Personality Disorder Axes

Personality disorders are just the tip of the iceberg. They are built on a foundation of causes and effects, interactions and events, emotions and cognitions, functions and dysfunctions. The DSM analyzes, classifies, and describes these data using five axes. The DSM acknowledges that the clinician's first impression of the patient is at least as important as any "objective" data gathered during the evaluation phase. The diagnostician's assessment of "the individual's overall level of functioning" is fraught with ambiguity and bias.

Personality disorders are just the tip of the iceberg. They are built on a foundation of causes and effects, interactions and events, emotions and cognitions, functions and dysfunctions that all contribute to the patient's identity.

The DSM analyzes, classifies, and describes these data using five axes. The patient (or subject) presents himself to a mental health diagnostician, who evaluates him, administers tests, fills out questionnaires, and renders a diagnosis. The diagnostician employs the DSM's five axes to "make sense" and meaningfully organize the data gathered during this process.

Axis I insist on him naming all of the patient's clinical mental health issues that aren't personality disorders or mental retardation. Thus, Axis I includes issues that are first diagnosed in infancy, childhood, or adolescence; cognitive problems (e.g., delirium, dementia, amnesia); mental disorders caused by a medical condition (for example, dysfunctions caused by brain injury or metabolic diseases); substance-related disorders; schizophrenia and psychosis; mood disorders; anxiety and panic; somatoform disorders; factitious disorders; dissociative disorders; sexual paraphilias; eating disorders;

In the following articles, we will go over Axis II in depth. It includes personality disorders as well as mental retardation (an intriguing combination!).

Axis III is used to record medical conditions that affect the patient's mental health and state of mind. Some psychological problems are caused directly by medical issues (hyperthyroidism causes depression). In other cases, the latter coexist with or aggravate the former. Almost all biological illnesses can alter a patient's psychological makeup, behavior, cognitive functioning, and emotional landscape.

However, the machinery of life - both body and "soul" - is both reactive and proactive. It is influenced by one's psychosocial situation and environment. Life crises, stresses, deficiencies, and insufficient support all work together to destabilize and, if severe enough, ruin one's mental health. Death in the family or of a close friend; health problems; divorce; remarriage; abuse; doting or smothering parenting; neglect; sibling rivalry; social isolation; discrimination; life cycle transition (such as retirement); unemployment; workplace bullying; housing or economic problems; limited or no access to health care services; incarceration or litigation; traum

Finally, the DSM acknowledges that the clinician's first impression of the patient is at least as important as any "objective" data gathered during the evaluation phase. Axis V allows the diagnostician to record his judgment of "the individual's overall level of functioning". This is, admittedly, a broad mandate fraught with ambiguity and bias. The DSM recommends that mental health professionals use the Global Assessment of Functioning (GAF) Scale to mitigate these risks. Simply administering this structured test forces the diagnostician to rigorously formulate his views and to eliminate cultural and social prejudices.

The therapist, psychologist, psychiatrist, or social worker now has a complete picture of the subject's life, personal history, medical background, environment, and psyche after going through this lengthy and complicated process. She is now ready to proceed with the formal diagnosis of a personality disorder, with or without co-morbid (concurrent) conditions.

But, what exactly is a personality disorder? There are so many of them, and they all seem to us to be either similar or dissimilar! What are the strands that connect them? What characteristics are shared by all personality disorders?