This work may not be copied, distributed, displayed, published, reproduced, transmitted, modified, posted, sold, licensed, or used for commercial purposes. By downloading this file, you are agreeing to the publisher’s Terms & Conditions.

Letter to the Editor

DSM-5 Drops the 5 Axes of Mysticism: A Supportive Survey

Elias K. Shaya, MD, DFAPA; Fouad J. Chidiac, BS; Nicole K. Daya; and Karan S. Kverno, PhD, CRNP-PMH

Published: April 15, 2014

DSM-5 Drops the 5 Axes of Mysticism: A Supportive Survey

To the Editor: The Institute of Medicine report Improving the Quality of Health Care for Mental and Substance-Use Conditions: Quality Chasm Series1 identified failures in collaboration among mental and general health care clinicians as important barriers to quality care. Interprofessional collaboration requires communication of information in a format that uses non-discipline-specific terminology when possible.2 Simplified and effective interdisciplinary communication is becoming progressively more important as various collaborative care models evolve in the quest to integrate behavioral health with the rest of medical care. The shared language for communicating psychiatric diagnoses is based on the DSM, yet the fluency of non-mental health providers is relatively unexplored. The multiaxial diagnostic system of the DSM-IV has been dropped by the DSM-5. By law, all hospitals, health care providers, and insurers will have to make the conversion from DSM-IV to DSM-5 and from ICD-9 to ICD-10 by October 2014. As part of a hospital quality improvement process, we evaluated the current DSM-IV multiaxial knowledge of our hospital interprofessional health care team. The purpose was to obtain a baseline assessment of non-mental health providers’ understanding of the DSM axial system, with the goal of identifying potential learning needs for DSM-5 training.

Method. This cross-sectional survey took place in an urban teaching hospital. During a 2-week period in August 2012, two students on the consultation-liaison psychiatry team approached working hospital health care professionals and students and asked for volunteer participation in a DSM survey. Demographic information included discipline and year of graduation from professional training. The knowledge questions were as follows: (1) What is the general purpose of the DSM-IV? (2) What is Axis I? (3) What is Axis II? (4) What is Axis III? (5) What is Axis IV? (6) What is Axis V?

Results. Exactly 100 health care workers participated in the survey. The data were analyzed descriptively. The sample included 44 physicians (including 16 residents), 14 nurses, 11 physician assistants, 9 medical students, 7 social workers, and 15 others. The survey showed that 78% of the participants knew the general purpose of the DSM-IV. Also, 19% knew the meaning of Axis I, 15% knew Axis II, 11% knew Axis III, 9% knew Axis IV, and 10% knew Axis V; 9% knew all of the DSM axes. The percentages of professionals by discipline who were able to define all 5 axes are as follows: physicians and residents: 4.5%, medical students: 22.2%, nurses: 7.1%, social workers: 57.1%, and all others: 0%. Of the survey participants, 70% graduated in 1994 or later.

Conclusions. The interpretation and generalization of our survey findings are limited by the use of health care providers in a single teaching hospital. We identified a breakdown in communication between psychiatry and other health care disciplines due to a lack of understanding of the multiaxial diagnostic system of the DSM-IV. Most prominent in our results is that over 90% of the physicians and nurses did not know the meaning of the DSM-IV axes, despite that being the means for communicating psychiatric diagnoses for nearly 20 years.

The findings from this survey increase awareness of the impact of the classification system itself on communication across disciplines. Given that within general hospital systems and emergency departments persons with mental health needs are primarily treated by non-mental health providers, the simplification of the DSM into the common language of diagnosis, contributing factors, and disability may eliminate barriers to understanding and enhance collaborative care. Our goal is to take the lead in preparing our hospital care providers for the DSM transition. The question remains whether further research will confirm that eliminating communication barriers will facilitate the integration of behavioral medicine with general medicine, enhance collaborative care models, and improve outcomes.


1. Institute of Medicine Committee on Crossing the Quality Chasm. Adaptation to Mental Health and Addictive Disorders. Improving the Quality of Health Care for Mental and Substance-Use Conditions: Quality Chasm Series. Washington, DC: The National Academies Press; 2005.

2. Interprofessional Education Collaborative Expert Panel. Core Competencies For Interprofessional Collaborative Practice: Report of an Expert Panel. Washington, DC: Interprofessional Education Collaborative; 2011.

Elias K. Shaya, MD, DFAPA

Fouad J. Chidiac, BS

Nicole K. Daya

Karan S. Kverno, PhD, CRNP-PMH

Author affiliations: Department of Psychiatry, Medstar Good Samaritan Hospital, Baltimore, Maryland (Dr Shaya); University of Balamand, Lebanon (Mr Chidiac); Department of Psychology, University of Maryland, College Park (Ms Daya); and Department of Acute and Chronic Care, Johns Hopkins University School of Nursing, Baltimore, Maryland (Dr Kverno).

Potential conflicts of interest: None reported.

Funding/support: None reported.

Previous presentation: Poster presented at the Medstar Health Research Symposium; March 4, 2013; Colombia, Maryland.

Published online: March 13, 2014.

Volume: 16

Quick Links:


Buy this Article as a PDF