The Axes of a Diagnosis

Psychiatrists and psychologists use criteria in the DSM-IV, or Diagnostic and Statistical Manual, to diagnose a patient. If you are not familiar with this manual, check this out first.

Axis I: Clinical syndromes that are the focus of the diagnosis

Axis II: Long standing chronic conditions that may affect the clinical syndromes listed in Axis I

Axis III: Medical conditions

Axis IV: Psychosocial and environmental stressors that may affect the clinical syndromes listed in Axis I

Axis V: GAF Score (1 - 100)

There exists a standard notation for DSM-IV diagnosis for use by all psychologists in the West, and primarily the United States. This notation functions as the language by which the fine institution of psychology communicates with the insurance companies. For many patients, this sort of diagnosis is the red tape itself. The standard form of a DSM-IV diagnosis exists in five parts, or axes.  Each axis represents the condition of an aspect of the patient's mental health.

I. On this line, the diagnostician writes the DSM code for the particular disorder, followed by the name of the disorder. This line includes any extra notes as well, such as whether the disorder is "early onset." This line might include common clinical syndromes such as Obsessive Compulsive Disorder, Dysthymic Disorder, or Panic Disorder. Axis I includes less common disorders such as schizophrenia and autism.  Axis I also includes any appropriate V Codes.  V Codes are defined in the DSM-IV as "other conditions or problems that may be a focus of clinical attention," such as "Noncompliance With Treatment" or "Parent-Child Relational Problem."

II. These conditions include mental retardation and personality disorders.  Typified as any permanent, usually genetic condition of the patient, personality disorders affect the way an Axis I syndrome manifests itself in a patient.  For example, a patient with obsessive compulsive tendencies ought to be treated differently if they also suffer from a Schizoid Personality Disorder. Note: The newest version of the DSM (DSM-IV) no longer includes Passive-aggressive Personality Disorder as a personality disorder, which is listed in the respective node.

III. This broad category includes any of the patient's relevant medical conditions, such as diabetes or physical injury. It should be noted that Downs Syndrome is considered an Axis III medical condition, because the syndrome is a holistic disorder affecting the entire body, and not just a mental disorder.  The focus of the diagnosis (conditions listed in Axis I or II), of course, might be direct results of a more basic problem here in Axis III, such as a mood disorder that results from the debilitating circumstances of a spinal injury.

IV. These non-clinical, albeit medically significant, stressors on the individual include economic, social, or criminal barriers. Examples include whether the patient is homeless, currently under foster care, or living in jail. Just as with Axis II, these stressors affect the patient's clinical syndromes.

V. The Global Assessment of Functioning Scale is a relatively subjective score given on a scale between 0 and 100, used to quickly communicate the general mental health of the patient.  Every tenth value on the scale correspond to specific criteria, with the numbers in-between representing a more specific assessment of functioning.  The higher the score, the healthier the patient.

Rule Out (R/O) Notation

Although it is considered unethical to over-diagnose or under-diagnose a patient, psychologists who feel a patient is on the border of a certain illness will often use a certain notation to show which diagnosis may be recommended in the future.  Consider this situation:  A patient reports feeling "blue" for about a year and half.  The DSM-IV states that in order to diagnose the patient with dysthymic disorder, there must be a "depressed mood for most of the day, for more days than not, as indicated either by subjective account or observation by others, for at least two years." Since the patient reported the condition for six months less than required, the psychologist cannot diagnose dysthymic disorder. Instead, the psychologist will report "311 Depressive Disorder Not Otherwise Specified, R/O Dysthemia."  This notation calls for a ruling out of dysthemia in a future diagnosis. Confusedly, psychologists use the rule out notation to also remove a disorder from consideration.

Example Diagnosis

Axis I: 296.84 Bipolar II Disorder, Early Onset.

Axis I: 307.51 Bulimia Nervosa, Nonpurging Type.

Axis II: 301.6 Dependent Personality Disorder

Axis III: 426.00 Complete Atrioventricular Block

Axis IV: Child abuse victim, unemployment

Axis V: 28


Desk Reference to the Diagnostic Criteria from DSM-IV-TR

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