Wednesday, December 12, 2012

Superquick Guide to the DSM Axes

Oh, I know. It sounds pretty dry, doesn't it? I'm writing this post partially in response to searches that bring people to my blog. Sometimes I see things like "5-axis diagnosis of OCD." And perhaps you've heard of an "Axis" or "Axes" when someone's talking about a diagnosis made using the Diagnostic and Statistical Manual of Mental Disorders (DSM)? I've heard it on TV shows and the like. It's just part of the jargonny jargon.

But the DSM Axes are the way we organize our thoughts about diagnosis, so they're useful jargonny jargon. Not a perfect system, like I've said before, but still valuable.

When I do psychological evaluations, and I've done hundreds, it's not as simple as saying, "This kiddo has ADHD." In fact, it's really far from that. My final diagnostic--which is only a small piece of the evaluation--looks something like this:

Axis I: 314.01 Attention Deficit/Hyperactivity Disorder, Predominately Hyperactive-Impulsive Type
Axis II: none (or I might note history of significant developmental delay)
Axis III: History of acute otitis media, resolved
Axis IV: Problems with primary support group (parental stress level)
Axis V: 55

There's a lot that can be translated from this. I use the Axes to deliver as much information as possible (though, keep in mind, this comes near the end of my 10-page, single-spaced report).

Axis I: these are the primary mental disorders, with the exception of personality disorders and intellectual disabilities. Affective, anxiety, disruptive behavior, and thought disorders are all coded here. Pervasive developmental disorders (such as Autism Spectrum Disorder) are also listed here, as well as "V-codes", which are not disorders, but things that should be the focus of clinical intervention (in my speciality, "V61.20 Parent-Child Relational Problem" is the most common, but there are many others).

Axis II: Personality disorders and intellectual disabilities (formerly called "mental retardation") are coded here. Because of the group I work with, I also note significant developmental delays, because they are crucial context. Anyway, Axis II is for "long-term" conditions likely to affect resolution of the conditions diagnosed on Axis I.

Axis III: Medical conditions. I list significant ones, but also anything that might have an impact on the child's behavior or development. Like above, I listed acute middle ear infections because they can influence hearing, language development, attention, and mood in a child.

Axis IV: For me, this one's sooooo important. No mental disorder occurs in a vacuum! So here, I'll list any social/environmental/relational stressor that influences the child's functioning or behavior. Sometimes, I don't even diagnose a kid on Axis I--because the big issue is on Axis IV.

Axis V: This number is either the Global Assessment of Functioning or the Children's Global Assessment Scale. It just gives a numerical description of the approximate level of overall function or impairment.

Whenever someone has a psychological evaluation, this 5-Axis diagnosis should be one of the final outcomes. But only one of them! One of the longest sections of my reports are my recommendations, the part where I actually make suggestions for how to make things better, which is part of why they came to me in the first place. I never see the diagnosis as the most important outcome of an evaluation, but it is one piece of data, a snapshot of what's going on for this person.

If you're a writer and including psychological stuff in your manuscript, it's important to get these details right, and good research is key. So ... any questions?


  1. Thank you! I type medical transcription part-time and one of our accounts is a child psychiatrist who includes this info at the end of her report. (She sees a lot of kids in state facilities...the stories are sad, so sad. My heart breaks every time, typing out the horrors some of these children have lived through.) I've typed hundreds of these and had a pretty good idea what each Axis related to, just through common sense and repetition, but you've put the stamp on it. No questions, just a big thanks.

  2. I'm usually on the receiving end of these reports and trying to integrate those wonderful recommendations into the child's IEP at school. Thanks for the refresher. I'm also a big fan of Axis IV, although I often find that parents tend to gloss over that and focus mainly on I.

  3. So interesting! I have more to say, but it would incriminate my elders. And one day, I will be in their position. ;)

  4. Very interesting to read as always. :-)

  5. I like casting Psychiatrists as the antagonists, since that's what they've always been to me in real life. Bwah ha ha ha ha!