DSM-IV TR versus DSM-5: Turned on its Axes

The real version of the DSM-5. Credit: annrkiszt from Flickr. License: Creative Commons.
The real version of the DSM-5. Credit: annrkiszt from Flickr. License: Creative Commons.

For those social workers trained under the older DSM IV-TR, the changes in the DSM-5 can seem like an overwhelming roadblock to preparing for the licensing exam. The DSM-5 brings with it many changes, and many of the posts on this blog will address each change piece by piece.

Before looking at the “meat and potatoes” of the changes, one of the most important changes in the DSM-5 has been in its structure. Let’s look at some of the most important changes by looking at its most basic “skeleton,” the structure of diagnosis.

Removal of the multi-axial system
One of the most marked changes in the DSM 5 is the abandonment of the multi-axial system (Wakefield, 2013).

Most social workers and other mental health professionals are used to the multi-axial system where Axis I lists the main mental disorder, Axis II is used to denote to stable conditions such as personality disorders and cognitive impairment, Axis III to general medical conditions, Axis IV to psychosocial stressors, and Axis V to a global assessment of functioning number.

Instead, Axis I, II, and III will simply be combined as one list. Researchers like Wakefield attribute this change to psychiatry’s desire to move toward a medical model where standard International Classification of Diseases (ICD) codes are used. In addition, it goes in the direction of conceptualizing personality disorder as conditions that can be malleable and hopefully responsive to treatment, as opposed to lifelong conditions.

Social workers will notice the abandonment of Axis IV the most, since this is the axis where our person-in-environment perspective will inform our diagnosis. For example, our clinical “picture” of a client who is diagnosed with an adjustment disorder with anxious features will make much more sense if we’re able to attribute it to recent homelessness or a recent loss. After all, this would a reasonable reaction to a major stressor.

The “V” codes used in the DSM IV-TR for these stressors will have their replacement with the “Z” codes used in ICD-10 (Wakefield, 2013).

DSM-5 and the Exam

One of the main takeaways about this change for social workers preparing the exam is that despite the removal of the multi-axial format, our profession still remains oriented in the person-in-environment perspective. Likewise, social work values will still be one of the underpinnings exam questions will be looking at in application of your knowledge to vignettes.

On a more big picture scale, the DSM-5 change will have social workers be reminded of the profession’s historical struggle between gaining validation from the scientific field while remaining entrenched in its roots of social justice. A foundational example was Mary Richmond’s Social Diagnosis (1917) as a response to Dr. Abraham Flexner’s exhortation of the field’s validity as a profession. The DSM-5 will certainly re-open questions about how we conceptualize mental illness, the influence of culture in our conceptualization of diagnosis, and our conceptualization of the social justice factors that shape both our conceptualization and treatment of it.


Richmond, M. E. (1917). Social diagnosis. New York: Russell Sage Foundation.

Wakefield, J. (2013). DSM-5 and Clinical Social Work: Mental Disorder and Psychological Justice as Goals of Clinical Intervention. Clinical Social Work Journal, Volume 41(2), pp.139-154.


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