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Explore Axis IV of the ‘Diagnostic and Statistical Manual of Mental Disorders.’ Learn about environmental and psychosocial factors and how they are related to the treatment of mental disorders.

An Example of the Axis Scale

Imagine that you are a clinician, and a 50-year-old male client walks into your office and reports feeling extremely sad and empty for the past month. He also says that he spends most of the day in his room crying and has no interest in any activities.

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You may immediately think he’s experiencing symptoms of depression and consider diagnosing him with major depressive disorder; however, you find out that the client’s wife of 30 years died one month ago, right around the time the client’s symptoms started. Since the client’s symptoms can be accounted for by the normal grieving process associated with losing a spouse, he no longer qualifies for a diagnosis of major depressive disorder, which is an Axis I disorder. Instead, you record death of spouse, which is an Axis IV disorder.

The Five Axes of the DSM

The Diagnostic and Statistical Manual of Mental Disorders (DSM) is used by psychologists and other mental health professionals throughout the United States to assist with the classification and diagnosis of mental health disorders.The DSM categorizes disorders according to the following five axes:

  • Axis I: Clinical disorders, such as panic disorder and bipolar disorder
  • Axis II: Personality disorders and mental retardation, including narcissistic personality disorder and avoidant personality disorder
  • Axis III: General medical conditions, including cystic fibrosis and glaucoma, which can result in mental health issues
  • Axis IV: Environmental and psychosocial factors, including unemployment and sexual abuse, which can result in mental health issues
  • Axis V: Global Assessment of Functioning – a numerical scale that ranges from 0 to 100 and is used to indicate at what level the client is functioning

Axis IV: Environmental and Psychosocial Factors

Environmental and psychosocial factors are negative life events and difficulties that may affect a client’s mental health. Such factors are important to the understanding, treatment and diagnosis of mental disorders, and these factors can also affect the client’s prognosis.In the example above, the client reported symptoms of major depressive disorder; however, there is a bereavement exclusion that states that major depressive disorder should not be diagnosed in individuals who have lost a loved one in the past two months. Without knowing that the client had recently lost a loved one, you might have diagnosed him with a major depressive disorder, even though what he is experiencing is a typical reaction to the death of a spouse.

By understanding the relationship between the client’s grief and depressive symptoms, you can assist your client in finding healthy ways to cope with the loss of his wife instead of prescribing him antidepressants that he does not need.Environmental and psychosocial factors don’t always appear before the mental illness, as in the example above. These factors can also be a consequence of the client’s mental disorder. For example, a person with schizophrenia could hear voices telling him not go to work or else he will die. As a result, the person may stop going to work, and, in this case, the unemployment is a direct result of the auditory hallucinations that accompany schizophrenia.It is important to list all psychosocial and environmental factors that are relevant to the client’s mental disorder.

Usually, only events that have happened during the year are recorded, although there are instances where you may choose to go beyond a year if the factors are contributing to the client’s mental disorder or are important to treatment. For example, if you are working with a 20-year-old client who was sexually abused as a child and now suffers from post-traumatic stress disorder (PTSD) because of the abuse, you should document sexual abuse on Axis IV, since it is relevant to the treatment of PTSD.

Categories and Examples

The DSM lists Axis IV factors into the following groups:

  • Problems with primary support group, such as death of a spouse, recent divorce, or child neglect
  • Problems related to the social environment, such as inadequate social support, retirement, or death of a close friend
  • Educational problems, like the inability to read, academic problems, or problems with classmates
  • Occupational problems, including loss of employment, recent change in careers, or inadequate work conditions
  • Housing problems. This could be a dangerous neighborhood, homelessness, or a recent foreclosure.
  • Economic problems, including poverty, discontinuation of food stamps, or the loss of childcare assistance
  • Problems with access to health care services, such as lack of insurance or lack of transportation to doctor’s appointments
  • Problems related to interaction with the legal system/crime. These could include recent arrest, being the victim of sexual assault, or incarceration due to DUI.
  • Other psychosocial and environmental problems can also contribute to an Axis IV diagnosis, such as being a refugee, being a displaced hurricane victim, or even discord with a school counselor.

Lesson Summary

Axis IV of the Diagnostic and Statistical Manual of Mental Disorders contains environmental and psychosocial factors that may affect clients’ mental health. These factors are important to the understanding, treatment, diagnosis, and prognosis of mental disorders. Occupational problems, housing problems, and financial problems are some of the factors that are listed on Axis IV. It’s important for clinicians to ask their clients about their environmental and psychosocial problems – they may be surprised by what they find.

Learning Outcomes

After you’ve completed this lesson, you should have the ability to:

  • Identify the five axes of the Diagnostic and Statistical Manual of Mental Disorders (DSM)
  • Describe Axis IV of the DSM
  • Explain examples of Axis IV factors

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