Abstract: An empirical investigation of the feasibility and importance of implementing a multi-axial diagnostic system for assessing personality disorders in China

The following abstract was presented at the Implementation Science and Global Health satellite meeting on March 17, 2010 at Bethesda, Maryland.


Tianhong Zhang, MD
Attending Doctor
Shanghai Mental Health Center
Shanghai Jiao Tong University

FIC Award


Personality disorders (PDs) have not become the focus of attention among psychiatric professionals in China, in contrast to other serious mental illnesses such as schizophrenia and major depression. PDs are often neglected by Chinese clinicians and viewed as unmeasurable or untreatable, and little attention has been given to the co-occurrence of PDs and other disorders. It is our group’s hypothesis that this leads to missed or improper diagnoses and less effective treatments.  Substantial evidence suggests that PDs influence other mental disorders’ prognosis, treatment response, and costs, and progress has been made in improving diagnosis and treatment of PDs, providing support for multi-axial diagnostic systems. The current Chinese diagnostic manual (CCMD-3) is a uni-axial system, which excludes diagnoses of co-occurring PDs and other disorders. This paper reports on a program of research carried out by a team of researchers at the Shanghai Mental Health Center aimed at comparing diagnoses of PDs using Axis II of DSM-IV (multi-axial) and the Chinese CCMD-3 (uni-axial), with the larger goal of determining the potential for implementing multi-axial diagnoses in China.


A sample of 3,075 patients presenting for medical treatment in a Shanghai psychiatric clinic from May-October 2006 were randomly assigned to be screened for PDs using either DSM-IV or CCMD-3 diagnostic criteria.  Patients were randomly assigned to two groups according to their order of registration for outpatient service and evaluated by attending psychiatrists for PDs, using CCMD-3 criteria or the SCID-II translated and adapted for the Chinese context, to establish the respective diagnoses.  The rates of PDs diagnosis in each group were compared.


In our sample of 3,075 outpatients, 9 (0.3%) were diagnosed with PD based on CCMD-3 criteria and 984 (31.9%) were diagnosed with PD using DSM-IV criteria.  The results suggest that personality disorders may be easily overlooked by Chinese psychiatrists using the CCMD-3 uni-axial diagnostic system.  Most PD patients diagnosed with a PD using DSM-IV criteria were diagnosed exclusively with a disorder other than PD using CCMD-3 criteria.  The multi-axial diagnostic system increased PD recognition rates significantly and offered three additional advantages over the uni-axial system.  First, it enhanced the psychiatrist’s understanding by encouraging a multidimensional view of the patient. Second, it encouraged a more focused approach to treatment, especially with psychotherapy.  Finally, it provided a new approach for the prediction of Axis I disorder’s prognosis and treatment response.  One significant difficulty was found using the DSM-IV Axis II criteria: high levels of diagnostic overlap among Axis II PDs were found using the DSM-IV approach (co-morbidity rate: 44.4%).  Using regression analysis, we found that patients who are younger, have an introverted character, and have mood disorders are susceptible to higher frequency of multiple PDs.  Overall, this project suggests important benefits of moving towards a multi-axial diagnostic approach in Chinese clinical psychiatric practice, while suggesting that further work needs to be done to reduce overlap and co-morbidity among specific PD diagnoses.

Updated May 2010