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
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
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
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