The Multi-Axial System in the DSM-IV

In the United States, healthcare professionals consult the Diagnostic and Statistical Manual of Mental Disorders (DSM) when diagnosing mental health conditions. The DSM is published by the American Psychiatric Association (APA).

The DSM has gone through many changes over the years. The shift from the previous version of the manual (DSM-IV) to the most recent version (DSM-5) included a number of significant changes, including the removal of the multi-axial system.

A diagnosis under the fourth edition of this manual, the DSM-IV, had five parts called Axes. Each Axis of this multi-axial system provided a different type of information about a diagnosis.

However, the multi-axial system was done away with starting with the DSM-5.

History of the Multi-Axial System

The APA instituted the multi-axial system in the third edition of the DSM (DSM-III). The Axes were introduced as a way for clinicians to record additional diagnostic information.

In other words, a person diagnosed with major depressive disorder (found in Axis I) may have additional information added to their diagnosis, say, if they lacked a support system (Axis IV) and they posed a risk to themselves or others (Axis V).

Uses for the Multi-Axial System

Organizing diagnostic information into the separate Axes was meant to help clinicians more efficiently diagnose patients and collect comprehensive data.

However, there was controversy that surrounded the multi-axial system, including confusion surrounding the distinction between mental health and medical disorders.

The non-axial system used in the DSM-5 combines the former Axes I, II and III and includes separate notations for the type of information which would have previously fallen into Axes IV and V. The non-axial system seems to be the preferred organization by healthcare professionals who use the DSM.

Axis I: Mental Health and Substance Use Disorders

Axis I provided information about clinical disorders. Any mental health conditions, other than personality disorders or intellectual development disorders, would have been included here. Disorders which would have fallen under this Axis include:

• Disorders Usually 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 Else Classified
• Adjustment Disorders
• Other Conditions That May Be a Focus of Clinical Attention

Changes in the DSM-5

In the DSM-5, the classification of Mental Disorders Due to a General Medical Condition was dropped, as was Factitious Disorders and Adjustment Disorders. This means that conditions listed under those categories were recategorized in the DSM-5. Eating Disorders was renamed to Feeding and Eating Disorders.

In addition, Mood Disorders was broken out into two separate categories: Bipolar and Related Disorders and Depressive Disorders. Sexual and Gender Identity Disorders was revised to Sexual Dysfunctions, Gender Dysphoria, and Paraphilic Disorders.

The following categories were added:

• Neurodevelopmental Disorders
• Obsessive-Compulsive and Related Disorders
• Trauma- and Stressor-Related Disorders
• Medication-Induced Movement Disorders and Other Adverse Effects of Medication

Axis II: Personality Disorders and Mental Retardation

Axis II provided information about personality disorders and mental retardation. Disorders which would have fallen under this Axis include:

• 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 the DSM-5

The categories listed above were kept in the DSM-5 with the exception of Mental Retardation. The DSM-5 changed this to Intellectual Disability.

However, the updated version of the DSM-5, called the DSM-5-TR (text revision), changed Intellectual Disability to Intellectual Development Disorder. Intellectual disability is still included in parentheses for continued use.

Axis III: General Medical Conditions

Axis III provided information about any medical conditions present which might affect a patient's mental health.

For instance, someone who has cancer and is undergoing chemotherapy may experience mental health issues like anxiety and depression. Their cancer would be considered an Axis III condition because it is a health issue that influences mental health.

Changes in the DSM-5

Any conditions that were previously categorized in Axis III are still documented as mental health concerns in the DSM-5. Clinicians can simply make note of this in order of priority.

Axis IV: Psychosocial and Environmental Problems

Axis IV was used to describe psychosocial and environmental factors affecting the person. Factors which might have been included here were:

• Problems with a primary support group
• Problems related to the 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 from Axis IV is now included in separate notations in the DSM-5. These notations can be added on to diagnoses as needed.

Axis V: Global Assessment of Functioning (GAF)

Axis V was a rating scale called the Global Assessment of Functioning; the GAF went from 0 to 100 and provided a way to summarize in a single number just how adaptively a person was functioning overall. A general outline of this scale would be as follows:

• 100: No symptoms
• 90: Minimal symptoms with good functioning
• 80: Transient symptoms that are expected reactions to psychosocial stressors
• 70: 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 such as work or school, family relations, judgment, thinking, or mood
• 30: Behavior is considerably influenced by delusions or hallucinations; serious impairment in communication or judgment; or, inability to function in almost all areas
• 20: Some danger of hurting self or others; occasionally fails to maintain minimal personal hygiene; or, gross impairment in communication
• 10: Persistent danger of severely hurting self or others; persistent inability to maintain minimal personal hygiene; or, serious suicidal act with clear expectation of death

Changes in the DSM-5

Similar to information previously in Axis IV, information in Axis V is now included in the DSM-5 as separate notations of psychosocial and contextual factors.

Pitfalls of the Multi-Axial System

There were a number of reasons that healthcare professionals found that the multi-axial system was unnecessary.

Many felt that the distinction was arbitrary between diagnoses in Axis I and Axis II. There were concerns that some diagnoses didn't fit "cleanly" into either category. In addition, there was concern that the GAF (Axis V) didn't take into account suicide risk and disabilities in individual patients.

Overall, healthcare professionals can successfully diagnose patients—and account for the nuances of each person they diagnose—without the use of the multi-axial system.

Takeaways

The multi-axial system was previously used as a way to record additional diagnostic information for people with mental health conditions. However, there was a lack of scientific support for this system and it led to confusion for many professionals, which is why it was removed in the fifth edition of the diagnostic manual. While no longer used, understanding how it worked can provide some historical context for how conditions were previously diagnosed and why changes were made in the DSM-5.