Psychothcr Psychosom 1995;63:71-80

JuanE. Mezzicha Multiaxial Diagnosis and

Margit M. Schmolkeb
Psychotherapy Planning: On the
a Department of Psychiatry.
University of Pittsburgh. Pa.. Relevance of ICD-10, DSM-IV and
USA. and
f> Dynamic Psychiatric Hospital. Complementary Schemas
Munich, Germany

Key Words Abstract

Multiaxial diagnosis
Comprehensive diagnosis
Idiographic and cultural
formulations
ICD-10
DSM-IV
Psychotherapy planning
This paper reviews, first, the historical development of mul­
tiaxial diagnostic schemas, with particular attention to those
designed for the World Health Organisation’s Tenth Revision
of the International Classification of Diseases (ICD-10) and
the American Psychiatric Association’s DSM-IV. To comple­
ment standardized or nomographic multiaxial schemas, sever­
al personalized, or idiographic formulations are outlined, i.e.
cultural, biographic, psychodynamic, group dynamic, and one
dealing with quality of life. Contributions of comprehensive
diagnosis (multiaxial and idiographic formulations) to psycho­
therapy planning and psychotherapy research are then dis­
cussed. The potential contributions of the psychotherapy pro­
cess to diagnostic verification and clarifications are consid­
ered as well. Finally, the need for empirical validation re­
search on the outlined relationships as well as the potential
value of exploring further the synergism of nomographic and
idiographic approaches are elaborated.

Reviewing the literature on diagnosis and
psychotherapy, Beutler and Clarkin [1] con­
cluded that effective treatment planning must
involve the reliable and valid description of
the problem areas that are the focus of inter­
vention. It is also widely acknowledged [e.g.
ref. 2-4] that patient variables of interest for
treatment decisions should include not only
traditional syndromic diagnoses but a broad
range of health-related domains, from patho­
logical conditions (i.e. psychopathological,
personality and physical problems) to motiva­
tional factors, adaptive functioning, contex­
tual or environmental considerations, and
quality of life.
A number of proposals for more compre­
hensive diagnostic formulations have been
published in recent years which are pertinent
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Juan E. Mezzich, MD. PhD © 1995

Professor of Psychiatry and Epidemiology S. Karger AG, Basel
University of Pittsburgh 0033-3190/95/
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3811 O’Hara Street 0632-0071 S8.00/0

Pittsburgh, PA 15213 (USA)
to the broad informational demands for psy­
chotherapy planning mentioned above. Most
of these comprehensive approaches have been
developed under the term ‘multiaxial diagno­
sis.’ This typically involves the portrayal of
the patient’s condition through the systematic
assessment and formulation of its key aspects
or axes.
The next section briefly reviews the princi­
ples of multiaxial diagnosis and the specific
schemas developed for two standard diagnos­
tic systems of high international visibility,
ICD-10 [5] and DSM-IV [6], This will be fol­
lowed by a discussion of complementary cul­
tural and other idiographic formulations. The
final section will consider the two-way rela­
tionship between diagnostic formulations and
psychotherapy.
Multiaxial Diagnostic Concepts and
Schemas
Multiaxial diagnosis represents an attempt
to deal more effectively with the complexity
of clinical conditions by assessing and formu­
lating them in terms of separate, highly infor­
mative clinical domains.
Pertinent to the origins of multiaxial ideas
was the controversy around the turn of the
century between Kraepelin [7] proposing an
all-encompassing diagnostic-entity concept
and Hoche [8] defending an empirical separa­
tion of syndrome from etiology. This separa­
tion constituted the kernel of what later be­
came multiaxial schemas, the first of which
were designed by Essen-Moller and Wohlfahrt
[9] in Sweden and Lecomte et al. [10] in
France.
More recent schemas [e.g. ref. 11-14] have
covered not only the elements of an illness but
the patient’s whole clinical condition, for ex­
ample environmental factors and the impact
of pathology on human functioning.
72 Mezzich/Schmolkc
The DSM Multiaxial Systems
A conspicuous national classification sys­
tem incorporating a multiaxial approach that
helped to disseminate this diagnostic model
across the world was the third edition of the
American Psychiatric Association Diagnostic
and Statistical Manual of Mental Disorders
(DSM-1II) [ 15], It includes five axes: I: clinical
syndromes; II: personality and developmental
disorders; III: physical disorders; IV: overall
psychosocial stressor severity, and V:
adaptive functioning. This array was slightly
revised in DSM-III-R [16]. A more substan­
tial revision has been conducted within the
framework of the developmental of DSM-IV,
characterized by a careful review of the expe­
rience gained with DSM-III and DSM-III-R
[17].
The multiaxial schema in DSM-IV [18]
contains the following axes:
(I) Clinical syndromes and other condi­
tions that may be a focus of clinical attention.
This axis houses the majority of diagnostic
categories in the catalog of mental disorders.
(II) Mental retardation and personality dis­
orders. This axis may additionally be used for
noting (uncoded) prominent maladaptive per­
sonality features and defense mechanisms.
(III) General medical conditions. This axis
includes all disorders in the International
Classification of Diseases outside the chapter
on mental disorders. Of particular interest
here are disorders such as peptic ulcer and
bronchial asthma which are prominent psy­
chosomatic or psychophysiological disorders
coded as specific illnesses in this axis and as
psychological factors affecting general medi­
cal condition in axis I.
(IV) Psychosocial and environmental
problems. In contrast to DSM-III and DSM-
III-R which just rated overall stressor severi­
ty, in this axis DSM-IV considers the identifi­
cation of psychosocial and environmental
problems, such as negative life events, envi­
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 ronmental difficulties or deficiencies, and functioning with family and general social
inadequate social supports. functioning.
(V) Global assessment of functioning. The (Ill) Contextual factors. Included here are
100-point scale for this axis covers psychopa- events of a psychosocial nature as well as
thological symptomatology as well as occupa­ problems that are related to personal life-
tional and interpersonal functioning. Option­ management and life-style.
al instruments conceptually connected to this
axis and included in the DSM-IV appendix Multiaxial Schemas for Psychotherapy
encompass a social and occupational func­ and Psychosomatics
tioning assessment scale, a global assessment In addition to multiaxial diagnostic sys­
of relational functioning, and a defensive tems for general psychiatric purposes, there
functioning scale. have been proposals for multiaxial schemas
specifically designed for psychotherapy.
ICD-IO and MultiaxiaI Diagnosis Schiissler et al. [21] published a seven-axis
The tenth revision of the International diagnostic system for the assessment of pa­
Classification of Diseases and Health-Related tients in psychosomatic medicine and psycho­
Problems (ICD-10) constitutes a major step therapy. The axes proposed are as follow:
forward in the 100-year ICD history, primari­ (I) Psychiatric disorders. Axes I, II and III
ly because of its broad scope. In fact, it consti­ are to be assessed according to ICD-9 [22].
tutes a family of classifications, including core (II) Personality disorders and traits.
components such as the chapters organizing (III) Somatic disorders.
the full range of human illnesses, as well as (IV) Severity of psychosocial stressors.
accessorial classifications such as those sim­ This axis and axes V and VI below are
plified for primary care or elaborated further assessed with a 3-point scale (mild, moderate,
for use by specialists, the catalogue of factors severe) with reference to the year preceding
influencing health status and contact with the onset-of-illness manifestations.
health services, and the classification of im­ (V) Occupational performance.
pairments, disabilities and handicaps. The (VI) Social contacts.
ICD-10 chapter on menial and behavioral dis­ (VII) Stage of object relations according to
orders incorporates all major contemporary Kernberg [23], This axis is appraised on a
methodological developments for diagnosis three-level scale: low, medium and high.
such as a descriptive syndromic emphasis, the A more recent multiaxial system intended
use of more explicit categorical definitions, for use in psychosomatic and psychotherapy
and a multiaxial schema. settings is partially referenced to ICD-10 and
The multiaxial presentation of ICD-10 has encompasses the following three axes [24]:
emerged from a historical review of the perti­ (I) Mental and somatic disorders. This axis
nent international literature [19] and current­ is assessed in terms of the core chapters of
ly includes the following axes [20]: ICD-10.
(I) Clinical diagnoses. This covers all men­ (II) Experience of the disorder. Considered
tal and nonmental disorders included in the in this axis are defense mechanisms, coping
core chapters of ICD-10. and motivation for psychotherapy.
(II) Disabilities. Difficulties in adaptive (III) Psychodynamics. Covered here are
functioning are assessed in terms of four ar­ quality of relationships, conflict areas and
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 It can be noted that the two multiaxial culture; language abilities, use and prefer­
schemas outlined above contain some axes ences, and in the case of immigrants and refu­
corresponding to mental and physical disor­ gees, involvement with the original and host
ders structured according to standard diag­ cultures.
nostic systems such as ICD-9 and ICD-10, as (B) Cultural explanations of the patient’s
well as some axes constituting elements of a illness. Encompassed here are predominant
psychodynamic formulation specifically de­ idioms of distress, cultural meaning and per­
signed for psychosomatic and psychothera­ ceived severity of symptoms, local illness cat­
peutic work. egories used by the reference group, perceived
causes or explanatory models for the illness,
and professional and popular sources of care.
Complementary Diagnostic Formulations (C) Cultural factors related to psychosocial
environment and functioning. Considered
The manuals for standard diagnostic sys­ here are cultural interpretations of stressors
tems such as DSM-IV and ICD-10 acknowl­ and disabilities. Special attention is to be giv­
edge that even broad-scope multiaxial sche­ en to the supportive role of religion and kin
mas which involve standardized ratings are networks.
not adequate to cover everything that is im­ (D) Intercultural elements of the diagnosti­
portant for understanding the patient’s condi­ cian-patient relationship. This covers differ­
tion (pathological and healthy aspects) and for ences in culture and social status between cli­
treatment planning. This is particularly true nician and patient, and the problems these
in the case of psychotherapy, for which idio- cause in communication and evaluating the
graphic or personalized approaches are con­ patient’s illness.
sidered essential [e.g. ref. 1,3,4, 25,26], Idio- (E) Overall assessment. The formulation
graphic approaches are applicable not only to concludes with a discussion of how the above
pathology but to other aspects of the clinical cultural considerations specifically influence
condition as well, such as environmental fac­ comprehensive diagnosis and care.
tors and adaptive functioning. Some formula­
tions representing this perspective are out­ Additional Idiographic Formulations
lined below. An important idiographic option is the bio­
graphicalformulation. Meyer [28] through his
Cultural Formulation ‘theory of psychobiology’ emphasized the im­
One of the innovative features of DSM-IV portance of a biographical study for under­
is the development of a cultural formulation standing the whole person. He argued that an
guideline [27], This is an idiographic state­ ordered presentation of the facts was truly a
ment to reflect predominantly the perspec­ diagnosis. More recently, and from a psycho­
tives of the patient’s personal experience and therapeutic perspective, Fischer [29] has arti­
the corresponding cultural reference group, culated the value of the study of life history as
intended to complement standardized mul­ ‘biographical diagnosis.’ Related to this is the
tiaxial diagnostic ratings. The elements of this concept of longitudinal ‘critical life events’
formulation follow: [e.g. ref. 30, 31]. The life history investigation
(A) Cultural identity of the patient. Thisis to be performed primarily by the patient
includes information on the cultural reference her- or himself with the guidance of the clini­
group and orientation towards the majority cian [32]. It is posited that such a self-reflexive
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 process can be very helpful for identity formu­
lation and clarification [29, 33]. Additionally,
it can lead to the elucidation of repetitive and
other life patterns [34],
Psychodynamic formulations have had a
prominent role in clinical workups and men­
tal health assessment for several decades. The
largely subjective nature of this domain
marks it as an idiographic field par excellence.
It is also salient that psychodynamics power­
fully inform the diagnostic process itself, par­
ticularly the therapeutic atmosphere and the
clinician-patient interaction [35, 36]. This do­
main has been considered as a specific axis in
multiaxial systems for psychotherapeutic use,
such as those proposed by Schiissler et al. [21 ]
and the Arbeitsgruppe Operationalisierte Psy-
chodynamische Diagnostik [24], as men­
tioned above. Encompassed in such an axis
have been object relations, conflict areas, de­
fense mechanisms, coping, motivation, quali­
ty of relationships and personality structure.
An optional axis on defensive-functioning as­
sessment has been included in the appendix of
DSM-IV [6], Additional areas suggested in the
literature for a psychodynamic formulation
include ego functions and self-symbolization
[37], alienation and vicious cycles [38], un­
conscious wishes and fears and identification
patterns [39], deficits and distortions in the
intrapsychic structures [40], resistance styles,
transference and countertransference [41,42],
Furthermore, psychodynamics have been
posited as a paradigm linking etiology, noso­
logy and therapy [43-45],
An evolving field for complementary idio­
graphic formulation is group dynamics. An ini­
tial organization of this domain can be found
in the field theory of Lewin [46]. In line with
this, Sullivan [47] conceptualized psychiatry as
the study of interpersonal processes. More re­
cently, Ammon [48] has integrated this do­
main within a theory of psychopathology and
therapy, in which the concept o f‘social energy’
emerging from and influencing interpersonal
relationships plays a key role. Within this gen­
eral framework, group dynamics in early life as
well as in unfolding relationships may impact
decisively on the development of personality
and identity formation [35, 49], Additional
areas under group dynamics include familial
communication problems, such as inducement
of self-disqualification [50] and the pressures
of expressed expectations [51],
Quality o f life as an important aspect of
comprehensive diagnosis has emerged rela­
tively recently. Its development has not been
restricted to psychiatry and mental health but,
in fact, it is quite strong and growing in a
number of general health care areas [e.g. ref.
52], While the assessment of quality of life can
be approached quantitatively, its scope and
intricacy make it particularly pertinent to id­
iographic formulation [53]. It covers, first, the
basic components of health assessment, i.e.
physical health, emotional health, and
adaptive (social and occupational) function­
ing, and then higher-order factors that are
more difficult to define and assess [54],
Among the latter are comfort, physical enjoy­
ment and sensual pleasure, intimate relation­
ships, enriching environmental factors, per­
sonal effectiveness and accomplishments,
self-awareness and self-actualization, sense of
social responsibility and solidarity, and spiri­
tual fulfillment [2, 54-56]. It should be
pointed out that attainment of a high quality
of life does not require experiencing all the
above levels or situations; in fact, it can coex­
ist with the presence of illness.
The Two-Way Relationship Between
Diagnosis and Therapy
The relationships between comprehensive
diagnosis and psychotherapy are complex and
bidirectional. A major objective of diagnosis
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 Table 1. Illu strativ e relatio n s betw een co m p re h en siv e diagnosis a n d p sy ch o th erap y p lan n in g
(I) Psychopathological syndromes
e.g. phobic disorder
(II) Personality conditions
e.g. dependent personality disorder or traits
(III) General medical disorders
e.g. hypertension or diabetes
(IV) Psychosocial environmental problems
e.g. explosive family situation
(V) Dysfunctions or disabilities
e.g. chronic work disability
Psychopathologcial comorbidity
e.g. bulimia nervosa and social phobia
Combining axial information
e.g. patient with schizophrenia (I) and
medium-level functioning (V)
Enhanced diagnostic description through
idiographic assessment
is to assist in planning treatment or care, and
this relationship is outlined here first. The
second corresponds to another use of a diag­
nostic formulation, i.e. the enhancement of
psychotherapy research. We will finally con­
sider the impact of therapy processes on diag­
nostic formulation.
Use o f Comprehensive Diagnosis for
Psychotherapy Planning
A critical purpose of a comprehensive
diagnostic formulation, in addition to en­
hancing understanding of the patient’s condi­
tion, is to facilitate the preparation of an effec­
tive treatment plan. Table l illustrates, in a
simplified way, the relevance of various com­
ponents of a diagnostic formulation for select­
ing treatment strategies.
Psychiatric syndromic diagnosis, as con­
tained in axis I of DSM-I1I or DSM-IV, con­
stitutes the focus of attention of many clini­
cians, particularly those with more conven­
tional or traditional training. Correspond­
ingly, information in this axis is widely used
for decision-making involving a broad range
76 Mczzich/Schmolke
behavior therapy
long-term psychodynamic therapy
medication maintenance group therapy
crisis intervention
vocational rehabilitation
nonverbal and group psychotherapics
art therapy to potentiate quality of life
use of more specific or combined therapies
of psychiatric treatments, including specific
psychotherapeutic approaches as pointed out
by Schneider [57] and illustrated in table 1.
However, more frequent than the use of
single-axis information for treatment plan­
ning, especially regarding psychotherapy, is
the utilization or consideration of informa­
tion from several diagnostic axes. Prominent­
ly reported in the literature (perhaps because
of clinical tradition) is the combined use of
DSM-III axis 1 (general psychiatric disorders)
and axis II (personality disorders and traits)
[e.g. ref. 58-60], Also reported is the use of
information on personality disorders and psy­
chosocial stressors (DSM-III axis IV) [61],
For psychotherapy planning, it appears
that a major use of comprehensive diagnostic
schemas is through the consideration, for each
patient, of information from several axes.
This has been reported, for example, by Bon-
ierbale-Branchereau and Dubois-Chevalier
[62] for treating impotence with behavioral
techniques, and by Bech [63] for treating de­
pressive patients with various therapeutic
modalities.
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 Table 2. Illu strativ e m u ltiax ial diagnostic c h ara cte riz atio n o f a th erap y research sam ple
(I) Psychopathological syndromes
(II) Personality conditions
(HI) General medical disorders
(IV) Psychosocial environmental problems
(V) Functioning
Another conspicuous use of comprehen­
sive diagnosis in psychotherapy planning is in
terms of idiographic formulations, as can be
expected from the more sensitive and person­
alized information that they contain. For ex­
ample, psychodynamic diagnostic informa­
tion has been used with a focus on specific
areas such as interpersonal relations [64] in a
large variety of areas [e.g. ref. 65]. The thera­
peutic planning value of group-dynamic in­
formation is illustrated by Schmolke and
Dworschak [66] through a special form of
diagnostic case conference. Most importantly,
idiographic formulations (whether biograph­
ic, cultural, psychodynamic, group dynamic
or dealing with quality of life) have para­
mount value when the treatment perspective
is centered on the person of the patient, with
all its richness and uniqueness, as emphasized
by Strauss [3] in proposing ‘a new dynamic
psychiatry.’
Multiaxial Diagnostic Information for
Psychotherapy Research
In addition to psychotherapy planning,
psychotherapy research may be enhanced by
multiaxial diagnosis. One of the specific ways
for such enhancement is the fuller character­
ization of research subjects participating in
psychotherapy research.
Conventional characterization of research
samples focuses on demographic identifica­
tion and principal psychiatric diagnosis. The
inadequacy of such limited information has
e.g. distribution by major disorders and by comorbidities
c.g. frequency of borderline personality disorder
e.g. frequency of prominent psychosomatic illnesses
(e.g. asthma, colitis)
e.g. frequency of social isolation
c.g. functioning-levels distribution
been recognized clearly by distinguished clini­
cal researchers, such as Rafaelsen and Shapiro
[67] who proposed a multiaxial system for the
selection of patient samples for psychophar-
macological studies. More recently, Kupfer
and Rush [68], on behalf of a community of
researchers on affective disorders, have listed,
in order to facilitate comparisons across re­
search studies, a number of desirable descrip­
tors of research subjects, which amount to a
multiaxial characterization. Table 2 illus­
trates the relevance of multiaxial diagnosis for
such characterization.
The criteria employed for evaluating the
outcome of treatment in general and psycho­
therapy in particular could also be optimized
by a multiaxial evaluation schema. Strauss
and Carpenter [69] demonstrated the value of
such an approach in a longitudinal study of
schizophrenic patients showing that different
outcome variables (symptoms, social func­
tioning, work functioning) were best pre­
dicted by the corresponding baseline vari­
ables. Giller et al. [70] found in an evaluation
of treatment for depressed patients that dif­
ferent outcome areas (symptoms, work per­
formance, family functioning and social func­
tioning) improved at different rates and to
different extents.
Extending the impact of multiaxial diagno­
sis for treatment research, Cassano-Giovanni
et al. [71] have explored the value of comput­
erized data banks containing multiaxial diag­
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 Use o f the Psychotherapeutic Process for
Enhancing Comprehensive Diagnosis
As explicated by Fabrega et al. [72], a diag­
nostic formulation can be usefully conceptual­
ized as an evolving informational statement
on the patient’s condition. As such, its pur­
pose is to progressively decrease uncertainty
in our understanding of the clinical condition.
It is never perfect, but susceptible to improve­
ment.
The opportunity for longitudinal observa­
tion is maximized in the process of psycho­
therapy, where probes, interventions and
analyses of responses obtained can all contrib­
ute to improving the diagnostic formulation.
Such contributions may involve, in some
cases, the verification or correction of the ini­
tial diagnosis, for example, identifying a per­
sonality disorder as the principal diagnosis
[e.g. ref. 73]. In other cases, the contribution
may consist in a better understanding of inter-
axial relationships, for example, clarifying the
role of interpersonal conflicts (DSM-III axis
IV) on the emergency of a depressive syn­
drome (axis I) [74] or on personality condi­
tions [61],
In line with the above, it is appropriate to
consider diagnosis as a process accompanying
a therapeutic endeavor and from which spe­
cific interventions result [36, 75].
Colophon
While the value of multiaxial diagnosis has
been substantially documented in child psy­
chopathology [e.g. ref. 11, 76] and psychoso­
matic rehabilitation [e.g. ref. 77], much em­
pirical research is still needed in other areas of
application, including psychotherapy.
In the further development of useful rela­
tionships between comprehensive diagnosis
and psychotherapy it will be important, as
plead by Strauss [3], ‘to go beyond the level of
child preoperational thinking (able to attend
only to one dimension at a time) and think in
terms of more complex constructs.’ In fact,
newer approaches to diagnostic formulation
[78] are offering the opportunity, not only of
considering nomographic and idiographic ap­
proaches but of exploring their synergism as
well.
New breakthroughs may additionally
emerge from following the recommendation
of Meyer [28] for thinking of ‘the clinician
interested in the scientific understanding of
the patient as a methodical investigator,
biographer, artist and educator,’ and the sug­
gestions of Strauss [3] for considering ‘the per­
son as an actor and not only as a subject of
illness.’

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