In the realm of mental health in the United States, the Diagnostic and Statistical Manual of Mental Disorders (DSM), published by the American Psychiatric Association (APA), serves as the authoritative guide for healthcare professionals in diagnosing mental health conditions. The DSM has undergone several revisions throughout its history, with each update reflecting advancements in our understanding of mental illness. A significant shift occurred with the transition from the DSM-IV to the DSM-5, most notably the removal of the multi-axial system.
The DSM-IV, the fourth edition of this essential manual, employed a 5 Axis Diagnosis system, also known as a multi-axial system. This system aimed to provide a comprehensive diagnostic profile by evaluating patients across five distinct dimensions, or “Axes.” Each axis was designed to capture a different facet of the patient’s condition, offering a more holistic view beyond just the primary clinical diagnosis.
The five axes of the DSM-IV were categorized as follows:
- Axis I: Clinical Disorders: This axis encompassed the primary clinical disorders, including mood disorders, anxiety disorders, schizophrenia, substance use disorders, and others, except for personality disorders and mental retardation.
- Axis II: Personality Disorders and Mental Retardation: This axis focused on personality disorders and mental retardation (now referred to as Intellectual Development Disorder). These conditions were categorized separately due to their pervasive and enduring nature.
- Axis III: General Medical Conditions: This axis was dedicated to documenting any general medical conditions that could be relevant to understanding or managing the patient’s mental disorder.
- Axis IV: Psychosocial and Environmental Problems: This axis captured significant psychosocial and environmental stressors that might be impacting the individual’s mental health, such as relationship issues, occupational difficulties, or economic problems.
- Axis V: Global Assessment of Functioning (GAF): This axis provided a numerical score, ranging from 0 to 100, representing the clinician’s judgment of the individual’s overall level of psychological, social, and occupational functioning.
However, with the publication of the DSM-5 in 2013, the APA discontinued the multi-axial system, marking a significant change in diagnostic practice.
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The History and Evolution of the Multi-Axial System
The multi-axial system was introduced in the DSM-III, the third edition of the manual, by the APA. Its inception was driven by the desire to create a more detailed and nuanced diagnostic process. The axes were conceived as a method for clinicians to record supplementary diagnostic information, going beyond a single, categorical diagnosis.
For example, an individual diagnosed with major depressive disorder (Axis I) might also have relevant information documented on other axes. If they lacked a strong social support network (Axis IV) or presented a risk to themselves (reflected in a lower GAF score on Axis V), these factors would be noted to provide a more complete clinical picture.
Despite its initial intent, the APA ultimately determined that the division of disorders across the axes lacked a robust scientific foundation. Consequently, the multi-axial system was removed with the advent of the DSM-5 in 2013.
The Intended Uses of the 5 Axis Diagnosis System
The primary goal of implementing the 5 axis diagnosis system was to enhance the efficiency and comprehensiveness of patient diagnosis and data collection. By organizing diagnostic information into separate axes, clinicians were expected to systematically evaluate patients, considering various dimensions of their condition in a standardized manner.
The multi-axial system aimed to provide a structured framework for healthcare professionals to methodically analyze diagnostic information, axis by axis, ensuring that all relevant aspects of a patient’s mental health were considered. This structured approach was intended to lead to more thorough and well-rounded diagnoses.
However, the multi-axial system was not without its drawbacks. It faced criticism and controversy, including concerns about the sometimes-artificial separation between mental health and medical conditions, and the potential for confusion in categorizing certain disorders.
The DSM-5 transitioned to a non-axial system, integrating the information previously captured in Axes I, II, and III. Information that would have been included in Axes IV and V is now incorporated through separate notations, offering a more streamlined approach. This non-axial system has generally been favored by healthcare professionals utilizing the DSM.
A Closer Look at Each Axis of the DSM-IV
To fully understand the 5 axis diagnosis system, it’s crucial to examine each axis in detail:
Axis I: Clinical Disorders
Axis I was designated for reporting clinical disorders, encompassing a wide range of mental health conditions, excluding personality disorders and intellectual development disorders. Examples of disorders classified under Axis I included:
- Disorders Typically Diagnosed in Infancy, Childhood, or Adolescence
- Delirium, Dementia, and Amnestic and Other Cognitive Disorders
- Mental Disorders Due to a General Medical Condition
- Substance-Related Disorders
- Schizophrenia and Other Psychotic Disorders
- Mood Disorders
- Anxiety Disorders
- Somatoform Disorders
- Factitious Disorders
- Dissociative Disorders
- Sexual and Gender Identity Disorders
- Eating Disorders
- Sleep Disorders
- Impulse-Control Disorders Not Elsewhere Classified
- Adjustment Disorders
- Other Conditions That May Be a Focus of Clinical Attention
Changes in DSM-5: The DSM-5 brought about several changes to the categories previously under Axis I. “Mental Disorders Due to a General Medical Condition,” “Factitious Disorders,” and “Adjustment Disorders” were removed as distinct classifications, with conditions falling under these categories being reclassified or integrated elsewhere in the DSM-5. “Eating Disorders” was broadened to “Feeding and Eating Disorders.” Furthermore, “Mood Disorders” was divided into “Bipolar and Related Disorders” and “Depressive Disorders,” and “Sexual and Gender Identity Disorders” was revised to encompass “Sexual Dysfunctions,” “Gender Dysphoria,” and “Paraphilic Disorders.” New categories were also introduced in the DSM-5.
Axis II: Personality Disorders and Mental Retardation
Axis II was specifically designed to capture personality disorders and mental retardation. Disorders classified under Axis II included:
- Paranoid Personality Disorder
- Schizoid Personality Disorder
- Schizotypal Personality Disorder
- Antisocial Personality Disorder
- Borderline Personality Disorder
- Histrionic Personality Disorder
- Narcissistic Personality Disorder
- Avoidant Personality Disorder
- Dependent Personality Disorder
- Obsessive-Compulsive Personality Disorder
- Personality Disorder Not Otherwise Specified
- Mental Retardation
Changes in DSM-5: While the personality disorder categories remained largely unchanged in the DSM-5, “Mental Retardation” was updated to “Intellectual Disability.”
In the DSM-5-TR (text revision), “Intellectual Disability” was further refined to “Intellectual Development Disorder,” with “Intellectual disability” retained in parentheses for continued reference.
Axis III: General Medical Conditions
Axis III served to document any general medical conditions that were potentially relevant to the individual’s mental health. The purpose was to acknowledge the interplay between physical and mental health.
For instance, a patient undergoing chemotherapy for cancer might experience mental health challenges like anxiety and depression. In such cases, cancer would be noted on Axis III because it represented a medical condition with potential implications for mental well-being.
Changes in DSM-5: The DSM-5 does not have a direct equivalent to Axis III. However, the DSM-5 still recognizes the importance of documenting medical conditions. Clinicians are now expected to note relevant medical conditions within the diagnostic formulation, prioritizing them as needed in relation to the mental health diagnosis.
Axis IV: Psychosocial and Environmental Problems
Axis IV was used to record psychosocial and environmental factors that could be contributing to or exacerbating the individual’s mental health issues. Examples of factors considered under Axis IV included:
- Problems with primary support group
- Problems related to social environment
- Educational problems
- Occupational problems
- Housing problems
- Economic problems
- Problems with access to healthcare services
- Problems related to interaction with the legal system/crime
- Other psychosocial and environmental problems
Changes in DSM-5: Information that was previously captured on Axis IV is now integrated into the DSM-5 through separate notations. Clinicians can document relevant psychosocial and environmental factors as supplementary information alongside the primary diagnosis, as needed.
Axis V: Global Assessment of Functioning (GAF)
Axis V utilized the Global Assessment of Functioning (GAF) scale, a 0 to 100 rating system, to provide a quantitative summary of the individual’s overall functioning. The GAF score reflected the clinician’s judgment of the person’s psychological, social, and occupational functioning. A general outline of the GAF scale was as follows:
- 100: Superior functioning in a wide range of activities, no symptoms.
- 90: Functioning well in all areas, minimal symptoms.
- 80: No more than slight impairment in social, occupational, or school functioning, transient symptoms.
- 70: Some mild symptoms OR some difficulty in social, occupational, or school functioning, but generally functioning pretty well.
- 60: Moderate symptoms OR moderate difficulty in social, occupational, or school functioning.
- 50: Serious symptoms OR any serious impairment in social, occupational, or school functioning.
- 40: Some impairment in reality testing or communication OR major impairment in several areas (work or school, family relations, judgment, thinking, mood).
- 30: Behavior considerably influenced by delusions or hallucinations OR serious impairment in communication or judgment OR inability to function in almost all areas.
- 20: Some danger of hurting self or others OR occasionally fails to maintain minimal personal hygiene OR gross impairment in communication.
- 10: Persistent danger of severely hurting self or others OR persistent inability to maintain minimal personal hygiene OR serious suicidal act with clear expectation of death.
Changes in DSM-5: Similar to Axis IV, the DSM-5 incorporates information related to functioning through separate notations rather than the GAF scale. Clinicians now assess and document psychosocial and contextual factors relevant to functioning as part of a more narrative and less numerically driven approach. While the GAF was removed, alternative assessment tools and methods for evaluating functional impairment are utilized in current practice.
The Shortcomings of the Multi-Axial System
Despite its aims, the multi-axial system faced criticism and was ultimately deemed unnecessary by many healthcare professionals for several reasons.
A primary concern was the perceived arbitrary distinction between Axis I and Axis II diagnoses. Clinicians often found that certain disorders did not fit neatly into either category, leading to ambiguity and confusion. Furthermore, there was a growing recognition that the GAF (Axis V) had limitations in its ability to comprehensively capture critical aspects of a patient’s condition, such as suicide risk and the impact of disabilities.
Ultimately, the consensus among many professionals was that accurate and nuanced diagnoses could be achieved effectively without the constraints of the multi-axial system.
Updates in the DSM-5-TR
The most recent update to the DSM, the DSM-5-TR (text revision), further refined diagnostic criteria and incorporated new codes for documenting suicidal behavior and non-suicidal self-injury. It also focused on clarifying language and addressing potential biases related to race and culture within diagnostic criteria.
Key Takeaways
The 5 axis diagnosis system, a feature of the DSM-IV, was initially implemented to provide a more comprehensive approach to diagnosing mental health conditions by considering clinical disorders, personality disorders and intellectual disability, general medical conditions, psychosocial and environmental problems, and global functioning. However, due to a lack of strong scientific support and practical limitations, this system was discontinued in the DSM-5. While no longer in use, understanding the 5 axis diagnosis system offers valuable historical context for the evolution of diagnostic practices in mental health and highlights the ongoing efforts to refine and improve the diagnostic process. The shift away from the multi-axial system reflects a move towards a more integrated and less compartmentalized approach to understanding and diagnosing mental disorders.
