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Pearls


Using a ‘MAP’ to navigate follow-up visits

Vol. 3, No. 3 / March 2004

Knowing each patient’s problems and life situation is critical to conducting an effective follow-up examination. But with limits on your time and patients often changing psychiatrists, keeping track can be challenging.

A multiaxial problem (MAP) list, which we devised based on clinical experience, can help you organize key symptoms and remember which issues to address during repeat visits. It can quickly get you up to speed with a patient who:

  • has multiple disorders or symptoms
  • is treatment-resistant
  • has not been seen in months or years
  • is a candidate for a change in treatment
  • or was treated by another psychiatrist.

Table

Sample multiaxial problem (MAP) list

Jane Doe. Age 49—white female. Continuous with exacerbations since age 19.

Axis A

  • Depression
  • Anxiety
  • Onset insomnia
  • Intermittent suicidal ideation
  • No suicide attempts
  • Panic attacks
  • Agoraphobia
  • SSRI-induced anorgasmia
  • Heavy smoker (~ 1 pack/day)
  • Alcohol abuse—in partial remission since 2/5/03


Axis C

  • Type 2 diabetes
  • Hyperlipidemia
  • Obesity
  • History of stroke


Axis B

  • Reluctant to “depend” on medications
  • Periodically stops medications to see how she will do
  • Thinks everyone tries to boss her around
  • Very irritated if doctor is late
  • Wants to improve socialization


Axis D

  • Financial problems (disability income $640/month; overspends on clothes)
  • Conflict with mother
  • Son abusing alcohol and cocaine
  • No car
  • Socially isolated because of agoraphobia
  • Husband is supportive
  • Daughter takes her out at times


Creating the list

The MAP list can be compiled from information obtained by:

  • asking the patient to list complaints
  • reviewing the patient’s chart
  • interviewing family members
  • or talking with other care team members.

On a blank sheet of paper, write at the top the patient’s name, age, race/sex (for fast identification), and age at onset of symptoms (to differentiate between chronic, episodic, and recent onset).

Then draw four quadrants and organize the information as follows (Table):

  • Axis A—symptoms and issues addressed by the psychiatrist
  • Axis B—behavior patterns and attitudes that might affect treatment. Also include intellectual limitations. A behavior attributed to a personality disorder (such as selfmutilation) falls under Axis A because the psychiatrist would treat it directly.
  • Axis C—physical symptoms or disorders to be addressed by another physician
  • Axis D—psychosocial, physical, and other patient stressors. A physical illness may fall under both Axes C and D if the stress is significant.

Pertinent negatives such as “No suicide attempt” may be recorded on Axis A or C, psychological strengths/coping skills on Axis B, and supportive persons and factors (such as “Mother helps financially”) on Axis D.

Using the list

Keep the MAP list handy while seeing the patient. Start by going through the symptoms/problems listed under Axis A. Review the patterns noted under Axis B and look for ways to promote insight and coping by reflecting those patterns back to the patient. For the hypothetical patient illustrated in the Table, we would prescribe a medication, then tell her, “We’ve discussed your pattern of stopping medications because you’re afraid of becoming dependent on them. We need to discuss this further so that you can keep taking this medication regularly.”

Next, check the physical conditions under Axis C before choosing a medication to avoid possible drug-drug interactions or side effects. We find that Axis C also helps us ensure that the patient seeks appropriate medical care from another physician. Finally, Axis D reminds us to be empathic toward patients who report psychosocial stressors and to intervene where appropriate.

Remember that the MAP list is not a substitute for taking a full history and physical.

MAP maintenance

Revise the MAP list after each visit as the patient responds to treatment or as his or her life changes. For example, a psychosocial stressor that has been resolved should be struck, although some cases call for leaving the item in and noting “resolved” or “in remission” after it. For example, even if a patient was no longer being physically abused by her spouse, we would not delete the problem because we would want to keep monitoring it.

Include only relevant data on the list or it will become unwieldy. Add diagnoses only if they are certain.

Dr. Mago is assistant professor of psychiatry, Thomas Jefferson University, Philadelphia.

Dr. Joshi is a fellow in child and adolescent psychiatry at Massachusetts General Hospital, Boston.

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