Improving the DSM Axis System

I read with interest the letter “DSM Proposal” by Roger Peele, M.D., in the March 21 issue. I agree that DSM diagnoses currently listed under Axes I and II should not be separated for the reasons mentioned by Dr. Peele. Also, I agree that character traits, defense mechanisms, and so on are important aspects in the treatment of our patients.

However, I would like to extend Dr. Peele’s arguments further and suggest that we replace the axis system with a purely diagnostic system. The current axis system is not purely diagnostic, because Axes IV and V do not contain diagnostic information. They contain important information, but it should be documented separately. Diagnosis has been a cornerstone of medicine for centuries, and it should not be mixed with, or confused with, nondiagnostic information. No specialty other than psychiatry would take this approach, and, at best, it confuses our nonpsychiatric colleagues when we attempt to communicate with them using this approach. Witness the fact that almost no clinician outside of psychiatry has adopted the axis system when listing psychiatric diagnoses in their patients.

It does seem practical to list the diagnoses that we as psychiatrists make (currently listed under Axes I and II) separately from the diagnoses that our colleagues make (currently listed under Axis III).

Another source of confusion pertains to the terms that we use to distinguish psychiatric from nonpsychiatric medical disorders. The term “medical disorder” refers to any medical disorder, psychiatric and nonpsychiatric. The term “physical disorder” refers to any disorder with a physical substrate, which includes any medical disorder. The term “somatic medical disorder,” or more simply “somatic disorder,” is more useful than “general medical disorder” to refer to medical disorders other than psychiatric disorders. In support of the latter point, in many hospitals, physicians who specialize in the treatment of patients with nonpsychiatric disorders are referred to as “somatic physicians.”

Following this line of reasoning, it would be preferable to group Axis I and Axis II disorders together and refer to them as “psychiatric disorders.” And it would be preferable to refer to Axis III disorders as “somatic medical disorders,” or more simply “somatic disorders.” The information contained in Axes IV and V should be included elsewhere in the medical record.