGE:

35

Pt. has no history of substance abuse. She has never smoked. She is involved with promoting the schools’ “Just Say No Program” through the PTA. She is seen as a model of someone who does not have a problem with substance abuse. . . . . . .

. . . . .

. . . .

. . .

. .

.


2) SOC = 100

3) VIO = 100

4) ADL = 100

5) SAb = 100

6) MED = 100 7) ANC = 100

GAF Eq = 100 Dangerousness Level = 90 Explanation of Substance Abuse Rating No history of substance abuse = 90 or better Never smoked = 90 or better Strong stance against substance abuse = 90 or better Seen as a model of someone who does not have a problem with substance abuse = 100

6–74


Substance Abuse NAME: Rosenthal, William AGE:

51

No current or past problems other than being a very heavy smoker. . . . . . .

. . . . .

. . . .

. . .

. .

.


2) SOC = 10

3) VIO = 45

4) ADL = 20

5) SAb = 70

GAF Eq = 25 Dangerousness Level = 15 Explanation of Substance Abuse Rating Very heavy smoker = 70

6) MED = 40

7) ANC = 70


6–75

Substance Abuse NAME: Scott, David AGE:

50

Alcohol was reported to have been a significant contributor to his problems at work. Pt. was noted to have an alcohol problem by an employer about 10 years ago. Pt.’s drinking is said to have increased after the death of a close friend about 4 years ago. Before the present admission, pt. reports drinking alcohol on a daily basis (½ to ¾ of a fifth of wine or a six-pack of beer). Pt. does not see alcohol as a problem. Pt. went to AA in the past; however, he was not interested in any significant involvement in AA. Pt. denies any use of drugs or alcohol while in the hospital; however, he does not plan to give up alcohol totally. Heavy smoker. . . . . . .

. . . . .

. . . .

. . .

. .

.


2) SOC = 75

3) VIO = 50

4) ADL = 75

5) SAb = 60

6) MED = 70

GAF Eq = 60 Dangerousness Level = 50 Explanation of Substance Abuse Rating Problems at work = 60 Drinks on daily basis to mild excess = 60 Heavy smoker = 70 No IV drug use = 50 or better Factor out no recent use due to hospitalization Poor insight and long history of alcohol abuse (these are strong negative factors)

7) ANC = 70

6–76


Substance Abuse NAME: Sellers, Mark AGE:

63

Smokes cigarettes. No history of drug or alcohol abuse. . . . . . .

. . . . .

. . . .

. . .

. .

.


2) SOC = 45

3) VIO = 40

4) ADL = 30

5) SAb = 85

GAF Eq = 35 Dangerousness Level = 40 Explanation of Substance Abuse Rating Smokes cigarettes = 80 No history of drug or alcohol abuse (this is a positive factor)

6) MED = 40

7) ANC = 80


6–77

Substance Abuse NAME: Woods, Gilbert AGE:

28

No problems. Does not smoke cigarettes. . . . . . .

. . . . .

. . . .

. . .

. .

.


2) SOC = 35

3) VIO = 35

4) ADL = 30

5) SAb = 90

GAF Eq = 30 Dangerousness Level = 35 Explanation of Substance Abuse Rating No problems = 90 or better Does not smoke cigarettes = 90 or better No indication that this is an area of superior functioning = 90

6) MED = 90

7) ANC = 70

Notes

Scoring Clinical Vignettes (Self-Examination)—Medical Impairment

CLINICAL VIGNETTES

Medical Impairment (Problem Area 6)

6–79

6–80


Kennedy Axis V—Medical Impairment

(Problem Area 6)

100 Superior medical health; physical exam and laboratory tests are normal, including no significant weight problem; illnesses never seem to affect him/her; few if any problems with even common medical problems (e.g., colds, headaches, indigestion, constipation, diarrhea); virtually never has to miss work or school due to medical problems; exercises regularly; on no medication, except may take a prophylactic medication, such as a multivitamin; doesn’t wear glasses/contacts. No significant medical problems or symptoms. 90 Good medical health; has few if any medical problems; physical exam and laboratory test reveal no more than minor abnormalities; illnesses seldom seem to affect him/her; average difficulties with common medical problems (e.g., colds, headaches, indigestion, constipation, diarrhea); wears glasses/contacts that correct minor visual problems; wears dentures; only occasionally misses work or school due to medical problems; occasionally needs over-the-counter medication.

80 If medical problems are present, they are transient and cause minimal impairment in social, occupational, or school functioning; somewhat more than average missing of work or school due to medical problems; impairment in mobility or use of hands or hearing that is totally corrected by the use of a prosthesis, hearing aids, and the like; mild obesity or mild emaciation; occasional urinary incontinence due to organic problems.

70 Mild medical problems which may cause some difficulty in social, occupational, or school functioning; however, generally functioning fairly well; missing no more than about 1 to 2 weeks a year from work or school due to medical problems; mild impairment in mobility, speech, use of hands, vision, or hearing despite use of prosthesis, glasses, hearing aids, and the like; has chronic illness but has few if any overt signs or symptoms of the illness (e.g., mild asthma, mild hypertension, mild diabetes, mild arthritis; mild dysphagia; epilepsy easily controlled with medication; mild tardive dyskinesia); requires medical follow-up several times a year; takes prescription medication on a daily basis.

60 Moderate difficulty in social, occupational, or school functioning due to medical problems; missing no more than about 1 month a year from work or school due to medical problems (e.g., moderate asthma, moderate hypertension, moderate diabetes, moderate COPD, mild to moderate hyponatremia secondary to polydipsia, HIV positive, chronic hepatitis, mild cerebral palsy, mild cystic fibrosis, mild hemophilia, mild angina on exertion); medical problems requiring daily or weekly monitoring and treatments beyond po medications (e.g., injections, blood levels, nebulizer, physical therapy); needs bladder bag.

50 Serious impairment in social, occupational, or school functioning due to medical problems; serious impairment in mobility, speech, use of hands, vision, or hearing despite use of prosthesis, glasses, hearing aids, and the like; considered a serious risk for falling; only partially controlled epilepsy; equipment is needed for mobility (e.g., wheelchair, portable oxygen). Medical problems prevent him/her from driving a car.

40 Major impairment in several areas (such as work or school or family relations) because of medical problems; missing about 2 months a year or more from work or school due to medical problems; medical problems result in major impairment in mobility, speech, use of hands, vision, or hearing despite use of prosthesis, glasses, hearing aids, and the like; frequently confined to bed or wheelchair because of chronic medical problems.

30 Behavior and/or lifestyle is considerably impaired by medical problems; very serious medical problems confine him/her to bed or wheelchair most of the time (e.g., very symptomatic cases of diseases such as metastatic cancer, multiple sclerosis, cerebral palsy, or AIDS); chronic failure of a major body system (e.g., heart, lung, kidney, liver); on dialysis for kidney failure.

20 Major medical problems confine him/her to bed all of the time and intensive, continuous medical treatment is required without which he/she would rapidly progress to death (e.g., late stages of metastatic cancer, multiple sclerosis, AIDS, and the like); chronic, near terminal failure of a major body system (e.g., heart, lung, kidney, liver); quadriplegic.

10 Chronic medical incapacity requiring basic life support (e.g., ventilator); removal of life support would rapidly lead to death; he/she is in chronic vegetative or near vegetative state; persistent delirium or coma. NR Not rated


6–81

Medical Impairment NAME: Abbott, George AGE:

35

Pt. has no acute or chronic medical problems. He is slightly overweight. He exercises sporadically. He has no more than average difficulty with common medical problems, which he treats with over-the-counter medications. He occasionally misses work due to medical problems. . . . . . .

. . . . .

. . . .

. . .

. .

.

Ratings Medical Impairment = 90 1) PSY = 100

2) SOC = 90

3) VIO = 90

4) ADL = 90

5) SAb = 80

GAF Eq = 95 Dangerousness Level = 80 Explanation of Medical Impairment Rating No acute or chronic medical problems = 90 or better Slightly overweight = 90 Exercises sporadically (mildly negative factor) No more than average difficulty with common medical problems = 90 Occasionally takes over-the-counter medications = 90 Occasionally misses work due to medical problems = 90

6) MED = 90

7) ANC = 90

6–82


Medical Impairment NAME: Butler, Eleanor AGE:

47

Pt. has mild cerebral palsy with left-sided weakness. The cerebral palsy is associated with a mildly to moderately distorted posture and moderate difficulty walking. Over many years, the cerebral palsy has led to degenerative back disease with associated moderate, chronic back pain. The cerebral palsy is also associated with some difficulty swallowing, and the patient has experienced a couple of choking episodes. This has made it necessary for the pt. to be on a chopped diet. She has a history of hypertension; however, it is well controlled without medication. . . . . . .

. . . . .

. . . .

. . .

. .

.


2) SOC = 50

3) VIO = 60

4) ADL = 50

5) SAb = 80

GAF Eq = 50 Dangerousness Level = 55 Explanation of Medical Impairment Rating Mild cerebral palsy = 60 Moderate difficulty walking = 60 Moderate chronic back pain = 60 Some difficulty swallowing = 70 History of hypertension = 85

6) MED = 60

7) ANC = 70


6–83

Medical Impairment NAME: Cross, Anthony AGE:

24

Pt. has no acute medical problems. Pt. has mild hyperlipidemia. Mild diabetes (treated with daily oral hypoglycemic medication). Mild obesity. He has frequent gastrointestinal upset (treated fairly well with overthe-counter antacids). . . . . . .

. . . . .

. . . .

. . .

. .

.


2) SOC = 60

3) VIO = 50

4) ADL = 80

5) SAb = 95

6) MED = 70

GAF Eq = 60 Dangerousness Level = 50 Explanation of Medical Impairment Rating No acute medical problems = 90 or better Mild hyperlipidemia = 90 Mild diabetes (treated with oral hypoglycemic medication) = 70 Mild obesity = 90 Frequent gastrointestinal upset (fairly well treated with over-the-counter antacids) = 85

7) ANC = 80

6–84


Medical Impairment NAME: Davis, Richard AGE:

45

Pt. has no acute medical problems. Last year, he had a positive PPD (tuberculosis skin test). He had no symptoms of lung disease and his chest X ray was negative. He was given prophylactic treatment with INH (isoniazid) and vitamin B6 for 6 months. . . . . . .

. . . . .

. . . .

. . .

. .

.


2) SOC = 35

3) VIO = 50

4) ADL = 25

5) SAb = 80

6) MED = 80

7) ANC = 70

GAF Eq = 35 Dangerousness Level = 35 Explanation of Medical Impairment Rating No acute medical problems = 90 or better Positive PPD last year. No evidence of active disease and prophylactic treatment given = 80 or better


6–85

Medical Impairment NAME: Griffin, Paul AGE:

30

Pt. is being treated with a thyroid supplement for his mild hypothyroidism. Pt. had a head injury during an auto accident 3 years ago; however, there is no indication that he has any residual brain damage. Electroencephalogram (asleep and awake) was normal. Pt. has mild to moderate acne. Pt. is mildly obese. Pt. has no known drug allergies. . . . . . .

. . . . .

. . . .

. . .

. .

.


2) SOC = 50

3) VIO = 40

4) ADL = 55

5) SAb = 30

GAF Eq = 45 Dangerousness Level = 30 Explanation of Medical Impairment Rating Mild hypothyroidism = 70 or better History of head injury noted with no known damage (no effect on rating) Mild to moderate acne = 85 Mildly obese = 80 No known drug allergies noted (no effect on rating)

6) MED = 70

7) ANC = 50

6–86


Medical Impairment NAME: Hope, Allen AGE:

56

Pt. is medically stable; however, he is wheelchair-bound due to left hemiparesis and osteoarthritis. He has moderate dysphagia, which requires monitoring during meals. Pt. is moderately obese with moderate hyperlipidemia. Moderate hypothyroidism (treated with daily thyroid replacement). Moderate COPD secondary to smoking. . . . . . .

. . . . .

. . . .

. . .

. .

.


2) SOC = 45

3) VIO = 55

4) ADL = 50

5) SAb = 65

GAF Eq = 50 Dangerousness Level = 55 Explanation of Medical Impairment Rating Medically stable = 90 or better Wheelchair bound due to hemiparesis and osteoarthritis = 30 Moderate dysphagia; requires monitoring during meals = 60 Moderately obese = 75 Moderate hyperlipidemia = 75 Moderate hypothyroidism = 60 Moderate COPD secondary to smoking = 60

6) MED = 35

7) ANC = 70


6–87

Medical Impairment NAME: Palmer, John AGE:

44

Pt. has no significant medical problems except tardive dyskinesia. The tardive dyskinesia was manifested by mild to moderate irregular movements of his tongue. These included occasionally involuntarily sticking his tongue out of his mouth. Pt. denied being bothered by the tardive dyskinesia. Pt. was switched to Clozaril, and the tardive dyskinesia disappeared after a few months. . . . . . .

. . . . .

. . . .

. . .

. .

.


2) SOC = 50

3) VIO = 70

4) ADL = 50

5) SAb = 50

GAF Eq = 55 Dangerousness Level = 50 Explanation of Medical Impairment Rating No significant medical problems = 90 or better Mild tardive dyskinesia, in remission = 80 Not bothered by the tardive dyskinesia (this is a positive factor)

6) MED = 80

7) ANC = 70

6–88


Medical Impairment NAME: Powers, Jennifer AGE:

35

Pt. is in excellent health. She has no acute or chronic medical problems. She is in the normal weight range for her height. She exercises on a regular basis. She is not on medication except a daily multivitamin. She almost never misses work due to medical problems. . . . . . .

. . . . .

. . . .

. . .

. .

.


2) SOC = 100

3) VIO = 100

4) ADL = 100

5) SAb = 100

GAF Eq = 100 Dangerousness Level = 90 Explanation of Medical Impairment Rating In excellent health = 100 No acute or chronic medical problems = 90 or better Normal weight (this is a positive factor) Exercises on a regular basis (this is a positive factor) No medication is required for any illness (this is a positive factor) Almost never misses work due to medical problems = 90 or better

6) MED = 100 7) ANC = 100


6–89

Medical Impairment NAME: Sawyer, Barbara AGE:

42

Pt. has had insulin-dependent diabetes mellitus for the last 5 years. Her diabetes is severe and very brittle; her blood sugars often range from 200 to 450 mg/dL during a single day. Due to the extreme variations in her blood sugar and poor compliance with her medication and diet, she requires supervision with her treatments at least twice daily, as well as ongoing monitoring to ensure that her diabetes is not dangerously out of control. Pt. had a head injury in 1970 that resulted in a hairline fracture. The fracture healed with no subsequent problems. Pt. is sensitive to Haldol. . . . . . .

. . . . .

. . . .

. . .

. .

.


2) SOC = 80

3) VIO = 50

4) ADL = 60

5) SAb = 80

6) MED = 50

7) ANC = 80

GAF Eq = 60 Dangerousness Level = 50 Explanation of Medical Impairment Rating Severe diabetes mellitus (requiring two to three injections every day) with continuing poor control = 50 Requires supervision with her treatments at least twice daily (this is a negative factor) Requires ongoing monitoring to ensure that her diabetes is not dangerously out of control = 50 (more than routine daily monitoring) Head injury in 1970 is noted (no effect on the rating) Sensitivity to Haldol is noted (no effect on the rating)

6–90


Medical Impairment NAME: Sellers, Mark AGE:

63

Pt. has temporal lobe epilepsy, which is well controlled with medication. Pt. is felt to be a mild dysphagia risk. He is considered to be a high risk for falls due to his unsteady gait. Sometimes he has problems with skin integrity (pressure sores) because he is frequently confined to a Geri Chair. . . . . . .

. . . . .

. . . .

. . .

. .

.


2) SOC = 45

3) VIO = 40

4) ADL = 30

5) SAb = 85

6) MED = 40

GAF Eq = 35 Dangerousness Level = 40 Explanation of Medical Impairment Rating Well-controlled temporal lobe epilepsy = 70 Mild dysphagia risk = 70 High risk for falls due to unsteady gait with need to frequently be in a Geri Chair = 40 Occasional skin integrity problems = 60 or better

7) ANC = 80


6–91

Medical Impairment NAME: Stewart, Helen AGE:

58

Pt. is terminally ill with metastatic breast cancer that has spread to her liver. She has lost nearly 50 pounds. She is having problems with liver failure, and her heart is also showing signs of failing. She is confined to her bed and on continuous IV treatment, including potent narcotics to control her pain. Recently she was transferred out of the hospital back to her home with her family. Hospice nurses come in twice daily to monitor her medications and progress. . . . . . .

. . . . .

. . . .

. . .

. .

.


2) SOC = 90

3) VIO = 70

4) ADL = 90

5) SAb = 100

6) MED = 20

GAF Eq = 80 Dangerousness Level = 35 Explanation of Medical Impairment Rating Late stages of a terminal illness = 20 or worse Liver failure and heart showing signs of failing = 20 or worse Confined to bed with continuous IV treatment, including narcotics = 30 or worse Qualified for hospice care as a terminally ill person = 30 or worse

7) ANC = 90

6–92


Medical Impairment NAME: White, Janet AGE:

43

Overall, pt.’s health is fairly good. She had a gastric resection about 10 years ago because of a peptic ulcer. She has no residual problems, except for heartburn that is relieved by occasional prn antacid. She is mildly obese; however, she exercises on a regular basis. Recently she started on a diet. She is edentulous. . . . . . .

. . . . .

. . . .

. . .

. .

.


2) SOC = 70

3) VIO = 90

4) ADL = 85

5) SAb = 80

GAF Eq = 80 Dangerousness Level = 65 Explanation of Medical Impairment Rating Overall fairly good health = 80 or better Gastric resection 10 years ago, uses occasional prn antacid = 85 Mildly obese; however, exercises regularly = 85 Edentulous = 90

6) MED = 85

7) ANC = 65


6–93

Medical Impairment NAME: Woods, Gilbert AGE:

28

Pt. has no acute or chronic medical problems. He is not significantly overweight. He does not exercise or take any active steps to take care of his health. . . . . . .

. . . . .

. . . .

. . .

. .

.


2) SOC = 35

3) VIO = 35

4) ADL = 30

5) SAb = 90

GAF Eq = 30 Dangerousness Level = 35 Explanation of Medical Impairment Rating No acute or chronic medical problems = 90 or better Not significantly overweight (this is a positive factor) Not doing anything to actively take care of his health (this is a negative factor)

6) MED = 90

7) ANC = 70

Notes

Scoring Clinical Vignettes (Self-Examination)—Ancillary Impairment

CLINICAL VIGNETTES

Ancillary Impairment (Problem Area 7)

6–95

6–96


Kennedy Axis V—Ancillary Impairment

(Problem Area 7)

100 Superior life situation; currently in or has ready access to ideal living environment (neighborhood, home, school, work, etc.); superior financial resources for his/her needs; no legal problems; extremely safe environment. No significant ancillary problems or symptoms. 90 Good life situation; has few if any ancillary problems; no more than minor problems with living environment, financial resources, and/or legal problems, e.g., occasionally living environment doesn’t fully meet his/her needs, rare late payment on a bill, rare parking or traffic ticket.

80 If ancillary problems are present, they are transient and cause no more than minimal difficulty with his/her living situation, financial resources, or the law; somewhat more than average problems with his/her living environment, financial resources, or legal problems.

70 Mild ancillary problems, e.g., some difficulty with his/her living environment, financial resources, or the law; mild difficulty paying bills/credit cards; mild difficulty with parking or traffic tickets; occasional mild verbal violence in his/her environment; however, generally safe living situation. 60 Moderate difficulty with living situation, finances, or the law; high risk for being in a dangerous homeless or jail situation; criminal charges place him/her at high risk of incarceration; no stable residence and/or income, often having to move from one living situation to another; moderate difficulty paying bills/credit cards; evaluation and/or disposition is being made for nonviolent criminal activity (e.g., trespassing, stealing, defacing/destruction of property, or lewd behavior); evaluation and/or disposition is being made for competency to make decisions concerning person, estate, and/or treatment.

50 Serious problems with living situation, finances, and/or the law; frequent risks or threats of moderate violence in his/her environment; evaluation and/or disposition is being made for relatively minor but violent or dangerous criminal activity (e.g., minor assault, threats to do physical harm, driving while under the influence, sexually touching someone or exposing self); serious placement difficulties, even when ready for placement. 40 Major problems with living situation, finances, and/or the law; some real danger of being physically injured in his/her environment; evaluation and/or disposition is being made for very violent criminal activity (e.g., vicious assault, attempted rape, attempting to molest a child, arson).

30 Lifestyle is considerably influenced by ancillary problems; he/she is in a very dangerous homeless or jail situation most of the time; unable to obtain basic food, shelter and/or clothing; frequent, mild to moderate physical injuries from violence in his/her environment. 20 Major ancillary problems (e.g., he/she is in a very dangerous homeless or jail situation all of the time); at times, his/her life is at serious risk due to lack of resources for basic food, shelter, and/or clothing or because of high level of violence in his/her environment; evaluation and/or disposition is being made for extremely serious criminal charges (e.g., attempted murder, vicious rape, viciously molesting a child).

10 Living/financial situation is totally inadequate; his/her life is continually at serious risk due to lack of basic food, shelter, and/or clothing or because of extremely high level of violence in his/her environment; evaluation and/or disposition is being made for the most extreme charges of violence (e.g., murdering anyone, very viciously harming or very viciously raping a child, arson with intent of hurting others).

NR Not rated


6–97

Ancillary Impairment NAME: Allen, Diane AGE:

27

Client is in the Shelter for Battered Women because her husband is becoming increasingly violent toward her. On two occasions, she was hospitalized from injuries because of his abuse; however, she told her physician that the injuries were due to accidents at home. Today her husband threatened to kill her with a gun. She fears that he will actually try to kill her. Her husband has a history of violence, and her fears appear to be well founded. As a homemaker, she is dependent on her husband for support of herself and their two children. Leaving her husband places her in a very serious financial situation; however, because of her increasing fears for her safety, she is willing to accept help from the shelter. . . . . . .

. . . . .

. . . .

. . .

. .

.

Ratings Ancillary Impairment = 20 1) PSY = 70

2) SOC = 90

3) VIO = 80

4) ADL = 90

5) SAb = 90

6) MED = 90

7) ANC = 20

GAF Eq = 85 Dangerousness Level = 20 Explanation of Ancillary Impairment Rating The client is living in a very dangerous home environment. Her life is felt to be at high risk because of the violent history of her husband, the fact that he has a gun, and his threats to kill her with the gun. This justifies a rating of 20 or less. If he had actually attempted to murder her, the rating would have dropped to 10 or even 5. The client has extremely limited financial resources = 60. Legal issues are likely to develop in this area (e.g., restraining orders, formal charges against her husband, petition for divorce). These may impact the rating as the clinical course unfolds.

6–98


Ancillary Impairment NAME: Brown, Keith AGE:

55

Pt. has no more than minimal difficulty with his current living situation (i.e., chronic hospitalization). Staff has been very effective in preventing him from assaulting others and vice versa. . . . . . .

. . . . .

. . . .

. . .

. .

.


2) SOC = 45

3) VIO = 40

4) ADL = 25

5) SAb = 80

6) MED = 70

7) ANC = 80

GAF Eq = 35 Dangerousness Level = 40 Explanation of Ancillary Impairment Rating Even though the patient is in a hospital, this does not appear to cause him any more than minimal difficulty. Some hospital environments may be very impairing for an individual patient. Other hospital environments may be ideal to support and bring out a particular patient’s best level of functioning. The rating should reflect this. Do not simply assume because the patient is in the hospital that this is a good or bad environment for the patient. In this case, the patient appears to be functioning fairly well in his hospital environment = 80. It is assumed that because no mention was made of financial or legal problems, he does not have any significant impairment from those factors. If he had serious financial or legal problems, his rating would reflect a much more dysfunctional level.


6–99

Ancillary Impairment NAME: Brown, Patricia AGE:

35

Pt. has no significant financial problems or legal problems. She appears safe in her community residence (halfway house). Financial assistance from her sister helps to prevent her from having any significant financial problems. . . . . . .

. . . . .

. . . .

. . .

. .

.


2) SOC = 60

3) VIO = 70

4) ADL = 50

5) SAb = 50

6) MED = 90

7) ANC = 90

GAF Eq = 55 Dangerousness Level = 50 Explanation of Ancillary Impairment Rating No significant legal or financial problems = 90 to 100 Some halfway-house environments may be ideal to support and to bring out a particular pt.’s best level of functioning. The rating should reflect this. Do not simply assume that because the patient is in a halfway house that this is a good or bad environment for the patient. Pt. appears to be doing very well in her current environment = 90 Whether a pt. were homeless or lived in a mansion, the rating would be based on how much that environment impaired his or her functioning. Even living in a mansion could be very impairing if the burden of keeping and maintaining that mansion were very difficult and the mansion was not a significant part of what the person wanted out of life (i.e., it just impaired the pt.’s functioning rather than enhanced it). Likewise, even some homeless situations can be very functional for some individuals if that lifestyle truly meets their needs and sense of what they want out of life.

6–100


Ancillary Impairment NAME: Graham, Ronald AGE:

37

Ongoing court evaluations and dispositions are being made around whether the patient can be safely released back into the community. About 5 years ago, he made a serious attempt to kill someone by stabbing that person four times. The victim is currently still confined to a wheelchair as a result of his injuries. The patient’s next court appearance will be in about 3 months. Pt. feels that he is long overdue for discharge. . . . . . .

. . . . .

. . . .

. . .

. .

.


2) SOC = 90

3) VIO = 50

4) ADL = 90

5) SAb = 60

6) MED = 90

7) ANC = 20

GAF Eq = 65 Dangerousness Level = 20 Explanation of Ancillary Impairment Rating Evaluations and dispositions are being made for an extremely serious criminal charge (attempted murder) with very serious residual injury to the victim. Even though 5 years have passed, because the pt. continues to be felt to be violent (Violence rating of 50), he will be facing a very serious court hearing on whether to release him from his current commitment. Rating, therefore, = 20


6–101

Ancillary Impairment NAME: Johnson, Helen AGE:

62

Pt. has some difficulty paying for her cigarettes, snacks, and other basic needs with her disability income. Pt.’s residence is generally safe except for some occasional mild violence. . . . . . .

. . . . .

. . . .

. . .

. .

.


2) SOC = 50

3) VIO = 70

4) ADL = 40

5) SAb = 80

6) MED = 90

7) ANC = 70

GAF Eq = 50 Dangerousness Level = 55 Explanation of Ancillary Impairment Rating Pt.’s basic food and shelter are being provided; however, she has some mild difficulty paying for her cigarettes, snacks, and other basic needs with her disability income = 70 Pt.’s residence is generally safe, except for some occasional mild violence = 70

6–102


Ancillary Impairment NAME: Smith, Mark AGE:

38

Client has been living in a dangerous homeless situation for the last several years. He is often victimized on the streets; however, thus far, he has never been seriously injured while living on the streets. He refuses to live in a homeless shelter or halfway house. When he decompensates, he is picked up in a dangerous state and rehospitalized. However, after stabilization and despite the objections of psychiatric testimony, the court releases him. He then goes directly back to the streets. Pt. supports himself with his Social Security Disability Income check, which covers his basic needs. He could afford a modest apartment; however, he prefers living on the streets. . . . . . .

. . . . .

. . . .

. . .

. .

.


2) SOC = 50

3) VIO = 70

4) ADL = 50

5) SAb = 80

6) MED = 70

7) ANC = 60

GAF Eq = 50 Dangerousness Level = 55 Explanation of Ancillary Impairment Rating The client is living in a dangerous homeless situation; however, threats of violence are only occasional, and he has avoided serious injury; therefore, a score of 60 was chosen. If the client were felt to be the subject of frequent violent acts, the rating would be 50 or worse. The client’s financial resources meet his basic needs with no more than mild difficulty paying his bills = 70 or better


6–103

Ancillary Impairment NAME: Williams, Barbara AGE:

34

Ongoing consultations with pt.’s medical guardian and court are being made for various permissions to provide pt. with needed psychiatric treatment. She and her husband, a schoolteacher, have ongoing financial difficulties as a result of her years of soaring medical expenses. This appears to be causing them to lose their home. . . . . . .

. . . . .

. . . .

. . .

. .

.


2) SOC = 70

3) VIO = 50

4) ADL = 95

5) SAb = 60

6) MED = 70

7) ANC = 50

GAF Eq = 55 Dangerousness Level = 15 Explanation of Ancillary Impairment Rating The patient requires ongoing consultations with her medical guardian and court for various permissions to provide her with needed psychiatric treatment = 60 Patient and her husband have serious financial difficulties as a result of her years of soaring medical expenses that appear to be causing them to lose their home = 50

Notes

CHAPTER 7

COMPLETED KENNEDY AXIS V SCORING SHEETS

7–1


Completed Kennedy Axis V Scoring Sheets

7–3

COMPLETED KENNEDY AXIS V SCORING SHEETS CONTENTS I. Standard-Form Scoring Sheet ......................................................................................................... 7–5 II. Long-Form Scoring Sheet.............................................................................................................. 7–13 III. Computerized, Variable-Length Scoring Sheet ............................................................................ 7–18



7–5

COMPLETED KENNEDY AXIS V SCORING SHEETS I. Standard-Form Scoring Sheet This form should allow you to quickly rate the K Axis and just as quickly enter some very brief clinical information to support the ratings. The following are samples of completed K Axis scoring sheets using the standard-form scoring sheet.

7–6


Kennedy Axis V: Scoring Sheet Name: Susan Anderson (Front Street Residence)

© 1986–2003

#: 12341

Age:

34


ÄÄ FUNCTIONAL

DYSFUNCTIONAL ÅÅ

1. Psychological Impairment 100 ___95 ___90 ___85 ___80 ___75 ___70 ___65 ___60 ___55 ___50 ___45 ___40 ___35 ___30 X 25 ___20 ___15 ___10 ___5 ___ 100 95 90 90 85 80 75 75 70 70 65 60 55 55 40 35 25 15 5 50 Not Impaired___

Primarily (check one):


Other Impairment X

Both___

Pt. hears command hallucinations and tends to follow them. She believes the voices are real.

2. Social Skills 100 ___95 ___90 ___85 ___80 ___75 ___70 ___65 ___60 X 55 ___50 ___45 ___40 ___35 ___30 ___25 ___20 ___15 ___10 ___5 ___ 100 95 90 90 85 80 75 70 65 65 60 55 45 40 30 25 20 15 5 50 Pt. has few, if any, friends due to poor social skills. Interactions with others are usually somewhat awkward; however, she is not grossly inappropriate in her social skills.

3. Violence 100 ___95 ___90 ___85 ___80 ___75 ___70 ___65 ___60 X 55 ___50 ___45 ___40 ___35 ___30 ___25 ___20 ___15 ___10 ___5 ___ 100 95 90 85 80 75 70 65 60 55 45 40 35 30 25 20 15 10 5 50 Nonviolent___


Violent to Self___

Violent to Others X


She made a serious assault on her mother 2 years ago. She is easily provoked. She often becomes angry and hostile during conflicts with peers around food and other household issues. Some occasional thoughts that life is not worth living; however, she is not seen as a risk for attempting suicide.

4. ADL–Occupational Skills 100 ___95 ___90 ___85 ___80 ___75 ___70 ___65 ___60 ___55 ___50 X 45 ___40 ___35 ___30 ___25 ___20 ___15 ___10 ___5 ___ 100 95 90 90 85 80 75 75 70 70 65 60 55 55 40 35 25 15 5 50 Pt. is able to cook fairly well and is able to do some basic housework. She cannot budget money. She is unable to drive a car. She has some difficulty using public transportation, and she needs supervision when shopping for food.

5. Substance Abuse 100 ___95 ___90 X 85 ___80 ___75 ___70 ___65 ___60 ___55 ___50 ___45 ___40 ___35 ___30 ___25 ___20 ___15 ___10 ___5 ___ 100 95 90 85 80 75 70 65 60 55 45 40 35 30 25 20 15 10 5 50 Nonabuser X


Alcohol Abuser___

Drug Abuser___

Both___

Pt. has no significant problems with drugs or alcohol. She used to smoke. Occasional social drinker.

6. Medical Impairment 100 ___95 ___90 ___85 ___80 ___75 ___70 ___65 X 60 ___55 ___50 ___45 ___40 ___35 ___30 ___25 ___20 ___15 ___10 ___5 ___ 100 95 90 90 85 80 75 75 70 70 65 60 55 55 40 35 25 15 5 50 Pt. has non-insulin-dependent diabetes. Her compliance with her diabetic diet is poor. She takes an oral hypoglycemic agent every day and has a FBS (fasting blood sugar) taken q 2 weeks.

7. Ancillary Impairment (optional) 100 ___95 ___90 ___85 ___80 ___75 ___70 ___65 ___60 X 55 ___50 ___45 ___40 ___35 ___30 ___25 ___20 ___15 ___10 ___5 ___ 100 95 90 85 80 75 70 65 60 55 45 40 35 30 25 20 15 10 5 50 Pt. is in an environment with moderately violent clients and neighbors. She, like others in this environment, is at risk of being assaulted.

GAF Equivalent:

#1

30

+ #2

60

+ #3

60

+ #4

50


James A. Kennedy, MD

= 200 /

4

=

50

50 Date:

1/22/03


Kennedy Axis V: Scoring Sheet Name: Keith Brown (Lakeview State Hospital)

7–7

© 1986–2003

#: 12342

Age:

55


ÄÄ FUNCTIONAL

DYSFUNCTIONAL ÅÅ




Other Impairment X

Both___

Pt. is delusional, only partly oriented, and able to focus his attention for only a few minutes. He often talks to himself. He is very socially withdrawn.

2. Social Skills 100 ___95 ___90 ___85 ___80 ___75 ___70 ___65 ___60 ___55 ___50 ___45 X 40 ___35 ___30 ___25 ___20 ___15 ___10 ___5 ___ 100 95 90 90 85 80 75 70 65 65 60 55 45 40 30 25 20 15 5 50 Pt. has no friends and virtually no peer relationships due to impaired social skills. Pt.’s verbalizations are often grossly inappropriate. However, pt.’s interactions with others are very awkward but not grossly inappropriate.

3. Violence 100 ___95 ___90 ___85 ___80 ___75 ___70 ___65 ___60 ___55 ___50 ___45 ___40 X 35 ___30 ___25 ___20 ___15 ___10 ___5 ___ 100 95 90 85 80 75 70 65 60 55 45 40 35 30 25 20 15 10 5 50 Nonviolent___


Violent to Self___

Violent to Others X


Pt. often attempts to assault others and is felt to be in real danger of hurting someone if not supervised closely. He is generally angry and verbally abusive. He also has some mild problems with being self-abusive (biting his arm and banging his head).

4. ADL–Occupational Skills 100 ___95 ___90 ___85 ___80 ___75 ___70 ___65 ___60 ___55 ___50 ___45 ___40 ___35 ___30 ___25 X 20 ___15 ___10 ___5 ___ 100 95 90 90 85 80 75 75 70 70 65 60 55 55 40 35 25 15 5 50 Pt. needs assistance with his personal hygiene including bathing, dressing, and grooming. He has great difficulty focusing on any vocational tasks, and his workmanship is very sloppy. Pt. has difficulty responding to a fire alarm. He has some difficulty finding his way around the hospital

5. Substance Abuse 100 ___95 ___90 ___85 ___80 X 75 ___70 ___65 ___60 ___55 ___50 ___45 ___40 ___35 ___30 ___25 ___20 ___15 ___10 ___5 ___ 100 95 90 85 80 75 70 65 60 55 45 40 35 30 25 20 15 10 5 50 Nonabuser X


Alcohol Abuser___

Drug Abuser___

Both___

Pt. has no history of abuse of drugs or alcohol. Pt. smokes cigarettes daily.

6. Medical Impairment 100 ___95 ___90 ___85 ___80 ___75 ___70 X 65 ___60 ___55 ___50 ___45 ___40 ___35 ___30 ___25 ___20 ___15 ___10 ___5 ___ 100 95 90 90 85 80 75 75 70 70 65 60 55 55 40 35 25 15 5 50 Pt. has mild TD. Pt. has a hiatal hernia, which is well controlled with antacids. Otherwise, pt. has fairly good health.

7. Ancillary Impairment (optional) 100 ___95 ___90 ___85 ___80 X 75 ___70 ___65 ___60 ___55 ___50 ___45 ___40 ___35 ___30 ___25 ___20 ___15 ___10 ___5 ___ 100 95 90 85 80 75 70 65 60 55 45 40 35 30 25 20 15 10 5 50 Pt. has no more than minimal difficulty with his current living situation (i.e., chronic hospitalization). Staff has been very effective in preventing him from assaulting others and vice versa.

GAF Equivalent:

#1

30

+ #2

45

+ #3

40

+ #4

25



= 140 /

4

=

35

40 Date:

1/25/03

7–8


Kennedy Axis V: Scoring Sheet Name: Helen Johnson (Friendly House Residence)

© 1986–2003

#: 12343

Age:

62


ÄÄ FUNCTIONAL

DYSFUNCTIONAL ÅÅ

1. Psychological Impairment 100 ___95 ___90 ___85 ___80 ___75 ___70 ___65 ___60 ___55 ___50 ___45 ___40 X 35 ___30 ___25 ___20 ___15 ___10 ___5 ___ 100 95 90 90 85 80 75 75 70 70 65 60 55 55 40 35 25 15 5 50 Not Impaired___



Other Impairment X

Both___

Pt. has some impairment in reality testing, including being delusional at times. No hallucinations.

2. Social Skills 100 ___95 ___90 ___85 ___80 ___75 ___70 ___65 ___60 ___55 ___50 X 45 ___40 ___35 ___30 ___25 ___20 ___15 ___10 ___5 ___ 100 95 90 90 85 80 75 70 65 65 60 55 45 40 30 25 20 15 5 50 Pt. has no friends; however, she has some peer relationships. Her social functioning is clearly impaired.

3. Violence 100 ___95 ___90 ___85 ___80 ___75 ___70 X 65 ___60 ___55 ___50 ___45 ___40 ___35 ___30 ___25 ___20 ___15 ___10 ___5 ___ 100 95 90 85 80 75 70 65 60 55 45 40 35 30 25 20 15 10 5 50 Nonviolent___


Violent to Self___

Violent to Others X


Pt. has mild problems with anger and irritability. She assaulted a neighbor more than 10 years ago.

4. ADL–Occupational Skills 100 ___95 ___90 ___85 ___80 ___75 ___70 ___65 ___60 ___55 ___50 ___45 ___40 X 35 ___30 ___25 ___20 ___15 ___10 ___5 ___ 100 95 90 90 85 80 75 75 70 70 65 60 55 55 40 35 25 15 5 50 Pt. completed the 11th grade. Pt. did housework in the neighborhood for many years; however, she has been unable to work for many years. She now needs supervision to do even basic housework and other routine tasks of living, such as shopping or using public transportation.



Alcohol Abuser___

Drug Abuser___

Both___

No history of use of drugs or alcohol. She smokes cigarettes. She does not drink.

6. Medical Impairment 100 ___95 ___90 X 85 ___80 ___75 ___70 ___65 ___60 ___55 ___50 ___45 ___40 ___35 ___30 ___25 ___20 ___15 ___10 ___5 ___ 100 95 90 90 85 80 75 75 70 70 65 60 55 55 40 35 25 15 5 50 Generally pt. has good medical health (i.e., few, if any, medical problems).

7. Ancillary Impairment (optional) 100 ___95 ___90 ___85 ___80 ___75 ___70 X 65 ___60 ___55 ___50 ___45 ___40 ___35 ___30 ___25 ___20 ___15 ___10 ___5 ___ 100 95 90 85 80 75 70 65 60 55 45 40 35 30 25 20 15 10 5 50 Pt. has some difficulty paying for her cigarettes, snacks, and other basic needs with her disability income. Pt.’s residence is generally safe, except for some occasional mild violence.

GAF Equivalent:

#1

40

+ #2

50

+ #3

70

+ #4

40



= 200 /

4

=

50

55 Date:

7/25/03


Kennedy Axis V: Scoring Sheet Name: Albert Morgan (Lakeview Residence)

7–9

© 1986–2003

#: 12344

Age:

24


ÄÄ FUNCTIONAL

DYSFUNCTIONAL ÅÅ




Other Impairment X

Both___

Pt. has persistent persecutory delusions, thought broadcasting, and impaired judgment. He has moderate impairment in motivation; however, he is cooperative with treatment programs and taking his meds.

2. Social Skills 100 ___95 ___90 ___85 ___80 ___75 ___70 X 65 ___60 ___55 ___50 ___45 ___40 ___35 ___30 ___25 ___20 ___15 ___10 ___5 ___ 100 95 90 90 85 80 75 70 65 65 60 55 45 40 30 25 20 15 5 50 No obvious impairment in social skills. He has friends who are not clients. At times, females take advantage of him.

3. Violence 100 ___95 ___90 ___85 ___80 X 75 ___70 ___65 ___60 ___55 ___50 ___45 ___40 ___35 ___30 ___25 ___20 ___15 ___10 ___5 ___ 100 95 90 85 80 75 70 65 60 55 45 40 35 30 25 20 15 10 5 50 Nonviolent X


Violent to Self___



Occasionally angry and upset over minor problems. He does not get overtly hostile or threatening. No history of assaults. No problems with suicidal ideation or attempts.

4. ADL–Occupational Skills 100 ___95 ___90 ___85 ___80 ___75 X 70 ___65 ___60 ___55 ___50 ___45 ___40 ___35 ___30 ___25 ___20 ___15 ___10 ___5 ___ 100 95 90 90 85 80 75 75 70 70 65 60 55 55 40 35 25 15 5 50 Pt. is a high school graduate with fairly good ADL skills. It is felt that he could work at a job, if he were motivated to work (i.e., he has the work skills but not the motivation).



Alcohol Abuser___

Drug Abuser___

Both___

Smokes cigarettes. Drinks socially about once a month.

6. Medical Impairment 100 ___95 ___90 ___85 ___80 X 75 ___70 ___65 ___60 ___55 ___50 ___45 ___40 ___35 ___30 ___25 ___20 ___15 ___10 ___5 ___ 100 95 90 90 85 80 75 75 70 70 65 60 55 55 40 35 25 15 5 50 Only occasionally ill; however, he is mildly obese. He does not exercise, and his diet is poor.

7. Ancillary Impairment (optional) 100 ___95 ___90 ___85 ___80 X 75 ___70 ___65 ___60 ___55 ___50 ___45 ___40 ___35 ___30 ___25 ___20 ___15 ___10 ___5 ___ 100 95 90 85 80 75 70 65 60 55 45 40 35 30 25 20 15 10 5 50 No more than mild difficulties living in a halfway house and being supported with Social Security Disability Income. No legal problems.

GAF Equivalent:

#1

40

+ #2

70

+ #3

80

+ #4

75



= 265 /

4

=

65

55 Date:

7/22/03

7–10


Kennedy Axis V: Scoring Sheet Name: Janet Smith (Lakeview Nursing Home)

© 1986–2003

#: 12345

Age:

64


ÄÄ FUNCTIONAL

DYSFUNCTIONAL ÅÅ

1. Psychological Impairment 100 ___95 ___90 ___85 ___80 ___75 ___70 ___65 ___60 X 55 ___50 ___45 ___40 ___35 ___30 ___25 ___20 ___15 ___10 ___5 ___ 100 95 90 90 85 80 75 75 70 70 65 60 55 55 40 35 25 15 5 50 Not Impaired___



Other Impairment X

Both___

Pt. is often preoccupied and has some difficulties with depression. No hallucinations or delusions.

2. Social Skills 100 ___95 ___90 ___85 ___80 ___75 ___70 ___65 ___60 X 55 ___50 ___45 ___40 ___35 ___30 ___25 ___20 ___15 ___10 ___5 ___ 100 95 90 90 85 80 75 70 65 65 60 55 45 40 30 25 20 15 5 50 Pt. has moderate difficulty with her social skills.



Violent to Self___

Violent to Others X


Pt. has a past history of assaultive behavior. Currently she is having no more than mild problems with anger and irritability.

4. ADL–Occupational Skills 100 ___95 ___90 ___85 ___80 ___75 ___70 ___65 ___60 ___55 ___50 ___45 ___40 ___35 ___30 X 25 ___20 ___15 ___10 ___5 ___ 100 95 90 90 85 80 75 75 70 70 65 60 55 55 40 35 25 15 5 50 Due to cognitive decline and unsteady gait, pt. is unable to independently care for herself. She has great difficulty doing basic housework. She needs supervision to dress. She is unable to use public transportation.

5. Substance Abuse 100 ___95 ___90 ___85 ___80 ___75 ___70 X 65 ___60 ___55 ___50 ___45 ___40 ___35 ___30 ___25 ___20 ___15 ___10 ___5 ___ 100 95 90 85 80 75 70 65 60 55 45 40 35 30 25 20 15 10 5 50 Nonabuser___


Alcohol Abuser X

Drug Abuser___

Both___

Pt. has renal failure that requires weekly dialysis. She has hypertension. About 3 years ago, she suffered a CVA. Currently her gait is unstable, and she is at high risk for falling.

6. Medical Impairment 100 ___95 ___90 ___85 ___80 ___75 ___70 ___65 ___60 ___55 ___50 ___45 ___40 ___35 ___30 X 25 ___20 ___15 ___10 ___5 ___ 100 95 90 90 85 80 75 75 70 70 65 60 55 55 40 35 25 15 5 50 Pt. is in a very supportive and reasonably safe environment. Pt. has a guardian for person and estate. The institution meets her basic needs. She has no significant legal problems.

7. Ancillary Impairment (optional) 100 ___95 ___90 X 85 ___80 ___75 ___70 ___65 ___60 ___55 ___50 ___45 ___40 ___35 ___30 ___25 ___20 ___15 ___10 ___5 ___ 100 95 90 85 80 75 70 65 60 55 45 40 35 30 25 20 15 10 5 50

GAF Equivalent:

#1

60

+ #2

60

+ #3

70

+ #4

30



= 220 /

4

=

55

50 Date:

12/12/03


Kennedy Axis V: Scoring Sheet Name: Jacqueline Young (Roberts Memorial Outpatient)

7–11

© 1986–2003

#: 12346

Age:

6


ÄÄ FUNCTIONAL

DYSFUNCTIONAL ÅÅ

1. Psychological Impairment 100 ___95 X 90 ___85 ___80 ___75 ___70 ___65 ___60 ___55 ___50 ___45 ___40 ___35 ___30 ___25 ___20 ___15 ___10 ___5 ___ 100 95 90 90 85 80 75 75 70 70 65 60 55 55 40 35 25 15 5 50 Not Impaired X



Other Impairment___

Both___

Pt. appears psychologically very healthy except for being shy. Her shyness is well within the normal limits. She copes well with day-to-day problems. She is very cooperative with her medical treatments, unless they are painful (e.g., she is certainly not pleased with getting shots or IVs).

2. Social Skills 100 ___95 X 90 ___85 ___80 ___75 ___70 ___65 ___60 ___55 ___50 ___45 ___40 ___35 ___30 ___25 ___20 ___15 ___10 ___5 ___ 100 95 90 90 85 80 75 70 65 65 60 55 45 40 30 25 20 15 5 50 Despite her shyness, she gets along well with other kids and adults. When motivated, she can be very socially effective. She has many friends and no difficulty developing new friendships. Generally, she is very pleasant and engaging. She has good communication skills.

3. Violence 100 ___95 X 90 ___85 ___80 ___75 ___70 ___65 ___60 ___55 ___50 ___45 ___40 ___35 ___30 ___25 ___20 ___15 ___10 ___5 ___ 100 95 90 85 80 75 70 65 60 55 45 40 35 30 25 20 15 10 5 50 Nonviolent X


Violent to Self___



For her age, she has no problems with impulse control. Occasionally angry and upset over minor problems. She has a very normal level of conflicts with others. She gets into occasional short, nonvicious fights when her 4-year-old brother torments or picks on her. No self-abusive behaviors.

4. ADL–Occupational Skills 100 ___95 X 90 ___85 ___80 ___75 ___70 ___65 ___60 ___55 ___50 ___45 ___40 ___35 ___30 ___25 ___20 ___15 ___10 ___5 ___ 100 95 90 90 85 80 75 75 70 70 65 60 55 55 40 35 25 15 5 50 She has above-average intelligence. She had some minor problems with reading; however, with special attention, this quickly resolved. She is able to do small chores around the house with no difficulty. She is able to ride her bicycle and drive her “Barbie” car with no difficulty.

5. Substance Abuse 100 X 95 ___90 ___85 ___80 ___75 ___70 ___65 ___60 ___55 ___50 ___45 ___40 ___35 ___30 ___25 ___20 ___15 ___10 ___5 ___ 100 95 90 85 80 75 70 65 60 55 45 40 35 30 25 20 15 10 5 50 Nonabuser X


Alcohol Abuser___

Drug Abuser___

Both___

She sees smoking as “nasty,” otherwise, she has no significant exposure to, knowledge of, or craving for substance abuse. No one smokes at her home or abuses drugs or alcohol.

6. Medical Impairment 100 ___95 ___90 ___85 ___80 ___75 ___70 ___65 ___60 X 55 ___50 ___45 ___40 ___35 ___30 ___25 ___20 ___15 ___10 ___5 ___ 100 95 90 90 85 80 75 75 70 70 65 60 55 55 40 35 25 15 5 50 She has cystic fibrosis. At this point in her illness, she has only mild symptoms. She has never required hospitalization; however, she requires treatments several times a day, including chest therapy.

7. Ancillary Impairment (optional) 100 X 95 ___90 ___85 ___80 ___75 ___70 ___65 ___60 ___55 ___50 ___45 ___40 ___35 ___30 ___25 ___20 ___15 ___10 ___5 ___ 100 95 90 85 80 75 70 65 60 55 45 40 35 30 25 20 15 10 5 50 She lives in a very safe neighborhood in a stable home situation with her parents. She has good financial security. Her treatments are mostly covered by insurance. No legal or custody problems.

GAF Equivalent:

#1

95

+ #2

95

+ #3

95

+ #4

95



= 300 /

4

=

95

70 Date:

8/12/03

Notes


II. Long-Form Scoring Sheet The long-form scoring sheet simply provides the rater with more space to enter the problem descriptions. Two completed long-form scoring sheets for the K Axis follow.

7–13

7–14


Kennedy Axis V: Scoring Sheet Name: Ronald Graham (Lakeview State Hospital)

© 1986–2003

#: 12347

Age:

37


ÄÄ FUNCTIONAL

DYSFUNCTIONAL ÅÅ

1. Psychological Impairment 100 ___95 ___90 ___85 ___80 ___75 ___70 ___65 ___60 ___55 ___50 ___45 ___40 ___35 ___30 X 25 ___20 ___15 ___10 ___5 ___ 100 95 90 90 85 80 75 75 70 70 65 60 55 55 40 35 25 15 5 50 Primarily (check one):

Not Impaired___

Antisocially Impaired X

Other Impairment___

Both___

Pt. has a long history of antisocial behaviors and arrests, including breaking and entering, credit card theft, and embezzlement from work. It is felt that pt. was feigning mental illness before being found “not guilty by reason of insanity” for attempted murder. After being found not guilty by reason of insanity, despite his refusal to continue taking antipsychotic medication, pt.’s “psychotic” symptoms rapidly diminished. Pt. is felt to be very self-centered and almost totally insensitive to the feelings and needs of others. This is supported by psychological testing, which substantiates the clinical impression that pt. is impaired by severe antisocial and narcissistic traits. Pt. is meticulously well dressed. He has good eye contact. He reports being pleased that he is in various treatment activities and that he is looking forward to being released by the courts because he feels that all of his mental problems have been resolved. During the interview, pt. was friendly but arrogant and condescending.

2. Social Skills 100 ___95 ___90 X 85 ___80 ___75 ___70 ___65 ___60 ___55 ___50 ___45 ___40 ___35 ___30 ___25 ___20 ___15 ___10 ___5 ___ 100 95 90 90 85 80 75 70 65 65 60 55 45 40 30 25 20 15 5 50 Pt. appears to have very good but superficial social skills. Pt. is able to be very polite, engaging, and friendly. Pt. is not at all awkward in his interactions with others. Pt. has a good understanding of the feelings and needs of others and uses this to his advantage, often at the expense of others. He is able to maintain many fairly close relationships as long as those relationships meet his needs.

3. Violence 100 ___95 ___90 ___85 ___80 ___75 ___70 ___65 ___60 ___55 ___50 X 45 ___40 ___35 ___30 ___25 ___20 ___15 ___10 ___5 ___ 100 95 90 85 80 75 70 65 60 55 45 40 35 30 25 20 15 10 5 50 Primarily (check one):

Nonviolent___

Violent to Self___

Violent to Others X


Five years ago, pt. attempted to murder someone with whom he had been in jail. He savagely stabbed that person four times. Years later that person continued to be confined to a wheelchair as a result of his injuries. Pt. states that he is now glad that he did not kill the person; however, otherwise he shows very little remorse for his victim. Pt. claims that the person he stabbed was someone who broke pt.’s arm when they were in prison together because pt. would not provide him with sexual favors. They were both out of jail at the time of the attempted murder. During pt.’s hospitalization, he has had episodic problems with being intimidating and threatening. Pt. has not been assaultive. He is often very angry and frustrated over delays in his discharge from the hospital. Pt. admits to a background of violence; however, he currently does not see himself as violent. Pt. continues to be fascinated with violent video games and weapons, especially knives. Pt. denies having any thoughts or impulses to hurt himself or others. Pt. has no history of suicidal or self-abusive behavior except for cutting his wrist once to get transferred out of the general inmate area into the much safer mental health unit.



7–15

KENNEDY AXIS V: SCORING SHEET © 1986–2003, Continued from previous page Name: Ronald Graham (Lakeview State Hospital)

#: 12347

Age:

37

4. ADL–Occupational Skills 100 ___95 X 90 ___85 ___80 ___75 ___70 ___65 ___60 ___55 ___50 ___45 ___40 ___35 ___30 ___25 ___20 ___15 ___10 ___5 ___ 100 95 90 90 85 80 75 75 70 70 65 60 55 55 40 35 25 15 5 50 Pt. appears to be very bright, and, as expected, his IQ is in the high-normal range. He is a high school graduate. He had no difficulty with college courses he took in prison. His initial imprisonment was because of two convictions for embezzling money, one while managing an auto parts store. He hopes to eventually complete a college degree in business. Since his hospitalization following being found not guilty by reason of insanity, he progressed well on computers in his job at the Rehab Business Center. In his community vocational placement, he has worked for a couple of years in an office supply store where he is felt to be quite successful.

5. Substance Abuse 100 ___95 ___90 ___85 ___80 ___75 ___70 ___65 ___60 X 55 ___50 ___45 ___40 ___35 ___30 ___25 ___20 ___15 ___10 ___5 ___ 100 95 90 85 80 75 70 65 60 55 45 40 35 30 25 20 15 10 5 50 Nonabuser___


Alcohol Abuser X

Drug Abuser___

Both___

Pt. reports having problems with alcohol from age 15 until his arrest for attempted murder at age 32. He reports that just before his arrest, he was drinking 2 fifths of scotch each week. He was reported to have been drinking at the time of the attempted murder. He has had no overdoses, blackouts, delirium tremens, or withdrawal seizures. He denies any past use of illicit drugs, except for occasional use of cocaine or marijuana. Pt. has never been arrested for DWI or drug-related crimes. Pt. smokes one pack per day. Pt. denies any current impulses to use drugs or alcohol; however, he is monitored closely with urine toxicology screens and Breathalyzer tests to ensure that he does not abuse substances while in the community.

6. Medical Impairment 100 ___95 ___90 X 85 ___80 ___75 ___70 ___65 ___60 ___55 ___50 ___45 ___40 ___35 ___30 ___25 ___20 ___15 ___10 ___5 ___ 100 95 90 90 85 80 75 75 70 70 65 60 55 55 40 35 25 15 5 50 Pt. has fairly good health. He has no significant medical problems except for a mild, chronic cough from smoking. Pt.’s broken arm healed years ago with no residual problems.

7. Ancillary Impairment (optional) 100 ___95 ___90 ___85 ___80 ___75 ___70 ___65 ___60 ___55 ___50 ___45 ___40 ___35 ___30 ___25 ___20 X 15 ___10 ___5 ___ 100 95 90 85 80 75 70 65 60 55 45 40 35 30 25 20 15 10 5 50 Ongoing court evaluations and dispositions are being made around whether the patient can be safely released back into the community. About 5 years ago he made a serious attempt to kill someone by stabbing that person four times. The victim is currently still confined to a wheelchair as a result of his injuries. The pt.’s next court appearance will be in about 3 months. Pt. feels that he is long overdue for discharge.

GAF Equivalent:

#1

30

+ #2

90

+ #3

50

+ #4

95



= 265 /

4

=

65

20 Date:

7/24/03

7–16


Kennedy Axis V: Scoring Sheet Name: Natalie Moore (Roberts Memorial Hospital)

© 1986–2003

#: 12348

Age:

14


ÄÄ FUNCTIONAL

DYSFUNCTIONAL ÅÅ

1. Psychological Impairment 100 ___95 ___90 ___85 ___80 ___75 ___70 ___65 ___60 ___55 ___50 ___45 ___40 X 35 ___30 ___25 ___20 ___15 ___10 ___5 ___ 100 95 90 90 85 80 75 75 70 70 65 60 55 55 40 35 25 15 5 50 Primarily (check one):

Not Impaired___


Other Impairment X

Both___

Pt. has a history of being sexually abused by her father and a neighborhood boy. She has occasional flashbacks of the sexual abuse. She is usually dressed in a morbid manner with black makeup, black dress, black jewelry, pierced eyebrows, and studded leather wrist and neck bands. She is stubborn, rebellious, oppositional, and very negativistic. She has some sexual identity problems and is obsessed with Marilyn Manson. She complains of mild sadness; however, she has no vegetative signs of depression. At times, she is withdrawn and paranoid and isolates herself. She is not delusional or hallucinating, except for the flashbacks.

2. Social Skills 100 ___95 ___90 ___85 ___80 X 75 ___70 ___65 ___60 ___55 ___50 ___45 ___40 ___35 ___30 ___25 ___20 ___15 ___10 ___5 ___ 100 95 90 90 85 80 75 70 65 65 60 55 45 40 30 25 20 15 5 50 Pt. appears to have fairly good social skills; however, she is very much into “antiestablishment” issues. Pt. is able to be polite and engaging. She has some close friends; however, when around strangers, she is generally withdrawn and isolative. Her friends are mostly very antiestablishment, like herself. She has good verbal skills.

3. Violence 100 ___95 ___90 ___85 ___80 ___75 ___70 ___65 ___60 ___55 ___50 ___45 ___40 ___35 ___30 ___25 ___20 ___15 ___10 X 5 ___ 100 95 90 85 80 75 70 65 60 55 45 40 35 30 25 20 15 10 5 50 Primarily (check one):

Nonviolent___

Violent to Self X



Pt. has made a number of suicide attempts and is generally preoccupied with death. She carries around a black orchid as a symbol of death and collects sharp objects to cut herself with. She states that she is a freak and that she hates herself. At times she knowingly places herself in situations in which she is at risk of sexual abuse. She states that suicide attempts can happen very spontaneously. For example, her last attempt, 1 week ago, occurred because she became very angry when she learned that her mother was listening in on her phone conversations. She picked up a vase and threw it through a window of her mother’s fourthfloor apartment. Her mother and a cousin had to restrain her to prevent her from jumping out of the window. During the attempt, pt. sustained a deep, 3-inch cut on her right leg. She states that periodically she also cuts her leg or stomach without telling anyone. She states that the cuts are usually superficial. Once she tried to stab herself in the stomach; however, the knife wouldn’t go through. She states that currently she is having impulses to throw herself down the hospital stairs; however, she states that she doesn’t believe that she would act on the impulses.



7–17

KENNEDY AXIS V: SCORING SHEET © 1986–2003, Continued from previous page Name: Natalie Moore (Roberts Memorial Hospital)

#: 12348

Age:

14

4. ADL–Occupational Skills 100 ___95 ___90 X 85 ___80 ___75 ___70 ___65 ___60 ___55 ___50 ___45 ___40 ___35 ___30 ___25 ___20 ___15 ___10 ___5 ___ 100 95 90 90 85 80 75 75 70 70 65 60 55 55 40 35 25 15 5 50 Pt. is bright and does well in school when motivated. She has no difficulty functioning at her grade level; however, because of failing motivation, truancy, and conflicts with teachers and other students, she is doing very poorly in school. She has no difficulty with her ADLs.



Alcohol Abuser___

Drug Abuser___

Both X

Pt. reports frequently using marijuana and alcohol over the last 2 years. She would not report the exact frequency of drug and alcohol use; however, she reports last using marijuana about 1 week ago. Pt. smokes cigarettes on a daily basis.

6. Medical Impairment 100 ___95 ___90 X 85 ___80 ___75 ___70 ___65 ___60 ___55 ___50 ___45 ___40 ___35 ___30 ___25 ___20 ___15 ___10 ___5 ___ 100 95 90 90 85 80 75 75 70 70 65 60 55 55 40 35 25 15 5 50 Pt. has good health. Her good health is probably because of her young age because she neglects her health and does not do anything to maintain her good health.

7. Ancillary Impairment (optional) 100 ___95 ___90 ___85 ___80 ___75 ___70 ___65 ___60 X 55 ___50 ___45 ___40 ___35 ___30 ___25 ___20 ___15 ___10 ___5 ___ 100 95 90 85 80 75 70 65 60 55 45 40 35 30 25 20 15 10 5 50 Pt. lives in a dysfunctional family. When her father lived at home, he sexually abused her. Pt.’s parents are now divorced and she has not had any contact with her father for 2 years. Her mother works as a nurse and often has to work long hours to pay the bills. It has been very difficult for her mother to support the family without the father’s help. Pt. is often home alone. Pt.’s home is located in a relatively safe neighborhood; however, pt. hangs out with older kids who often use and deal drugs and get into trouble with the law. At times, she knowingly places herself at risk of sexual abuse by adolescent boys that she hangs around with in her neighborhood. She has never been arrested and is in no trouble with the law.

GAF Equivalent:

#1

40

+ #2

80

+ #3

10

+ #4

90



= 220 /

4

=

55

10 Date:

10/15/03

7–18


III. Computerized, Variable-Length Scoring Sheet This variable-length scoring sheet can be created on the computer by simply entering the short-form scoring sheet into any sophisticated word processor, such as Microsoft Word or Corel WordPerfect. Then simply enter the necessary information directly onto the computerized form as you would enter any text information into a word processor. Once you have completed entering the necessary information, you can use the word processor to delete any unused space from the scoring sheet, enter any necessary page breaks, make any other necessary changes to “clean up” the document, and print the computerized, variable-length scoring sheet. The following are samples of completed computerized, variable-length scoring sheets.


Kennedy Axis V: Scoring Sheet Name: Patricia Brown (Lakeview Residence)

7–19

© 1986–2003

#: 12349

Age:

35


ÄÄ FUNCTIONAL

DYSFUNCTIONAL ÅÅ




Other Impairment X

Both___

Pt. has multiple delusions and religious preoccupations. Pt. is actively responding to hallucinations, including yelling at the voices. Pt.’s insight and judgment are impaired.

2. Social Skills 100 ___95 ___90 ___85 ___80 ___75 ___70 ___65 ___60 X 55 ___50 ___45 ___40 ___35 ___30 ___25 ___20 ___15 ___10 ___5 ___ 100 95 90 90 85 80 75 70 65 65 60 55 45 40 30 25 20 15 5 50 Pt. is pleasant but moderately awkward in her attempts to be friendly and engaging. Because of her pleasant personality, she is well liked by staff. Pt. states that she has many friends. Pt. states that she keeps in touch with her friends mostly by telephone; however, it is felt that she is greatly exaggerating her circle of friends. It is likely that her only real friend is her sister. Despite a fairly engaging personality, it is felt that her yelling at the voices frightens off potential friends. Pt.’s communications are somewhat vague.



Violent to Self___

Violent to Others X


Pt. has mild problems with anger and irritability; however, when she drinks excessive amounts of caffeine, she becomes very hostile. Currently, this is not a problem for pt. because staff prevents her from drinking excessive amounts of caffeine.

4. ADL–Occupational Skills 100 ___95 ___90 ___85 ___80 ___75 ___70 ___65 ___60 ___55 ___50 X 45 ___40 ___35 ___30 ___25 ___20 ___15 ___10 ___5 ___ 100 95 90 90 85 80 75 75 70 70 65 60 55 55 40 35 25 15 5 50 Pt. appears to have normal intelligence. Before the onset of her illness, she completed 1 year of college. Pt. has fairly good independent living skills and is able to live independently in the community for short periods. At times, she is able to work for a few weeks. Pt. has some difficulty using public transportation.

5. Substance Abuse 100 ___95 ___90 ___85 ___80 ___75 ___70 ___65 ___60 ___55 ___50 X 45 ___40 ___35 ___30 ___25 ___20 ___15 ___10 ___5 ___ 100 95 90 85 80 75 70 65 60 55 45 40 35 30 25 20 15 10 5 50 Nonabuser___


Alcohol Abuser___

Drug Abuser X

Both___

Pt. smokes cigarettes and is very dependent on caffeine. She reports frequently drinking 40 or more cups of coffee per day. When she is able to get the coffee she wants, she becomes very hostile and anxious from the caffeine. To prevent this, she is monitored closely to prevent her from drinking excessive caffeine. If given the opportunity, she would quickly revert back to drinking large quantities of coffee.

6. Medical Impairment 100 ___95 ___90 X 85 ___80 ___75 ___70 ___65 ___60 ___55 ___50 ___45 ___40 ___35 ___30 ___25 ___20 ___15 ___10 ___5 ___ 100 95 90 90 85 80 75 75 70 70 65 60 55 55 40 35 25 15 5 50 Pt. has fairly good medical health. She has no acute or chronic medical problems.

7. Ancillary Impairment (optional) 100 ___95 ___90 X 85 ___80 ___75 ___70 ___65 ___60 ___55 ___50 ___45 ___40 ___35 ___30 ___25 ___20 ___15 ___10 ___5 ___ 100 95 90 85 80 75 70 65 60 55 45 40 35 30 25 20 15 10 5 50 Pt. has no significant financial problems or legal problems. She appears safe in her community residence. Financial aid from her sister helps to prevent pt. from having any significant financial problems.

GAF Equivalent:

#1

30

+ #2

60

+ #3

70

+ #4

50



= 210 /

4

=

55

50 Date:

11/24/03

7–20


Kennedy Axis V: Scoring Sheet Name: Robert Davis (Lakeview State Hospital)

© 1986–2003

#: 12350

Age:

58


ÄÄ FUNCTIONAL

DYSFUNCTIONAL ÅÅ

1. Psychological Impairment 100 ___95 ___90 ___85 ___80 ___75 ___70 ___65 ___60 ___55 ___50 X 45 ___40 ___35 ___30 ___25 ___20 ___15 ___10 ___5 ___ 100 95 90 90 85 80 75 75 70 70 65 60 55 55 40 35 25 15 5 50 Not Impaired___



Other Impairment X

Both___

Pt. has a history of delusional thinking, mostly paranoia. The content of pt.’s speech is somewhat bizarre, and he is moderately guarded. There is no evidence of hallucinations.

2. Social Skills 100 ___95 ___90 ___85 ___80 X 75 ___70 ___65 ___60 ___55 ___50 ___45 ___40 ___35 ___30 ___25 ___20 ___15 ___10 ___5 ___ 100 95 90 90 85 80 75 70 65 65 60 55 45 40 30 25 20 15 5 50 Pt. appears to have fairly good social skills. He is able to be very charming, pleasant, and engaging, especially when in the company of the guys at a bar. He has a good sense of humor. His deafness and alcoholism, not his lack of social skills, make him vulnerable to victimization.

3. Violence 100 ___95 ___90 ___85 ___80 ___75 ___70 ___65 ___60 ___55 ___50 X 45 ___40 ___35 ___30 ___25 ___20 ___15 ___10 ___5 ___ 100 95 90 85 80 75 70 65 60 55 45 40 35 30 25 20 15 10 5 50 Nonviolent___


Violent to Self___

Violent to Others X


When intoxicated, pt. has been hostile, threatening, and assaultive. His assaults are mild and do not result in any significant injury. Because of his long-term hospitalization, he has had very little access to alcohol; however, it is felt that if given the opportunity, he would drink and become threatening and assaultive.

4. ADL–Occupational Skills 100 ___95 ___90 ___85 ___80 ___75 ___70 ___65 ___60 ___55 ___50 X 45 ___40 ___35 ___30 ___25 ___20 ___15 ___10 ___5 ___ 100 95 90 90 85 80 75 75 70 70 65 60 55 55 40 35 25 15 5 50 Pt. is a high school graduate who became physically disabled in the military by an injury to his ears. Despite his very impaired hearing, pt. is able to compensate fairly well. He is able to use public transportation with only minimal difficulty. He appears to be fairly good at budgeting his money. He is able to dress and attend to his personal hygiene without any significant assistance.

5. Substance Abuse 100 ___95 ___90 ___85 ___80 ___75 ___70 ___65 ___60 ___55 ___50 ___45 ___40 ___35 ___30 ___25 X 20 ___15 ___10 ___5 ___ 100 95 90 85 80 75 70 65 60 55 45 40 35 30 25 20 15 10 5 50 Nonabuser___


Alcohol Abuser X

Drug Abuser___

Both___

Pt. has a long history of severe alcohol abuse, including drinking to near lethal levels. If given the opportunity, it is felt that he would drink to a potentially lethal level and likely pass out in the streets. During his last escape, he nearly died when he passed out near a bar on Main Street. He also becomes hostile and aggressive when drinking. He has poor insight into his problem with alcohol and is not motivated to quit. He does not have independent privileges because of his high risk of escaping and drinking to a potentially lethal level while on escape. Pt. is a chronic smoker and has medical complications from both smoking and drinking.

6. Medical Impairment 100 ___95 ___90 ___85 ___80 ___75 ___70 ___65 ___60 ___55 ___50 ___45 ___40 X 35 ___30 ___25 ___20 ___15 ___10 ___5 ___ 100 95 90 90 85 80 75 75 70 70 65 60 55 55 40 35 25 15 5 50 Pt. is almost totally deaf. He is able to communicate fairly well using residual speech and crude sign language. He has mild cirrhosis of his liver and moderate COPD.

7. Ancillary Impairment (optional) 100 ___95 ___90 ___85 ___80 X 75 ___70 ___65 ___60 ___55 ___50 ___45 ___40 ___35 ___30 ___25 ___20 ___15 ___10 ___5 ___ 100 95 90 85 80 75 70 65 60 55 45 40 35 30 25 20 15 10 5 50 No more than mild difficulties living in the hospital. He is supported by money from his military disability income. No current legal problems.

GAF Equivalent:

#1

50

+ #2

80

+ #3

50

+ #4

50



= 230 /

4

=

60

25 Date:

7/22/03


Kennedy Axis V: Scoring Sheet Name: Joseph Jones (Lakeview State Hospital)

7–21

© 1986–2003

#: 12351

Age:

49


ÄÄ FUNCTIONAL

DYSFUNCTIONAL ÅÅ




Other Impairment X

Both___

Pt. is paranoid and suspicious of others. May act on suspicions that others are stealing from him. There is no evidence of hallucinations. Pt. is generally withdrawn and difficult to engage in conversation. His affect is blunted. Depressed at times. Periodically refuses to eat or drink with resultant dehydration and hypotension. Periodically noncompliant with meds.

2. Social Skills 100 ___95 ___90 ___85 ___80 ___75 ___70 ___65 ___60 ___55 ___50 ___45 X 40 ___35 ___30 ___25 ___20 ___15 ___10 ___5 ___ 100 95 90 90 85 80 75 70 65 65 60 55 45 40 30 25 20 15 5 50 Pt. is a loner and does not mix well with others. No friends. Able to interact superficially, although very awkwardly, with others. Able to be passively friendly. Never able to form close, intimate social relationships. Not grossly inappropriate in social interactions. No inappropriate touching.

3. Violence 100 ___95 ___90 ___85 ___80 ___75 ___70 ___65 ___60 ___55 ___50 ___45 ___40 ___35 ___30 ___25 X 20 ___15 ___10 ___5 ___ 100 95 90 85 80 75 70 65 60 55 45 40 35 30 25 20 15 10 5 50 Nonviolent___


Violent to Self___

Violent to Others X


Pt. has a long history of assaultive outbursts. In the past, pt. threatened to kill his sister. Pt. has threatened with a knife and a hammer. Pt. has thrown furniture during assaultive episodes. Pt. is labile, sullen, irritable, and easily agitated. Assaults are unpredictable and are usually in response to minor problems, such as thoughts that others are stealing his things. At times, pt. requires seclusion and prn meds for threatening behavior. Pt. will recompensate within hours to a few days after an assault. Pt. is felt to be at very high risk of seriously injuring others. No active suicidal ideation, but at times he states that he wants to die.

4. ADL–Occupational Skills 100 ___95 ___90 ___85 ___80 ___75 ___70 ___65 ___60 ___55 ___50 X 45 ___40 ___35 ___30 ___25 ___20 ___15 ___10 ___5 ___ 100 95 90 90 85 80 75 75 70 70 65 60 55 55 40 35 25 15 5 50 Pt. is a high school graduate, but he required special classes. Full-scale IQ = 78. Could maintain low-level employment, such as a stocking shelves in a supermarket, if not for his temper and impulsive behaviors. Fairly good fine-motor skills. Pt. has coping skills to function in the community. Works 10 hours per week in supportive environment.

5. Substance Abuse 100 X 95 ___90 ___85 ___80 ___75 ___70 ___65 ___60 ___55 ___50 ___45 ___40 ___35 ___30 ___25 ___20 ___15 ___10 ___5 ___ 100 95 90 85 80 75 70 65 60 55 45 40 35 30 25 20 15 10 5 50 Nonabuser X


Alcohol Abuser___

Drug Abuser___

Both___

No history of use of drugs, including cigarettes or alcohol.

6. Medical Impairment 100 ___95 ___90 ___85 ___80 ___75 ___70 ___65 ___60 X 55 ___50 ___45 ___40 ___35 ___30 ___25 ___20 ___15 ___10 ___5 ___ 100 95 90 90 85 80 75 75 70 70 65 60 55 55 40 35 25 15 5 50 Pt. had a massive congenital hydrocephalus and a CVA at age 15. Currently, pt. has left-sided weakness with a mild to moderate gait disturbance, temporal hemianopsia, and mildly dysarthric speech. Pt. has epilepsy, which is well controlled with medication. Chronic problems with seborrheic dermatitis. Periodic treatment needed for self-induced dehydration.

7. Ancillary Impairment (optional) 100 ___95 ___90 ___85 ___80 ___75 ___70 X 65 ___60 ___55 ___50 ___45 ___40 ___35 ___30 ___25 ___20 ___15 ___10 ___5 ___ 100 95 90 85 80 75 70 65 60 55 45 40 35 30 25 20 15 10 5 50 Pt. has things stolen from him in his hospital environment; otherwise, he is not having any problems in this area.

GAF Equivalent:

#1

40

+ #2

45

+ #3

25

+ #4

50



= 160 /

4

=

40

25 Date:

9/17/03

7–22


Kennedy Axis V: Scoring Sheet Name: Barbara Williams (Lakeview State Hospital)

© 1986–2003

#: 12352

Age:

34


ÄÄ FUNCTIONAL

DYSFUNCTIONAL ÅÅ

1. Psychological Impairment 100 ___95 ___90 ___85 ___80 ___75 ___70 ___65 ___60 ___55 ___50 ___45 ___40 ___35 ___30 ___25 ___20 ___15 ___10 X 5 ___ 100 95 90 90 85 80 75 75 70 70 65 60 55 55 40 35 25 15 5 50 Primarily (check one):

Not Impaired___


Other Impairment X

Both___

Pt. will do almost anything to ensure that she does not gain weight. It is felt that if given the opportunity, she would starve herself to a medically dangerous and potentially fatal state. At her current 79 pounds, she is close to a life-threatening situation. She makes inconsistent and contradictory statements about her ability to tolerate various foods. She makes false claims that various medical authorities have told her that she could not tolerate various foods. She also reports that they stated that because of her food intolerances, consuming food, even high-calorie foods, would not lead to any weight gain. She was extremely resistant to being placed on close observation to prevent her from self-induced vomiting. She claims that her vomiting is because of food intolerances rather than being self-induced. However, she was extremely resistant to working with the dietitian on resolving any food intolerances that she may have. She would quickly vomit almost any place available, including the toilet, bath drain, or shower drain. She would vomit into her sheets and hide the sheets. She sneaks in medication that she takes to disguise the medical symptoms of her vomiting. She was extremely resistive to efforts to tube-feed her; however, tying her down and tubefeeding her is often the only way to ensure adequate nutritional intake and to reverse a potentially life-threatening situation. Pt. often writes frivolous complaints about staff members and attempts to get her human rights representatives to block needed treatment. Pt. is at times consumed with strategies to fight treatment. This ties up a lot of staff time and makes it very difficult to provide needed treatment.

2. Social Skills 100 ___95 ___90 ___85 ___80 ___75 ___70 X 65 ___60 ___55 ___50 ___45 ___40 ___35 ___30 ___25 ___20 ___15 ___10 ___5 ___ 100 95 90 90 85 80 75 70 65 65 60 55 45 40 30 25 20 15 5 50 Pt. is somewhat awkward in her interactions with others. Despite this, she is able to maintain several long-term relationships, including her marriage of 8 years. She has some difficulty sharing with others and some difficulty understanding the feelings of others.

3. Violence 100 ___95 ___90 ___85 ___80 ___75 ___70 ___65 ___60 ___55 ___50 X 45 ___40 ___35 ___30 ___25 ___20 ___15 ___10 ___5 ___ 100 95 90 85 80 75 70 65 60 55 45 40 35 30 25 20 15 10 5 50 Primarily (check one):

Nonviolent___

Violent to Self X



Periodically, pt. has self-destructive and suicidal ideation. Pt.’s expressions of suicidal thoughts are seen as attempts to manipulate staff rather than actually wanting to hurt herself. Mostly, she cuts herself very superficially or burns herself with a cigarette. However, due to her high level of anger, she is felt to possibly be a real danger to attempt to seriously hurt herself in order to manipulate staff. On rare occasions, pt. attacks staff; however, because of her frail status, the assaults are usually minor. She reports while on day pass a couple of months ago that she laid on the railroad tracks and waited for a train to come. She reported that after laying on the tracks for ½ hour, she gave up and returned to the hospital. When on constant observation status, she would often be very resistive to allowing staff to adequately monitor her, including hiding under the covers or refusing to come out from under the bed. While hiding, she would at times cut herself superficially.

4. ADL–Occupational Skills 100 ___95 X 90 ___85 ___80 ___75 ___70 ___65 ___60 ___55 ___50 ___45 ___40 ___35 ___30 ___25 ___20 ___15 ___10 ___5 ___ 100 95 90 90 85 80 75 75 70 70 65 60 55 55 40 35 25 15 5 50 Pt. graduated from college with a teaching degree; however, she has never taught school. She received training in medical administration and ran a physician’s office for several years. She has very good ADL skills, which are consistent with a successful college graduate. Her IQ is well above average. Currently, she is working part-time as a medical secretary while on day passes. Before her hospitalization, she had no difficulty maintaining her home with her husband and driving her car.



7–23

KENNEDY AXIS V: SCORING SHEET © 1986–2003, Continued from previous page Name: Barbara Williams (Lakeview State Hospital)

#: 12352

Age:

34



Alcohol Abuser___

Drug Abuser X

Both___

There is evidence of moderate abuse of over-the-counter medications, such as diet pills and laxatives. As a teenager, she abused marijuana and alcohol; however, this has not been a problem for many years. She smokes about one pack a day.

6. Medical Impairment 100 ___95 ___90 ___85 ___80 ___75 ___70 X 65 ___60 ___55 ___50 ___45 ___40 ___35 ___30 ___25 ___20 ___15 ___10 ___5 ___ 100 95 90 90 85 80 75 75 70 70 65 60 55 55 40 35 25 15 5 50 Despite years of abusing her body through starvation, electrolyte imbalance, and the like, she is in fairly good health. Periodically she does have some problems with gastritis; however, there is no significant evidence that she has the food intolerances that she claims. Any food intolerances that she claims to have are felt to be psychological problems and malingering rather than actual physical problems. It is felt that she greatly exaggerates and feigns symptoms to avoid eating.

7. Ancillary Impairment (optional) 100 ___95 ___90 ___85 ___80 ___75 ___70 ___65 ___60 ___55 ___50 X 45 ___40 ___35 ___30 ___25 ___20 ___15 ___10 ___5 ___ 100 95 90 85 80 75 70 65 60 55 45 40 35 30 25 20 15 10 5 50 Ongoing consultations with pt.’s medical guardian and court are being made for various permissions to provide pt. with needed psychiatric treatment. She and her husband, a schoolteacher, have ongoing financial difficulties as a result of her years of soaring medical expenses. This situation appears to be causing them to lose their home.

GAF Equivalent:

#1

10

+ #2

70

+ #3

50

+ #4

95



= 225 /

4

=

55

15 Date:

2/25/03

Notes

CHAPTER 8

PROFILES

8–1


Profiles

8–3

PROFILES CONTENTS I. Conveying Clinical Information Quickly.......................................................................................... 8–5 II. Generating Profiles Using the K Axis .............................................................................................. 8–5 III. Profiling Various Treatment Options .............................................................................................. 8–6 IV. Matching Patient Profiles to Profiles of Various Treatment Options ............................................. 8–6 V. Examples of Individual Client Profiles............................................................................................. 8–7 VI. Examples of Profiles of Groups of Patients in Treatment ............................................................. 8–13 VII. Examples of Matching Patient Profiles to Therapist or Program Profiles .................................... 8–15 A. Patient Profiles .......................................................................................................................... 8–16 B. Therapist/Program Profiles ........................................................................................................ 8–19 C. Matching Patient and Therapist/Treatment Profiles ................................................................... 8–21 VIII. References ..................................................................................................................................... 8–26


Profiles

8–5

PROFILES I. Conveying Clinical Information Quickly In the face of mounting time pressures, it is important for clinicians to be able to rapidly communicate clinical information to each other. Clinicians and administrators are also increasingly asked to match individual patients to a wide range of treatment options. More and more these decisions are reviewed and approved by administrators or managed care representatives. To allow this process to work more efficiently, it is advantageous to have clinical information organized and condensed into a form that allows for quick communication and easy understanding. This will help clinicians, administrators, and managed care reviewers to more effectively communicate with each other. Being able to quickly convey critical clinical information is a very important role of the Kennedy Axis V (K Axis) and its profiles. Traditionally, the patient’s diagnosis has been an important means of conveying clinical information in a very condensed form. The diagnosis continues to be very useful; however, the diagnosis alone is often inadequate for many clinical decisions. The diagnosis is often limited to qualitative information. Clinical scales that quantify various psychiatric symptoms and behavior can be used to condense this quantifiable information into a more manageable form. However, few instruments can easily and effectively generate global scores, as well as meaningful clinical profiles for individuals and groups of patients, individual caregivers, and treatment programs. The K Axis was developed as a possible means of filling that void. Note that information in this chapter on profiling patients will generally apply for profiling prison inmates and parolees, as well as profiling various correctional facilities and matching prison inmates to particular treatment or rehabilitation programs within a correctional facility.

II.

Generating Profiles Using the K Axis

The K Axis is excellent for generating profiles that easily and effectively convey relevant clinical information. Four factors contribute to the success of K Axis profiles: 1.

2.

3. 4.

Each subscale measures an obvious clinical area. These areas are familiar to all clinicians. Even with no training or experience using the K Axis, clinicians already have an intuitive understanding of the subscale areas. Each subscale generates a single score whose severity can be easily understood because it corresponds to DSM-IV-TR Axis V. You can further improve that intuitive feel for the severity of particular scores as you rate clients using the K Axis and communicate with colleagues about the K Axis scores. Only the seven subscale scores are needed to convey a surprisingly complete clinical picture. They create a visually simple profile that can often be easily understood with just a glance. The K Axis is a universal questionnaire (i.e., it can be used to measure the level of functioning of anyone, from the lowest to the highest level of functioning, regardless of the person’s diagnosis or lack of a diagnosis).

These four factors make profiles created from the K Axis a powerful way to quickly convey clinical information. Therefore, once created, these profiles can visually represent a tremendous amount of clinical information about an individual patient or group of patients. To generate the profiles, simply use a line or bar graph to represent the seven subscales scores. You can also display the GAF Equivalent and Dangerousness Level scores on that graph. These profiles can be developed for individual patients or groups of patients or for various treatment options. Examples of these graphs or profiles are presented later in this chapter.

8–6


III. Profiling Various Treatment Options Profiles can be generated that, along with the patient’s diagnosis, can help portray the types of patients best treated with a particular treatment option or combination of treatment options. These profiles could be used to illustrate the following three treatment options: 1.

2.

3.

Individual caregiver (e.g., primary therapist, case manager, group therapist, psychiatric nurse): Each profile represents the types of patients assigned to a particular caregiver(s) and, subsequently, the types of treatment that had the best treatment outcome. This strategy could be used to help match a patient to a particular therapist or to a therapist with a particular treatment approach, such as behavior therapy. Therapeutic group activity (e.g., anger management group, substance abuse group, social skills group, vocational training group): Each profile represents the types of patients that were assigned to a particular set of therapeutic group activities and subsequently those that had the best treatment outcome. This strategy could be used to help match a patient to a particular therapeutic group activity. Health care agency or facility (e.g., clinic, community residence, community shelter, community drop-in program, specialty ward within a hospital): Each profile represents the types of patients that were accepted into a particular treatment facility and that subsequently had the best treatment outcome. This strategy could be used to help match a patient to a particular health care agency or facility.

The K Axis profiles could be used to capture profiles of those patients successfully treated by various therapists, treatment groups, or treatment facilities. Along the same line, the K Axis profiles may be used to profile those patients who are successfully treated when provided a particular level of care, including staffing requirements. This can be very helpful when trying to match patients to specific treatment options or trying to determine what staff resources are needed to meet the patient’s clinical needs. Because of long waiting lists, it is not unusual for clients to simply be assigned to the next available opening within a range of program activities or to the next bed within a range of treatment facilities. The K Axis score may allow clinicians to be more informed about matching their patients to specific treatment options. This may help to move resources toward those treatments that have the greatest beneficial effects and, therefore, reduce or eliminate waiting lists for the more effective treatments.

IV.

Matching Patient Profiles to Profiles of Various Treatment Options

Once individual patient profiles and profiles of patients successfully treated with various treatment options have been generated, it is possible to match individual patients to particular treatments by matching each patient profile to the profiles of various treatment options. This strategy can be used to look for a best fit between patient and treatment. This information could be valuable to those who screen and refer patients for the most appropriate care (i.e., those who triage patients). Matching a patient to a particular treatment makes sense only when there are a number of treatment options. If you are discharging a patient who has a problem with substance abuse and there is only one substance abuse treatment program available, then profiling that program does not make much sense. However, if there are a large number of treatment options, then matching profiles of patients to various treatment options can be a very effective screening tool to help determine which treatment options may be best for your patients. In the next two sections of this chapter, a number of profiles are presented that can be generated using the K Axis. These profiles illustrate the following:

• •

Individual clients, including patients and prison inmates Groups of clients (If the outcome is known for particular treatments on individual clients within a group, group profiles of the successfully treated clients can be generated. These

Profiles

8–7

profiles could include those being treated by an individual therapist or those clients being treated in particular treatment groups or facilities.) In the final section of this chapter, the individual profiles are matched to the profiles of groups of clients successfully treated with particular interventions. This section illustrates how clients can be quickly screened for referral to the best-available treatment option. This match between client and program would certainly not be the only factor to consider when triaging clients; however, it could play a key role in the triage of clients.

V.

Examples of Individual Client Profiles

A profile of an individual client can convey an instant overview of that client. This can be particularly helpful when trying to quickly screen a large number of patients or prison inmates. Graphs that demonstrate how the K Axis can be used to profile individuals are found on the following pages. Note that the K Axis can be used to profile patients with specific diagnoses. Although the K Axis profiles are at times very suggestive of a particular diagnosis, the K Axis generally cannot be used to make a specific diagnosis. In other words, patients with the same diagnosis may have similarities in their K Axis profiles; however, there is often significant overlap with other diagnoses. Four individual profiles are presented: 1. 2. 3. 4.

Normal/exceptional person (Barbara Doe) Chronic inpatient (John Doe) Difficult-to-manage patient (Jane Doe) Serial killer (Gregory Doe)

Figure 8–1 is the Kennedy Axis V scoring sheet for a normal/exceptional person (Barbara Doe). Figure 8–2 is a profile based on the Kennedy Axis V scoring sheet for Barbara Doe. This graph is intended to represent the ability of the K Axis to rate not only very impaired patients but also some of the most functional individuals within our society. Figure 8–3 demonstrates the ability of the K Axis to rate very low functioning patients. Figure 8–4 is an interesting profile because it demonstrates that strengths can be “weaknesses.” This is often seen in patients with a diagnosis of borderline personality disorder or antisocial personality disorder. These patients can be extremely difficult to treat, in part because they may have significant “strengths.” These strengths often show up in the areas of Social Skills and ADL–Occupational Skills. These patients use their strengths against staff to “successfully” fight treatment, against themselves by being effective in acting on suicidal and other self-injurious impulses, and against others by being effective in carrying out antisocial and manipulative behaviors. Such patients are often seen as their “own worst enemy.” Figure 8–5 is a Kennedy Axis V scoring sheet of a serial killer, Gregory Doe, and Figure 8–6 is his associated profile. Based on his history and his profile, he will likely be found guilty of first-degree murder. Even though he has mental problems, they do not appear to prevent him from understanding right from wrong; therefore, he is unlikely to be found not guilty by reason of insanity.

8–8


Kennedy Axis V: Scoring Sheet Name: Barbara Doe

© 1986–2003

#: N/A

Age:

46


ÄÄ FUNCTIONAL

DYSFUNCTIONAL ÅÅ

1. Psychological Impairment 100 ___95 ___90 ___85 X 80 ___75 ___70 ___65 ___60 ___55 ___50 ___45 ___40 ___35 ___30 ___25 ___20 ___15 ___10 ___5 ___ 100 95 90 90 85 80 75 75 70 70 65 60 55 55 40 35 25 15 5 50 Not Impaired X



Other Impairment___

Both___

As the local high school principal, she functions well at a very demanding job; however, she feels “stressed out” at times. Her spirits are generally very good; however, at times she has some preoccupations with problems at home and at work. She has exceptional empathy and sensitivity for others. Those who know her well feel that she is a very good, honest, and sincere person.

2. Social Skills 100 X 95 ___90 ___85 ___80 ___75 ___70 ___65 ___60 ___55 ___50 ___45 ___40 ___35 ___30 ___25 ___20 ___15 ___10 ___5 ___ 100 95 90 90 85 80 75 70 65 65 60 55 45 40 30 25 20 15 5 50 She has exceptional social and communication skills. She relates extremely well to a wide range of people in a wide range of situations. She has many friends and has no difficulty making new friends. Her excellent social skills are demonstrated by her prevention of or resolution of conflicts at work and at home.

3. Violence 100 ___95 ___90 ___85 ___80 X 75 ___70 ___65 ___60 ___55 ___50 ___45 ___40 ___35 ___30 ___25 ___20 ___15 ___10 ___5 ___ 100 95 90 85 80 75 70 65 60 55 45 40 35 30 25 20 15 10 5 50 Nonviolent X


Violent to Self___



She is known to be a tough negotiator; however, she has never been threatening or violent. She has somewhat of a temper; however, she hides it well. Her occasional, minor blowups with a family member or colleague are expectable reactions to family and professional stressors. No suicidal ideation.

4. ADL–Occupational Skills 100 X 95 ___90 ___85 ___80 ___75 ___70 ___65 ___60 ___55 ___50 ___45 ___40 ___35 ___30 ___25 ___20 ___15 ___10 ___5 ___ 100 95 90 90 85 80 75 75 70 70 65 60 55 55 40 35 25 15 5 50 Superior ADL–occupational functioning. She is a college graduate who is functioning extremely well in a job that would tax the skills of even the most successful college graduate.

5. Substance Abuse 100 ___95 ___90 X 85 ___80 ___75 ___70 ___65 ___60 ___55 ___50 ___45 ___40 ___35 ___30 ___25 ___20 ___15 ___10 ___5 ___ 100 95 90 85 80 75 70 65 60 55 45 40 35 30 25 20 15 10 5 50 Nonabuser X


Alcohol Abuser___

Drug Abuser___

Both___

Social drinker. Nonsmoker. She is embarrassed by the fact that she occasionally used marijuana many years ago. She is now very much against the use of any illegal drugs, including marijuana.

6. Medical Impairment 100 ___95 X 90 ___85 ___80 ___75 ___70 ___65 ___60 ___55 ___50 ___45 ___40 ___35 ___30 ___25 ___20 ___15 ___10 ___5 ___ 100 95 90 90 85 80 75 75 70 70 65 60 55 55 40 35 25 15 5 50 She has good medical health. She is within the ideal body weight. She exercises regularly (jogging and tennis). She wears glasses. She almost never misses work due to illness. She takes no medications.

7. Ancillary Impairment (optional) 100 ___95 ___90 ___85 ___80 ___75 ___70 ___65 ___60 ___55 ___50 ___45 ___40 ___35 ___30 ___25 ___20 ___15 ___10 ___5 ___ 100 95 90 85 80 75 70 65 60 55 45 40 35 30 25 20 15 10 5 50 NR

GAF Equivalent:

#1

85

+ #2 100

+ #3

80

+ #4 100


Figure 8–1.


= 365 /

4

=

90

80 Date:

Kennedy Axis V scoring sheet for a normal/exceptional person (Barbara Doe).

9/14/03

Profiles

8–9

100

Î Functional

90

Dysfunctional

80

Ï

70 60 50 40 30 20 10 0 PSY

Figure 8–2.

SOC

VIO

ADL

SAb

MED

Profile for a normal/exceptional person (Barbara Doe) using the K Axis.

100

Î

90

Functional Dysfunctional

80

Ï

70 60 50 40 30 20 10 0 PSY

SOC

VIO

ADL

SAb

MED

Figure 8–3. Profile for a chronic inpatient (John Doe) using the K Axis and demonstrating that the K Axis can be used to rate very low functioning patients.

8–10


100

Î

90


80

Ï

70 60 50 40 30 20 10 0 PSY

Figure 8–4.

SOC

VIO

ADL

SAb

MED

Profile for a difficult-to-manage patient (Jane Doe) using the K Axis.

Profiles

8–11

Kennedy Axis V: Scoring Sheet Name: Gregory Doe

© 1986–2003

#: N/A

Age:

34


ÄÄ FUNCTIONAL

DYSFUNCTIONAL ÅÅ



Antisocially Impaired X

Other Impairment___

Both___

Inmate has severe sexual perversions characterized by sadistic, violent sexual impulses toward women. These sexual impulses can overwhelm the little empathy he has for people. He has no delusions or hallucinations. He has no significant problems with depression or anxiety.

2. Social Skills 100 X 95 ___90 ___85 ___80 ___75 ___70 ___65 ___60 ___55 ___50 ___45 ___40 ___35 ___30 ___25 ___20 ___15 ___10 ___5 ___ 100 95 90 90 85 80 75 70 65 65 60 55 45 40 30 25 20 15 5 50 Inmate appears to have excellent social skills. He can be extremely charming and engaging. He has outstanding communication skills. He has some friends and longstanding relationships. He has no difficulty making new friends; however, he often exploits anyone close to him.

3. Violence 100 ___95 ___90 ___85 ___80 ___75 ___70 ___65 ___60 ___55 ___50 ___45 ___40 ___35 ___30 ___25 ___20 ___15 ___10 ___5 X 100 95 90 85 80 75 70 65 60 55 45 40 35 30 25 20 15 10 5 50 Nonviolent___


Violent to Self___

Violent to Others X


Inmate appears to have cunningly and viciously murdered numerous women over many years. The murders appear to have been acts to satisfy overwhelming, violent, sadistic sexual impulses. He has little evidence of remorse. He is felt to be extremely likely to murder again to satisfy his sadistic sexual impulses if he gets the opportunity. Treatment is unlikely to have any impact on his dangerousness.

4. ADL–Occupational Skills 100 X 95 ___90 ___85 ___80 ___75 ___70 ___65 ___60 ___55 ___50 ___45 ___40 ___35 ___30 ___25 ___20 ___15 ___10 ___5 ___ 100 95 90 90 85 80 75 75 70 70 65 60 55 55 40 35 25 15 5 50 Inmate is very bright. For years, he has successfully avoided capture and conviction for a string of murders. He graduated from college with honors and he received an honorable discharge from the Marines. His limited employment success is due to his moving frequently from state to state to avoid capture rather than any lack of occupational skills.



Alcohol Abuser___

Drug Abuser___

Both___

Social drinker. Smokes cigarettes. Does not abuse marijuana or other street drugs.

6. Medical Impairment 100 ___95 X 90 ___85 ___80 ___75 ___70 ___65 ___60 ___55 ___50 ___45 ___40 ___35 ___30 ___25 ___20 ___15 ___10 ___5 ___ 100 95 90 90 85 80 75 75 70 70 65 60 55 55 40 35 25 15 5 50 Inmate has excellent medical health except for an occasional cough from smoking. No significant weight problem. Exercises fairly regularly. He does not take any medication and is almost never sick.

7. Ancillary Impairment (optional) 100 ___95 ___90 ___85 ___80 ___75 ___70 ___65 ___60 ___55 ___50 ___45 ___40 ___35 ___30 ___25 ___20 ___15 ___10 ___5 ___ 100 95 90 85 80 75 70 65 60 55 45 40 35 30 25 20 15 10 5 50 NR

GAF Equivalent:

#1

30

+ #2 100

+ #3

5

+ #4 100

Dangerousness Level (indicate only the most dangerous rating): James A. Kennedy, MD Signature:

Figure 8–5.

= 235 /

4

=

60

5 Date: After arrest for murder 9/15/03

Kennedy Axis V scoring sheet for a serial killer (Gregory Doe).

8–12


100

Î

90

Functional

80

Dysfunctional

70

Ï

60 50 40 30 20 10 0 PSY

Figure 8–6.

SOC

VIO

ADL

SAb

Profile for a serial killer (Gregory Doe) using the K Axis.

MED

Profiles

8–13

VI. Examples of Profiles of Groups of Patients in Treatment Profiles can be used to describe patient populations that a therapist or program serves or wishes to serve. To increase their usefulness, the profiles can be made up of only the patients successfully treated by a particular therapist or in a particular program or treatment group. They also can be used to profile patients who are not appropriate for a particular treatment or provider. Profiles can be done on patients who share a common quality or characteristic, such as diagnosis, gender, length of stay in the hospital, number of hospitalizations, and the like. For example, you can profile all the patients in a facility being treated for borderline personality disorder or who have been hospitalized for longer than 3 months. The following three groups of patients are profiled in this section of the chapter. These three profiles are based on actual clinical data from a pilot study at Worcester State Hospital (Kennedy et al. 1999): 1. 2. 3.

Chronic inpatient ward Discharge-resistant patients Patients in a long-term hospital versus long-term supportive housing

Figure 8–7 is the profile of a chronic inpatient ward at Worcester State Hospital. Figure 8–8 is the profile of patients who could not be discharged from Worcester State Hospital even after years of aggressive attempts to have them placed in the community. Figure 8–9 compares patients hospitalized at Worcester State Hospital for at least 3 years to long-term-care patients living in supportive housing in the community. This graph profiles differences between two chronic populations; the outpatient (supportive housing) is the higher-functioning population.

100

Î

90

Functional

80

Dysfunctional

70

Ï

60 50 40 30 20 10 0 PSY

Figure 8–7.

SOC

VIO

Profile of a chronic inpatient ward.

ADL

SAb

MED

8–14

Mastering the Kennedy Axis V 100

Î

90


80

Ï

70 60 50 40 30 20 10 0 PSY

Figure 8–8.

SOC

VIO

ADL

SAb

MED

Profile of discharge-resistant patients.

100

Î

90

Functional

80

Dysfunctional

70

Ï

60 50 40 30 20 10 0 PSY

Figure 8–9.

SOC

VIO

ADL

SAb

Inpatient

Supportive Housing

MED

GAF-Eq

Profiles of chronic patients: long-term hospitalization versus supportive housing.

Profiles

VII.

8–15

Examples of Matching Patient Profiles to Therapist or Program Profiles

As indicated earlier, patients are often referred to the next available therapist, treatment program, or treatment facility. Matching patient profiles to program profiles is another powerful feature of the K Axis. Program profiles can be used to describe patient populations that various programs serve or wish to serve. Patient profiles can be matched to these program profiles to help match patients with programs that are more likely to effectively treat their particular problems. Adding this to the triage process could be very helpful and would certainly improve on the procedure of simply placing a patient in the next available treatment slot. Matching patient profiles to profiles of patients successfully treated by various therapists or treatment situations will be most useful when there are a large number of choices. If only two therapists are available and they are well known to the clinicians making the referrals, the information presented in the profiles on these two therapists may not be very helpful. However, if there are 25 to 50 therapists in the area, it may be almost impossible for the referring clinician to differentiate one therapist from the next. In such a situation, it can be very helpful to have a K Axis profile of patients typically referred to each therapist or, ideally, those patients who are successfully treated by each therapist. The profile also should be accompanied by a statement as to whether the therapist or program specializes in working with various diagnostic groups or patients with particular problems or symptoms. In other words, a K Axis profile of the patients that a particular therapist or program treats successfully can provide important additional information when considering a patient for referral to a specific therapist or program. Similarly, if an agency or therapist cannot successfully provide treatment to particular groups of patients, such as very dysfunctional patients who score below a certain level in particular clinical areas, consideration should be given to diverting these patients to another, more appropriate treatment facility or therapist. For example, an agency using confrontational group methods to treat substance abuse may be unable to successfully treat patients who have great difficulty understanding and coping with the complicated and intimidating social interactions often found in such groups. Potential clients may require a certain minimal score in the subscale area of Social Skills to be accepted into such a program. A particular score on Social Skills may act as a cutoff point for acceptance into their group. If there is no cutoff point or “admission barrier,” clients without adequate social skills may be accepted into these groups. These clients may then have great difficulty handling the social pressures in these groups or may totally misinterpret what is happening in these groups. This may lead to deterioration in the client’s symptoms rather than improvement. To best illustrate profiles of groups of clients that individual patients will be matched to, the median in each subscale is used in conjunction with the “interquartile range.” The median is the middle score in a series of scores. The interquartile range is the 25% of clients on each side of the median (i.e., 50% of the total scores). The median and interquartile range are believed to quickly convey an intuitive understanding of the spread of the scores in a data set. In this situation, they are thought to be better than the standard deviation because the standard deviation works best with data that fit a normal curve (bell-shaped curve); however, it is not unusual for the subscale scores to be skewed. Equally important, both the median and interquartile range can be calculated easily without having to resort to any complicated data analysis. For example, in the following set of scores, the median is 55 and the interquartile range is 40 to 75: 30

30

30

{40 Ä

40

55 55 65 Middle 50%

75} Å

75

85

95

In the next set of scores, the median is 45 and the interquartile range is 30 to 85. 25

25

25

30

{30 Ä

30

40

40 45 55 Middle 50%

65

75

85} Å

85

90

90

90

8–16


In the next set of scores, the median is 80 and the interquartile range is 75 to 85. 45

55

65

70

75

{75

Ä

75

75

80

80 80 Middle 50%

85

85

85

85} Å

90

90

90

90

95

Later, the median and interquartile range are used to illustrate clients successfully treated in four profiles of available treatment options. Five patient profiles are overlaid onto these four therapist/program profiles to determine whether there is a match for the individual patients. A. Patient Profiles The following five profiles of individual patients are based on a combination of actual clinical data and years of clinical experience: 1. 2. 3. 4. 5.

Mildly depressed patient (Figure 8–10) Typical inpatient schizophrenic patient (Figure 8–11) Patient with severe schizophrenia (Figure 8–12) Patient with borderline personality disorder (Figure 8–13) Antisocial, violent, alcoholic patient (Figure 8–14)

100

Î

90


80

Ï

70 60 50 40 30 20 10 0 PSY

Figure 8–10.

SOC

VIO

ADL

SAb

Profile based on the K Axis of a mildly depressed patient.

MED

Profiles

8–17

100

Î

90


80

Ï

70 60 50 40 30 20 10 0 PSY

Figure 8–11.

SOC

VIO

ADL

SAb

MED

Profile based on the K Axis of a typical inpatient schizophrenic patient.

100

Î

90


80

Ï

70 60 50 40 30 20 10 0 PSY

Figure 8–12.

SOC

VIO

ADL

SAb

MED

Profile based on the K Axis of a patient with severe schizophrenia.

8–18


100

Î

90

Functional

80

Dysfunctional

Ï

70 60 50 40 30 20 10 0 PSY

Figure 8–13.

SOC

VIO

ADL

SAb

MED

Profile based on the K Axis of a patient with borderline personality disorder.

100

Î

90


80

Ï

70 60 50 40 30 20 10 0 PSY

Figure 8–14.

SOC

VIO

ADL

SAb

MED

Profile based on the K Axis of an antisocial, violent, alcoholic patient.

Profiles

8–19

B. Therapist/Program Profiles The following therapist/program profiles are presented next: 1. 2. 3. 4.

Outpatient therapist (Figure 8–15) Outpatient supportive-housing units (Figure 8–16) Inpatient long-term ward (Figure 8–17) Inpatient dual-diagnosis group (Figure 8–18)

The profiles represent the median and the interquartile range of successfully treated clients.

100

Î

90


80

Ï

70 60 50 40 30 20 High Range Median

10

Low Range

0 PSY

Figure 8–15.

SOC

VIO

ADL

SAb

MED

Profile based on the K Axis of patients seen by an outpatient therapist.

8–20


100

Î

90


80

Ï


10

Low Range

0 PSY

Figure 8–16.

SOC

VIO

ADL

SAb

MED

Profile based on the K Axis of outpatient supportive-housing units.

100

Î

90


80

Ï

70 60 50 40 30 20 High Range

10

Median Low Range

0 PSY

Figure 8–17.

SOC

VIO

ADL

SAb

Profile based on the K Axis of an inpatient long-term ward.

MED

Profiles

8–21

100

Î

90


80

Ï

70 60 50 40 30 20 High Range

10

Median Low Range

0 PSY

Figure 8–18.

SOC

VIO

ADL

SAb

MED

Profile based on the K Axis of an inpatient dual-diagnosis group.

C. Matching Patient and Therapist/Treatment Profiles The following pages contain graphs that demonstrate how the K Axis can assist in matching patients to the specific treatment options. Each graph contains a note as to whether the patient is a reasonable match to the treatment.

8–22


100

Î

—— Mildly depressed patient

Functional

90

Dysfunctional 80

Ï


10

Low Range

0 PSY

SOC

VIO

ADL

SAb

MED

Figure 8–19. Profile based on the K Axis of patients seen by an outpatient therapist overlaid with the patient profile of a mildly depressed patient. This patient is a good match for this therapist. 100

Î

—— Patient with severe schizophrenia

Functional

90

Dysfunctional 80

Ï

70 60 50 40 30 20 High Range Median Low Range

10 0 PSY

SOC

VIO

ADL

SAb

MED

Profile based on the K Axis of patients seen by an outpatient therapist overlaid with the patient profile of a patient with severe schizophrenia. This patient is not a good match for this therapist because the patient is too low functioning for outpatient treatment. Figure 8–20.

Profiles

8–23

100

Î

—— Antisocial, violent, alcoholic patient

Functional

90

Dysfunctional 80

Ï

70 60 50 40 30 20 High Range Median Low Range

10 0 PSY

SOC

VIO

ADL

SAb

MED

Figure 8–21. Profile based on the K Axis of patients seen by an outpatient therapist overlaid with the patient profile of an antisocial, violent, alcoholic patient. This patient is not a good match for this therapist because the therapist is unable to handle the patient’s violence and substance abuse.

Î

100 —— Mildly depressed patient

Functional

90

Dysfunctional 80

Ï

70 60 50 40 30 20 High Range

10

Median Low Range

0 PSY

SOC

VIO

ADL

SAb

MED

Figure 8–22. Profile based on the K Axis of an inpatient long-term ward overlaid with the patient profile of a mildly depressed patient. The inpatient ward is not a match for this patient. Therapy should probably be conducted on an outpatient basis.

8–24


Î

100 —— Borderline personality disorder patient

Functional

90

Dysfunctional 80

Ï

70 60 50 40 30 20 High Range

10

Median Low Range

0 PSY

SOC

VIO

ADL

SAb

MED

Figure 8–23. Profile based on the K Axis of an inpatient long-term ward overlaid with the patient profile of a patient with borderline personality disorder. The inpatient ward is a good match for this patient.

100

Î

—— Typical patient with schizophrenia

Functional

90

Dysfunctional 80

Ï

70 60 50 40 30 20 High Range

10

Median Low Range

0 PSY

SOC

VIO

ADL

SAb

MED

Figure 8–24. Profile based on the K Axis of an inpatient long-term ward overlaid with the patient profile of a typical patient with schizophrenia. The inpatient ward is a good match for this patient.

Profiles

8–25

100 90

Î

—— Patient with severe schizophrenia


80

Ï

70 60 50 40 30 20

High Range 10

Median Low Range

0 PSY

SOC

VIO

ADL

SAb

MED

Figure 8–25. Profile based on the K Axis of an inpatient long-term ward overlaid with the patient profile of a patient with severe schizophrenia. This patient may be treated better on a ward for lower-functioning patients. 100 —— Antisocial, violent, alcoholic patient

Î

90

Functional

80

Dysfunctional

70

Ï

60 50 40 30 20 High Range Median Low Range

10 0 PSY

SOC

VIO

ADL

SAb

MED

Figure 8–26. Profile based on the K Axis of an inpatient dual-diagnosis group overlaid with the patient profile of an antisocial, violent, alcoholic patient. This patient is possibly too violent and too high functioning for this group.

8–26


100

Î

—— Borderline personality disorder patient

Functional

90

Dysfunctional 80

Ï

70 60 50 40 30 20 10

High Range Median

0

Low Range PSY

SOC

VIO

ADL

SAb

MED

Figure 8–27. Profile based on the K Axis of an inpatient dual-diagnosis group overlaid with the patient profile of a patient with borderline personality disorder. This patient is a fair match but has fewer problems with substance abuse.

VIII. References Kennedy JA, Fisher W, Skog S: Kennedy Axis V in Long-Term-Care Patients (Pilot). Worcester State Hospital, University of Massachusetts Medical Center, Worcester, MA, and the Massachusetts Department of Mental Health, unpublished data, 1999

APPENDIX

A–1


Appendix

A–3

APPENDIX CONTENTS I. Spreadsheets for the K Axis Ratings in the Book ............................................................................A–5 II. Problem-Oriented Progress Notes Using the K Axis .....................................................................A–17 III. Comprehensive Psychiatric Assessment Using the K Axis.............................................................A–21 IV. Kennedy NOSIE and Guide ...........................................................................................................A–24 V. References .....................................................................................................................................A–32


Appendix

A–5

APPENDIX I.

Spreadsheets for the K Axis Ratings in the Book

The K Axis scores can be entered into a spreadsheet easily. Clients can then be sorted from least to most impaired in each of the seven subscales, as well as by the GAF Equivalent and Dangerousness Level values. To demonstrate this, the K Axis ratings from Chapters 6, 7, and 8 were entered into spreadsheets and are displayed on the following pages. Once you have sorted records on your patients, you and your staff may find it helpful to review these sorted ratings. This can quickly point out inconsistencies; that is, it may be obvious that particular patients, when compared with other patients, are more or less impaired in various subscale areas than their individual ratings indicate. Exploring these inconsistencies can often act as an important check for the accuracy of the ratings and provide an excellent training exercise. The importance of using spreadsheets to check the accuracy of K Axis ratings and as a training exercise cannot be overstated. Putting your K Axis ratings into spreadsheets is highly recommended.

A–6


Kennedy Axis V—Sorted by Name Name

Age

PSY

SOC

VIO

ADL SAb

MED

ANC GAF Eq

DL

Chapter

Abbott, George

35

100

90

90

90

80

90

90

95

80

6

Allen, Diane

27

70

90

80

90

90

90

Anderson, Susan

34

30

60

60

50

90

65

20

85

20

6

60

50

50

7

Brown, Keith

55

30

45

40

25

80

Brown, Patricia

35

30

60

70

50

50

70

80

35

40

6, 7

90

90

55

50

6, 7

Butler, Eleanor

47

40

50

60

50

80

60

70

50

55

6

Caruso, Janice

33

65

70

90

80

80

80

90

75

75

6

Cross, Anthony

24

45

60

50

80

95

70

80

60

50

7

Davis, Richard

45

20

35

50

25

80

80

70

35

35

6

Davis, Robert

58

50

80

50

50

25

40

80

60

25

6

Doe, Barbara

46

85

100

80

100

90

95

NR

90

80

8

Doe, Gregory

34

30

100

5

100

80

95

NR

60

5

8

Graham, Ronald

37

30

90

50

95

60

90

20

65

20

6, 7

Griffin, Paul

30

40

50

40

55

30

70

50

45

30

6

Hope, Allen

56

50

45

55

50

65

35

70

50

55

6

Jacobs, Joseph

27

40

35

70

50

80

90

80

50

45

6, 7

Johnson, Helen

62

40

50

70

40

80

90

70

50

55

6, 7

Jones, Joseph

49

40

45

25

50

100

60

70

40

25

7

Lane, Barbara

25

40

50

30

60

30

70

40

50

30

6

Mann, William

47

15

10

50

20

50

60

80

25

15

6

Moore, Natalie

14

40

80

10

90

60

90

60

55

10

7

Morgan, Albert

24

40

70

80

75

80

80

80

65

55

7

Palmer, Brenda

37

30

50

30

60

70

80

70

40

30

6

Palmer, John

44

40

50

70

50

50

80

70

55

50

6

Powers, Jennifer

35

90

100

100

100

100

100

100

100

90

6

Renaldo, Alice

24

50

80

70

90

90

70

90

70

65

6

Robbins, Clyde

48

30

50

5

50

80

80

80

35

5

6

Rosenthal, William

51

20

10

45

20

70

40

70

25

15

6

Sawyer, Barbara

42

50

80

50

60

80

50

80

60

50

6

Scott, David

50

40

75

50

75

60

70

70

60

50

6

Sellers, Mark

63

30

45

40

30

85

40

80

35

40

6

Smith, Janet

64

60

60

70

30

70

30

90

55

50

7

Smith, Mark

38

35

50

70

50

80

70

60

50

55

6

Stewart, Helen

58

70

90

70

90

100

20

90

80

35

6

White, Janet

43

75

70

90

85

80

85

65

80

65

6

Williams, Barbara

34

10

70

50

95

60

70

50

55

15

6, 7

Woods, Gilbert

28

20

35

35

30

90

90

70

30

35

6

Young, Jacqueline

6

95

95

95

95

100

60

100

95

70

7

40

46

63

56

63

74

71

72

57

43

Average

In Chapter 6, only those scores in bold have a problem description/vignette. In Chapters 7 and 8, all scores have an accompanying problem description.

Appendix

A–7

Kennedy Axis V—Sorted by Age Name

Age

PSY

SOC

VIO

Young, Jacqueline

6

95

95

95

ADL SAb

Moore, Natalie

14

40

80

10

90

Cross, Anthony

24

45

60

50

80

Morgan, Albert

24

40

70

80

75

80

Renaldo, Alice

24

50

80

70

90

90

70

90

70

65

6

Lane, Barbara

25

40

50

30

60

30

70

40

50

30

6

95

DL

Chapter

60

100

95

70

7

60

90

60

55

10

7

95

70

80

60

50

7

80

80

65

55

7

100

MED

ANC GAF Eq

Allen, Diane

27

70

90

80

90

90

90

20

85

20

6

Jacobs, Joseph

27

40

35

70

50

80

90

80

50

45

6, 7

Woods, Gilbert

28

20

35

35

30

90

90

70

30

35

6

Griffin, Paul

30

40

50

40

55

30

70

50

45

30

6

Caruso, Janice

33

65

70

90

80

80

80

90

75

75

6

Anderson, Susan

34

30

60

60

50

90

65

60

50

50

7

Doe, Gregory

34

30

100

5

100

80

95

NR

60

5

8

Williams, Barbara

34

10

70

50

95

60

70

50

55

15

6, 7

Abbott, George

35

100

90

90

90

80

90

90

95

80

6

Brown, Patricia

35

30

60

70

50

50

90

90

55

50

6, 7

Powers, Jennifer

35

90

100

100

100

100

100

100

100

90

6

Graham, Ronald

37

30

90

50

95

60

90

20

65

20

6, 7

Palmer, Brenda

37

30

50

30

60

70

80

70

40

30

6

Smith, Mark

38

35

50

70

50

80

70

60

50

55

6

Sawyer, Barbara

42

50

80

50

60

80

50

80

60

50

6

White, Janet

43

75

70

90

85

80

85

65

80

65

6

Palmer, John

44

40

50

70

50

50

80

70

55

50

6

Davis, Richard

45

20

35

50

25

80

80

70

35

35

6

Doe, Barbara

46

85

100

80

100

90

95

NR

90

80

8

Butler, Eleanor

47

40

50

60

50

80

60

70

50

55

6

Mann, William

47

15

10

50

20

50

60

80

25

15

6

Robbins, Clyde

48

30

50

5

50

80

80

80

35

5

6

Jones, Joseph

49

40

45

25

50

100

60

70

40

25

7

Scott, David

50

40

75

50

75

60

70

70

60

50

6

Rosenthal, William

51

20

10

45

20

70

40

70

25

15

6

Brown, Keith

55

30

45

40

25

80

70

80

35

40

6, 7

Hope, Allen

56

50

45

55

50

65

35

70

50

55

6

Davis, Robert

58

50

80

50

50

25

40

80

60

25

6

Stewart, Helen

58

70

90

70

90

100

20

90

80

35

6

Johnson, Helen

62

40

50

70

40

80

90

70

50

55

6, 7

Sellers, Mark

63

30

45

40

30

85

40

80

35

40

6

Smith, Janet

64

60

60

70

30

70

30

90

55

50

7

Average

40

46

63

56

63

74

71

72

57

43


A–8


Kennedy Axis V—Sorted by Psychological Impairment Name

Age

PSY

SOC

VIO

34

10

70

50

Mann, William

47

15

10

50

20

50

60

80

25

15

6

Davis, Richard

45

20

35

50

25

80

80

70

35

35

6

Rosenthal, William

51

20

10

45

20

70

40

70

25

15

6

Woods, Gilbert

28

20

35

35

30

90

90

70

30

35

6

Williams, Barbara

ADL SAb 95

60

MED 70

ANC GAF Eq 50

55

DL

Chapter

15

6, 7

Anderson, Susan

34

30

60

60

50

90

65

60

50

50

7

Brown, Keith

55

30

45

40

25

80

70

80

35

40

6, 7

Brown, Patricia

35

30

60

70

50

50

90

90

55

50

6, 7

Doe, Gregory

34

30

100

5

100

80

95

NR

60

5

8

Graham, Ronald

37

30

90

50

95

60

90

20

65

20

6, 7

Palmer, Brenda

37

30

50

30

60

70

80

70

40

30

6

Robbins, Clyde

48

30

50

5

50

80

80

80

35

5

6

Sellers, Mark

63

30

45

40

30

85

40

80

35

40

6

Smith, Mark

38

35

50

70

50

80

70

60

50

55

6

Butler, Eleanor

47

40

50

60

50

80

60

70

50

55

6

Griffin, Paul

30

40

50

40

55

30

70

50

45

30

6

Jacobs, Joseph

27

40

35

70

50

80

90

80

50

45

6, 7

Johnson, Helen

62

40

50

70

40

80

90

70

50

55

6, 7

Jones, Joseph

49

40

45

25

50

100

60

70

40

25

7

Lane, Barbara

25

40

50

30

60

30

70

40

50

30

6

Moore, Natalie

14

40

80

10

90

60

90

60

55

10

7

Morgan, Albert

24

40

70

80

75

80

80

80

65

55

7

Palmer, John

44

40

50

70

50

50

80

70

55

50

6

Scott, David

50

40

75

50

75

60

70

70

60

50

6

Cross, Anthony

24

45

60

50

80

95

70

80

60

50

7

Davis, Robert

58

50

80

50

50

25

40

80

60

25

6

Hope, Allen

56

50

45

55

50

65

35

70

50

55

6

Renaldo, Alice

24

50

80

70

90

90

70

90

70

65

6

Sawyer, Barbara

42

50

80

50

60

80

50

80

60

50

6

Smith, Janet

64

60

60

70

30

70

30

90

55

50

7

Caruso, Janice

33

65

70

90

80

80

80

90

75

75

6

Allen, Diane

27

70

90

80

90

90

90

20

85

20

6

Stewart, Helen

58

70

90

70

90

100

20

90

80

35

6

White, Janet

43

75

70

90

85

80

85

65

80

65

6

Doe, Barbara

46

85

100

80

100

90

95

NR

90

80

8

Powers, Jennifer

35

90

100

100

100

100

100

100

100

90

6

Young, Jacqueline

6

95

95

95

95

100

60

100

95

70

7

Abbott, George

35

100

90

90

90

80

90

90

95

80

6

Average

40

46

63

56

63

74

71

72

57

43


Appendix

A–9

Kennedy Axis V—Sorted by Social Skills Name

Age

PSY

SOC

VIO

47

15

10

50

20

50

Rosenthal, William

51

20

10

45

20

Davis, Richard

45

20

35

50

25

Jacobs, Joseph

27

40

35

70

50

80

90

80

Woods, Gilbert

28

20

35

35

30

90

90

70

Brown, Keith

55

30

45

40

25

80

70

80

Hope, Allen

56

50

45

55

50

65

35

70

Mann, William

ADL SAb

MED

ANC GAF Eq 25

DL

Chapter

15

6

60

80

70

40

70

25

15

6

80

80

70

35

35

6

50

45

6, 7

30

35

6

35

40

6, 7

50

55

6

Jones, Joseph

49

40

45

25

50

100

60

70

40

25

7

Sellers, Mark

63

30

45

40

30

85

40

80

35

40

6

Butler, Eleanor

47

40

50

60

50

80

60

70

50

55

6

Griffin, Paul

30

40

50

40

55

30

70

50

45

30

6

Johnson, Helen

62

40

50

70

40

80

90

70

50

55

6, 7

Lane, Barbara

25

40

50

30

60

30

70

40

50

30

6

Palmer, Brenda

37

30

50

30

60

70

80

70

40

30

6

Palmer, John

44

40

50

70

50

50

80

70

55

50

6

Robbins, Clyde

48

30

50

5

50

80

80

80

35

5

6

Smith, Mark

38

35

50

70

50

80

70

60

50

55

6

Anderson, Susan

34

30

60

60

50

90

65

60

50

50

7

Brown, Patricia

35

30

60

70

50

50

90

90

55

50

6, 7

Cross, Anthony

24

45

60

50

80

95

70

80

60

50

7

Smith, Janet

64

60

60

70

30

70

30

90

55

50

7

Caruso, Janice

33

65

70

90

80

80

80

90

75

75

6

Morgan, Albert

24

40

70

80

75

80

80

80

65

55

7

White, Janet

43

75

70

90

85

80

85

65

80

65

6

Williams, Barbara

34

10

70

50

95

60

70

50

55

15

6, 7

Scott, David

50

40

75

50

75

60

70

70

60

50

6

Davis, Robert

58

50

80

50

50

25

40

80

60

25

6

Moore, Natalie

14

40

80

10

90

60

90

60

55

10

7

Renaldo, Alice

24

50

80

70

90

90

70

90

70

65

6

Sawyer, Barbara

42

50

80

50

60

80

50

80

60

50

6

Abbott, George

35

100

90

90

90

80

90

90

95

80

6

Allen, Diane

27

70

90

80

90

90

90

20

85

20

6

Graham, Ronald

37

30

90

50

95

60

90

20

65

20

6, 7

Stewart, Helen

58

70

90

70

90

100

20

90

80

35

6

Young, Jacqueline

6

95

95

95

95

100

60

100

95

70

7

Doe, Barbara

46

85

100

80

100

90

95

NR

90

80

8

Doe, Gregory

34

30

100

5

100

80

95

NR

60

5

8

Powers, Jennifer

35

90

100

100

100

100

100

100

100

90

6

Average

40

46

63

56

63

74

71

72

57

43


A–10


Kennedy Axis V—Sorted by Violence Name Doe, Gregory

Age

PSY

SOC

VIO

34

30

100

5

ADL SAb 100

80

MED 95

ANC GAF Eq NR

60

DL

Chapter

5

8

Robbins, Clyde

48

30

50

5

50

80

80

80

35

5

6

Moore, Natalie

14

40

80

10

90

60

90

60

55

10

7

Jones, Joseph

49

40

45

25

50

100

60

70

40

25

7

Lane, Barbara

25

40

50

30

60

30

70

40

50

30

6

Palmer, Brenda

37

30

50

30

60

70

80

70

40

30

6

Woods, Gilbert

28

20

35

35

30

90

90

70

30

35

6

Brown, Keith

55

30

45

40

25

80

70

80

35

40

6, 7

Griffin, Paul

30

40

50

40

55

30

70

50

45

30

6

Sellers, Mark

63

30

45

40

30

85

40

80

35

40

6

Rosenthal, William

51

20

10

45

20

70

40

70

25

15

6

Cross, Anthony

24

45

60

50

80

95

70

80

60

50

7

Davis, Richard

45

20

35

50

25

80

80

70

35

35

6

Davis, Robert

58

50

80

50

50

25

40

80

60

25

6

Graham, Ronald

37

30

90

50

95

60

90

20

65

20

6, 7

Mann, William

47

15

10

50

20

50

60

80

25

15

6

Sawyer, Barbara

42

50

80

50

60

80

50

80

60

50

6

Scott, David

50

40

75

50

75

60

70

70

60

50

6

Williams, Barbara

34

10

70

50

95

60

70

50

55

15

6, 7

Hope, Allen

56

50

45

55

50

65

35

70

50

55

6

Anderson, Susan

34

30

60

60

50

90

65

60

50

50

7

Butler, Eleanor

47

40

50

60

50

80

60

70

50

55

6

Brown, Patricia

35

30

60

70

50

50

90

90

55

50

6, 7

Jacobs, Joseph

27

40

35

70

50

80

90

80

50

45

6, 7

Johnson, Helen

62

40

50

70

40

80

90

70

50

55

6, 7

Palmer, John

44

40

50

70

50

50

80

70

55

50

6

Renaldo, Alice

24

50

80

70

90

90

70

90

70

65

6

Smith, Janet

64

60

60

70

30

70

30

90

55

50

7

Smith, Mark

38

35

50

70

50

80

70

60

50

55

6

Stewart, Helen

58

70

90

70

90

100

20

90

80

35

6

Allen, Diane

27

70

90

80

90

90

90

20

85

20

6

Doe, Barbara

46

85

100

80

100

90

95

NR

90

80

8

Morgan, Albert

24

40

70

80

75

80

80

80

65

55

7

Abbott, George

35

100

90

90

90

80

90

90

95

80

6

Caruso, Janice

33

65

70

90

80

80

80

90

75

75

6

White, Janet

43

75

70

90

85

80

85

65

80

65

6

Young, Jacqueline

6

95

95

95

95

100

60

100

95

70

7

Powers, Jennifer

35

90

100

100

100

100

100

100

100

90

6

Average

40

46

63

56

63

74

71

72

57

43


Appendix

A–11

Kennedy Axis V—Sorted by ADL–Occupational Skills Name

Age

PSY

SOC

VIO

47

15

10

50

20

50

Rosenthal, William

51

20

10

45

20

70

Brown, Keith

55

30

45

40

25

80

Davis, Richard

45

20

35

50

25

80

Sellers, Mark

63

30

45

40

30

85

Smith, Janet

64

60

60

70

30

Woods, Gilbert

28

20

35

35

30

Johnson, Helen

62

40

50

70

40

Anderson, Susan

34

30

60

60

50

Brown, Patricia

35

30

60

70

50

Butler, Eleanor

47

40

50

60

50

Davis, Robert

58

50

80

50

50

25

40

80

60

25

6

Hope, Allen

56

50

45

55

50

65

35

70

50

55

6

Jacobs, Joseph

27

40

35

70

50

80

90

80

50

45

6, 7

Jones, Joseph

49

40

45

25

50

100

60

70

40

25

7

Palmer, John

44

40

50

70

50

50

80

70

55

50

6

Mann, William

ADL SAb

MED 60

ANC GAF Eq

DL

Chapter 6

80

25

15

40

70

25

15

6

70

80

35

40

6, 7

80

70

35

35

6

40

80

35

40

6

70

30

90

55

50

7

90

90

70

30

35

6

80

90

70

50

55

6, 7

90

65

60

50

50

7

50

90

90

55

50

6, 7

80

60

70

50

55

6

Robbins, Clyde

48

30

50

5

50

80

80

80

35

5

6

Smith, Mark

38

35

50

70

50

80

70

60

50

55

6

Griffin, Paul

30

40

50

40

55

30

70

50

45

30

6

Lane, Barbara

25

40

50

30

60

30

70

40

50

30

6

Palmer, Brenda

37

30

50

30

60

70

80

70

40

30

6

Sawyer, Barbara

42

50

80

50

60

80

50

80

60

50

6

Morgan, Albert

24

40

70

80

75

80

80

80

65

55

7

Scott, David

50

40

75

50

75

60

70

70

60

50

6

Caruso, Janice

33

65

70

90

80

80

80

90

75

75

6

Cross, Anthony

24

45

60

50

80

95

70

80

60

50

7

White, Janet

43

75

70

90

85

80

85

65

80

65

6

Abbott, George

35

100

90

90

90

80

90

90

95

80

6

Allen, Diane

27

70

90

80

90

90

90

20

85

20

6

Moore, Natalie

14

40

80

10

90

60

90

60

55

10

7

Renaldo, Alice

24

50

80

70

90

90

70

90

70

65

6

Stewart, Helen

58

70

90

70

90

100

20

90

80

35

6

Graham, Ronald

37

30

90

50

95

60

90

20

65

20

6, 7

Williams, Barbara

34

10

70

50

95

60

70

50

55

15

6, 7

Young, Jacqueline

6

95

95

95

95

100

60

100

95

70

7

Doe, Barbara

46

85

100

80

100

90

95

NR

90

80

8

Doe, Gregory

34

30

100

5

100

80

95

NR

60

5

8

Powers, Jennifer

35

90

100

100

100

100

100

100

100

90

6

Average

40

46

63

56

63

74

71

72

57

43


A–12


Kennedy Axis V—Sorted by Substance Abuse Name

Age

PSY

SOC

VIO

58

50

80

50

50

Griffin, Paul

30

40

50

40

Lane, Barbara

25

40

50

30

Brown, Patricia

35

30

60

Mann, William

47

15

10

Davis, Robert

ADL SAb

MED

ANC GAF Eq

DL

Chapter

25

40

80

60

25

6

55

30

70

50

45

30

6

60

30

70

40

50

30

6

70

50

50

90

90

55

50

6, 7

50

20

50

60

80

25

15

6

Palmer, John

44

40

50

70

50

50

80

70

55

50

6

Graham, Ronald

37

30

90

50

95

60

90

20

65

20

6, 7

Moore, Natalie

14

40

80

10

90

60

90

60

55

10

7

Scott, David

50

40

75

50

75

60

70

70

60

50

6

Williams, Barbara

34

10

70

50

95

60

70

50

55

15

6, 7

Hope, Allen

56

50

45

55

50

65

35

70

50

55

6

Palmer, Brenda

37

30

50

30

60

70

80

70

40

30

6

Rosenthal, William

51

20

10

45

20

70

40

70

25

15

6

Smith, Janet

64

60

60

70

30

70

30

90

55

50

7

Abbott, George

35

100

90

90

90

80

90

90

95

80

6

Brown, Keith

55

30

45

40

25

80

70

80

35

40

6, 7

Butler, Eleanor

47

40

50

60

50

80

60

70

50

55

6

Caruso, Janice

33

65

70

90

80

80

80

90

75

75

6

Davis, Richard

45

20

35

50

25

80

80

70

35

35

6

Doe, Gregory

34

30

100

5

100

80

95

NR

60

5

8

Jacobs, Joseph

27

40

35

70

50

80

90

80

50

45

6, 7

Johnson, Helen

62

40

50

70

40

80

90

70

50

55

6, 7

Morgan, Albert

24

40

70

80

75

80

80

80

65

55

7

Robbins, Clyde

48

30

50

5

50

80

80

80

35

5

6

Sawyer, Barbara

42

50

80

50

60

80

50

80

60

50

6

Smith, Mark

38

35

50

70

50

80

70

60

50

55

6

White, Janet

43

75

70

90

85

80

85

65

80

65

6

Sellers, Mark

63

30

45

40

30

85

40

80

35

40

6

Allen, Diane

27

70

90

80

90

90

90

20

85

20

6

Anderson, Susan

34

30

60

60

50

90

65

60

50

50

7

Doe, Barbara

46

85

100

80

100

90

95

NR

90

80

8

Renaldo, Alice

24

50

80

70

90

90

70

90

70

65

6

Woods, Gilbert

28

20

35

35

30

90

90

70

30

35

6

Cross, Anthony

24

45

60

50

80

95

70

80

60

50

7

Jones, Joseph

49

40

45

25

50

100

60

70

40

25

7

Powers, Jennifer

35

90

100

100

100

100

100

100

100

90

6

Stewart, Helen

58

70

90

70

90

100

20

90

80

35

6

Young, Jacqueline

6

95

95

95

95

100

60

100

95

70

7

40

46

63

56

63

74

71

72

57

43

Average


Appendix

A–13

Kennedy Axis V—Sorted by Medical Impairment Name

Age

PSY

SOC

VIO

ADL SAb

Stewart, Helen

58

70

90

70

90

100

Smith, Janet

64

60

60

70

30

Hope, Allen

56

50

45

55

50

Davis, Robert

58

50

80

50

Rosenthal, William

51

20

10

45

Sellers, Mark

63

30

45

40

30

Sawyer, Barbara

42

50

80

50

60

MED

ANC GAF Eq

DL

Chapter

20

90

80

35

6

70

30

90

55

50

7

65

35

70

50

55

6

50

25

40

80

60

25

6

20

70

40

70

25

15

6

85

40

80

35

40

6

80

50

80

60

50

6

Butler, Eleanor

47

40

50

60

50

80

60

70

50

55

6

Jones, Joseph

49

40

45

25

50

100

60

70

40

25

7

Mann, William

47

15

10

50

20

50

60

80

25

15

6

Young, Jacqueline

6

95

95

95

95

100

60

100

95

70

7

Anderson, Susan

34

30

60

60

50

90

65

60

50

50

7

Brown, Keith

55

30

45

40

25

80

70

80

35

40

6, 7

Cross, Anthony

24

45

60

50

80

95

70

80

60

50

7

Griffin, Paul

30

40

50

40

55

30

70

50

45

30

6

Lane, Barbara

25

40

50

30

60

30

70

40

50

30

6

Renaldo, Alice

24

50

80

70

90

90

70

90

70

65

6

Scott, David

50

40

75

50

75

60

70

70

60

50

6

Smith, Mark

38

35

50

70

50

80

70

60

50

55

6

Williams, Barbara

34

10

70

50

95

60

70

50

55

15

6, 7

Caruso, Janice

33

65

70

90

80

80

80

90

75

75

6

Davis, Richard

45

20

35

50

25

80

80

70

35

35

6

Morgan, Albert

24

40

70

80

75

80

80

80

65

55

7

Palmer, Brenda

37

30

50

30

60

70

80

70

40

30

6

Palmer, John

44

40

50

70

50

50

80

70

55

50

6

Robbins, Clyde

48

30

50

5

50

80

80

80

35

5

6

White, Janet

43

75

70

90

85

80

85

65

80

65

6

Abbott, George

35

100

90

90

90

80

90

90

95

80

6

Allen, Diane

27

70

90

80

90

90

90

20

85

20

6

Brown, Patricia

35

30

60

70

50

50

90

90

55

50

6, 7

Graham, Ronald

37

30

90

50

95

60

90

20

65

20

6, 7

Jacobs, Joseph

27

40

35

70

50

80

90

80

50

45

6, 7

Johnson, Helen

62

40

50

70

40

80

90

70

50

55

6, 7

Moore, Natalie

14

40

80

10

90

60

90

60

55

10

7

Woods, Gilbert

28

20

35

35

30

90

90

70

30

35

6

Doe, Barbara

46

85

100

80

100

90

95

NR

90

80

8

Doe, Gregory

34

30

100

5

100

80

95

NR

60

5

8

Powers, Jennifer

35

90

100

100

100

100

100

100

100

90

6

Average

40

46

63

56

63

74

71

72

57

43


A–14


Kennedy Axis V—Sorted by Ancillary Impairment Name

Age

PSY

SOC

VIO

ADL SAb

Allen, Diane

27

70

90

80

90

Graham, Ronald

37

30

90

50

Lane, Barbara

25

40

50

30

Griffin, Paul

30

40

50

Williams, Barbara

34

10

70

MED

ANC GAF Eq

DL

Chapter

20

6

90

90

20

85

95

60

90

20

65

20

6, 7

60

30

70

40

50

30

6

40

55

30

70

50

45

30

6

50

95

60

70

50

55

15

6, 7

Anderson, Susan

34

30

60

60

50

90

65

60

50

50

7

Moore, Natalie

14

40

80

10

90

60

90

60

55

10

7

Smith, Mark

38

35

50

70

50

80

70

60

50

55

6

White, Janet

43

75

70

90

85

80

85

65

80

65

6

Butler, Eleanor

47

40

50

60

50

80

60

70

50

55

6

Davis, Richard

45

20

35

50

25

80

80

70

35

35

6

Hope, Allen

56

50

45

55

50

65

35

70

50

55

6

Johnson, Helen

62

40

50

70

40

80

90

70

50

55

6, 7

Jones, Joseph

49

40

45

25

50

100

60

70

40

25

7

Palmer, Brenda

37

30

50

30

60

70

80

70

40

30

6

Palmer, John

44

40

50

70

50

50

80

70

55

50

6

Rosenthal, William

51

20

10

45

20

70

40

70

25

15

6

Scott, David

50

40

75

50

75

60

70

70

60

50

6

Woods, Gilbert

28

20

35

35

30

90

90

70

30

35

6

Brown, Keith

55

30

45

40

25

80

70

80

35

40

6, 7

Cross, Anthony

24

45

60

50

80

95

70

80

60

50

7

Davis, Robert

58

50

80

50

50

25

40

80

60

25

6

Jacobs, Joseph

27

40

35

70

50

80

90

80

50

45

6, 7

Mann, William

47

15

10

50

20

50

60

80

25

15

6

Morgan, Albert

24

40

70

80

75

80

80

80

65

55

7

Robbins, Clyde

48

30

50

5

50

80

80

80

35

5

6

Sawyer, Barbara

42

50

80

50

60

80

50

80

60

50

6

Sellers, Mark

63

30

45

40

30

85

40

80

35

40

6

Abbott, George

35

100

90

90

90

80

90

90

95

80

6

Brown, Patricia

35

30

60

70

50

50

90

90

55

50

6, 7

Caruso, Janice

33

65

70

90

80

80

80

90

75

75

6

Renaldo, Alice

24

50

80

70

90

90

70

90

70

65

6

Smith, Janet

64

60

60

70

30

70

30

90

55

50

7

Stewart, Helen

58

70

90

70

90

100

20

90

80

35

6

Powers, Jennifer

35

90

100

100

100

100

100

100

100

90

6

Young, Jacqueline

6

95

95

95

95

100

60

100

95

70

7

Doe, Barbara

46

85

100

80

100

90

95

NR

90

80

8

Doe, Gregory

34

30

100

5

100

80

95

NR

60

5

8

Average

40

46

63

56

63

74

71

72

57

43


Appendix

A–15

Kennedy Axis V—Sorted by GAF Equivalent Name

Age

PSY

SOC

VIO

ADL SAb

Mann, William

47

15

10

50

20

50

Rosenthal, William

51

20

10

45

20

Woods, Gilbert

28

20

35

35

30

Brown, Keith

55

30

45

40

Davis, Richard

45

20

35

50

MED

ANC GAF Eq

DL

Chapter

60

80

25

15

6

70

40

70

25

15

6

90

90

70

30

35

6

25

80

70

80

35

40

6, 7

25

80

80

70

35

35

6

Robbins, Clyde

48

30

50

5

50

80

80

80

35

5

6

Sellers, Mark

63

30

45

40

30

85

40

80

35

40

6

Jones, Joseph

49

40

45

25

50

100

60

70

40

25

7

Palmer, Brenda

37

30

50

30

60

70

80

70

40

30

6

Griffin, Paul

30

40

50

40

55

30

70

50

45

30

6

Anderson, Susan

34

30

60

60

50

90

65

60

50

50

7

Butler, Eleanor

47

40

50

60

50

80

60

70

50

55

6

Hope, Allen

56

50

45

55

50

65

35

70

50

55

6

Jacobs, Joseph

27

40

35

70

50

80

90

80

50

45

6, 7

Johnson, Helen

62

40

50

70

40

80

90

70

50

55

6, 7

Lane, Barbara

25

40

50

30

60

30

70

40

50

30

6

Smith, Mark

38

35

50

70

50

80

70

60

50

55

6

Brown, Patricia

35

30

60

70

50

50

90

90

55

50

6, 7

Moore, Natalie

14

40

80

10

90

60

90

60

55

10

7

Palmer, John

44

40

50

70

50

50

80

70

55

50

6

Smith, Janet

64

60

60

70

30

70

30

90

55

50

7

Williams, Barbara

34

10

70

50

95

60

70

50

55

15

6, 7

Cross, Anthony

24

45

60

50

80

95

70

80

60

50

7

Davis, Robert

58

50

80

50

50

25

40

80

60

25

6

Doe, Gregory

34

30

100

5

100

80

95

NR

60

5

8

Sawyer, Barbara

42

50

80

50

60

80

50

80

60

50

6

Scott, David

50

40

75

50

75

60

70

70

60

50

6

Graham, Ronald

37

30

90

50

95

60

90

20

65

20

6, 7

Morgan, Albert

24

40

70

80

75

80

80

80

65

55

7

Renaldo, Alice

24

50

80

70

90

90

70

90

70

65

6

Caruso, Janice

33

65

70

90

80

80

80

90

75

75

6

Stewart, Helen

58

70

90

70

90

100

20

90

80

35

6

White, Janet

43

75

70

90

85

80

85

65

80

65

6

Allen, Diane

27

70

90

80

90

90

90

20

85

20

6

Doe, Barbara

46

85

100

80

100

90

95

NR

90

80

8

Abbott, George

35

100

90

90

90

80

90

90

95

80

6

Young, Jacqueline

6

95

95

95

95

100

60

100

95

70

7

Powers, Jennifer

35

90

100

100

100

100

100

100

100

90

6

Average

40

46

63

56

63

74

71

72

57

43


A–16


Kennedy Axis V—Sorted by Dangerousness Level Name Doe, Gregory

Age

PSY

SOC

VIO

34

30

100

5

ADL SAb 100

80

MED 95

ANC GAF Eq NR

60

DL

Chapter

5

8

Robbins, Clyde

48

30

50

5

50

80

80

80

35

5

6

Moore, Natalie

14

40

80

10

90

60

90

60

55

10

7

Mann, William

47

15

10

50

20

50

60

80

25

15

6

Rosenthal, William

51

20

10

45

20

70

40

70

25

15

6

Williams, Barbara

34

10

70

50

95

60

70

50

55

15

6, 7

Allen, Diane

27

70

90

80

90

90

90

20

85

20

6

Graham, Ronald

37

30

90

50

95

60

90

20

65

20

6, 7

Davis, Robert

58

50

80

50

50

25

40

80

60

25

6

Jones, Joseph

49

40

45

25

50

100

60

70

40

25

7

Griffin, Paul

30

40

50

40

55

30

70

50

45

30

6

Lane, Barbara

25

40

50

30

60

30

70

40

50

30

6

Palmer, Brenda

37

30

50

30

60

70

80

70

40

30

6

Davis, Richard

45

20

35

50

25

80

80

70

35

35

6

Stewart, Helen

58

70

90

70

90

100

20

90

80

35

6

Woods, Gilbert

28

20

35

35

30

90

90

70

30

35

6

Brown, Keith

55

30

45

40

25

80

70

80

35

40

6, 7

Sellers, Mark

63

30

45

40

30

85

40

80

35

40

6

Jacobs, Joseph

27

40

35

70

50

80

90

80

50

45

6, 7

Anderson, Susan

34

30

60

60

50

90

65

60

50

50

7

Brown, Patricia

35

30

60

70

50

50

90

90

55

50

6, 7

Cross, Anthony

24

45

60

50

80

95

70

80

60

50

7

Palmer, John

44

40

50

70

50

50

80

70

55

50

6

Sawyer, Barbara

42

50

80

50

60

80

50

80

60

50

6

Scott, David

50

40

75

50

75

60

70

70

60

50

6

Smith, Janet

64

60

60

70

30

70

30

90

55

50

7

Butler, Eleanor

47

40

50

60

50

80

60

70

50

55

6

Hope, Allen

56

50

45

55

50

65

35

70

50

55

6

Johnson, Helen

62

40

50

70

40

80

90

70

50

55

6, 7

Morgan, Albert

24

40

70

80

75

80

80

80

65

55

7

Smith, Mark

38

35

50

70

50

80

70

60

50

55

6

Renaldo, Alice

24

50

80

70

90

90

70

90

70

65

6

White, Janet

43

75

70

90

85

80

85

65

80

65

6

Young, Jacqueline

6

95

95

95

95

100

60

100

95

70

7

Caruso, Janice

33

65

70

90

80

80

80

90

75

75

6

Abbott, George

35

100

90

90

90

80

90

90

95

80

6

Doe, Barbara

46

85

100

80

100

90

95

NR

90

80

8

Powers, Jennifer

35

90

100

100

100

100

100

100

100

90

6

Average

40

46

63

56

63

74

71

72

57

43


Appendix

II.

A–17

Problem-Oriented Progress Notes Using the K Axis

The structure, scores, and problem descriptions of the K Axis could be a routine part of problemoriented treatment plans, nursing care plans, psychosocial histories, and comprehensive psychiatric assessments. In traditional and computerized medical records, the K Axis could act to tie together critical components of the patient’s medical record. This section presents formats for problem-oriented progress notes using the K Axis. The integration of the K Axis into problem-oriented treatment planning and nursing care planning is demonstrated in Fundamentals of Psychiatric Treatment Planning (Kennedy 2003). Integration of the K Axis into the comprehensive psychiatric assessment is demonstrated in the next section. In addition to its use in a traditional medical record, the structure of the K Axis helps to organize clinical information in such a way that should allow information to be readily computerized for use in an electronic medical record. It is unlikely that the K Axis would be rated in association with every psychiatric progress note. When the K Axis is rated in association with a psychiatric progress note, the K Axis scores or problem descriptions can be easily included in that progress note. The following are formats for several basic psychiatric progress notes using the K Axis, including a comprehensive problem-oriented psychiatric progress note.

A–18


PSYCHIATRIC PROGRESS NOTE Agency:

Date:

Name:

Pt. #:

1.0 Psychological Impairment:

3.0 Violence:

5.0 Substance Abuse:

Assessment/Impression:

Treatment Plan/Recommendations:

Signature:

Date: James A. Kennedy, MD

The format in the first note addresses three problem areas (subscales). From one to all seven problem areas could be addressed, depending on the clinical focus of the note. The next note is an example using a format that addresses only one problem area.


Date:

Name:

Pt. #:

3.0 Violence:



Signature:


Appendix

A–19

Next is an example of a format for a comprehensive psychiatric progress note that integrates all seven problem areas (subscales) into the note, plus the K Axis scores, including the GAF Equivalent and Dangerousness Level.


Date:

Name:

Pt. #:

1.0 Psychological Impairment:

2.0 Social Skills:

3.0 Violence:

4.0 ADL–Occupational Skills:


6.0 Medical Impairment:

7.0 Ancillary Impairment:

Ratings:

PSY =

SOC =

GAF Equivalent =

VIO =

ADL =

SAb =




Signature:


MED =

ANC =

Notes

Appendix

A–21

III. Comprehensive Psychiatric Assessment Using the K Axis The K Axis problem descriptions and scores can be integrated into the medical record in a number of ways, including in psychiatric progress notes, psychiatric treatment plans, nursing care plans, the psychosocial history, and the comprehensive psychiatric assessment. This section presents an example of a format for a comprehensive psychiatric assessment that incorporates the K Axis.

A–22


COMPREHENSIVE PSYCHIATRIC ASSESSMENT Agency:

Date:

Name:

Pt. #:

Problem List:

Strength List:

DOA:

Sex:

Race:

Marital Status:

DOB:

Age:

SS#:

Religion:

Psychiatric History (all of the history can be included in the K Axis seven subscale domains): 1.0 Psychological Impairment/Mental Status Exam:

2.0 Social Skills:

3.0 Violence:

4.0 ADL–Occupational Skills:


6.0 Medical Impairment (including medical history and significant past laboratory and diagnostic tests, as well as consultations and procedures):

7.0 Ancillary Impairment (including family/social history and legal history):

Appendix

A–23

Present Illness/K Axis (the current problem descriptions can provide the heart of the information needed for this section of the comprehensive psychiatric assessment): 1.0 Psychological Impairment/Mental Status Exam (usually most of the mental status exam can be captured in this subscale area): 2.0 Social Skills: 3.0 Violence: 4.0 ADL–Occupational Skills: 5.0 Substance Abuse: 6.0 Medical Impairment (including medical history and significant past laboratory and diagnostic tests, as well as consultations and procedures): 7.0 Ancillary Impairment:

Ratings:

PSY =

SOC =

VIO =

ADL =

GAF Equivalent =

SAb =

MED =

ANC =


Psychiatric Medication History:

Current Medication and Informed Consent for Medication:

Legal Competency Impression/Current Legal Status:

Diagnostic Impression (K Axis can substitute for Axis IV and Axis V): Axis I: Axis II: Axis III: K Axis:

PSY =

SOC =

VIO =

ADL =

SAb =

MED =

GAF Equivalent: #1 ______ + #2 ______ + #3 ______ + #4 ______ = ______ / 4 = ______ Dangerousness Level: ______ Discharge Plan:



Signature:


ANC =

A–24


IV. Kennedy NOSIE and Guide The Kennedy Nurses’ Observation Scale for Inpatient Evaluation (NOSIE) can be used to capture additional information to rate the K Axis. The Kennedy NOSIE is especially important because it can be rated by nurses or mental health assistants working under the supervision of a nurse. The direct observations of the nurses and mental health assistants can be rich in clinical information. The Kennedy NOSIE offers a formal method for capturing these direct clinical observations. It can be rare for mental health assistants to have such a formal opportunity to provide input into the assessment of a patient’s functioning, including helping with the assessment of the outcome of treatment. The mental health assistants often appreciate this opportunity; however, it is especially important for the nurses to be involved in the training and supervision of the mental health assistants on the use of the Kennedy NOSIE. The overall interrater reliability of the NOSIE-QF is approximately 0.90 (Kennedy 2003). Because the only change in the NOSIE-QF in its conversion to the Kennedy NOSIE was to develop a quicker method for computing the scores, the original interrater reliability should apply equally well to the Kennedy NOSIE (i.e., there were no changes in the items or in the method used to rate each individual item). The interrater reliability results were based on ratings performed by nurses and mental health assistants who were trained in the use of the NOSIE-QF and who were encouraged to use the “Guide to the NOSIE-QF” when making the ratings. Therefore, to obtain similar interrater reliability, training in rating the Kennedy NOSIE and use of the Guide to the Kennedy NOSIE are critical. The Kennedy NOSIE and the “Guide to the Kennedy NOSIE” follow.

Appendix

A–25

Kennedy Nurses’ Observation Scale for Inpatient Evaluation

Kennedy NOSIE or K NOSIE Copyright © 1985–2003 James A. Kennedy, MD

Patient’s Name: _______________________________________________ #: _____________________ Date: ____/____/____ Name and Title of Rater: _______________________________________________________________________________________ Note: Closely follow the “Guide to the Kennedy NOSIE” by James A. Kennedy, MD (available at www.kennedymd.com), to significantly improve the reliability and validity of your ratings.

1.

Social Competence

Never

Sometimes

Often

Usually

Always

A.

Refuses to do the ordinary things expected of him/her

–0

–1

–2

–3

–4

B.

Has trouble remembering

–0

–1

–2

–3

–4

C.

Has to be reminded what to do

–0

–1

–2

–3

–4

D.

Has to be told to follow hospital routine

–0

–1

–2

–3

–4

E.

Has difficulty completing even simple tasks on his/her own

–0

–1

–2

–3

–4

Never

Sometimes

Often

Usually

Always

Sec. #1: –______

2.

Social Interest A.

Shows interest in activities around him/her

+0

+1

+2

+3

+4

B.

Tries to be friendly with others

+0

+1

+2

+3

+4

C.

Laughs or smiles at funny comments or events

+0

+1

+2

+3

+4

D.

Starts up a conversation with others

+0

+1

+2

+3

+4

E.

Talks about his/her interests

+0

+1

+2

+3

+4

Never

Sometimes

Often

Usually

Always

Sec. #2: +______

3.

Personal Neatness A.

Is sloppy

–0

–1

–2

–3

–4

B.

Keeps clothes neat

+0

+1

+2

+3

+4

C.

Is messy in eating habits

–0

–1

–2

–3

–4

D.

Keeps self clean

+0

+1

+2

+3

+4

Sec. #3: ______ Subtotal: ______

Transfer subtotal to the back

Å

Enter Licensing Agreement Number Here:

Based on NOSIE–30 (Gilbert Honigfeld, Roderic D. Gillis, and C. James Klett: “NOSIE-30: A Treatment-Sensitive Ward Behavior Scale.” Psychological Reports 19:180–182, 1966).

A–26


Kennedy NOSIE (Page 2 of 2) 4.

Irritability

Never

Sometimes

A.

Is impatient

Often

Usually

Always

–0

–1

–2

–3

–4

B.

Gets angry or annoyed easily

–0

–1

–2

–3

–4

C.

Becomes easily upset if something doesn’t suit him/her

–0

–1

–2

–3

–4

D.

Is irritable and grouchy

–0

–1

–2

–3

–4

E.

Is quick to fly off the handle

–0

–1

–2

–3

–4

Sec. #4: –______

5.

Manifest Psychosis

Never

Sometimes

Often

Usually

Always

A.

Hears things that are not there

–0

–1

–2

–3

–4

B.

Sees things that are not there

–0

–1

–2

–3

–4

C.

Talks, mutters, or mumbles to self

–0

–1

–2

–3

–4

D.

Giggles or smiles to self without any apparent reason

–0

–1

–2

–3

–4

Never

Sometimes

Often

Usually

Always

Sec. #5: –______

6.

Motor Retardation A.

Sits, unless directed into activity

–0

–1

–2

–3

–4

B.

Sleeps, unless directed into activity

–0

–1

–2

–3

–4

C.

Is slow moving and sluggish

–0

–1

–2

–3

–4

Sec. #6: –______

Final Scoring Section I. Subtotal from front: II. Subtotal from back: III. Kennedy NOSIE total:

– (Range –76 to +28) (–76 ÄDysfunctional –––– FunctionalÅ +28)

Rating for last 3 days ________ or typical 3-day period during the last 2 weeks ________

Appendix

A–27

GUIDE TO THE Kennedy Nurses’ Observation Scale for Inpatient Evaluation Kennedy NOSIE or K NOSIE

James A. Kennedy, MD www.kennedymd.com Copyright © 1986–2003 James A. Kennedy, MD

THE KENNEDY NOSIE SHOULD NOT BE RATED WITHOUT FOLLOWING THIS GUIDE

Based on “NOSIE-30: Programmed Instruction,” by Pinto Alcides, PhD, and Ernest R. DeRosa, BA, unpublished, 1973.

A–28


General Instructions Note: When rating the Kennedy NOSIE, it is essential that raters refer to this guide. Pay special attention to the section “Descriptions of Each Item” for brief explanations of each item on the questionnaire. Caution: The guide should not be interpreted too literally. Patients often do not fit cleanly into rigid definitions of measurements of their behavior. Common sense should be used along with the guide when interpreting the points along the continuum as well as the brief explanation of each item given in this guide.

Time Period Being Rated The time period that the rater is assessing is the last 3 days or a typical 3-day period during the last 1 or 2 weeks. The default is the last 3 days for acute-care, short-term hospitalization. The default for longterm care is a typical 3-day period during the last 1 or 2 weeks. Indicate directly on the questionnaire which time period is being rated by checking: Rating for last 3 days ________ or typical 3-day period during the last 2 weeks ________

Who Should Rate the Kennedy NOSIE? The Kennedy NOSIE is intended for rating by nurses and nursing staff, including mental health assistants. The Kennedy NOSIE does not require licensed staff to rate the questionnaire; however, regardless of who rates the Kennedy NOSIE, a licensed professional should always supervise its use. The Kennedy NOSIE was created for use by nurses; however, mental health assistants with training on the use of the Kennedy NOSIE and with supervision by nurses could also very accurately rate the questionnaire. The ratings are based on direct observations of the patient’s behavior, and often the mental health assistants are most likely to make these direct observations. Nurses who are mainly supervising other nurses or mainly passing out medications may not have the opportunity to make the direct observations necessary to accurately rate the Kennedy NOSIE. The rating of the Kennedy NOSIE could be expanded to include anyone who has the opportunity to make ongoing observations of a patient. This could include staff at halfway houses, nursing homes, day treatment programs, and even family members or significant others living at home with the patient. However, a licensed professional should always supervise the use of the Kennedy NOSIE.

Comparison to Hospitalized Psychiatric Patients The ratings are a comparison of the patient being rated to hospitalized psychiatric patients, that is, the rating should be based on the frequency of behavior observed in the patient compared with the frequency often seen in long-term-care psychiatric inpatients. The scale is divided along a 5-point continuum from “Never” to “Always”: 1.

2.

3.

Never: This represents the patients who are doing the best or worst on an item depending on whether the item is a positive or negative item. If the patient is rated as “Never,” this should indicate that this behavior is very uncharacteristic of the patient. For many items, “Never” means that the behavior is observed never, or almost never, during the typical 3-day period. Sometimes: The frequency is relatively low; however, it is not at the extreme noted in 1. For some items, this may mean that the behavior is observed 1 to 2 hours over the typical 3-day period. “Sometimes” and “Often” are the ratings most often given as the average rating for many of the items. Often: This frequency of occurrence is the midpoint between “Never” and “Always.” For some items, “Often” may mean that the behavior is observed more than 2 hours over the typical 3-day period but less than 50% of the time.

Appendix

4.

5.

A–29

Usually: The frequency is relatively high; however, it is not at the extreme noted in 5. For some items, “Usually” means that the behavior is observed more than 50% of the time. “Usually” and “Always” are not terms that describe the typical patient on any of the items, that is, there are no items that the typical patient does “Usually” or “Always.” Always: This represents patients who are doing the best or worst on this item depending on whether the item is a positive or negative item. If the patient is rated as “Always” on the item, this should indicate that this behavior is very characteristic of the patient. For some items, “Always” means that the characteristic is observed almost 100% of the time during the rating period.

Using the Average and Extreme Frequency of Occurrence to Help Determine the Ratings To assist the rater in determining the frequency of the behaviors in long-term-care psychiatric inpatients, the average score is underlined for each item on the Kennedy NOSIE. This point represents the approximate average frequency of occurrence of the item in long-term-hospitalized psychiatric patients based on clinical and empirical observations by the author. The patient being rated should be compared with this rating of the “average” inpatient. If the behavior of the patient being rated is equal to that of the average patient, then that is the rating. If not, then compare the patient to the patients in the extreme categories. If the patient matches the patients at one of the extremes, then that is the rating. If the patient does not fit one of the extreme scores, the patient should fall somewhere between these extreme patients and the average patient. Then compare the patient with the patients who are on the same side of the average patient as the patient being rated. In other words, when making the rating, pay special attention to the following: 1.

2.

3.

Average score. The approximate average score for hospitalized psychiatric patients is underlined on each item on the questionnaire. First compare the patient being rated to this group of patients. If this is where the patient fits, then you have the score for that item. If not, go to the next step. Extreme scores. At one end of the continuum are the patients who are doing the best on the item and at the other end are the patients who are doing the worst on that item. If the patient fits one of the extremes, then you have the score for that item. If not, go to the final step. Area between the average and extreme scores. Compare the patient with hospitalized psychiatric patients who are known to fall between the average score and one of the extreme scores on the side the patient falls. By this point, you have usually narrowed the rating down to one or two choices. This often makes the final choice much easier.

Descriptions of Each Item In this section, a brief description is given of each item on the Kennedy NOSIE. This will help to ensure that raters are consistent in their understanding of what each item measures. 1.

Social Competence A.

Refuses to do the ordinary things expected of him/her. For example, will not dress, make bed, take meds, or feed self although physically able. This is a measure of uncooperativeness. If patient has a rational reason for refusing to do something, he or she should not be rated as uncooperative.

B.

Has trouble remembering. For example, has to be reminded to tie shoes, has to be reminded what time to go to work therapy or other activity. This may reflect an actual memory loss. This may also reflect an impaired attention span, for example, patient did not notice that shoes were untied or was not paying attention or “wasn’t listening” when told the time for an activity.

A–30

2.

3.


C.

Has to be reminded what to do. With simple multistep tasks, patient must be reminded what to do or refocused every step of the way. This is a measurement of ability to stay focused on a task, as well as ability to remember the steps necessary to complete a task. This does not refer to uncooperativeness as implied in the next item.

D.

Has to be told to follow hospital (or program) routine. This item refers to uncooperativeness. Patient requires more aggressive or firmer “reminding” than is the case when rating “Has to be reminded what to do.” Patient wants to do things when he or she is ready. Due to uncooperativeness, patient requires constant prompting to stick to a schedule or a multistep task.

E.

Has difficulty completing simple tasks on his/her own. Patient may start a task such as making bed, sweeping the floor, cleaning up the kitchen area, or putting a simple puzzle together; however, patient is easily diverted away from the task by internal or external stimuli and does not complete that task without staff intervention. Also included here would be the inability to complete a simple task because of the lack of skills to complete even simple tasks. This item is not a measure of refusal to do tasks.

Social Interest A.

Shows interests in activities around him/her. Patient appears aware of and interested in things going on around him or her and may even get up and go over to an activity to get a better look or participate in the activity.

B.

Tries to be friendly with others. Patient talks in a friendly manner to other patients or staff and will share things with others, such as cigarettes, money, or coffee.

C.

Laughs or smiles at funny comments or events. Patient clearly shows laughter or amusement at a joke or at some comical situation. This item does not refer to inappropriate laughing and giggling to self.

D.

Starts up a conversation with others. Initiates conversations with others. This refers to conversations, that is, an exchange of ideas or information, not simply making statements to or demands of others.

E.

Talks about his/her interests. Patient has real, nondelusional interests or hobbies and talks about those interests or hobbies. This relates to non-treatment-related and non-illness-related interests. This does not refer to interests such as “When am I going to be discharged?” “Why do I have to take medication? There is nothing wrong with me” or “Why are these people trying to kill me?”

Personal Neatness (if the patient is clean and neat because of staff member’s direct, aggressive efforts rather than the patient’s efforts, this should be rated negatively) A.

Is sloppy. Patient is missing one or two articles of clothing, has untied shoes, and has clothing buttoned in the incorrect holes or not buttoned at all. This generally reflects a greater lack of concern or incapacity with personal appearance than “Keeps clothes neat.”

B.

Keeps clothes neat. Patient presents a relatively neat appearance considering the availability of pressed clothes and clothes that fit. Stains and tears should be rated if it is felt that patient could have selected clothes free of stains or tears.

C.

Is messy in eating habits. Patient drops or spills food on the table and floor or on clothing or has food residue on face or hands.

D.

Keeps self clean. This item refers to personal hygiene. Patient brushes his or her teeth, washes face, takes a bath. Patient shaves face when appropriate. Again, if the patient is neat because of staff member’s direct and aggressive efforts, this should be rated negatively.

Appendix

4.

5.

6.

A–31

Irritability A.

Is impatient. Patient will not wait in line 10 minutes for meals. Cuts ahead in line for cigarettes, snacks, or medication. After the time for an activity or privileges is set, repeatedly asks that he or she be allowed to immediately participate in the activity or immediately use privileges.

B.

Gets angry or annoyed easily. When even approached to do something, patient may yell loudly or threaten the person, that is, only a minimal interaction is necessary for the patient to become angry.

C.

Becomes easily upset if something doesn’t suit him/her. This item reflects a lesser degree of irritability than the preceding item. In this item, the patient may shout or become angry for generally more reason than just being asked to do something, that is, having privileges denied, someone taking his or her favorite chair, jealousy over someone else receiving cigarettes, snacks, or privileges.

D.

Is irritable and grouchy. This item is similar to the above item “Gets angry or annoyed easily.” This item reflects a general state of anger. The anger is already there; no precipitant is needed to bring on the anger. The patient wants to be left alone and is easily angered when approached.

E.

Is quick to fly off the handle. This item refers to more unpredictable anger and explosiveness. The patient may be calm, talking with someone, and in no apparent distress, when suddenly he or she explodes into an episode of anger or shouting and may even become assaultive.

Manifest Psychosis A.

Hears things that are not there. May state that he or she is hearing voices or looks around as if someone is talking to him or her. Carries on a conversation when no one is talking to him or her. If possible, the patient should be questioned directly about hearing voices.

B.

Sees things that are not there. Patient appears to be responding to things that are not there. May try to brush something off clothing when there is nothing on clothing. May move to avoid something that is not there. May appear frightened of something that only he or she sees. Eyes may be moving back and forth as if watching something that is not there. If possible, the patient should be questioned directly about seeing things that are not there.

C.

Talks, mutters, or mumbles to self. Carries on a conversation with self or mumbles under breath to self.

D.

Giggles or smiles to self without any apparent reason. Patient may be sitting by self and suddenly laugh for no apparent reason or may be talking with someone and suddenly laugh or smile when nothing funny was said.

Motor Retardation A.

Sits, unless directed into activity. Patient sits, stands, or crouches in one place unless directed to do something. Of course, this item does not apply to situations in which the patient is expected to be sitting or is instructed to sit.

B.

Sleeps, unless directed into activity. Patient is found asleep (or lying supine) in his or her bed during the day or falls asleep in a chair unless told to do something.

C.

Is slow moving and sluggish. When up and around, patient’s movement is noticeably slow. He or she is one of the last people to arrive for an activity. Appears to require significant effort just to move around.

A–32

V.


References

Alcides P, DeRosa ER: “NOSIE-30: Programmed Instruction.” Unpublished, Crownville, MD, Research Department, Crownville Hospital Center, 1973 Honigfeld G, Gillis RD, Klett JD: NOSIE-30: A Treatment Sensitive Ward Behavior Scale. Psychological Reports 19:180–182, 1966 Kennedy JA: Fundamentals of Psychiatric Treatment Planning, 2nd Edition. Washington, DC, American Psychiatric Publishing, 2003

Mastering the Kennedy Axis V: A New Psychiatric Assessment of Patient Functioning

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The American Psychiatric Publishing Textbook of Suicide Assessment And Management

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The Difficult-to-Treat Psychiatric Patient

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Mastering Hyper-V Deployment

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The American Psychiatric Publishing Textbook of Suicide Assessment And Management

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