What Was the Multiaxial System?
Prior to the DSM-5, the DSM-IV-TR utilized a multiaxial system of diagnosis. This system was introduced in the 1980 DSM-III and existed to ensure that psychological, biological, environmental, and psychosocial factors were taken into account as they pertained to mental disorders. This system utilized diagnoses across five axes to look at the different impacts and elements of disorders. The five axes included: 1. The primary diagnosis, 2. Personality disorders and/or mental retardation, 3. Medical and/or neurological problems impacting the individual’s psychological concerns, 4. The nine categories of environmental and psychosocial stressors impacting the client’s psychological functioning, (such as job loss, romantic separations, or deaths), and 5. A 0-100 rating called the Global Assessment of Functioning (or “GAF”), quantifying the person’s overall level of functioning.
Why Was the Multiaxial System Removed?
The authors of the DSM-5 streamlined and simplified the diagnostic process by developing a single axis system for assessment and diagnosis of mental disorders. Information from the first four axes are still taken into consideration, but are not separated as they were in previous editions of the DSM. Namely, the DSM-5 has combined axes 1-3 into a single axis that accounts for mental and other medical diagnoses. There are no longer distinct categories for mental health diagnoses, medical diagnoses, and personality disorders. Prior to the combined axes, many experts argued there were no fundamental differences between Axis 1 and Axis 2 diagnoses and that separating them lead to confusion in and lack of adequate treatment. Contributing stressors that were previously accounted for on the fourth axis are now taken into account through a broadened set of V and Z codes that clinicians can use to indicate additional areas of concern that could be impacting diagnosis and treatment, or that could require further clinical attention (Kress et al., 2014). The fifth axis had long been criticized for a lack of reliability and consistency amongst clinicians. It was because of that lack of reliability as well as poor clinical utility that the APA chose to remove this measure from the DSM-V. Moving forward the APA recommends that clinicians find alternate ways to document an individual’s distress and impaired functioning (APA, 2013).
What Implications Does This Have?
The long term impact of these changes is yet to be seen, but will surely reveal itself over time. So what impact might these changes have? Well, it has been noted that removing the distinction of personality disorders from their own axis may help remove some of the stigma previously associated with these diagnoses (Kress et al., 2014). Experts cite both possible benefits as well as drawbacks to combining medical and mental health diagnoses. Possible benefits include decreased stigmatization of mental health disorders, as a single axis system points towards a shared biological basis for both mental health and medical conditions. The previous distinction between mental health and medical disorders led to unequal health care coverage for mental health treatment, and removing this division could prove helpful in equal coverage being provided for mental health conditions.
In terms of drawbacks, however, having a view of mental health disorders being rooted in biology could suggest those with mental health disorders are flawed biologically (Ben-Zeev, Young, & Corrigan, 2010). Some argue this view could result in a lessening of the consideration of environmental factors on mental health conditions. Further, some say it could lead to an increased use of psychopharmacology to treat mental health disorders (Frances, 2013).
Note for Test-Takers: Will the Multiaxial System Show Up on My Exam?
Absolutely not! The exam only reflects material from the DSM-V, so you will not see the multiaxial system show up in any way, shape, or form on the test, or in any of our social work or MFT exam prep study systems.
What are your thoughts on the removal of the Multiaxial System? How have you seen it impact your own practice? Share in the comments below!
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: Author.
Ben-Zeev, D., Young, M. A., & Corrigan, P. W. (2010). DSM-V and the stigma of mental illness. Journal of Mental Health, 19, 318–327. doi:10.3109/09638237.2010.492484
Frances, A. (2013). Essentials of psychiatric diagnosis: Responding to the challenge of DSM-5. New York, NY: Guilford Press.
Kress, V. C., Barrio Minton, C. A., Adamson, N. A., Paylo, M. J., & Pope, V. (2014). The removal of the multiaxial system in the DSM‐5: Implications and practice suggestions for counselors. The Professional Counselor, 4, 191‐201. doi: :10.15241/vek.4.3.191