Diagnosis: The Multiaxial System
As part of her intake writeup for the client's file, the therapist has to make a preliminary diagnosis.
Psychology's diagnostic coding system relies on diagnostic axes. Each of the five axes holds a different kind of information.
Though clinical trainees (and people filling out forms for insurance) are usually expected to complete all five axes, more experienced clinicians will often only write out Axis I and, if it's relevant, Axis II.
Consistently writing up all five axes is actually a good habit, since it allows you to summarize important information in a single place using a format that's easily accessible to other clinicians if you ever need to consult or transfer a client.
The five axes are:
Axis I: Clinical and symptom disorders
- This line contains all but two of the diagnostic categories; every diagnosis has something on Axis I.
- When the multiaxial system was developed, these disorders were thought to be affected by the environment. We've since learned that some of them have a strong biological basis, so the distinction that was originally made between the two axes isn't particularly relevant anymore.
Axis II: Personality disorders and mental retardation
- Most people who have Axis II disorders also have Axis I symptoms, so it's rare to have a diagnosis only on Axis II.
- These problems were initially thought to be more long-standing and resistant to treatment than Axis I disorders; again, that distinction has narrowed a great deal.
- Personality disorders refer to 10 long-standing characterological patterns that cause problems in the person's interactions and relationships with other people. They are grouped into three clusters:
- Odd/Eccentric
- Dramatic/Erratic
- Anxious
Axis III: General medical conditions
Axis IV: Psychosocial stressors
Axis V: Global Assessment of Functioning
- The GAF is a number from 0-100, with 0 being dead and 100 being inhumanly well-off, like a Care Bear. Or maybe Barney. Or Elmo. You get the picture.
Sample Intake Report
This writeup is for a character in an old scifi anime series called Gatchaman. (My Gatch site 
)