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Axis IV: A reliable and valid measure of psychosocial stressors?
Axis IV: A Reliable and Valid Measure Psychosocial Stressors?
of
Andrew E. Skodol DSM-III axis IV, Severity of Psychosocial Stressors, has been a disappointment to many because of the apparently infrequent use of the axis in clinical and research settings. This report is a review of literature on the use, reliability, and validity of axis IV. Although the concept of multiaxial evaluation has considerable appeal, clinicians have not routinely used axis IV, possibly because they do not fully understand the complexities involved in making ratings. The relatively few published empirical studies on axis IV indicate modest reliability and limited validity, beyond the value in identifying severe psychosocial stressors for the purpose of planning clinical interventions. The results of this review have led the DSM-IV Multiaxial Issues Work Group to consider several options for major changes in the format of axis IV to be recommended to the DSM-IV Task Force. Copyright 0 1991 by W.B. Saunders Company
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OR MANY OF THOSE charged with the development of DSM-IV, experience with DSM-III axis IV, Severity of Psychosocial Stressors, has been disappointing. Axis IV is generally believed to be used infrequently in clinica settings, possibly because reliable severity ratings are too difficult to make or because the rating fails in its intended purposes, as part of the DSM-III multiaxial evaluation system. In addition, axis IV has been criticized for stimulating meager numbers of research studies. A consensus has formed that axis IV may require dramatic revision for DSM-IV, in order to make it more usable and more useful. Axis IV was modestly revised in DSM-III-R in response to initial criticisms and a few empirical studies. The revised axis IV differs from its predecessor in that separate sets of examples are given for rating the severity of acute events and enduring circumstances. DSM-III-R ratings are made on a six-point scale of severity that no longer includes a “minimal” stress rating. A number of examples of specific stressors illustrating scale points were changed in DSM-III-R to make the lists more consistent with other lists of psychosocial stressors used in research. The purpose of this report is to review evidence regarding the use of DSM-III (and III-R) axis IV in clinical and research settings. Critiques of professionals with experience in using axis IV will be summarized. Results on the reliability of axis IV severity ratings will be reported. The usefulness of the axis will be assessed by means of review of theoretical reports and empirical data relevant to the construct validity of the scale and review of studies addressing its predictive validity. CLINICAL
USE OF AXIS IV
In the DSM-III field trials,’ reaction to axis IV was mixed. Almost half of the field trial participants favored some major change in the conventions for
From the Departments of Pvchiatry, Columbia University College of Physicians and Surgeons. and New York State PJychiattic Institute, New York, NY Address reprint requests to Andrew E. Skodol, M.D., Box 8, New York State PTchiattic Institute, 722 W 168th St, New York, NY 10032. OOIO-44OXl9113206-0003$03.00/O Comprehensive
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identifying stressors or making the severity rating, or elimination of the axis altogether. Only 38% believed that axis IV was likely to be clinically useful and stated that they would use it regularly in their diagnostic evaluations. This figure compared with 63% who judged axis V useful. Spitzer and Forman expressed reservations about the changes proposed for axis IV, but concluded that future studies were necessary to determine the extent to which axis IV would be used in clinical practice and its impact on patient care. There are two sources of information regarding clinical use of DSM-III axis IV: (1) surveys of clinical practitioners, and (2) surveys of directors of training programs in psychiatry. Data on clinical practice are available from the United States’ and Canada.3z4 Mezzich et a1.5,6have also reported on patterns of use among a multinational panel of experts in psychiatric diagnosis, 45% of whom identified their major professional activity as clinical practice. Jampala et al2 surveyed practicing psychiatrists and 1984 graduates of residency training and found considerable resistance to the use of the DSM-III multiaxial system, due to its complexity and to incomplete knowledge of how to use it. However, similar resistance and reasons for it were reported for axis I and II diagnoses, as were for axes IV and V. In Canada, DSM-III became the preferred system of classification shortly after its publication.3 Two thirds of responding practitioners recommended a multiaxial system similar to that of DSM-III for the International Classification of Diseases, 10th Revision (ICD-10). Junek and Leichner4 later found that psychiatric residents trained since publication of DSM-III preferred the system to ICD-9 more than twice as often as members of the Canadian Psychiatric Association, most of whom were trained in the pre-DSM-III era. More than 90% of residents recommended a multiaxial system for ICD-10. Respondents to Mezzich et al.’ used the DSM-III multiaxial system more than any other. Identification of psychosocial stressors was rated less valuable in a multiaxial schema than psychiatric syndromes, personality disorders, physical disorders with brain dysfunction, and course or duration of illness, but more valuable than physical disorders without brain dysfunction and either highest or current level of adaptive functioning. Rating overall severity of psychosocial stressors was deemed less useful than their specific identification and “unclear principles” guiding axis IV was occasionally mentioned as a specific problem.6 The US and Canadian studies suffer from modest completion rates and no attempt to assess potential differences between responders and nonresponders. They also pointed to limited knowledge as a result of inadequate training as a potential source of reluctance to use the multiaxial system, making the causes, and thus the cure, ambiguous. The Jampala et al.’ survey respondents’ perception that axis IV was not useful was only slightly more pronounced than for axis V for practicing psychiatrists and similar to proportions of all respondents who did not believe that diagnoses on axes I and II were valid. All surveys have relied on reported use and usefulness, rather than on systematic reviews of actual practice patterns, through records for example. Two surveys of psychiatric residency training directors’ and of directors of medical student education in psychiatry’ indicated that, by 1983, less than half of US training programs in psychiatry had integrated the complete multiaxial system
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into their curricula or required its use by trainees. Nearly 75% taught and used the first three axes, in contrast. At about the same time, 45% of Canadian academic psychiatrists taught axis IV to trainees; 40% taught axis V.” In a subsequent survey, only 18% of directors of residency training programs in Canada expected residents to use axes IV and V most or all of the time.‘” Thus, although use of axis IV has lagged behind use of axes I through III, the limited surveys available suggest no significant difference between axis IV and V use and point to incomplete understanding as the reason for nonuse. The findings that few training programs emphasize axes IV and V, and that when trained, clinicians more readily accept the system, suggest that change unaccompanied by rigorous training will be unlikely to increase use of additional axes. Although it may be argued that educators had rejected axis IV on the basis that it was not useful, at the time of these surveys there were virtually no empirical data on which to base this judgment. Therefore, even at the level of psychiatric academicians, the conclusion might be drawn that the axes were rejected because they were new, complex, and unfamiliar.” EMPIRICAL
STUDIES
OF AXIS IV
Excluding surveys of patterns of use and educational practices, I found 22 published reports empirically evaluating some aspect of DSM-III axis IV as of November 30, 1990. This compares with 24 reports addressing axis V and 12 reports using axis III. Axis IV reports have been based on data collected primarily at Iowa, Pittsburgh, Florida, and Columbia University and the Royal Prince Alfred Hospital and the University of Adelaide, both in Australia. Thus, although research on axis IV has tended to be limited to centers interested generally in psychiatric nosology, in terms of the numbers of studies generated, axis IV appears to have fared no worse than axis V and has far exceeded axis III (as part of the multiaxial evaluation system) as a research focus, thus far. Reliability Only three studies report reliability of axis IV severity ratings. The best figures were obtained during the DSM-III field trials’: joint interviews yielded an intraclass correlation coefficient (ICC) of 0.62 and test-retest evaluations, 0.58. This is the only study to report reliability figures for axis IV ratings on adult patients. Two studies reported poor reliability for axis IV ratings on adolescents (ICC = 0.44)‘” and on children (ICC = 0.25).13 One additional study of children reported modest agreement on the listing of psychosocial stressors on axis IV.” The latter two studies used written case vignettes as opposed to live interviews for the ratings. Sources of error. In a study identifying common errors in the use of DSM-III through diagnostic supervision, Skodol et al.” found an error rate of 22.5% on axis IV, with 10% of cases requiring a change of two scale points or more. The overall error rate for axis V was only 13.5%. Errors were due to the complicated conventions for making ratings described in the brief instructions included in DSM-III for the use of axis IV. Skodol and Shrout’h have demonstrated, for example, that the instruction that the rating reflect the summed effect of all stressors listed was too complex to be incorporated into routine clinical practice,
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even by relatively well-trained evaluators with expert supervision. Rey et al.” have also cited the complex instructions for making severity ratings as sources of unreliability. In contrast, despite low reliability in their ratings, more than three quarters of the respondents in the Mezzich et a1.13study judged the clarity of the axis IV scale to be “more clear than unclear” or “very clear.“” No reliability study appears to have been done following intensive training, such as commonly precedes a formal study of the reliability of a semistructured diagnostic interview.‘* Construct Validity Axis IV was included in the DSM-III and DSM-III-R multiaxial systems as a shorthand way to note the occurrence and rate the severity of psychosocial stressors that may have contributed to the onset or exacerbation of a current mental disorder. Identifying stressors was thought to be important for formulating a treatment plan and the severity rating was expected to have prognostic value. Much has been written about how well (or poorly) axis IV with its scale and rating conventions fulfills its functions. Most critics have expressed negative views, although these views were not based on empirical studies. One of the most commonly cited criticisms has been of the convention to rate the severity on the basis of an average person’s reaction rather than the patient’s possibly idiosyncratic reaction’9.20; a patient’s peculiar vulnerability to particular stressors might be more clinically meaningful. Also criticized was the decision to combine all stressors, including chronic and acute, into a single global rating implying a single mechanism of effect.21.22 Stressor theory and axis IV severity ratings. Rey et aLz3 comment on axis IV conventions, which bear on the DSM-III operationalization of the rating of stress: (1) assessing the impact of individual stressors, (2) assessing the impact of multiple stressors, and (3) assessing the relevance of the stressors. The authors note that numerous models and methods exist for qualitatively describing and quantitatively estimating the impact of individual psychosocial stressors on a person. DSM-III axis IV requires a composite impact rating that includes consideration of the amount of change in the person’s life caused by the stressor and the degree to which the event is desired and under the person’s control. Change or adjustment resulting from a stressor is common to many attempts to quantify stressor impact in the life events literature24-26and undesirability or other indication of negative impact (threat, loss, or exit) frequently characterizes description of important life events. 27The fact that such theoretically independent dimensions of impact are often highly correlatedZ makes the DSM-III approach of an overall rating reasonable. Approaches to assigning a specific severity rating to a particular event also vary. The original approach of Holmes and Rahez6 used objective raters to assign severity scores. They viewed subjective ratings by affected individuals as biased because someone with a negative health outcome would view events retrospectively as more severe.28’29This bias became known as “effort after meaning.“3o However, a single scale for rating severity of specific events does not take into account intraevent variability; not all equivalent events have the same impact on all people in all situations.31 This led Brown and Harris32 to include a measure of
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“contextual threat” in determining severity. Brown and Harris’ approach has in turn been criticized by Tennant et a1.33as artificially producing an association between life events and other antecedent conditions such as an individual’s social situation and personality attributes that result in an overestimate of the causal role of life events in illness. The axis IV approach in which the severity rating is made by the presumably more objective clinician taking into account some of the particulars of each patient’s situation again appears to be reasonably justifiable. DSM-III stated that the axis IV severity rating should reflect the summed effect of all stressors judged relevant, but no guidelines were given on which to base these combined ratings. Again, in the life events literature there is controversy over whether multiple less severe events are as stressful as a single major one or if an accumulation of mild stressors might not also be pathogenic. As Rey et a1.‘3 point out, DSM-III’s lack of explicit guidelines may again be a compromise justified by ambiguity in life events research. Finally, the DSM-III convention that only stressors judged relevant to the onset of exacerbation of a current disorder are rated appears to Rey et al.” to require judgments of etiological significance that are beyond the ability of the clinician, given the controversy that surrounds the role that stressful life events may play in the development and maintenance of mental disorder.34-36On the other hand, clinicians routinely assess the relevance of recent stressors to a patient’s condition, since a judgment one way or another can affect the treatment plan. Evaluation of axis ZVseverity ratings. Empirical data have begun to accumulate on the construct validity of DSM-III axis IV. These studies address, at the simplest level, whether the ratings on axis IV conform to clinical sense and to previous research on the relationship of stress to mental disorders. Several also assess how the complex DSM-III conventions for listing and rating events affect the assessment of psychosocial stressors compared with more standardized life event assessment methods. Finally, one study assessed the convergence of external validators on depression with high versus low axis IV severity of psychosocial stressor ratings. Skodol and ShrouP found that axis I diagnoses of V codes, adjustment disorder, anxiety disorders, and major depression, were associated with more severe stressors than schizophrenia, in a combined sample of inpatients and outpatients. However, axis IV ratings were not redundant with axis I diagnosis, as considerable variability existed within diagnostic categories. Schrader et aL3’ reported higher axis IV ratings for nonpsychotic as compared with psychotic inpatients and affective psychotic as compared with nonaffective psychotic inpatients. In a sample of over 10,000 psychiatric patients, Mezzich et a1.“8found that patients with depressive disorders had higher axis IV ratings than patients with other mental disorders. Bronheim et a1.39found that axis IV severity ratings distinguished patients hospitalized on ear, nose, and throat (ENT) services from other hospitalized patients for whom psychiatric consultation was sought, despite higher levels of premorbid adaptive functioning and lower rates of severe mental disorder in the ENT group. More severe stressors also appear to be associated with first episodes of any mental disorder than with repeat epis0des.l’ In contrast, Westermeyer4” found no correlation between presence of an axis I diagnosis and severity of psychosocial stressors ratings in a group of Asian refugees. Further,
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Trzepacz et al.4’ found no difference on axis IV between delirious and nondelirious patients awaiting liver transplantation. Plapp et al.42reported that raters had difficulty assigning axis IV severity ratings to a list of psychosocial stressors, even using simpler five-point or three-point severity scales. This was interpreted as a manifestation of the difficulty of applying DSM-III’s complicated definition of impact. However, Skodol and Shrout16 found that residents and psychology intern raters could assign severity ratings that corresponded well (r = .72) to a standardized severity rating system used in life events research.43 Neither Rey et al.12 nor Skodol and Shrout’6 found that multiple stressors materially changed a severity rating. In both studies, the severity rating was predominantly determined by the first-listed, most severe stressor. Axis IV severity ratings were found by Zimmerman et al.44to be more highly correlated with undesirable than desirable events, exits (i.e., losses) than entrances, and discrete and time-limited events than ongoing circumstances in a sample of depressed patients. Higher axis IV ratings were also associated with a lower rate of abnormal dexamethasone suppression test results, a higher rate of risk for alcoholism, a greater likelihood of comorbid personality disorders, and a greater frequency of attempted suicide during the index depressive episode. These results support the construct validity of axis IV for depressed patients, but similar studies have not been reported for other diagnostic groups. The ratings were also made following administration of a systematic life events interview, rather than on the basis of a routine clinical evaluation of stressors. Identifying psychosocial stressors using axis IV Brugha et al.,45 using the methods of Brown and Harris3” have found that most etiologically significant life events comprise a relatively short list of more severely stressful experiences. Axis IV has been found to function well as a shorthand method for identifying severe psychosocial stressors when compared in practice with the use of a lengthy, comprehensive assessment of life events.46 However, discrepancies were found between the methods for less severe events and for events that clinicians judged were either the result of a patient’s mental disorder or produced no change in a patient’s condition (i.e., occurring but not etiologically significant). Some etiologitally significant stressors were not acutely occurring, discrete events, but rather chronic strains such as poverty. DSM-III-R axis IV may be an improvement over DSM-III because it includes separate examples of rating scale points for acute events and for enduring circumstances. Relationship to Treatment Planning
Mezzich et al.47 have studied the relationship of axis IV ratings to treatment decisions. They found a modest but significant correlation between axis IV ratings and the decision to admit a patient from a walk-in clinic to inpatient hospital care. The relationship was weaker than that found for axis V ratings of highest level of adaptive functioning, which was in turn weaker than that found for a rating of current adaptive functioning. Predictive Validity
In DSM-III, the description of axis IV includes a hypothesis that patients with the same diagnosis would be expected to have a better prognosis if the axis IV
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rating is high as opposed to low. The ability of axis IV severity ratings to predict outcome remains an open question. Gordon et a1.48.49 have found that a measure, which they call the “strain ratio,” derived by dividing axis IV ratings by inverted (8 minus the axis V score) axis V ratings, is related to length of hospital stay. The higher the strain ratio, that is, the greater the degree of psychosocial stress associated with the disorder compared with the level of adaptive functioning, the longer patients needed to be hospitalized. High axis IV ratings alone also appear to be related to longer inpatient stays in subsequent analyses.” A study comparing outcomes after 6 months between two groups of patients with depressive disorders, one of which rated high on the axis IV scale and the other low, failed to find the predicted relationship between high severity-of-stressor ratings and good prognosis.” RECOMMENDATIONS
It seems reasonable to conclude that a thorough evaluation of axis IV has yet to be done. There are, for example, no published studies using DSM-III-R axis IV and, thus, no way to evaluate whether the changes made in the revision are improvements. However, the preceding review supports the following recommendations, listed in order from most to least conservative: 1. To increase use of axis IV, better training in its complexities would be needed. 2. Reliability in the future should be studied using live patients only, following focused training such as would precede reliability testing of a structured interview. 3. Statements in the text describing axis IV should continue (as in DSM-III-R) to describe its usefulness in terms of planning or focusing treatment, but not in terms of its prognostic significance. 4. Reliability may be improved by changing instructions for use such that the rating is based solely on the most severe stressor. Reliability may also be improved by asking clinicians to rate any stressor that occurred rather than requiring the additional judgment of etiologic significance. 5. If axis IV were dismantled, the severity rating scale should be the first casualty; continuing to note acute or enduring psychosocial stressors may itself be valuable in planning clinical interventions.5’,5’ 6. It may be desirable to limit stressor identification to only those stressors that would be associated with severity ratings of severe or greater. OPTIONS
FOR DSM-IV
One option for axis IV in DSM-IV is to make no changes, given the relative paucity of empirical data to guide further revision. Although this option may appear misguided, given the disappointment expressed by some with the current format, changes in officially sanctioned diagnostic standards are likely to disrupt the limited ongoing research in the area.” At least a few investigators (e.g., Gordon et al., at the University of Florida) are quite content with current axes and their research yield. In addition, there is no guarantee that a change will necessarily be for the better. Furthermore, given limited data, it is unclear whether axis IV is not more widely used because clinicians and researchers are not
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invested in the relevance of psychosocial stressors to mental disorders (doubtful), they are invested but find the specifics of axis IV as a means to attaining this information deficient (more likely), or because of other reasons. Finally, the needs and desires of clinicians and researchers may be different. As Malt’* has written, it may be “impossible to have an axis IV that is clinically meaningful and simultaneously valid according to current standards of life event research.” Further research is needed to answer these questions and to test alternative axial concepts and methods. If a decision is made to revamp the axis based on the limited available data in order to increase its use and usefulness, then several possibilities emerge. It may be possible, for example, to imbed severe stressful life events in a broader context of psychosocial problems, maintaining discrimination between discrete life event stress and ongoing stressful life circumstances. Support for the content of such a list comes from at least three sources. First, the upcoming ICD-10 is scheduled to include a chapter (XXI) for codes referring to “Factors Influencing Health Status and Contact with Health Services” (Z codes). Second, primary care physicians have developed their own classification, the International Classification of Health Problems in Primary Care (ICHPPC), which includes a Chapter Z, “Social Problems.“56 Finally, Williams, Karls, and Wandrei57*58have proposed a system for classifying the problems that clients of social workers may present. The Person in Environment System (PIE) lists “Environmental Problems” as its Factor II. Appendix A shows a comparison of the psychosocial problems of these three systems. Therefore, in addition to the current DSM-III-R axis IV, two alternative options are being considered for field testing by the DSM-IV Multiaxial Issues Work Group. The first is a simple list of psychosocial problems (Appendix B). The rater would check problem areas judged to adversely affect the individual and, thus, associated with mental disorders, physical disorders, or other clinically relevant conditions coded on axes I, II, or III. Specific problems would also be listed. The other format for a revised axis IV is depicted as Appendix C. It would consist of two brief resource scales, which would be used to indicate the adequacy of a person’s social supports and environmental resources. In a field test, the three options for axis IV would be compared for reliability, feasibility, and perceived usefulness for making clinical decisions about treatment and management by clinicians. A clear winner would be presented to the DSM-IV Task Force as recommended for axis IV. The implications of a more ambiguous outcome to the field trial are not yet clear. It is conceivable that ratings of stressors and problems/resources could be recommended, although redundancy of ratings would become a risk and added complexity to the multiaxial system could further compromise its use. ACKNOWLEDGMENT The author gratefully acknowledges the comments of the other members of the DSM-IV Multiaxial Issues Work Group (Co-chair: Howard H. Goldman, M.D., Ph.D.; Alan M. Gruenberg, M.D.; Juan E. Mezzich, M.D., Ph.D.; and Chair, Janet B.W. Williams, D.S.W.) and advisors to the Work Group (Richard E. Gordon, M.D., Ph.D.; Dr. Geoff Schrader; John S. Strauss, M.D.; Professor Christopher Tennant; Mary Durand Thomas, Ph.D., R.N., C.S.; and Holly Skodol Wilson, R.N., Ph.D., F.A.A.N.) on an earlier draft of this work. The Axis IV Personal Resources Scales (Appendix C) were developed by Janet B.W. Williams, D.S.W. and Robert L. Spitzer, M.D.
255
256
257 258
259
260 261 262 263
264 265
275
272 273 274 281
Education and literacy
Exposure to occupational risk factors Social environment
Housing and economic circumstances
Physical environment Negative events in childhood Upbringing of child Primary support group/family
Other psychosocial circumstances
Health care
Life-style Life management difficulty Care provider dependency Family history of mental disorder
Code
Employment and unemployment
ICD-10 Term
behavior
zo9 225 ZlO
Assault Health care
212 220 213 217 221 214 218 222 215 z19 223
202 Z16
205 Z06 205 204 Zll 224 227 228 ZOl 202 203 208
207
Code
Legal
Death of partner/child/parent
III partner/child/parent
Parter/child/parent
Food and water Child abuse Partner/parent
Working conditions Unemployment Working conditions Migration Social/cultural system Friends Fear of social problem Social handicap Financial Food and water Housing Welfare
Education
ICHPPC Term
system
system Health/mental health Social services Discrimination in health/safety/social
Safety Justice/legal Discrimination in justice/legal
service system
Affectional support Discrimination in affectional support system
Food/nutrition Shelter Economic resources Transportation Discrimination
Religious groups Community groups Discrimination in voluntary association system
Education and training Discrimination in education/training Employment
PIE Term
810X 830X 84xx
820X 710x 72XX
1010x 102xX
510x 520X 540x 550x 560X
910x 920x 930x
z;;
610X
Code
APPENDIX A A Comparison of KID-10 Draft Chapter XXI “Factors Influencing Health Status and Contact With Health Services” (2 codes), International Classification of Health Problems in Primary Care (ICHPPC) Chapter 2 “Social Problems,” and Factor II of Person in Environment System “Environmental Problems”
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APPENDIX B Axis IV. Psychosocial Problem Checklist Listed below are problem areas that may adversely ated (either causally or in a contributory fashion) with cal conditions, or other clinically significant problems apply, and write in the specific problems in the space Problem Areas
Check
Educational problems Occupational
problems
Unemployment
-
Job dissatisfaction
-
Exposure to hazards Environmental
problems
Inadequate housing Inadequate food Inadequate finances Unsafe environment Inadequate access to health and other services
-
Inadequate social supports/interpersonal losses of Family Friends Sociocultural/community groups Legal problems Other problem areas (e.g., immigration, war)
-
affect the individual and may be associmental disorders, nonpsychiatric medicoded on axes I, II, or Ill. Check all that provided. List Specific Problems
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STRESSORS
APPENDIX C Axis IV. Personal Resources
Scales
These scales are for coding the adequacy of two areas of personal resources in children and adults: social supports and environmental resources. The adequacy of each of these areas should be rated for the current time period at the time of the evaluation. The following descriptors are to be used as general guidelines. Ratings should be made regardless of cause of inadequacy (e.g., rate “1” on Environmental Resources Scale even if lack of finances and housing is related to psychopathology.) Social Supports
Scale
Consider the quantity and quality of social relationships and contact; include familial and nonfamilial resources. For children and adolescents, include the supervision, guidance, warmth, and security provided by important caretakers. 5 = Optimal-Relationships provide extensive social support with little or no social conflict, e.g., frequent contact with several close friends, and excellent relations with family, including consistent and appropriate supervision and guidance for children. 4 = Adequate-Relationships provide an average amount of social support, with occasional social conflict. 3 = Somewhat inadequate-Relationships provide less than adequate social support, with frequent social conflict, e.g., some contact with a small number of friends, no close friends, and a minimal frequency of contact with family and/or somewhat strained relations with family. For children, inadequacies of supervision or caretakers’ sensitivity to developmental needs falls short of neglect or abuse. 2 = Clearly deficient-Social relationships provide little nurturance or support. Family contacts, if any, are insensitive and unsupportive. For children, neglect or abuse may be present due to inadequate supervision or hostility. 1 = Markedly deficient-Social relationships are nonexistent or, if present, are generally unsupportive or abusive. No contact with family, or family relations are extremely strained or hostile. Overt child neglect or abuse are present at this level. Environmental Consider the adequacy of housing, health and other services, etc.
Resources
finances,
Scale
safety of the environment,
access to
5 = Optimal-No significant financial problems, comfortable housing in a safe neighborhood, easy access to health and other services. 4 = Adequate-Adequate finances to meet basic needs, including entertainment; housing is adequate in size and location; health and other services may be accessed with minimal effort. 3 = Somewhat inadequate-Finances adequate for necessities only; somewhat cramped or decrepit housing in neighborhood of questionable safety; limited access to health and other services. 2 = Clearly deficient-Income regularly inadequate for meeting basic needs; housing extremely decrepit in an unsafe neighborhood, health and other services not available without extreme effort (e.g., traveling great distances). 1 = Markedly deficient-No sources of income; homeless.
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REFERENCES 1. Spitzer RL, Forman JB: DSM-III field trials: II. Initial experience with the multiaxial system. Am J Psychiatry 136:818-820,1979 2. Jampala VC, Sierles FS, Taylor MA: Consumers’ views of DSM-III: Attitudes and practices of U.S. psychiatrists and 1984 graduating psychiatric residents. Am J Psychiatry 143:148-153,1986 3. Junek RW: The DSM-III in Canada: A survey. Can J Psychiatry 28:182-187,1983 4. Junek W, Leichner PP: Opinions of Canadian residents regarding DSM-III. J Psych Educ 10:87-91, 1986 5. Mezzich JE, Fabrega H Jr, Mezzich AC: An international consultation on multiaxial diagnosis, in Pichot P, Berner P, Wolf R, et al (eds): Psychiatry, ~011. London, England, Plenum, 1985a, pp 51-56 6. Mezzich JE, Fabrega H Jr, Mezzich AC, et al: International experience with DSM-III. J Nerv Ment Dis 173:738-741,1985b 7. Williams JBW, Spitzer RL, Skodol AE: DSM-III in residency training: Results of a national survey. Am J Psychiatry 142:755-758,1985 8. Williams JBW, Spitzer RL, Skodol AE: DSM-III in the training of psychiatric residents and medical students: A national survey. J Psych Educ 10:75-86,1986 9. Engles ML, Ghadirian AM, Dongier M: DSM-III: The view from the Canadian academe. Psychiatr J Univ Ottawa 10:37-40, 1985 10. Velamoor VR, Waring EM, Fisman S, et al: DSM-III in residency training: Results of a Canadian survey. Can J Psychiatry 34:103-106,1989 11. Skodol AE: Problems in Differential Diagnosis: From DSM-III to DSM-III-R in Clinical Practice. Washington, DC, American Psychiatric Association, 1989, pp 39-76 12. Rey JM, Plapp JM, Stewart GW, et al: Reliability of the psychosocial axes of the DSM-III in an adolescent population. Br J Psychiatry 150:228-234,1987 13. Mezzich AC, Mezzich JE, Coffman GA: Reliability of DSM-III vs DSM-II in child psychopathology. J Am Acad Child Psychiatry 24:273-280,1985 14. Russell AT, Cantwell DP, Mattison R, et al: A comparison of DSM-II and DSM-III in the diagnosis of childhood psychiatric disorders. III. Multiaxial features. Arch Gen Psychiatry 36:12231226,1979 15. Skodol AE, Williams JBW, Spitzer RL, et al: Identifying common errors in the use of DSM-III through diagnostic supervision. Hosp Commun Psychiatry 35:251-255, 1984 16. Skodol AE, Shrout PE: Use of DSM-III axis IV in clinical practice: Rating the severity of psychosocial stressors. Psychiatry Res 30:201-211,1989b 17. Mezzich AC, Mezzich JE: Perceived suitability and usefulness of DSM-III vs. DSM-II in child psychopathology. J Am Acad Child Psychiatry 24:281-285, 1985 18. Skodol AE, Shrout PE: Axis IV of DSM-III. Am J Psychiatry 145:1046,1988 19. Frances A, Cooper AM: Descriptive and dynamic psychiatry: A perspective on DSM-III. Am J Psychiatry 138:1198-1202,198l 20. Roth Sir M: The achievements and limitations of DSM-III, in Spitzer RL, Williams JBW, Skodol AE (eds): International Perspectives on DSM-III. Washington, DC, American Psychiatric Press, 1983, pp 91-105 21. Kendell RE: Reflections on psychiatric classification-For the architects of DSM-III and ICD-10. Integrat Psychiatry 2:43-47,1984 22. Rutter M, Shaffer D: DSM-III. A step forward or back in terms of the classification of child psychiatric disorders? J Am Acad Child Psychiatry 19:371-394, 1980 23. Rey JM, Stewart GW, Plapp JM, et ah DSM-III axis IV revisited. Am J Psychiatry 145:286-292,198s 24. Henderson S, Byrne DG, Duncan-Jones P: Neurosis and the Social Environment. London, England, Academic, 1982 25. Isherwood J, Adam KS, Hornblow AR: Readjustment, desirability, expectedness, mastery and outcome dimensions of life stress, suicide and auto-accident. J Hum Stress 8:11-18,1982 26. Holmes TH, Rahe RH: The social readjustment rating scale. J Psychosom Res 11:213-218,1967 27. Paykel ES, Myers JK, Dienelt MN, et al: Life events and depression: A controlled study. Arch Gen Psychiatry 21:753-760,1969 28. Grant I, Gerst M, Yager J: Scaling of life events by psychiatric patients and normals. J Psychosom Res 20:141-149,1976 29. Schless AP, Schwartz L, Goetz C, et al: How depressives view the significance of life events. Br J Psychiatry 125:406-410, 1974
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30. Brown GW: Meaning, BP (eds): Stressful Life 31. Dohrenwend BP, event categories. Stress 32. Brown G, Harris
measurement,
STRESSORS
and stress of life events, in Dohrenwend
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BS, Dohrenwend
Events: Their Nature and Effects. New York, NY, Wiley, 1974, pp 217-243 Link B, Kern R, et al: Measuring life events: The problem of variability within Med 6:179-187, 1990 T: Social Origins of Depression: A Study of Psychiatric Disorder in Women.
New York, NY, The Free Press, 1978 33. Tennant C, Bebbington P, Hurry J: The role of life events in depressive illness: Is there a substantial causal relation? Psycho1 Med 11:379-389,198l 34. Lloyd C: Life events and depressive disorder revisited, II: Events as precipitating factors. Arch Gen Psychiatry 37541-548, 1980 35. Tennant C: Life events and psychological morbidity: the evidence from prospective studies. Psycho1 Med 13:483-486,1983 36. Depue RA, Monroe SM: Conceptualization and measurement of human disorder in life stress research: The problem of chronic disturbance. Psycho1 Bull 99:36-51, 1986 37. Schrader G, Gordon M, Harcourt R: The usefulness of DSM-III axis IV and axis V assessments. Am J Psychiatry 143:904-907, 1986 38. Mezzich JE, Fabrega H Jr, Coffman GA: Multiaxial characterization of depressive patients. J Nerv Ment Dis 175:339-3451987 39. Bronheim H, Strain JJ, Biller HF, et al: Psychiatric consultation on an otolaryngology service. Gen Hosp Psychiatry 11:95-102, 1989 40. Westermeyer J: DSM-III psychiatric disorders among Hmong refugees in the United States: A point prevalence study. Am J Psychiatry 145:197-202, 1988 41. Trzepacz PT, Brenner R, Van Thiel DH: A psychiatric study of 247 liver transplantation candidates. Psychosomatics 30:147-153.1989 42. Plapp JM, Rey JM, Stewart GM, et al: Ratings of psychosocial stressors in adolescence using DSM-III axis IV criteria. J Am Acad Child Psychiatry 26:80-86,1987 43. Dohrenwend BS, Krasnoff L, Askenasy A, et al: Exemplification of a method for scaling life events: The PER1 life events scale. J Health Social Behav 19:205-229, 1978 44. Zimmerman M, Pfohl B, Stangl D, et al: The validity of DSM-III axis IV (severity of psychosocial stressors). Am J Psychiatry 142:1437-1441,1985 45. Brugha T, Bebbington P, Tennant C, et al: The list of threatening experiences: a subset of 12 life event categories with considerable long-term contextual threat. Psycho1 Med 15:189-194,1985 46. Skodol AE, Shrout PE: Use of DSM-III axis IV in clinical practice: Rating etiologically significant stressors. Am J Psychiatry 146:61-66, 1989 47. Mezzich JE, Evanczuk KJ, Mathias RJ, et al: Admission decisions and multiaxial diagnosis. Arch Gen Psychiatry41:1001-1004, 1984 48. Gordon RE, Jardiolin P, Gordon KK: Predicting length of hospital stay of psychiatric patients. Am J Psychiatry 142:235-237.1985 49. Gordon RE, Vijay J, Sloate SG, et al: Aggravating stress and functional level as predictors of length of psychiatric hospitalization. Hosp Commun Psychiatry 36:773-774. 1985 50. Gordon RE, Gordon KK: Relating axes IV and V of DSM-III to clinical severity of psychiatric disorders. Can J Psychiatry 32:423-424,1987 51. Zimmerman M, Pfohl B, Coryell W, et al: The prognostic validity of DSM-III axis IV in depressed inpatients. Am J Psychiatry 144:102-106, 1987 52. Mezzich JE: On developing a psychiatric multiaxial schema for ICD-10. Br J Psychiatry 1:38-43, 1988 (suppl) 53. Mezzich JE, Fabrega H Jr, Coffman GA, et al: DSM-III disorders in a large sample of psychiatric patients: Frequency and specificity of diagnoses. Am J Psychiatry 146:212-219, 1989 54. Zimmerman M: Why are we rushing to publish DSM-IV? Arch Gen Psychiatry 45:1135-l 138, 1988 55. Malt U: Five years of experience with the DSM-III system in clinical work and research: Some concluding remarks. Acta Psychiatr Stand 328:76-84, 1986 (suppl) 56. Jenkins R. Smeeton N, Shepherd M: Classification of mental disorders in primary care. Psycho1 Med 12:1-59, 1988 (suppl) 57. Williams JBW. Karls JM, Wandrei K: The Person-In-Environment (PIE) System for describing problems of social functioning. Hosp Commun Psychiatry 40:1125-l 127, 1989 58. Karls JM. Wandrei K: P-I-E: A new language for social work. Social Work (in press)
of
Andrew E. Skodol DSM-III axis IV, Severity of Psychosocial Stressors, has been a disappointment to many because of the apparently infrequent use of the axis in clinical and research settings. This report is a review of literature on the use, reliability, and validity of axis IV. Although the concept of multiaxial evaluation has considerable appeal, clinicians have not routinely used axis IV, possibly because they do not fully understand the complexities involved in making ratings. The relatively few published empirical studies on axis IV indicate modest reliability and limited validity, beyond the value in identifying severe psychosocial stressors for the purpose of planning clinical interventions. The results of this review have led the DSM-IV Multiaxial Issues Work Group to consider several options for major changes in the format of axis IV to be recommended to the DSM-IV Task Force. Copyright 0 1991 by W.B. Saunders Company
F
OR MANY OF THOSE charged with the development of DSM-IV, experience with DSM-III axis IV, Severity of Psychosocial Stressors, has been disappointing. Axis IV is generally believed to be used infrequently in clinica settings, possibly because reliable severity ratings are too difficult to make or because the rating fails in its intended purposes, as part of the DSM-III multiaxial evaluation system. In addition, axis IV has been criticized for stimulating meager numbers of research studies. A consensus has formed that axis IV may require dramatic revision for DSM-IV, in order to make it more usable and more useful. Axis IV was modestly revised in DSM-III-R in response to initial criticisms and a few empirical studies. The revised axis IV differs from its predecessor in that separate sets of examples are given for rating the severity of acute events and enduring circumstances. DSM-III-R ratings are made on a six-point scale of severity that no longer includes a “minimal” stress rating. A number of examples of specific stressors illustrating scale points were changed in DSM-III-R to make the lists more consistent with other lists of psychosocial stressors used in research. The purpose of this report is to review evidence regarding the use of DSM-III (and III-R) axis IV in clinical and research settings. Critiques of professionals with experience in using axis IV will be summarized. Results on the reliability of axis IV severity ratings will be reported. The usefulness of the axis will be assessed by means of review of theoretical reports and empirical data relevant to the construct validity of the scale and review of studies addressing its predictive validity. CLINICAL
USE OF AXIS IV
In the DSM-III field trials,’ reaction to axis IV was mixed. Almost half of the field trial participants favored some major change in the conventions for
From the Departments of Pvchiatry, Columbia University College of Physicians and Surgeons. and New York State PJychiattic Institute, New York, NY Address reprint requests to Andrew E. Skodol, M.D., Box 8, New York State PTchiattic Institute, 722 W 168th St, New York, NY 10032. OOIO-44OXl9113206-0003$03.00/O Comprehensive
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identifying stressors or making the severity rating, or elimination of the axis altogether. Only 38% believed that axis IV was likely to be clinically useful and stated that they would use it regularly in their diagnostic evaluations. This figure compared with 63% who judged axis V useful. Spitzer and Forman expressed reservations about the changes proposed for axis IV, but concluded that future studies were necessary to determine the extent to which axis IV would be used in clinical practice and its impact on patient care. There are two sources of information regarding clinical use of DSM-III axis IV: (1) surveys of clinical practitioners, and (2) surveys of directors of training programs in psychiatry. Data on clinical practice are available from the United States’ and Canada.3z4 Mezzich et a1.5,6have also reported on patterns of use among a multinational panel of experts in psychiatric diagnosis, 45% of whom identified their major professional activity as clinical practice. Jampala et al2 surveyed practicing psychiatrists and 1984 graduates of residency training and found considerable resistance to the use of the DSM-III multiaxial system, due to its complexity and to incomplete knowledge of how to use it. However, similar resistance and reasons for it were reported for axis I and II diagnoses, as were for axes IV and V. In Canada, DSM-III became the preferred system of classification shortly after its publication.3 Two thirds of responding practitioners recommended a multiaxial system similar to that of DSM-III for the International Classification of Diseases, 10th Revision (ICD-10). Junek and Leichner4 later found that psychiatric residents trained since publication of DSM-III preferred the system to ICD-9 more than twice as often as members of the Canadian Psychiatric Association, most of whom were trained in the pre-DSM-III era. More than 90% of residents recommended a multiaxial system for ICD-10. Respondents to Mezzich et al.’ used the DSM-III multiaxial system more than any other. Identification of psychosocial stressors was rated less valuable in a multiaxial schema than psychiatric syndromes, personality disorders, physical disorders with brain dysfunction, and course or duration of illness, but more valuable than physical disorders without brain dysfunction and either highest or current level of adaptive functioning. Rating overall severity of psychosocial stressors was deemed less useful than their specific identification and “unclear principles” guiding axis IV was occasionally mentioned as a specific problem.6 The US and Canadian studies suffer from modest completion rates and no attempt to assess potential differences between responders and nonresponders. They also pointed to limited knowledge as a result of inadequate training as a potential source of reluctance to use the multiaxial system, making the causes, and thus the cure, ambiguous. The Jampala et al.’ survey respondents’ perception that axis IV was not useful was only slightly more pronounced than for axis V for practicing psychiatrists and similar to proportions of all respondents who did not believe that diagnoses on axes I and II were valid. All surveys have relied on reported use and usefulness, rather than on systematic reviews of actual practice patterns, through records for example. Two surveys of psychiatric residency training directors’ and of directors of medical student education in psychiatry’ indicated that, by 1983, less than half of US training programs in psychiatry had integrated the complete multiaxial system
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into their curricula or required its use by trainees. Nearly 75% taught and used the first three axes, in contrast. At about the same time, 45% of Canadian academic psychiatrists taught axis IV to trainees; 40% taught axis V.” In a subsequent survey, only 18% of directors of residency training programs in Canada expected residents to use axes IV and V most or all of the time.‘” Thus, although use of axis IV has lagged behind use of axes I through III, the limited surveys available suggest no significant difference between axis IV and V use and point to incomplete understanding as the reason for nonuse. The findings that few training programs emphasize axes IV and V, and that when trained, clinicians more readily accept the system, suggest that change unaccompanied by rigorous training will be unlikely to increase use of additional axes. Although it may be argued that educators had rejected axis IV on the basis that it was not useful, at the time of these surveys there were virtually no empirical data on which to base this judgment. Therefore, even at the level of psychiatric academicians, the conclusion might be drawn that the axes were rejected because they were new, complex, and unfamiliar.” EMPIRICAL
STUDIES
OF AXIS IV
Excluding surveys of patterns of use and educational practices, I found 22 published reports empirically evaluating some aspect of DSM-III axis IV as of November 30, 1990. This compares with 24 reports addressing axis V and 12 reports using axis III. Axis IV reports have been based on data collected primarily at Iowa, Pittsburgh, Florida, and Columbia University and the Royal Prince Alfred Hospital and the University of Adelaide, both in Australia. Thus, although research on axis IV has tended to be limited to centers interested generally in psychiatric nosology, in terms of the numbers of studies generated, axis IV appears to have fared no worse than axis V and has far exceeded axis III (as part of the multiaxial evaluation system) as a research focus, thus far. Reliability Only three studies report reliability of axis IV severity ratings. The best figures were obtained during the DSM-III field trials’: joint interviews yielded an intraclass correlation coefficient (ICC) of 0.62 and test-retest evaluations, 0.58. This is the only study to report reliability figures for axis IV ratings on adult patients. Two studies reported poor reliability for axis IV ratings on adolescents (ICC = 0.44)‘” and on children (ICC = 0.25).13 One additional study of children reported modest agreement on the listing of psychosocial stressors on axis IV.” The latter two studies used written case vignettes as opposed to live interviews for the ratings. Sources of error. In a study identifying common errors in the use of DSM-III through diagnostic supervision, Skodol et al.” found an error rate of 22.5% on axis IV, with 10% of cases requiring a change of two scale points or more. The overall error rate for axis V was only 13.5%. Errors were due to the complicated conventions for making ratings described in the brief instructions included in DSM-III for the use of axis IV. Skodol and Shrout’h have demonstrated, for example, that the instruction that the rating reflect the summed effect of all stressors listed was too complex to be incorporated into routine clinical practice,
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even by relatively well-trained evaluators with expert supervision. Rey et al.” have also cited the complex instructions for making severity ratings as sources of unreliability. In contrast, despite low reliability in their ratings, more than three quarters of the respondents in the Mezzich et a1.13study judged the clarity of the axis IV scale to be “more clear than unclear” or “very clear.“” No reliability study appears to have been done following intensive training, such as commonly precedes a formal study of the reliability of a semistructured diagnostic interview.‘* Construct Validity Axis IV was included in the DSM-III and DSM-III-R multiaxial systems as a shorthand way to note the occurrence and rate the severity of psychosocial stressors that may have contributed to the onset or exacerbation of a current mental disorder. Identifying stressors was thought to be important for formulating a treatment plan and the severity rating was expected to have prognostic value. Much has been written about how well (or poorly) axis IV with its scale and rating conventions fulfills its functions. Most critics have expressed negative views, although these views were not based on empirical studies. One of the most commonly cited criticisms has been of the convention to rate the severity on the basis of an average person’s reaction rather than the patient’s possibly idiosyncratic reaction’9.20; a patient’s peculiar vulnerability to particular stressors might be more clinically meaningful. Also criticized was the decision to combine all stressors, including chronic and acute, into a single global rating implying a single mechanism of effect.21.22 Stressor theory and axis IV severity ratings. Rey et aLz3 comment on axis IV conventions, which bear on the DSM-III operationalization of the rating of stress: (1) assessing the impact of individual stressors, (2) assessing the impact of multiple stressors, and (3) assessing the relevance of the stressors. The authors note that numerous models and methods exist for qualitatively describing and quantitatively estimating the impact of individual psychosocial stressors on a person. DSM-III axis IV requires a composite impact rating that includes consideration of the amount of change in the person’s life caused by the stressor and the degree to which the event is desired and under the person’s control. Change or adjustment resulting from a stressor is common to many attempts to quantify stressor impact in the life events literature24-26and undesirability or other indication of negative impact (threat, loss, or exit) frequently characterizes description of important life events. 27The fact that such theoretically independent dimensions of impact are often highly correlatedZ makes the DSM-III approach of an overall rating reasonable. Approaches to assigning a specific severity rating to a particular event also vary. The original approach of Holmes and Rahez6 used objective raters to assign severity scores. They viewed subjective ratings by affected individuals as biased because someone with a negative health outcome would view events retrospectively as more severe.28’29This bias became known as “effort after meaning.“3o However, a single scale for rating severity of specific events does not take into account intraevent variability; not all equivalent events have the same impact on all people in all situations.31 This led Brown and Harris32 to include a measure of
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“contextual threat” in determining severity. Brown and Harris’ approach has in turn been criticized by Tennant et a1.33as artificially producing an association between life events and other antecedent conditions such as an individual’s social situation and personality attributes that result in an overestimate of the causal role of life events in illness. The axis IV approach in which the severity rating is made by the presumably more objective clinician taking into account some of the particulars of each patient’s situation again appears to be reasonably justifiable. DSM-III stated that the axis IV severity rating should reflect the summed effect of all stressors judged relevant, but no guidelines were given on which to base these combined ratings. Again, in the life events literature there is controversy over whether multiple less severe events are as stressful as a single major one or if an accumulation of mild stressors might not also be pathogenic. As Rey et a1.‘3 point out, DSM-III’s lack of explicit guidelines may again be a compromise justified by ambiguity in life events research. Finally, the DSM-III convention that only stressors judged relevant to the onset of exacerbation of a current disorder are rated appears to Rey et al.” to require judgments of etiological significance that are beyond the ability of the clinician, given the controversy that surrounds the role that stressful life events may play in the development and maintenance of mental disorder.34-36On the other hand, clinicians routinely assess the relevance of recent stressors to a patient’s condition, since a judgment one way or another can affect the treatment plan. Evaluation of axis ZVseverity ratings. Empirical data have begun to accumulate on the construct validity of DSM-III axis IV. These studies address, at the simplest level, whether the ratings on axis IV conform to clinical sense and to previous research on the relationship of stress to mental disorders. Several also assess how the complex DSM-III conventions for listing and rating events affect the assessment of psychosocial stressors compared with more standardized life event assessment methods. Finally, one study assessed the convergence of external validators on depression with high versus low axis IV severity of psychosocial stressor ratings. Skodol and ShrouP found that axis I diagnoses of V codes, adjustment disorder, anxiety disorders, and major depression, were associated with more severe stressors than schizophrenia, in a combined sample of inpatients and outpatients. However, axis IV ratings were not redundant with axis I diagnosis, as considerable variability existed within diagnostic categories. Schrader et aL3’ reported higher axis IV ratings for nonpsychotic as compared with psychotic inpatients and affective psychotic as compared with nonaffective psychotic inpatients. In a sample of over 10,000 psychiatric patients, Mezzich et a1.“8found that patients with depressive disorders had higher axis IV ratings than patients with other mental disorders. Bronheim et a1.39found that axis IV severity ratings distinguished patients hospitalized on ear, nose, and throat (ENT) services from other hospitalized patients for whom psychiatric consultation was sought, despite higher levels of premorbid adaptive functioning and lower rates of severe mental disorder in the ENT group. More severe stressors also appear to be associated with first episodes of any mental disorder than with repeat epis0des.l’ In contrast, Westermeyer4” found no correlation between presence of an axis I diagnosis and severity of psychosocial stressors ratings in a group of Asian refugees. Further,
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Trzepacz et al.4’ found no difference on axis IV between delirious and nondelirious patients awaiting liver transplantation. Plapp et al.42reported that raters had difficulty assigning axis IV severity ratings to a list of psychosocial stressors, even using simpler five-point or three-point severity scales. This was interpreted as a manifestation of the difficulty of applying DSM-III’s complicated definition of impact. However, Skodol and Shrout16 found that residents and psychology intern raters could assign severity ratings that corresponded well (r = .72) to a standardized severity rating system used in life events research.43 Neither Rey et al.12 nor Skodol and Shrout’6 found that multiple stressors materially changed a severity rating. In both studies, the severity rating was predominantly determined by the first-listed, most severe stressor. Axis IV severity ratings were found by Zimmerman et al.44to be more highly correlated with undesirable than desirable events, exits (i.e., losses) than entrances, and discrete and time-limited events than ongoing circumstances in a sample of depressed patients. Higher axis IV ratings were also associated with a lower rate of abnormal dexamethasone suppression test results, a higher rate of risk for alcoholism, a greater likelihood of comorbid personality disorders, and a greater frequency of attempted suicide during the index depressive episode. These results support the construct validity of axis IV for depressed patients, but similar studies have not been reported for other diagnostic groups. The ratings were also made following administration of a systematic life events interview, rather than on the basis of a routine clinical evaluation of stressors. Identifying psychosocial stressors using axis IV Brugha et al.,45 using the methods of Brown and Harris3” have found that most etiologically significant life events comprise a relatively short list of more severely stressful experiences. Axis IV has been found to function well as a shorthand method for identifying severe psychosocial stressors when compared in practice with the use of a lengthy, comprehensive assessment of life events.46 However, discrepancies were found between the methods for less severe events and for events that clinicians judged were either the result of a patient’s mental disorder or produced no change in a patient’s condition (i.e., occurring but not etiologically significant). Some etiologitally significant stressors were not acutely occurring, discrete events, but rather chronic strains such as poverty. DSM-III-R axis IV may be an improvement over DSM-III because it includes separate examples of rating scale points for acute events and for enduring circumstances. Relationship to Treatment Planning
Mezzich et al.47 have studied the relationship of axis IV ratings to treatment decisions. They found a modest but significant correlation between axis IV ratings and the decision to admit a patient from a walk-in clinic to inpatient hospital care. The relationship was weaker than that found for axis V ratings of highest level of adaptive functioning, which was in turn weaker than that found for a rating of current adaptive functioning. Predictive Validity
In DSM-III, the description of axis IV includes a hypothesis that patients with the same diagnosis would be expected to have a better prognosis if the axis IV
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rating is high as opposed to low. The ability of axis IV severity ratings to predict outcome remains an open question. Gordon et a1.48.49 have found that a measure, which they call the “strain ratio,” derived by dividing axis IV ratings by inverted (8 minus the axis V score) axis V ratings, is related to length of hospital stay. The higher the strain ratio, that is, the greater the degree of psychosocial stress associated with the disorder compared with the level of adaptive functioning, the longer patients needed to be hospitalized. High axis IV ratings alone also appear to be related to longer inpatient stays in subsequent analyses.” A study comparing outcomes after 6 months between two groups of patients with depressive disorders, one of which rated high on the axis IV scale and the other low, failed to find the predicted relationship between high severity-of-stressor ratings and good prognosis.” RECOMMENDATIONS
It seems reasonable to conclude that a thorough evaluation of axis IV has yet to be done. There are, for example, no published studies using DSM-III-R axis IV and, thus, no way to evaluate whether the changes made in the revision are improvements. However, the preceding review supports the following recommendations, listed in order from most to least conservative: 1. To increase use of axis IV, better training in its complexities would be needed. 2. Reliability in the future should be studied using live patients only, following focused training such as would precede reliability testing of a structured interview. 3. Statements in the text describing axis IV should continue (as in DSM-III-R) to describe its usefulness in terms of planning or focusing treatment, but not in terms of its prognostic significance. 4. Reliability may be improved by changing instructions for use such that the rating is based solely on the most severe stressor. Reliability may also be improved by asking clinicians to rate any stressor that occurred rather than requiring the additional judgment of etiologic significance. 5. If axis IV were dismantled, the severity rating scale should be the first casualty; continuing to note acute or enduring psychosocial stressors may itself be valuable in planning clinical interventions.5’,5’ 6. It may be desirable to limit stressor identification to only those stressors that would be associated with severity ratings of severe or greater. OPTIONS
FOR DSM-IV
One option for axis IV in DSM-IV is to make no changes, given the relative paucity of empirical data to guide further revision. Although this option may appear misguided, given the disappointment expressed by some with the current format, changes in officially sanctioned diagnostic standards are likely to disrupt the limited ongoing research in the area.” At least a few investigators (e.g., Gordon et al., at the University of Florida) are quite content with current axes and their research yield. In addition, there is no guarantee that a change will necessarily be for the better. Furthermore, given limited data, it is unclear whether axis IV is not more widely used because clinicians and researchers are not
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invested in the relevance of psychosocial stressors to mental disorders (doubtful), they are invested but find the specifics of axis IV as a means to attaining this information deficient (more likely), or because of other reasons. Finally, the needs and desires of clinicians and researchers may be different. As Malt’* has written, it may be “impossible to have an axis IV that is clinically meaningful and simultaneously valid according to current standards of life event research.” Further research is needed to answer these questions and to test alternative axial concepts and methods. If a decision is made to revamp the axis based on the limited available data in order to increase its use and usefulness, then several possibilities emerge. It may be possible, for example, to imbed severe stressful life events in a broader context of psychosocial problems, maintaining discrimination between discrete life event stress and ongoing stressful life circumstances. Support for the content of such a list comes from at least three sources. First, the upcoming ICD-10 is scheduled to include a chapter (XXI) for codes referring to “Factors Influencing Health Status and Contact with Health Services” (Z codes). Second, primary care physicians have developed their own classification, the International Classification of Health Problems in Primary Care (ICHPPC), which includes a Chapter Z, “Social Problems.“56 Finally, Williams, Karls, and Wandrei57*58have proposed a system for classifying the problems that clients of social workers may present. The Person in Environment System (PIE) lists “Environmental Problems” as its Factor II. Appendix A shows a comparison of the psychosocial problems of these three systems. Therefore, in addition to the current DSM-III-R axis IV, two alternative options are being considered for field testing by the DSM-IV Multiaxial Issues Work Group. The first is a simple list of psychosocial problems (Appendix B). The rater would check problem areas judged to adversely affect the individual and, thus, associated with mental disorders, physical disorders, or other clinically relevant conditions coded on axes I, II, or III. Specific problems would also be listed. The other format for a revised axis IV is depicted as Appendix C. It would consist of two brief resource scales, which would be used to indicate the adequacy of a person’s social supports and environmental resources. In a field test, the three options for axis IV would be compared for reliability, feasibility, and perceived usefulness for making clinical decisions about treatment and management by clinicians. A clear winner would be presented to the DSM-IV Task Force as recommended for axis IV. The implications of a more ambiguous outcome to the field trial are not yet clear. It is conceivable that ratings of stressors and problems/resources could be recommended, although redundancy of ratings would become a risk and added complexity to the multiaxial system could further compromise its use. ACKNOWLEDGMENT The author gratefully acknowledges the comments of the other members of the DSM-IV Multiaxial Issues Work Group (Co-chair: Howard H. Goldman, M.D., Ph.D.; Alan M. Gruenberg, M.D.; Juan E. Mezzich, M.D., Ph.D.; and Chair, Janet B.W. Williams, D.S.W.) and advisors to the Work Group (Richard E. Gordon, M.D., Ph.D.; Dr. Geoff Schrader; John S. Strauss, M.D.; Professor Christopher Tennant; Mary Durand Thomas, Ph.D., R.N., C.S.; and Holly Skodol Wilson, R.N., Ph.D., F.A.A.N.) on an earlier draft of this work. The Axis IV Personal Resources Scales (Appendix C) were developed by Janet B.W. Williams, D.S.W. and Robert L. Spitzer, M.D.
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Education and literacy
Exposure to occupational risk factors Social environment
Housing and economic circumstances
Physical environment Negative events in childhood Upbringing of child Primary support group/family
Other psychosocial circumstances
Health care
Life-style Life management difficulty Care provider dependency Family history of mental disorder
Code
Employment and unemployment
ICD-10 Term
behavior
zo9 225 ZlO
Assault Health care
212 220 213 217 221 214 218 222 215 z19 223
202 Z16
205 Z06 205 204 Zll 224 227 228 ZOl 202 203 208
207
Code
Legal
Death of partner/child/parent
III partner/child/parent
Parter/child/parent
Food and water Child abuse Partner/parent
Working conditions Unemployment Working conditions Migration Social/cultural system Friends Fear of social problem Social handicap Financial Food and water Housing Welfare
Education
ICHPPC Term
system
system Health/mental health Social services Discrimination in health/safety/social
Safety Justice/legal Discrimination in justice/legal
service system
Affectional support Discrimination in affectional support system
Food/nutrition Shelter Economic resources Transportation Discrimination
Religious groups Community groups Discrimination in voluntary association system
Education and training Discrimination in education/training Employment
PIE Term
810X 830X 84xx
820X 710x 72XX
1010x 102xX
510x 520X 540x 550x 560X
910x 920x 930x
z;;
610X
Code
APPENDIX A A Comparison of KID-10 Draft Chapter XXI “Factors Influencing Health Status and Contact With Health Services” (2 codes), International Classification of Health Problems in Primary Care (ICHPPC) Chapter 2 “Social Problems,” and Factor II of Person in Environment System “Environmental Problems”
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APPENDIX B Axis IV. Psychosocial Problem Checklist Listed below are problem areas that may adversely ated (either causally or in a contributory fashion) with cal conditions, or other clinically significant problems apply, and write in the specific problems in the space Problem Areas
Check
Educational problems Occupational
problems
Unemployment
-
Job dissatisfaction
-
Exposure to hazards Environmental
problems
Inadequate housing Inadequate food Inadequate finances Unsafe environment Inadequate access to health and other services
-
Inadequate social supports/interpersonal losses of Family Friends Sociocultural/community groups Legal problems Other problem areas (e.g., immigration, war)
-
affect the individual and may be associmental disorders, nonpsychiatric medicoded on axes I, II, or Ill. Check all that provided. List Specific Problems
AXIS IV AS MEASURE
OF PSYCHOSOCIAL
513
STRESSORS
APPENDIX C Axis IV. Personal Resources
Scales
These scales are for coding the adequacy of two areas of personal resources in children and adults: social supports and environmental resources. The adequacy of each of these areas should be rated for the current time period at the time of the evaluation. The following descriptors are to be used as general guidelines. Ratings should be made regardless of cause of inadequacy (e.g., rate “1” on Environmental Resources Scale even if lack of finances and housing is related to psychopathology.) Social Supports
Scale
Consider the quantity and quality of social relationships and contact; include familial and nonfamilial resources. For children and adolescents, include the supervision, guidance, warmth, and security provided by important caretakers. 5 = Optimal-Relationships provide extensive social support with little or no social conflict, e.g., frequent contact with several close friends, and excellent relations with family, including consistent and appropriate supervision and guidance for children. 4 = Adequate-Relationships provide an average amount of social support, with occasional social conflict. 3 = Somewhat inadequate-Relationships provide less than adequate social support, with frequent social conflict, e.g., some contact with a small number of friends, no close friends, and a minimal frequency of contact with family and/or somewhat strained relations with family. For children, inadequacies of supervision or caretakers’ sensitivity to developmental needs falls short of neglect or abuse. 2 = Clearly deficient-Social relationships provide little nurturance or support. Family contacts, if any, are insensitive and unsupportive. For children, neglect or abuse may be present due to inadequate supervision or hostility. 1 = Markedly deficient-Social relationships are nonexistent or, if present, are generally unsupportive or abusive. No contact with family, or family relations are extremely strained or hostile. Overt child neglect or abuse are present at this level. Environmental Consider the adequacy of housing, health and other services, etc.
Resources
finances,
Scale
safety of the environment,
access to
5 = Optimal-No significant financial problems, comfortable housing in a safe neighborhood, easy access to health and other services. 4 = Adequate-Adequate finances to meet basic needs, including entertainment; housing is adequate in size and location; health and other services may be accessed with minimal effort. 3 = Somewhat inadequate-Finances adequate for necessities only; somewhat cramped or decrepit housing in neighborhood of questionable safety; limited access to health and other services. 2 = Clearly deficient-Income regularly inadequate for meeting basic needs; housing extremely decrepit in an unsafe neighborhood, health and other services not available without extreme effort (e.g., traveling great distances). 1 = Markedly deficient-No sources of income; homeless.
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