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= Multiaxial diagnosis =

History
The need for a standardized classification system of mental disorders has been agreed upon throughout the history of psychology and medicine. It is, however, controversial as to what should and should not be included in the system and how to go about organizing such a breadth of criterion and information. For this reason, classification systems have varied greatly throughout the years in their foci (phenomenology, etiology, and course), their breadth, and their ultimate purpose (clinical, research, or statistical).

In the United States, the need to collect statistical information regarding mental health for the U.S. census purposes became apparent. By the 1880 census, seven categories of mental health were distinguished: mania, melancholia, moromania, paresis, dementia, dipsomania, and epilepsy. In 1917, the Bureau of the Census adopted a plan formulated collaboratively by the American Medico-Psychological Association and the National Commission on Mental Hygiene for gathering uniform and standard statistics across mental hospitals. This system - though its goal was clinical utility - was still mainly statistical in nature so the American Psychiatric Association and the New York Academy of Medicine worked to develop a new taxonomical system to be incorporated within the first edition of the American Medical Association’s Standard Classified Nomenclature of Disease. This system was designed primarily to diagnose patients with severe psychiatric and neurological disorders and thus its utility was narrow.

The U.S. Army developed a broader system to be inclusive of the World War II servicemen and veterans and the array of disorders that they faced. At the same time, the World Health Organization first included mental disorders in their sixth edition of the International Classification of Diseases (ICD). The American Psychiatric Association Committee on Nomenclature and Statistics developed their own version of the ICD-6 and published it in 1952. This was the first edition of the Diagnostic and Statistical Manual (DSM-I), of which the fifth edition is currently in use by professionals in the field of clinical psychology. The release of the DSM-III was chronologically coordinated with its counterpart, the British ICD-9. It was published in the year 1980 and introduced many new components, including the 'multiaxial system of diagnosis'.

Axis I: Clinical/Developmental/Learning Disorders
The first axis is where clinical, developmental, and learning disorders fall. This includes:
 * Disorders usually first diagnosed in infancy, childhood, or adolescence
 * Learning disorders (reading disorder, mathematics disorder, disorder of written expression)
 * Motor skills disorder (developmental coordination disorder)
 * Pervasive developmental disorders (autistic disorder, Rett’s disorder, childhood disintegrative disorder, Asperger’s disorder)
 * Attention deficit and disruptive behavior disorders (attention-deficit/hyperactivity disorder, oppositional defiant disorder, conduct disorder)
 * Feeding and eating disorders of infancy or early childhood (pica, rumination disorder, feeding disorder of infancy or early childhood)
 * Tic disorders (Tourette’s disorder, chronic motor or vocal tic disorder, transient tic disorder)
 * Communication disorders (expressive language disorder, mixed receptive/expressive language disorder, phonological disorder, stuttering)
 * Elimination disorders (encopresis, enuresis)
 * Other disorders of infancy, childhood, or adolescence (separation anxiety disorder, selective mutism, reactive attachment disorder of infancy or early childhood, stereotypic movement disorder)


 * Delirium, dementia, amnestic and other cognitive disorders
 * Delirium (delirium due to a general medical condition, substance-intoxicated delirium, substance-withdrawal delirium, delirium due to multiple etiologies)
 * Dementias (dementia of the Alzheimer’s type – with early onset if onset at age 65 or below OR late onset if onset after age 65, vascular dementia, dementias due to other general medical conditions, substance-induced persisting dementia, dementia due to multiple etiologies)
 * Amnestic disorders (amnestic disorder due to a general medical condition, substance-induced persisting amnestic disorder – refer to specific substance for code)


 * Substance-related disorders
 * Alcohol-related disorders
 * Amphetamine-related disorders
 * Caffeine-related disorders
 * Cannabis-related disorders
 * Cocaine-related disorders
 * Hallucinogen-related disorders
 * Inhalant-related disorders
 * Nicotine-related disorders
 * Opioid-related disorders
 * Phencyclidine (or related substance)-related disorders
 * Sedative, hypnotic, or anxiolytic-related disorders
 * Polysubstance-related disorder


 * Schizophrenia and other psychotic disorders
 * Schizophrenia (paranoid type, disorganized type, catatonic type, undifferentiated type, residual type)
 * Schizophreniform disorder
 * Schizoaffective disorder
 * Delusional disorder
 * Brief psychotic disorder
 * Shared psychotic disorder (folie à deux)
 * Psychotic disorder due to a general medical condition (with delusions, with hallucinations, substance-induced psychotic disorder)


 * Mood disorders
 * Depressive disorders (major depressive disorder, dysthymic disorder)
 * Bipolar disorders (bipolar I disorder, bipolar II disorder, cyclothymic disorder)
 * Mood disorder due to a general medical condition
 * Substance-induced mood disorder


 * Anxiety disorders
 * Panic disorder (without agoraphobia, with agoraphobia)
 * Agoraphobia without a history of panic disorder
 * Specific phobia
 * Social phobia (social anxiety disorder)
 * Obsessive-compulsive disorder
 * Posttraumatic stress disorder
 * Acute stress disorder
 * Generalized anxiety disorder
 * Anxiety disorder due to a general medical condition
 * Substance-induced anxiety disorder


 * Somatoform disorders
 * Somatization disorder
 * Conversion disorder
 * Hypochondriasis
 * Body dysmorphic disorder
 * Pain disorder


 * Factitious disorder
 * Dissociative disorders
 * Dissociative amnesia
 * Dissociative fugue
 * Dissociative identity disorder (multiple personality disorder)
 * Depersonalization disorder


 * Sexual and gender identity disorders
 * Sexual dysfunctions (hyperactive sexual desire disorder, sexual aversion disorder, female sexual arousal disorder, male erectile disorder, female orgasmic disorder, male orgasmic disorder, premature ejaculation, dyspareunia, vaginismus, sexual dysfunction due to a general medical condition, substance-induced sexual dysfunction)
 * Paraphilias (exhibitionism, fetishism, frotteurism, pedophilia, sexual masochism, sexual sadism, voyeurism, tranvestic fetishism)
 * Gender identity disorders (in children, in adolescents or adults – transsexualism)


 * Eating disorders
 * Anorexia nervosa
 * Bulimia nervosa


 * Sleep disorders
 * Primary sleep disorders (primary insomnia, primary hypersomnia, narcolepsy, breathing-related sleep disorder, circadian rhythm sleep disorder, parasomnias, nightmare disorder, sleep terror disorder, sleepwalking disorder, sleep disorders related to another mental disorder)
 * Sleep disorder due to a general medical condition (substance-induced sleep disorder)


 * Impulse control disorders not elsewhere classified
 * Intermittent explosive disorder
 * Kleptomania
 * Pyromania
 * Pathological gambling
 * Trichotillomania


 * Adjustment disorders
 * Adjustment disorder (with anxiety, with depressed mood, with disturbance of conduct, with mixed disturbance of emotions and conduct, with mixed anxiety and depressed mood)

Axis II: Personality Disorders & Mental Retardation
The second axis is where mental retardation and personality disorders fall. This includes:
 * Mental retardation (mild, moderate, severe, profound)
 * Personality disorders
 * Paranoid personality disorder
 * Schizoid personality disorder
 * Schizotypal personality disorder
 * Antisocial personality disorder
 * Borderline personality disorder
 * Histrionic personality disorder
 * Narcissistic personality disorder
 * Avoidant personality disorder
 * Dependent personality disorder
 * Obsessive-compulsive personality disorder

Axis III: Medical Conditions & Physical Disorders
The third axis is where general medical conditions fall.

Axis IV: Psychosocial/Environmental Factors
The fourth axis is where psychosocial and environmental problems fall. This includes:
 * Problems with primary support group
 * Problems related to the social environment
 * Educational problems
 * Occupational problems
 * Housing problems
 * Economic problems
 * Problems with access to health care services
 * Problems related to interaction with the legal system and/or crime
 * Other psychosocial and environmental problems

Axis V: Global Assessment of Functioning or Children's Global Assessment Scale
The fifth axis is where a numerical assessment of functioning falls. Depending on the age of the subject of diagnosis, either the Global Assessment of Functioning or the Children’s Global Assessment Scale will be used.

Global Assessment of Functioning
Considering psychological, social, and occupational functioning, a code number is given on a hypothetical continuum of mental health/illness. Impairment in functioning due to physical (or environmental) limitations is excluded. The categories are as follows:
 * '100-91': Superior functioning in a wide range of activities, life’s problems never seem to get out of hand, is sought out by others because of many positive qualities. No symptoms.
 * '90-81': Absent or minimal symptoms (e.g., mild anxiety before an exam), good functioning in all areas, interested and involved in a wide range of activities, socially effective, generally satisfied with life, no more than everyday problems or concerns (e.g., an occasional argument with family members).
 * '80-71': If symptoms are present, they are transient and expectable reactions to psychosocial stressors (e.g., difficulty concentrating after family argument); no more than slight impairment in social, occupational, or school functioning (e.g., an occasional argument with family members).
 * '70-61': Some mild symptoms (e.g., depressed mood and mild insomnia) OR some difficulty in social, occupational, or school functioning (e.g., occasional truancy, or theft within the household), but generally functioning pretty well, has some meaningful interpersonal relationships.
 * '60-51': Moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) OR moderate difficulty in social, occupational, or school functioning (e.g., no friends, unable to keep a job).
 * '50-41'Serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) OR any serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job).
 * '40-31': Some impairment in reality testing or communication (e.g., speech at times is illogical, obscure, or irrelevant) OR major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood (e.g., depressed man avoids friends, neglects family, and is unable to work; child frequently beats up younger children, is defiant at home, and is failing at school).
 * '30-21': Behavior is considerably influenced by delusions or hallucinations OR serious impairment in communication or judgment (e.g., sometimes incoherent, acts grossly inappropriately, suicidal preoccupation) OR inability to function in almost all areas (e.g., stays in bed all day; no job, home, or friends).
 * '20-11': Some danger of hurting self or others (e.g., suicide attempts without clear expectation of death, frequently violent, manic excitement) OR occasionally fails to maintain minimal personal hygiene (e.g., smears feces) OR gross impairment in communication (e.g., largely incoherent or mute).
 * '10-1': Persistent danger of severely hurting self or others (e.g., recurrent violence) OR persistent inability to maintain minimal personal hygiene OR serious suicidal act with clear expectation of death.
 * '0': Inadequate information.

Children's Global Assessment Scale
When it is a child being diagnosed, conditions affecting that child are different. For example, the child cannot be diagnosed based on occupational performance at the age of five. The functioning of children is thus rated on the Children's Global Assessment Scale, with categories as follows:
 * '100-91': Superior functioning in all areas (at home, at school and with peers), involved in a range of activities and his many interests (e.g., has hobbies or participates in extracurricular activities or belongs to an organized group such as Scouts, etc.). Likeable, confident, everyday worries never get out of hand. Doing well in school. No symptoms.
 * '90-81': Good functioning 'in all areas. Secure in family, school, and with peers. There may be transient difficulties and "everyday" worries that occasionally get out of hand (e.g. mild anxiety associated with an important exam, occasionally "blow-ups" with siblings, parents or peers).
 * '80-71': No more than slight impairment in functioning at home, at school, or with peers. Some disturbance of behavior or emotional distress may be present in response to life stresses (e.g., parental separations, deaths, birth of a sib) but these are brief and interference with functioning is transient, such children are only minimally disturbing to others and are not considered deviant by those who know them.
 * '70-61': Some difficulty in a single area, but generally functioning pretty well, (e.g., sporadic or isolated antisocial acts, such as occasionally playing hooky petty theft; consistent minor difficulties with school work, mood changes of brief duration, fears and anxieties winch do not lead to gross avoidance behavior; self-doubts). Has some meaningful interpersonal relationships. Most people who do not know the child well would not consider him/her deviant but those who do know him/her well might express concern.
 * '60-51': Variable functioning with sporadic difficulties or symptoms in several but not all social areas. Disturbance would be apparent to those who encounter the child in a dysfunctional setting or time but not to those who see the child in other settings.
 * '50-41': Moderate degree of interference in functioning in most social areas or severe impairment functioning in one area, such as might result from for example, suicidal preoccupations and ruminations, school refusal and other forms of anxiety, obsessive rituals major conversion symptoms, frequent anxiety attacks, frequent episodes of aggressive or other antisocial behavior with some preservation of meaningful social relationships.
 * '40-31': Major impairment in functioning in several areas and unable to function in one of these areas, i.e., disturbed at home, at school, with peers, or in the society at large, e.g., persistent aggression without clear instigation; markedly withdrawn and isolated behavior due to either mood or though disturbance, suicidal attempts with clear lethal intent. Such children are likely to require special schooling and/or hospitalization or withdrawal from school (but this is not a sufficient criterion for inclusion in this category).
 * '30-21': Unable to function in almost all areas, e.g., stays at home, in ward or in bed all day without taking part in social activities OR severe impairment in reality testing OR serious impairment in communication (e.g., sometimes incoherent or inappropriate).
 * '20-11': Needs considerable supervision to prevent hurting others or self, e.g., frequently violent, repeated suicide attempts OR to maintain personal hygiene OR gross impairment in all forms of communication, e.g., severe abnormalities in verbal and gestural communication, marked social aloofness, stupor, etc.
 * '10-1': Needs constant supervision (24-hour care) due to severely aggressive or self-destructive behavior or gross impairment in reality testing, communication, cognition, affect, or personal hygiene.
 * '0': Inadequate information.

Criticism
The Diagnostic and Statistical Manual of Mental Disorders has been subject to criticism for having many inconsistencies within its systems. It is also unclear about diagnostic criteria in many cases and is consistently being revised to mend this.