In the realm of mental health in the United States, the Diagnostic and Statistical Manual of Mental Disorders (DSM) serves as the primary guide for healthcare professionals in diagnosing mental health conditions. Published by the American Psychiatric Association (APA), the DSM has undergone several revisions to reflect the evolving understanding of mental disorders. One significant shift occurred between the fourth edition (DSM-IV) and the most recent fifth edition (DSM-5), with the removal of the multi-axial system.
The DSM-IV utilized a multi-axial system where a diagnosis was categorized into five distinct parts known as Axes. This system aimed to provide a comprehensive overview of an individual’s mental health by detailing different aspects of their condition across these axes.
The DSM-IV Axes were structured as follows:
- Axis I: Mental Health and Substance Use Disorders
- Axis II: Personality Disorders and Mental Retardation (now Intellectual Development Disorder)
- Axis III: General Medical Conditions
- Axis IV: Psychosocial and Environmental Problems
- Axis V: Global Assessment of Functioning (GAF)
However, with the introduction of the DSM-5, the APA moved away from this multi-axial approach.
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The DSM-IV multi-axial system, illustrating the five axes used for diagnosis, including Axis I for clinical disorders.
The Historical Context of the Multi-Axial System
The multi-axial system was first implemented in the DSM-III, the third edition of the manual, by the APA. Its purpose was to enable clinicians to record additional diagnostic information in a structured manner.
For example, a patient diagnosed with major depressive disorder, which falls under Axis I diagnosis list, could have supplementary details added to their diagnosis. This might include information such as a lack of social support (Axis IV) and potential self-harm or harm to others (Axis V).
However, over time, the APA determined that the division of disorders into these axes lacked a strong scientific basis. Consequently, the multi-axial system was discontinued with the release of the DSM-5 in 2013.
How the Multi-Axial System Was Intended to Be Used
The primary intention behind organizing diagnostic information into separate axes was to facilitate more efficient patient diagnoses and comprehensive data collection by clinicians.
The aim was to provide healthcare professionals with a standardized and organized method for evaluating diagnostic information. By systematically reviewing each axis, clinicians could determine which aspects were relevant to their patient.
Despite its intended benefits, the multi-axial system faced criticism, particularly concerning the perceived ambiguity in differentiating between mental health and medical disorders.
The DSM-5’s non-axial system now combines the previous Axes I, II, and III. Information that would have been categorized under Axes IV and V is now incorporated as separate notations. This non-axial approach has generally been favored by healthcare professionals utilizing the DSM.
Delving into Axis I: Mental Health and Substance Use Disorders
Axis I of the DSM-IV was specifically designed to capture information regarding clinical disorders. It encompassed any mental health conditions, excluding personality disorders and intellectual development disorders, which were classified under Axis II. The disorders categorized under this Axis represent what many consider the core of mental health diagnoses.
The Axis 1 Diagnosis List included a broad spectrum of conditions, categorized as follows:
- Disorders Usually Diagnosed in Infancy, Childhood, or Adolescence: This category encompassed conditions that typically manifest early in life, such as attention-deficit/hyperactivity disorder (ADHD), autism spectrum disorder, and separation anxiety disorder.
- Delirium, Dementia, and Amnestic and Other Cognitive Disorders: These disorders involve disturbances in cognitive functions, including memory, attention, and awareness, often due to medical conditions, substance use, or neurodegenerative diseases like Alzheimer’s.
- Mental Disorders Due to a General Medical Condition: This category was for mental health symptoms directly caused by a physical illness. For instance, depression resulting from hypothyroidism would fall under this classification.
- Substance-Related Disorders: This crucial category in the axis 1 diagnosis list included disorders related to the abuse and dependence on substances such as alcohol, opioids, cannabis, and stimulants. It covered a wide range of substance use patterns and their associated problems.
- Schizophrenia and Other Psychotic Disorders: These are severe mental illnesses characterized by disturbances in thought, perception, and behavior, including conditions like schizophrenia, schizoaffective disorder, and delusional disorder.
- Mood Disorders: Also a significant part of Axis 1 disorders, mood disorders involve disturbances in mood regulation. This category included major depressive disorder, bipolar disorder, and dysthymia.
- Anxiety Disorders: Common mental health conditions, anxiety disorders are marked by excessive fear, worry, and nervousness. Examples include generalized anxiety disorder, panic disorder, social anxiety disorder, and obsessive-compulsive disorder (OCD).
- Somatoform Disorders: These disorders involve physical symptoms that suggest a medical condition but cannot be fully explained by any underlying medical illness, substance use, or other mental disorder.
- Factitious Disorders: Factitious disorders are characterized by intentionally feigning, inducing, or exaggerating symptoms of illness.
- Dissociative Disorders: These disorders involve disruptions in consciousness, memory, identity, emotion, perception, body representation, motor control, and behavior. Dissociative identity disorder (formerly multiple personality disorder) is a well-known example.
- Sexual and Gender Identity Disorders: This category included disorders related to sexual function, sexual desire, and gender identity.
- Eating Disorders: Eating disorders are characterized by persistent disturbances of eating or eating-related behavior that result in the altered consumption or absorption of food and that significantly impair physical health or psychosocial functioning. Anorexia nervosa, bulimia nervosa, and binge-eating disorder are examples.
- Sleep Disorders: Sleep disorders involve disturbances in sleep patterns, such as insomnia, narcolepsy, and sleep apnea.
- Impulse-Control Disorders Not Elsewhere Classified: These disorders are characterized by difficulties in controlling impulses or urges, leading to behaviors that can be harmful to oneself or others. Examples include kleptomania, pyromania, and intermittent explosive disorder.
- Adjustment Disorders: Adjustment disorders are stress-related conditions that occur when a person is unable to adjust to or cope with a particular stressor.
- Other Conditions That May Be a Focus of Clinical Attention: This residual category allowed clinicians to note conditions that were not formal mental disorders but were still significant enough to warrant clinical attention.
DSM-5 Revisions to Axis I Categories
The DSM-5 brought about several changes to the categories previously listed under Axis I. Notably, “Mental Disorders Due to a General Medical Condition,” “Factitious Disorders,” and “Adjustment Disorders” were removed as distinct classifications. Conditions previously categorized under these headings were reclassified within the DSM-5 framework. “Eating Disorders” was also renamed to “Feeding and Eating Disorders” to be more inclusive.
Furthermore, “Mood Disorders” was divided into two separate categories: “Bipolar and Related Disorders” and “Depressive Disorders,” reflecting a refined understanding of these conditions. “Sexual and Gender Identity Disorders” was revised to “Sexual Dysfunctions,” “Gender Dysphoria,” and “Paraphilic Disorders,” with updated criteria and terminology.
For a more detailed exploration of the specific conditions that were classified as Axis I disorders, resources such as “Which Mental Health Conditions Were Axis I Disorders?” can provide further insight.
Axis II: Personality Disorders and Mental Retardation
Axis II of the DSM-IV was designated for personality disorders and mental retardation (now termed intellectual development disorder). Personality disorders are enduring patterns of perceiving, relating to, and thinking about the environment and oneself that are exhibited in a wide range of social and personal contexts, and cause significant distress or impairment in social, occupational, or other important areas of functioning.
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
DSM-5 Changes to Axis II
While the specific personality disorder categories remained largely consistent in DSM-5, “Mental Retardation” was updated to “Intellectual Disability.” The DSM-5-TR (text revision) further refined this to “Intellectual Development Disorder,” while still including “Intellectual disability” in parentheses for continued recognition of the term.
Axis III: General Medical Conditions
Axis III was used to document any general medical conditions that could potentially influence a patient’s mental health. The purpose of Axis III was to recognize the interplay between physical and mental health.
For example, a patient diagnosed with cancer undergoing chemotherapy might experience mental health challenges such as anxiety and depression. In this scenario, cancer would be noted as an Axis III condition due to its direct impact on mental well-being.
DSM-5 and Axis III
In the DSM-5, the concept of Axis III was integrated into the main diagnostic process. Clinicians are still expected to consider and document any relevant medical conditions, but they are no longer segregated into a separate axis. This information is now incorporated into the overall clinical picture.
Axis IV: Psychosocial and Environmental Problems
Axis IV focused on psychosocial and environmental factors that could be affecting the individual. These were external stressors or life circumstances that might contribute to or exacerbate mental health issues.
Examples of factors included in Axis IV were:
- Problems with primary support group (e.g., family issues, lack of support)
- Problems related to the social environment (e.g., social isolation, discrimination)
- 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
DSM-5 Approach to Axis IV Information
The DSM-5 eliminated Axis IV as a distinct category. However, the importance of psychosocial and environmental factors is still recognized. This information is now incorporated into the diagnostic formulation through the use of “V codes” and narrative descriptions, allowing clinicians to document these contextual factors alongside the primary diagnoses.
Axis V: Global Assessment of Functioning (GAF)
Axis V employed the Global Assessment of Functioning (GAF) scale, a numerical rating from 0 to 100, to provide an overall summary of an individual’s psychological, social, and occupational functioning. The GAF score was intended to represent a holistic measure of a person’s level of functioning at the time of assessment.
The GAF scale was broadly outlined as follows:
- 100: Superior functioning across a wide range of areas.
- 90: No symptoms; functioning well in all areas.
- 80: Symptoms are transient and expectable reactions to psychosocial stressors.
- 70: Some mild symptoms OR some difficulty in social, occupational, or school functioning.
- 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.
- 30: Behavior considerably influenced by delusions or hallucinations OR serious impairment in communication or judgment.
- 20: Some danger of hurting self or others OR occasional failure to maintain minimal personal hygiene.
- 10: Persistent danger of severely hurting self or others OR persistent inability to maintain minimal personal hygiene.
DSM-5 and the GAF
Similar to Axis IV, Axis V and the GAF scale were discontinued in DSM-5. The DSM-5 instead utilizes the WHODAS (World Health Organization Disability Assessment Schedule) as a recommended, but not mandatory, tool to assess functioning. The DSM-5 emphasizes a more dimensional approach to understanding the severity and impact of mental disorders, rather than a single global functioning score.
Criticisms of the Multi-Axial System
Despite its intention to provide a comprehensive diagnostic framework, the multi-axial system faced several criticisms from healthcare professionals.
One major concern was the perceived arbitrary distinction between Axis I and Axis II disorders. Clinicians often found it challenging to neatly categorize certain conditions into one axis or the other. There was also recognition that the GAF scale (Axis V) had limitations in capturing nuanced aspects of functioning, such as suicide risk and specific disabilities.
Ultimately, the consensus among many professionals was that accurate and nuanced diagnoses could be achieved without the complexities and perceived limitations of the multi-axial system.
Updates in the DSM-5-TR
The most recent revision, the DSM-5-TR (text revision), further refined the diagnostic criteria for over 70 disorders. It introduced new codes for documenting suicidal behavior and non-suicidal self-injury, and updated language to address potential biases related to race and culture, and improve clarity. These changes reflect an ongoing effort to enhance the clinical utility and cultural sensitivity of the DSM.
Key Takeaways
The DSM-IV multi-axial system was a historical approach to recording comprehensive diagnostic information for individuals with mental health conditions. While it aimed to provide a structured and multifaceted view of mental disorders, it lacked strong scientific support and led to practical challenges and confusion. The removal of the multi-axial system in DSM-5 signifies a shift towards a more streamlined, non-axial approach to diagnosis, emphasizing a more integrated and clinically relevant understanding of mental health conditions. Understanding the historical context of the multi-axial system, particularly the axis 1 diagnosis list and its categories, offers valuable insight into the evolution of mental health diagnosis and the rationale behind the changes implemented in the DSM-5 and DSM-5-TR.
For further information, refer to resources such as “List of Psychological Disorders”.
