What are the 5 axes in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV)?

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DSM-IV Multiaxial System: The Five Axes

The DSM-IV utilized a multiaxial diagnostic system consisting of five distinct axes: Axis I (Clinical Disorders), Axis II (Personality Disorders and Mental Retardation), Axis III (General Medical Conditions), Axis IV (Psychosocial and Environmental Problems), and Axis V (Global Assessment of Functioning). This system was discontinued in DSM-5, which was published in 2013 1.

The Five Axes Explained

Axis I: Clinical Disorders

  • Included all major mental disorders except personality disorders and mental retardation 2
  • Encompassed conditions such as mood disorders, anxiety disorders, psychotic disorders, and substance use disorders 1
  • In DSM-IV, substance abuse and dependence were diagnosed as separate disorders on this axis, with dependence requiring three or more criteria and abuse requiring at least one criterion among those without dependence 1

Axis II: Personality Disorders and Mental Retardation

  • Contained all personality disorders and developmental disorders including mental retardation 2
  • This axis was separated from Axis I to ensure these chronic conditions received appropriate clinical attention 2
  • The distinction between Axis I and Axis II has been shown to have validity, though some disorders like antisocial personality disorder and borderline personality disorder showed overlap with Axis I externalizing and internalizing spectra 2

Axis III: General Medical Conditions

  • Documented physical disorders and general medical conditions relevant to understanding or managing the mental disorder 3
  • The presence and number of major chronic physical disorders (MCPD) on Axis III showed significant predictive validity for functioning outcomes, with correlation coefficients ranging from .41 to .55 for patients with specific psychiatric disorders 3
  • This axis was particularly important for predicting course and outcome in patients with dysthymic disorders and major depression 3

Axis IV: Psychosocial and Environmental Problems

  • Assessed psychosocial and environmental stressors that may affect diagnosis, treatment, and prognosis 4
  • Categories included problems with primary support group, social environment, education, occupation, housing, economics, access to healthcare, and legal system 4
  • Reliability between professional assessment and self-assessment ranged from fair to almost perfect (kappa 0.31-0.83), and showed concurrent validity with Axis I disorders, comorbidity, personality disorders, and decreasing Global Assessment of Functioning scores 4

Axis V: Global Assessment of Functioning (GAF)

  • Provided a single numerical rating (0-100) of overall psychological, social, and occupational functioning 5, 6
  • The GAF scale showed modest reliability and validity, with very high levels of interrater reliability when used by trained clinicians 5, 6
  • A key limitation was the combination of symptom severity with social and occupational functioning on a single scale, making it difficult to distinguish between these different domains 5
  • The GAF was significantly related to concurrent measures of global psychopathology on standardized instruments 6

Important Context: Transition to DSM-5

  • The multiaxial system was eliminated in DSM-5 (published 2013), which moved to a non-axial documentation of diagnosis 1
  • DSM-5 combined the former Axis I and Axis II disorders into a single list, while medical conditions and psychosocial factors are now noted separately without axis designations 1
  • For substance use disorders specifically, DSM-5 eliminated the abuse/dependence distinction and created a single substance use disorder diagnosis with severity specifiers 1

References

1
Guideline

Guideline Directed Topic Overview

Dr.Oracle Medical Advisory Board & Editors, 2025

2
Research

The joint structure of DSM-IV Axis I and Axis II disorders.

Journal of abnormal psychology, 2011

4
Research

Axis IV--psychosocial and environmental problems--in the DSM-IV.

Journal of psychiatric and mental health nursing, 2013

5
Research

Revising axis V for DSM-IV: a review of measures of social functioning.

The American journal of psychiatry, 1992

6
Research

Reliability and validity of DSM-IV axis V.

The American journal of psychiatry, 2000

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