I hear it a lot: “She’s [and it usually is relating to a woman] got some axis II stuff”. Generally I find this a stigmatising attitude on the part of the person who says it – and in less charitable moments find myself thinking it could be instructive for them to suffer psychiatric illness and observe what happens to their “axis II stuff”.
First of all, what do I mean by “axis II stuff”? In the Diagnostic and Statistical Manual of mental disorders (DSM) since I think the 3rd edition (DSM III) we have used a multiaxial diagnostic system – meaning that instead of just diagnosing the main psychiatric illness (Axis I) we look at personality and defence mechanisms (Axis II), medical and surgical problems and interactions with the psychiatric illness, psychosocial stressors and consequences (Axis IV), and the patient’s overall functioning (Axis V).
So, Axis II is where we code personality styles or disorders, and psychological defence mechanisms – such as a tendency to use projection, or splitting in order to manage distress.
The question then is what does “… got some Axis II stuff” actually mean? Of course, the answer to that is going to require quite some typing – in my rambling way.
First of all, what if we try to take it at face value, and be a bit simple about it? Then “got some axis II stuff” just means something can be written on Axis II in the DSM diagnostic system. Recall what goes on Axis II: comments on personality (style or disorder) and psychological defence mechanisms. Now in fact there is no-one who doesn’t have a personality to comment on, and no-one who doesn’t use psychological defence mechanisms – some of course use more mature mechanisms than others.
Consequently “got some Axis II stuff” in that sense is meaningless.
What about the usually intended meaning? It’s shorthand of course, and the intended meaning is that the person has if not a personality disorder, then something approaching one. In this context it’s little (if at all) better than antivaccination wingnuts starting every sentence with “FACT:” – the idea is that if you say something confidently and authoritatively enough, and often enough, it becomes accepted truth.
It has something else in common with antivax wingnuts too: it’s sloppy thinking. Almost invariably it is said in response to one or two actions or requests by the patient: such as insisting on better service than they have received – that’s a common one (and how dare they … right? Right??!) Displays of ambivalence are another good way to get someone talking about “Axis II stuff”: if you have trouble accepting the help you want when it’s offered, for example.
Almost never is it said following a careful history – including other informants – taking a longitudinal view and referring to accepted diagnostic criteria. In other words, almost never is it valid.
Lastly, what is the subtext, and the consequence?
Sadly, while reality is if anything the inverse, once someone is seen as “having some Axis II stuff” the actual psychiatric disorder tends to get minimised: all the patient’s difficulties and symptoms get rationalised away as being due to their personality, rather than the result of “real” illness.
Consequence? Not surprisingly it can resul in a diminishment of care, as instead of needing their illness treated, the person is seen as needing to “take responsibility”. Hence there is under-treatment, which can lead to increased disability and chronicity.
This, essentially, is stigma and discrimination – by the very people who are supposed to advocate for psychiatrically ill people, and should be opposed to such stigmatisation. It saddens me that this has occurred in pretty much every place I’ve worked. I understand it’s born of frustration and overwork and the accompanying stress – but that doesn’t make it any better for the patient.
Finally, it’s not that I am diminishing he importance of personality and psychological aspects of illness – but someone “being difficult” does not mean they are not I’ll – or even that there are personality problems. I see this most often happen to intelligent and articulate women – who expect high quality care, and say so. With public sector resource constraints thy might not get what they think they should, and they are articulate enough to say so. That gets perceived by some people as (personal) criticism and attack, and is met with the “she’s got some Axis II” gambit.
I don’t know that I have a true conclusion. I can try to counter it/educate people whenever I notice it, but I’m not going to change the world. I certainly don’t think patients should stop insisting in proper care; I think public services need to stop seeing that as threatening – and need to stop think in concrete black and white about their patients’ problems.
Popularity: 4% [?]
The only correct response to assertions of Axis-11 stuff is, “Screw you too.”