Disorders (DSM-IV-TR), (2) the National Comprehensive Cancer Network’s (NCCN) Clinical Practice Guidelines for Distress Management, (3) illness self-management approaches, (4) conceptual models of health-related quality of life, and (5) other frameworks.


DSM-IV-TR list of psychosocial and environmental problems DSM-IV-TR, used by clinicians to diagnose and plan treatment for both mental disorders and less serious mental health problems, includes assessment of psychosocial and environmental problems that may affect diagnosis, treatment, and prognosis as one of five dimensions (axes)1 to be evaluated when planning treatment. It categorizes Psychosocial and Environmental Problems in Axis IV as

  • Problems with primary support group—e.g., death of a family member; health problems or discord in family; separation, divorce, estrangement; abuse or neglect.

  • Problems related to the social environment—e.g., death or loss of a friend, inadequate social support, living alone, discrimination.

  • Educational problems—e.g., literacy, school achievement, disruptions to education.

  • Occupational problems—e.g., unemployment, potential job loss, difficult work conditions.

  • Housing problems—e.g., homeless, unsafe or inadequate housing.

  • Economic problems—e.g., inadequate income for routine life needs, difficulty paying for health care.

  • Problems with access to health care—e.g., inadequate health insurance, transportation problems, geographic hardship accessing care.

  • Problems related to interactions with the legal system—e.g., arrest or fear of arrest, use of illegal substances, incarceration.

  • Other psychosocial and environmental problems—e.g., no telephone, exposure to natural disaster or violence, unavailability of social service agencies.

The American Psychiatric Association describes this categorization and DSM-IV-TR’s multiaxial assessment approach as a “format for organizing and communicating clinical information, for capturing the complexity


The other four axes are Axis I, Clinical Disorders and Other Conditions that may be a focus of clinical psychiatric care; Axis II, Personality Disorders and Mental Retardation; Axis III, General Medical Conditions; and AXIS V, Global Functioning.

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