What are the DSM-IV (Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition) axes for diagnosing depression and anxiety?

From the Guidelines

Depression and anxiety disorders were classified on Axis I in the DSM-IV, which included all major clinical disorders except personality disorders and intellectual disabilities. The DSM-IV used a multiaxial system with five axes: Axis I for clinical disorders, Axis II for personality disorders and intellectual disabilities, Axis III for general medical conditions, Axis IV for psychosocial and environmental problems, and Axis V for global assessment of functioning 1. This system allowed clinicians to consider multiple aspects of a patient's condition when making diagnoses.

Key Points

• Major depressive disorder, dysthymic disorder, and bipolar disorders with depressive episodes were categorized as mood disorders on Axis I.
• Anxiety disorders such as generalized anxiety disorder, panic disorder, social anxiety disorder, specific phobias, obsessive-compulsive disorder, and post-traumatic stress disorder were also classified on Axis I.
• The DSM-5, published in 2013, eliminated the multiaxial system entirely, and now all mental disorders including depression and anxiety are simply listed together without axial distinctions.
• According to the American Society of Clinical Oncology guideline update in 2023, all health care providers should routinely screen for the presence of emotional distress and specifically symptoms of anxiety from the point of diagnosis onward 1.
• The guideline also recommends using a valid and reliable tool, such as the GAD-7 scale, to screen for anxiety disorders, particularly generalized anxiety disorder, which is the most prevalent anxiety disorder and commonly comorbid with mood disorders or other anxiety disorders 1.

Recommendations for Screening and Assessment

• Screening for anxiety should be done at initial diagnosis, start of treatment, regular intervals during treatment, end of treatment, post-treatment or at transition to survivorship, at recurrence or progression, advanced disease, when dying, and during times of personal transition or reappraisal 1.
• Assessments should identify signs and symptoms of anxiety, severity of symptoms, possible stressors, risk factors, and times of vulnerability, and explore underlying problems/causes 1.
• Patients with moderate to severe or severe symptomatology should have a diagnostic assessment to identify the nature and extent of the anxiety symptoms and the presence or absence of an anxiety disorder or disorders 1.

From the FDA Drug Label

The efficacy of Prozac was established in 5– and 6–week trials with depressed adult and geriatric outpatients (≥18 years of age) whose diagnoses corresponded most closely to the DSM–III (currently DSM–IV) category of major depressive disorder A major depressive episode (DSM–IV) implies a prominent and relatively persistent (nearly every day for at least 2 weeks) depressed or dysphoric mood that usually interferes with daily functioning, and includes at least 5 of the following 9 symptoms: depressed mood, loss of interest in usual activities, significant change in weight and/or appetite, insomnia or hypersomnia, psychomotor agitation or retardation, increased fatigue, feelings of guilt or worthlessness, slowed thinking or impaired concentration, a suicide attempt or suicidal ideation. PTSD, as defined by DSM-III-R/IV, requires exposure to a traumatic event that involved actual or threatened death or serious injury, or threat to the physical integrity of self or others, and a response which involves intense fear, helplessness, or horror Social anxiety disorder, as defined by DSM-IV, is characterized by marked and persistent fear of social or performance situations involving exposure to unfamiliar people or possible scrutiny by others and by fears of acting in a humiliating or embarrassing way Patients in Study 1 met DSM-III-R criteria for Late Luteal Phase Dysphoric Disorder (LLPDD), the clinical entity now referred to as Premenstrual Dysphoric Disorder (PMDD) in DSM-IV.

The DSM-IV axis for depression and anxiety includes:

• Major Depressive Disorder: characterized by a prominent and relatively persistent depressed or dysphoric mood that usually interferes with daily functioning, and includes at least 5 of the following 9 symptoms: depressed mood, loss of interest in usual activities, significant change in weight and/or appetite, insomnia or hypersomnia, psychomotor agitation or retardation, increased fatigue, feelings of guilt or worthlessness, slowed thinking or impaired concentration, a suicide attempt or suicidal ideation 2.
• Post-Traumatic Stress Disorder (PTSD): requires exposure to a traumatic event that involved actual or threatened death or serious injury, or threat to the physical integrity of self or others, and a response which involves intense fear, helplessness, or horror 3.
• Social Anxiety Disorder: characterized by marked and persistent fear of social or performance situations involving exposure to unfamiliar people or possible scrutiny by others and by fears of acting in a humiliating or embarrassing way 3.
• Premenstrual Dysphoric Disorder (PMDD): characterized by markedly depressed mood, anxiety or tension, affective lability, and persistent anger or irritability, and physical symptoms such as breast tenderness, headache, joint and muscle pain, bloating and weight gain 3 and 3.

From the Research

DSM-IV Axis for Depression and Anxiety

• The DSM-IV field trial for mixed anxiety-depression 4 was designed to answer questions about patients presenting with anxious or depressed symptoms that do not meet DSM-III-R definitional thresholds for axis I anxiety or mood disorders.
• The study found that patients presenting with affective symptoms that did not meet definitional thresholds for DSM-III-R axis I disorders were at least as common as patients with several of the already established anxiety and mood disorders in each of the seven sites, and their disorders were associated with significant distress or impairment.
• A nonspecific pattern of anxious and depressed symptoms was the modal presentation among these patients with currently subdefinitional threshold disorders, and they could be significantly differentiated in terms of current symptoms from patients presenting with a principal diagnosis of generalized anxiety disorder, major depressive episode, or panic disorder with agoraphobia.
• The authors recommend that a mixed anxiety-depression category be included in the DSM-IV appendix for proposed diagnostic categories that need further study.

Diagnosis and Treatment

• Selective serotonin-reuptake inhibitors (SSRIs) are effective treatments for depression and anxiety disorders, including major depression, dysthymia, panic disorder, obsessive-compulsive disorder, eating disorders, and premenstrual dysphoric disorder 5.
• The combination of a selective serotonin reuptake inhibitor (SSRI) and cognitive behavioral therapy (CBT) consistently produces greater improvement than either treatment alone for children and adolescents with internalizing disorders, including depression and anxiety 6.
• The treatment goals for social anxiety disorder (SAD) are to reduce fear, avoidance, physical distress, disability, and comorbidity, and SSRIs are effective treatments for SAD 7.

Diagnostic Criteria

• The DSM-IV diagnostic criteria for major depressive disorder have not been subject to empirical scrutiny, and research has focused on the criteria used to diagnose major depressive disorder 8.
• The Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) project examined issues of nosology and the diagnostic criteria for major depression, and found that the assumptions underlying the DSM's diagnostic rules may not have empirical support 8.