The DSM Multiaxial Model

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The disorders in the DSM are grouped in terms of a multiaxial model. Multiaxial literally means multiple axes. Each axis represents a different kind or source of information. Later, we concentrate on exactly what these sources are; now, we just explain their purpose. The multiaxial model exists because some means is required whereby the various symptoms and personality characteristics of a given patient can be brought together to paint a picture that reflects the functioning of the whole person. For example, depression in a narcissistic personality is different from depression in a dependent personality. Because narcissists consider themselves superior to everyone else, they usually become depressed when confronted with objective evidence of failure or inadequacy too profound to ignore. Their usually puffed-up self-esteem deflates, leaving feelings of depression in its wake. In contrast, dependent personalities seek powerful others to take care of them, instrumental surrogates who confront a cruel world. Here, depression usually follows the loss of a significant caretaker. The point of the multiaxial model is that each patient is more than the sum of his or her diagnoses: Both are depressed, but for very different reasons. In each case, what differentiates them is not their surface symptoms, but rather the meaning of their symptoms in the context of their underlying personalities. By considering symptoms in relation to deeper characteristics, an understanding of the person is gained that transcends either symptoms or traits considered separately. To say that someone is a depressed narcissist, for example, conveys much more than does the label of depression or narcissism alone.

The multiaxial model is divided into five separate axes (see Figure 1.1), each of which gets at a different source or level of influence in human behavior. Axis I, clinical syndromes, consists of the classical mental disorders that have preoccupied clinical psychology and psychiatry for most of the history of these disciplines. Axis I is structured hierarchically. Each family of disorders branches into still finer distinctions, which compose actual diagnoses. For example, the anxiety disorders include obsessive-compulsive disorder, posttraumatic stress disorder, and generalized anxiety disorder. The mood

Axis Psychological Disorderrs
FIGURE 1.1 Abnormal Behavior and the Multiaxial Model.

disorders include depression and bipolar disorder. Other branches recognize sexual disorders, eating disorders, substance abuse disorders, and so on. Finally, each disorder is broken down into diagnostic criteria, a list of symptoms that must typically be present for the diagnosis to be given. Axis II, personality disorders, is the subject of this text.

Axis III consists of any physical or medical conditions relevant to understanding the individual patient. Some influences are dramatic, and others are more subtle. Examples of dramatic influences include head injury, the effects of drug abuse or prescribed medications, known genetic syndromes, and any other disease of the nervous, respiratory, digestive, or genitourinary system, brain structure, or other bodily system that impacts psychological functioning. Examples of subtle influence include temperament as the pattern of activity and emotionality to which an individual is genetically disposed, as well as constitutional and hormonal patterns. Essentially, Axis III recognizes that the body is not just the vessel of the soul. Instead, we are all integrated physical and psychological beings. A computer metaphor illustrates the concept: Software always requires hardware, and, depending on the hardware, different software functions may be either enhanced or disabled or just run in a different way. Some individuals have a central processing unit that keeps crunching busily, for example, whereas others run hot and have a great-looking case, but not much more. Physical factors always impact psychological functioning, if only because the body is the physical matrix from which mind emerges. Anyone who has had a lobotomy undoubtedly knows this already, but probably doesn't much care.

Axis IV consists of all psychosocial and environmental factors relevant to psychological functioning. Included are problems related to the family or primary support group, such as the death of a family member, marital separation or divorce, sexual or physical abuse, family conflict, or inappropriate or inadequate discipline at home. Also included are problems in the social environments outside the family. Educational problems include poor reading skills, lack of sufficient instruction, and conflict with teachers. Occupational problems include threats to employment, actual job loss, and conflict with authority figures and coworkers. Finally, Axis IV includes miscellaneous issues such as general economic and legal problems, for example, a pending criminal trial.

Axis IV recognizes that each person exists and functions in a variety of contexts and, in turn, these contexts often have profound effects on the individual. For example, if a narcissistic person is fired from employment, odds are that the firing has something to do with the person's intolerable attitude of superiority. Narcissists are above it all, to the point of not bowing to the boss. Some even view themselves as being above the law, as if the rules of ordinary living could not possibly apply to them. By putting all the pieces together—current symptoms, personality characteristics, and psychosocial stressors—a complex, but logical, picture of the total person is obtained. When considered in relation to specific biographical details, the result is an understanding that links the developmental past with the pathological present to explain how particular personality characteristics and current symptoms were formed, how they are perpetuated, and how they might be treated. This complex integration of all available information is known as the case conceptualization.

In contrast to the other axes, Axis V contains no specific content of its own. Once the case has been conceptualized, the next question is the level of severity: How pathological is this total picture? To make this determination, problems across all other axes are collapsed into a global rating of level of psychological, social, and occupational functioning, the Global Assessment of Functioning (GAF) Scale, which ranges from 0 to

100. Ratings may be made at any particular moment in time, perhaps admission to the hospital emergency room, at intake, or at discharge. Alternatively, ratings can sum up functioning across entire time periods, perhaps the past week or the past year. Limitations due to physical handicaps are excluded. In general, Axis V functions as an overall index of psychological health and pathology. Such measurements are often useful in tracking total progress over time.

Although you could memorize the five axes of the multiaxial model, it is much better to understand the purpose for which the model was constructed—why it exists as it does. The most fundamental reason is that the model increases clinical understanding by ensuring that all possible inputs to the psychopathology of the given subject receive attention. If you went to the doctor for a physical, you would want him or her to check your lungs, heart, kidneys, stomach, and all other major organs and systems. A doctor who pronounced you healthy after taking only your blood pressure would not be much of a doctor at all.

The same is true of the mental disorders. Psychopathology is much more complex, but nothing of importance should be neglected. Each of the axes in the multiaxial model corresponds to a different level of organization, so that each axis contextualizes the one immediately below it, changing its meaning and altering its significance. Axis I is the presenting problem, the reason the patient is currently being held in psychiatric emergency or sits chatting with a psychotherapist. In turn, Axis II, the personality disorders, provides both a substrate and context for understanding the symptoms of Axis I. As a substrate, personality inclines us toward the development of certain clinical disorders rather than others. For example, avoidant personalities typically shun contact with others, even though intimacy, approval, and self-esteem are what they most desperately seek. In contrast, narcissistic personalities, who are frequently indulged as children, grow up with a sense of superior self-worth that others often see as prideful and grandiose. Of the two, the avoidant is much more likely to develop a fear of public speaking, and the narcissist is much more likely to be fired from a job for being arrogant to everyone. The kinds of problems that a particular individual might develop can, in many cases, be predicted once his or her personality characteristics are known. In turn, personality rides on top of biology and rests within the psychosocial environment. We are both physical and social beings. When problems seem to be driven principally by personality factors, we speak of mal-adaptive personality traits or personality disorders. When difficulties concern primarily environmental or social factors, an Axis I adjustment disorder may be diagnosed or Axis IV problems in living may be noted. Personality is the level of organization in which these influences are synthesized (see Figure 1.2).

The multiaxial model draws attention to all relevant factors that feed into and perpetuate particular symptoms, and it also guides our understanding of how psychopathology develops. In most cases, the interaction of psychosocial stressors and personality characteristics leads to the expression of psychological symptoms; that is, Axis II and Axis IV interact to produce Axis I (see Figure 1.3). When personality includes many adaptive traits and relatively few maladaptive ones, the capacity to cope with psychosocial calamities such as death and divorce is increased. However, when personality includes many maladaptive traits and few adaptive ones, even minor stressors may precipitate an Axis I disorder.

In this sense, personality may be seen as the psychological equivalent of the body's immune system. Each of us lives in an environment of potentially infectious bacteria, and the strength of our defenses determines whether these microbes take hold, spread,

Psychological character and temperament, the patterning

Biological

Social derive from levels of organization of all influences on personality from levels of organization existing below the person, including such things as neurotransmitter profiles, and more directly genetically determined traits.

of characteristics across the entire matrix of the person.

Temperament represents the sum total

Character represents the sum total of all influences on personality that

Personality represents the complex interaction of influences from both in which the person is embedded, including family, peers, and society.

FIGURE 1.2 Levels of Organization and Their Relationship to the Multiaxial Model.

and ultimately are experienced as illness. Robust immune activity easily counteracts most infectious organisms, whereas weakened immune activity leads to illness. Psycho-pathology should be conceived as reflecting the same interactive pattern. Here, however, it is not our immunological defenses, but our overall personality pattern—that is, coping skills and adaptive flexibilities—that determine whether we respond constructively or succumb to the psychosocial environment. Viewed this way, the structure and characteristics of personality become the foundation for the individual's capacity to function in a mentally healthy or ill way. Every personality style is thus also a coping style, and personality becomes a cardinal organizing principle through which psychopathology should be understood.

Personality and the Medical Model: A Misconception

By describing the personality disorders as distinct entities that can be diagnosed, the DSM encourages the view that they are discrete medical diseases. They are not. The causal assumptions underlying Axis I and Axis II are simply different. Personality is the patterning of characteristics across the entire matrix of the person. Rather than being limited to a single trait, personality regards the total configuration of the person's characteristics: interpersonal, cognitive, psychodynamic, and biological. Each trait reinforces the others in perpetuating the stability and behavioral consistency of the total personality structure (see Figure 1.4). For the personality disorders, then, causality is literally everywhere. Each domain interacts to influence the others, and together, they maintain the integrity of the whole structure. In contrast, the causes of the Axis I clinical syndromes are assumed to be localizable. The cause of an adjustment disorder, for example, lies in a recent change in life circumstances that requires considerable getting used to. Here, causes and consequences are distinguishable, with discrete distinction

Circulo Dorado

between the underlying "disease" and its symptom expression. Difficulty making an adjustment might result in feelings of depression, for example. For the personality disorders, however, the distinction between disease and symptom is lost. Instead, causality issues from every domain of functioning. Each element in the whole structure sustains the others. This explains why personality disorders are notoriously resistant to psychotherapy.

Personality disorders are not diseases; thus, we must be very careful in our casual usage of the term. To imagine that a disorder, of any kind, could be anything other than a medical illness is very difficult. The idea that personality constitutes the immunological matrix that determines our overall psychological fitness is intended to break the

Axis I Clinical Syndrome

Personality Disorder symptom 1

symptom 2 symptom 3 symptom 4

trait A

trait H

Axis I Clinical Syndrome symptom 2 symptom 3 symptom 4

trait A

DISEASE

trait D

FIGURE 1.4 A Comparison of the Causal Pattern for Idealized Axis I and Axis II Disorders.

trait G

trait F

DISEASE

trait D

trait E

FIGURE 1.4 A Comparison of the Causal Pattern for Idealized Axis I and Axis II Disorders.

long-entrenched habit of conceiving syndromes of psychopathology as one or another variant of a disease, that is, as some "foreign" entity or lesion that intrudes insidiously within the person to undermine his or her so-called normal functions. The archaic notion that all mental disorders represent external intrusions or internal disease processes is an offshoot of prescientific ideas, such as demons or spirits that possess or hex the person. The role of infectious agents and anatomical lesions in physical medicine has reawakened this view. Demons are almost ancient history, but personality disorders are still seen as involving some external entity that invades and unsettles an otherwise healthy status. Although we are forced to use such terminology by linguistic habit, it is impossible for anyone to have a personality disorder. Rather, it is the total matrix of the person that constitutes the potential for psychological adaptation or illness.

Normality versus Pathology

Normality and abnormality cannot be differentiated objectively. All such distinctions, including the diagnostic categories of the DSM-IV, are in part social constructions and cultural artifacts. Although persons may be segregated into groups according to explicit criteria, ostensibly lending such classifications the respectability of science, the desire to segregate and the act of segregating persons into diagnostic groups are uniquely social. All definitions of pathology, ailment, malady, sickness, illness, or disorder are ultimately value-laden and circular (Feinstein, 1977). Disorders are what doctors treat, and what doctors treat is defined by implicit social standards. Given its social basis, normality is probably best defined as conformity to the behaviors and customs typical for an individual's reference group or culture. Pathology would then be defined by behaviors that are uncommon, irrelevant, or alien to the individual's reference group. Not surprisingly, American writers have often thought of normality as the ability to function independently and competently to obtain a personal sense of contentment and satisfaction.

Other cultures may have other standards; in Asian societies, for example, individualism is not valued as highly as respect for group norms.

Normality and pathology reside on a continuum. One slowly fades into the other. Because personality disorders are composed of maladaptive traits, there are two ways that personality pathology becomes more severe when moving along the continuum from health to pathology. First, single traits can become more intense in their expression; as-sertiveness can give way to aggression, for example, or deference can give way to

TABLE 1.2 The Compulsive Personality, from Adaptive to Severely Disordered

Adaptive

Subclinical

Disordered

Severely Disordered

Perfectionistic

"I take pride in what I do."

"I feel I have to work on things until I get them right."

"I can't stop working on something until it's perfect, even if it already satisfies what I need it for."

"Because nothing is ever good enough, I never finish anything."

Hard-working

"I believe in the work ethic."

"I rarely take time off for leisure or family."

"It drives me crazy if something is unfinished. I have never taken a vacation."

"I panic if I leave the office with something left undone. I work so late that I usually end up sleeping there."

Planful

"I like to consider my choices before I act on something."

"I have to analyze all the alternatives before I make up my mind."

"I try to consider so many eventualities that it becomes very difficult to make a decision."

"I get so lost in trying to anticipate all the possibilities and details that I put things off and never commit to anything."

Morally scrupulous

"I like to do the right thing."

"I am sometimes intolerant of people whose moral standards are less than my own."

"I am disgusted by the moral laxity and indulgence I see in 99% of humanity."

"I think anyone who deviates from the straight and narrow should be punished swiftly for their sins."

Conscientious

"I like to take my time and do things right."

"Sometimes I think others will disapprove of me if they find even one small mistake."

"I find it hard to stop working until I know others will be satisfied with the job I've done."

"I check and recheck my work until I'm absolutely sure that no one can find a mistake in what I've done."

Emotionally constricted

"I rarely get excited about anything."

"I don't believe in expressing much emotion."

"There are only a few things I enjoy, and even with those, I can't let myself go."

"I have never found any use for emotion. I have never felt any enjoyment from life."

masochism. Second, the number of maladaptive traits attributed to the given subject may increase. By comparing the statements given in Table 1.2 for a subset of compulsive traits, we can easily see how normality gradually gives way to personality disorder.

Personality disorders may best be characterized by three pathological characteristics (Millon, 1969). The first follows directly from the conception that personality is the psychological analogue of the body's immune system: Personality disorders tend to exhibit a tenuous stability, or lack of resilience, under conditions of stress. The coping strategies of most individuals are diverse and flexible. When one strategy or behavior isn't working, normal persons shift to something else. Personality disorder subjects, however, tend to practice the same strategies repeatedly with only minor variations. As a result, they always seem to make matters worse. Consequently, the level of stress keeps increasing, amplifying their vulnerability, creating crisis situations, and producing increasingly distorted perceptions of social reality.

A second characteristic overlaps somewhat with the first: Personality-disordered subjects are adaptively inflexible. Normal personality functioning entails role flexibility, knowing when to take the initiative and change the environment, and knowing when to adapt to what the environment offers. Normal persons exhibit flexibility in their interactions, such that their initiatives or reactions are proportional and appropriate to circumstances. When constraints on behavior come from the situation, the behavior of normal individuals tends to converge, regardless of personality. If the boss wants something done a particular way, most people will follow directions. Such situations are highly scripted. Almost everyone knows what to do and behaves in nearly the same way.

By contrast, the alternative strategies and behaviors of personality-disordered subjects are few in number and rigidly imposed on conditions for which they are poorly suited. Personality-disordered subjects implicitly drive or control interpersonal

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