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. Throughout its revisions, the DSM has adapted to evolving understandings of mental health. A significant shift occurred with the transition from the DSM-IV to DSM-5, most notably the removal of the multi-axial system.
The DSM-IV, the fourth edition, employed a multi-axial system where a diagnosis was considered across five distinct dimensions, known as Axes. This Axis I-v Diagnosis approach aimed to provide a comprehensive and multi-faceted evaluation of an individual’s mental health profile. Each Axis offered a different category of information, contributing to a richer understanding of the patient’s condition.
The five Axes in the DSM-IV system were structured as follows:
- Axis I: Clinical Disorders – This axis encompassed the primary mental health and substance use disorders that are typically considered the main reason for seeking clinical attention.
- Axis II: Personality Disorders and Mental Retardation – Axis II addressed enduring and pervasive conditions, including personality disorders and mental retardation (intellectual development disorder in current terminology).
- Axis III: General Medical Conditions – This axis was dedicated to reporting any physical medical conditions that could be relevant to understanding or managing the individual’s mental health.
- Axis IV: Psychosocial and Environmental Problems – Axis IV captured significant psychosocial and environmental stressors that might be impacting the individual’s mental state or functioning.
- Axis V: Global Assessment of Functioning (GAF) – This axis provided a numerical rating, the GAF score, to represent the clinician’s judgment of the individual’s overall level of psychological, social, and occupational functioning.
However, with the release of the DSM-5, the APA moved away from the multi-axial system.
:max_bytes(150000):strip_icc()/five-axes-of-the-dsm-iv-multi-axial-system-1067053_final-de64cd6b001f472f86ec6ed5b226ad3f.png)
The Origins and Purpose of the Multi-Axial System
The multi-axial system was introduced into the DSM with its third edition (DSM-III). Its inception was driven by the desire to enable clinicians to record more detailed and varied diagnostic information beyond just the principal diagnosis. The intention behind implementing Axes was to create a structured framework for clinicians. This framework would ensure that evaluations considered not just the acute clinical disorders but also chronic personality patterns, medical conditions, environmental factors, and overall functioning level.
For example, consider an individual diagnosed with major depressive disorder (an Axis I condition). Under the multi-axial system, further relevant information could be systematically noted. This might include factors like a lack of social support (Axis IV) or an assessment of their current ability to function in daily life (Axis V). This multi-dimensional approach aimed to provide a more holistic and nuanced understanding of the patient.
However, over time, the scientific basis for maintaining this distinct division of disorders and information across separate axes was questioned. Consequently, the APA decided to discontinue the multi-axial system with the publication of the DSM-5 in 2013.
How the Multi-Axial System Was Utilized in Diagnosis
The multi-axial system’s primary function was to streamline and organize the diagnostic process for mental health professionals. By categorizing diagnostic information into distinct axes, clinicians could systematically evaluate patients. This structured approach was intended to ensure a thorough assessment, moving through each Axis to determine its relevance to the patient’s overall clinical picture.
The goal was to provide a standardized and organized method for healthcare professionals to methodically analyze diagnostic information. This systematic approach, axis by axis, aimed to facilitate a more efficient and comprehensive diagnostic process.
Despite its intended benefits, the multi-axial system was not without its critics. One major point of contention was the perceived artificial separation between mental health disorders (Axis I) and medical conditions (Axis III). Furthermore, the DSM-5’s non-axial approach integrates the information previously found in Axes I, II, and III into the main diagnostic formulation. Information comparable to former Axes IV and V is now captured through separate supplemental notations, reflecting a shift towards a more integrated diagnostic approach favored by many clinicians.
Axis I: Understanding Clinical Disorders
Axis I of the DSM-IV was designated for clinical disorders, encompassing a wide range of mental health conditions, excluding personality disorders and intellectual development disorders which were categorized under Axis II. 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
Revisions in DSM-5
The DSM-5 brought about several changes to the categories previously listed under Axis I. Notably, the classification of “Mental Disorders Due to a General Medical Condition,” “Factitious Disorders,” and “Adjustment Disorders” were removed as distinct categories. Conditions formerly classified under these were either re-categorized or integrated into other sections within the DSM-5. “Eating Disorders” was broadened to “Feeding and Eating Disorders.”
Furthermore, “Mood Disorders” was divided into two separate, more refined categories: “Bipolar and Related Disorders” and “Depressive Disorders.” “Sexual and Gender Identity Disorders” was revised to encompass “Sexual Dysfunctions,” “Gender Dysphoria,” and “Paraphilic Disorders,” reflecting updated understandings and terminology in these areas.
Axis II: Personality Disorders and Intellectual Disability
Axis II was dedicated to personality disorders and mental retardation. This axis focused on conditions characterized by long-standing patterns of behavior and inner experience that deviate significantly from cultural expectations. Disorders included in Axis II were:
- 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
Updates in DSM-5
While the specific personality disorder categories remained largely consistent in DSM-5, a significant change was made to the terminology for “Mental Retardation.” The DSM-5 initially replaced this term with “Intellectual Disability.” Subsequently, the DSM-5-TR (text revision) further refined the terminology to “Intellectual Development Disorder,” while retaining “Intellectual disability” in parentheses for continued clarity and recognition.
Axis III: General Medical Conditions Explained
Axis III served to document general medical conditions that were potentially relevant to the individual’s mental health. The purpose was to acknowledge the interplay between physical health and mental well-being.
For instance, if a patient was diagnosed with depression (Axis I) and also had diabetes (a general medical condition), the diabetes would be recorded on Axis III if it was deemed to have a bearing on their mental health presentation or treatment. Conditions such as cancer, heart disease, or chronic pain, if impacting mental health, would be noted on Axis III.
DSM-5 Approach
In the DSM-5, the concept of noting general medical conditions remains crucial. While Axis III was eliminated, clinicians are still expected to document any relevant medical conditions that could influence the understanding, treatment, or course of a mental disorder. This information is now integrated within the clinical formulation without a separate axis designation.
Axis IV: Psychosocial and Environmental Factors
Axis IV was designed to capture psychosocial and environmental problems that could be impacting the individual. This axis broadened the diagnostic scope to consider contextual factors outside of individual psychopathology. Examples of factors recorded on Axis IV included:
- 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 (e.g., academic difficulties, illiteracy)
- Occupational problems (e.g., unemployment, job stress)
- Housing problems (e.g., homelessness, inadequate housing)
- Economic problems (e.g., poverty, financial strain)
- Problems with access to healthcare services (e.g., lack of insurance, transportation issues)
- Problems related to interaction with the legal system/crime (e.g., arrest, incarceration)
- Other psychosocial and environmental problems
DSM-5 Integration
In the DSM-5, the detailed assessment of psychosocial and environmental factors remains essential. The information that would have been captured in Axis IV is now incorporated through the use of V and Z codes. These codes, drawn from the International Classification of Diseases (ICD), allow clinicians to specify psychosocial and environmental factors that significantly contribute to the patient’s condition. This ensures these crucial contextual elements are still documented and considered in diagnosis and treatment planning.
Axis V: Global Assessment of Functioning (GAF)
Axis V utilized the Global Assessment of Functioning (GAF) scale. This scale provided a single numerical score, ranging from 0 to 100, representing the clinician’s overall judgment of the individual’s functioning. The GAF score aimed to summarize the person’s psychological, social, and occupational functioning on a continuum. Key points on the GAF scale included:
- 100-91: Superior functioning across a wide range of areas.
- 90-81: Minimal symptoms, good functioning in most areas.
- 80-71: Transient, expected reactions to stressors; mild functional impairment.
- 70-61: Mild symptoms or some difficulty in social, occupational, or school functioning.
- 60-51: Moderate symptoms or moderate difficulty in social, occupational, or school functioning.
- 50-41: Serious symptoms or significant impairment in social, occupational, or school functioning.
- 40-31: Some impairment in reality testing or communication; major impairment in several areas.
- 30-21: Behavior considerably influenced by delusions or hallucinations; serious impairment in communication or judgment.
- 20-11: Some danger of hurting self or others; occasional failure to maintain minimal personal hygiene.
- 10-1: Persistent danger of severely hurting self or others; persistent inability to maintain minimal personal hygiene; serious suicidal act expected death.
Shift in DSM-5
With the DSM-5, the GAF scale was removed. While the importance of assessing functioning was retained, the DSM-5 instead recommends using the WHO Disability Assessment Schedule 2.0 (WHODAS 2.0). The WHODAS 2.0 is a more refined and psychometrically robust tool for assessing disability across six domains: cognition, mobility, self-care, getting along, life activities, and participation in society. This shift reflects a move towards a more empirically grounded and comprehensive approach to evaluating functional impairment.
Limitations and Rationale for Discontinuation of the Multi-Axial System
Despite its aims, the multi-axial system faced criticisms and was eventually deemed unnecessary by many professionals. A central issue was the perceived arbitrary distinction between Axis I and Axis II disorders. Clinicians often found it challenging to neatly categorize certain conditions, leading to confusion. Furthermore, concerns were raised that the GAF scale (Axis V) had limitations in capturing specific aspects of risk, such as suicide risk, or the complexities of disability in individual cases.
Ultimately, the consensus among many healthcare professionals was that effective diagnosis and nuanced patient understanding could be achieved without the constraints of the multi-axial system.
DSM-5-TR Updates
The DSM-5-TR, the latest text revision, represents ongoing refinements to the diagnostic manual. It includes updated diagnostic criteria for over 70 disorders and introduces new coding for suicidal behavior and non-suicidal self-injury. The DSM-5-TR also emphasizes the importance of using inclusive language and addressing potential biases related to race and culture in diagnosis.
Conclusion: Legacy of the Multi-Axial System
The DSM-IV’s multi-axial system was initially implemented to enhance the comprehensiveness of mental health diagnoses by systematically recording information across five axes. 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 axis i-v diagnosis system provides valuable historical context. It illuminates how diagnostic thinking evolved and why contemporary diagnostic approaches in the DSM-5 and DSM-5-TR have moved towards a more integrated and less compartmentalized framework. The shift reflects an ongoing effort to refine diagnostic practices based on evolving research and clinical experience in the field of mental health.
List of Psychological Disorders
