[Abnormal Psychology]

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[Classifications of Mental Illnesses]

Classifications of Mental Illnesses

Objectives:
1. To discuss how mental diseases are classified
a) Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition
(DSM-5)
b) International Statistical Classification of Diseases and Related Health
Problems, 10th revision (ICD-10)
At the end of this module, students are expected to:
1. To classify mental disorders using internationally accepted standards of
classification
2. To understand the importance of the classification systems of mental
illness
“Not until we are lost do we begin to understand ourselves” - Henry David
Thoreau

Classification of Mental Health Illnesses

Why do we classify mental illnesses?

1. Communication

Establishment of a universal classification enables various specialists

involved in the care of mentally ill communicate with each other effectively.

2. Comprehension

By classifying mental illnesses, specialists will be able to understand what

causes them and the processes involved in the disease course.

3. Control

Classification of mental illnesses will allow specialists to improve treatment

strategies and disease prevention.

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What are the characteristics of a good classification system?

1. It is reliable.

It limits the errors that lead to false positive or false negative diagnosis.

2. It is valid.

It enables accurate recognition of mental illnesses.

3. It is universal.

It considers gender, sociocultural and racial diversity, allowing it to be

applicable across different settings.

4. It is efficient.

Ideal classification systems should have an impact on recognition and

treatment of mental illnesses with a consequent improvement in clinical
outcomes.

5. Meets the needs of clinicians, academic researchers and other

healthcare providers.

Approaches to Classification of Mental Illnesses

Categorical
This originated from the work of Emil Kraepelin (1856-1926), one of the
first psychiatrists to classify mental illnesses from a biologic perspective. In
this approach, every diagnosis is assumed to have an underlying mechanism,
called a pathophysiologic cause. The categorical approach of classifying
illnesses works on the assumption that individuals can be categorized as
healthy or ill. For those who are ill, different illnesses can be further
classified according to it similarity in disease presentation or causative
factor.

Dimensional
The dimensional approach of classifying illnesses works on the assumption
that a person’s usual behavior is a cumulative end result of various aspects
that lead to a person’s behavior. Examples of these aspects include mood,
personality, emotional stability, gender identity, interpersonal trust,
introversion and ability to communicate with other people. Normal
standards for these aspects can be defined, and use as a basis for classifying
abnormal behaviors. This approach to disease classification is beneficial in
deciding on appropriate treatment strategies. Because this approach
considers the objective measures of psychological aspects of the disease,
psychological based therapies may be individualized depending on the
severity of the patient’s presentation.
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Prototypal approach
A prototype is a designated entity that ideally fits the categorical description
of a certain disease classification. In this approach of disease classification, a
prototype or a ‘model disease entity’ is used as a comparative standard by
which other diseases are compared with using a rating scale. For example, in
diagnosing major depressive disorder, a clinician will compare the disease
presentation of the patient to the narrative description of symptoms that
must be present in a patient with major depressive disorder. In this manner,
the clinician is able to match the patient’s presenting symptom, with that of
the disease prototype.

Diagnostic and Statistical Manual of Mental Disorders (DSM)

Fig. 1 DSM Manuals (I-IV-TR) (PsychSearch,2012)

The Diagnostic and Statistical Manual of Mental Disorders (DSM) is a

diagnostic system of mental illnesses that was published by the American
Psychiatric Association (APA). This is the standard guide for clinicians in
the United States. Although, it is also being used internationally by many
mental health experts (See Fig.1).

The Fifth edition of DSM was published last 2013, and is the most recently
updated manual (See Fig. 2). Its first edition was published in 1952.
However, the biggest paradigm shift in diagnosing mental disorders occurred
during the transition from DSM-II to DSM-III. DSM II used diagnostic
categorization, while DSM-III utilized the multi-axial diagnostic system.

Two major changes were introduced in DSM-III, which have been adapted by
subsequent editions:
 Specific diagnostic criteria - includes specific symptoms of the disease
 Extensive characteristic features of the disease such as essential
features, associated features and laboratory findings

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This diagnostic manual is continuously being revised to ensure diagnostic
reliability, validity, and efficiency with each new revision. In the subsequent
editions, DSM-IV and DSM-IV TR (text revision), approach to diagnosis still
used the multi-axial system.

 Axis I contains all mental health illnesses (except those in Axis II).
 Axis II contains personality disorders and mental retardation
 Axis III contains non-psychiatric medical illnesses
 Axis IV contains psychosocial and environmental problems
 Axis V contains the Global Assessment of Functioning (GAF), which
is an objective measure of the patient’s psychosocial, occupational and
educational impairment.

This multi-axial diagnostic system is no longer applied in DSM-V. However,

DSM-IV TR is still useful for research and practical clinical applications.

Fig. 2 DSM-V Manual released in 2013 (DSM-V,2013)

DSM-V Chapters
Neurodevelopmental Disorders
This is a new chapter included in the Fifth edition of DSM. This includes
disorders that began during infancy, childhood or adolescence. Some
examples of diseases that are discussed here are autism and mental
retardation that is more appropriately known as intellectual disability and
intellectual development disorder subsequently. These disorders are not
exclusively seen in children because these conditions may persist across the
patient’s lifespan.

Schizophrenia Spectrum and Other Psychotic Disorders

This is one of the most popular mental health illnesses. It is easily
recognizable because patients with schizophrenia manifest with
disturbances in thought, perception and emotion. There are a variety of
symptoms that may be seen in patients with this disorder, but only a few
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must be present in order to recognize the disease as schizophrenia. More

often than not, the diagnosis of schizophrenia is only made when other
mental illnesses have been ruled out. For one, there is no cure for this illness
and the nature of the disease draws fear and concern among the relatives.

In this manual, symptoms of schizophrenia are grouped into positive or

negative. Positive symptoms are behaviors that occur in excess. This includes
abnormal thought processes such as hallucinations and delusions and
disorganized speech. Negative symptoms, on the other hand, indicate the lack
of normal reactions. This includes blunted affect, wherein patients lack facial
expressions, and poverty of speech, wherein patients speak minimally, if at
all. One special type of schizophrenia is catatonic schizophrenia, wherein
patients maintain abnormal body positions for a considerable length of time.
Sometimes patients maintain an uncomfortable position for hours, days and
weeks (See Fig 3.)

Fig. 3 A patient suffering from catatonic schizophrenia. (Grunnitus Studios,

n.d.)

Bipolar and Related Disorders

This disorder was previously known as manic-depressive disorder. Patients
with this condition manifest with two extreme disturbances in emotions.
When patients are in the “manic” phase, they express unusual happiness or
excitement. During this period they can also have delusions of grandeur,
wherein they have a false belief that they are superior in terms of power or
intellect compared to others. On the other hand, when the patient is in the
depressive phase, the patient appears gloomy or unusually sad. Moreover
depressive symptoms are also seen in depressive disorders, such as major

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depressive disorder. However, in depressive disorders, symptoms are not
temporary and it causes impairment of daily activities.

Anxiety Disorder
This is a group of disorders, which commonly involve feelings of anxiety and
fear. It is normal for people to be frightened or become anxious with an
appropriate stimulus. For example, it is normal to feel afraid after seeing a
horror movie. Some animals may also incite feelings of fear and anxiety such
as frogs, snakes and rodents. However, there is a pathologic expression of
fear and anxiety that causes impairment in daily activities. Usually people
with anxiety disorders have excessive feelings of fear and anxiety, even in the
absence of a stimulus. For example, when a person refuses to go out of the
house because of the fear of seeing a frog. These disorders have a wide range
of illnesses, which range from generalized anxiety disorder to phobias.

Obsessive-Compulsive and Related Disorders

This is a new chapter included in the Fifth edition of DSM. Patients with these
disorders generally manifest with obsessive thoughts and a consequent
compulsive action. An example of this behavior is seen among patients who
have excessive thoughts about becoming infected with microbes. As a
consequence, patients repeatedly wash their hands, or refuse to touch
surfaces without wearing gloves. Disorders included in this group of diseases
include hoarding disorder, skin picking disorder, medication-induced
obsessive-compulsive disorder and obsessive-compulsive and related
disorder due to another general medical condition.

Fig. 5 Five year-old Omran Daqneesh, victim of August 2016 terrorist attacks
in Aleppo, Syria. (Anadolou Agency/Getty,2016)
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Trauma-and Stressor-Related Disorders

Disorders included in this category involve abnormal coping mechanisms or
pathologic responses to stressful or traumatic life events. Post-traumatic
stress disorder is included in this disease category. This is commonly seen
among those who suffered from major natural calamities or victims of war
(See Fig.4).

Dissociative Disorders
Those who experience interrupted concept of reality, consciousness and
memory characterize patients with dissociative disorders. As the term
implies, patients suffering from this disorder become unfamiliar with his
identity and memory. The length of these disruptions has important
implications in diagnosis. Patients who experience temporary disruptions in
memory have a disorder called, dissociative amnesia. On the other hand,
those with a more permanent disease course have a disease entity referred
to as dissociative identity disorder. “Multiple personality disorder” is an old
term for patients with dissociative identity disorder.

Somatic Symptom Disorders

In ancient Greek, the word “soma” means “body”. Patients who suffer from
this condition usually complain of physical illness without a known medical
explanation. Patients become preoccupied with bodily symptoms causing a
significant impairment in daily living. Even though symptoms are
psychological in nature, the patient perceives these symptoms as real.

Fig 6. Jeremy Gillitzer, a model who suffered from anorexia nervosa. (Jeremy
Gillitzer, 2014)

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Feeding and Eating Disorders
Those who are suffering from eating disorders usually have disturbances in
their perception of body shape and image (See Fig. 6). Examples of common
eating disorders are anorexia nervosa and bulimia. Both of these disorders
cause malnutrition if they remain unrecognized or untreated.

Elimination Disorders
Patients suffering from this disorder excrete fecal material or urine in an
abnormal manner. These disorders can be voluntary or involuntary. Two
most common disorders belonging to this category are encopresis and
enuresis. Encopresis is a condition wherein the patient defecates in places
other than the toilet. On the other hand, enuresis causes individuals to
urinate inappropriately.

Sleep-Wake Disorders
Sleeping disorders include a wide-variety of illnesses that manifest with
disturbances in sleep pattern or behavior. Aside from those with insomnia,
patients with sleep disorders also include those who have difficulty
maintaining normal sleep duration or those who are unable to sleep during
normal sleeping hours. Some of these disorders have a biological
explanation, while others largely depend on the individual’s psychological
status.

Sexual Dysfunctions
Patients suffering from sexual dysfunction are those with functional
abnormalities that are psychological in nature. As an example, those who
derive sexual gratification from unusual sources, such as seen in
exhibitionism or voyeurism. Patients with erectile dysfunction or premature
ejaculation also belong to this category.

Fig. 7 Bruce Jenner, 1976 Montreal Summer Olympics (ABC Photo

Archives/Getty Images,n.d.)
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Fig. 8 Transition of Bruce Jenner to Caitlyn Jenner, July 2015 (Leibovitz,

2015)

Gender Dysphoria
Patients suffering from gender dysphoria are those who are not satisfied
with their gender identity. These individuals are uncomfortable of their
anatomical gender and they strongly believe that they should be otherwise.
As a result, patients usually dress up and act as the opposite gender. These
patients engage in “cross-dressing”, and some even opt for gender
reassignment surgery (See Fig.7 and Fig.8)

Disruptive, Impulse Control and Conduct Disorders

It is normal for individuals to sometimes have an urge to engage in morally
unacceptable behavior. However, normal people are usually able to control
their urges and are able to resist engaging in these immoral acts. Patients
suffering from these disorders are unable to resist these urges. An example is
an individual who cannot resist the urge to take things that does not belong
to him. This condition is commonly known as kleptomania.

Substance Use and Addictive Disorders

People suffering from substance abuse and addictive disorders have
significant lifestyle impairments as a result of addiction to a certain
substance or habit. Common substances that are often subject to abuse are
marijuana, amphetamines, metamphetamines, sleeping pills and pain
relievers. Ingestion of these substances is pathological when a person
becomes dependent on them. For example, when a person refuses to go to
work without taking amphetamines to keep him awake or when a person is
unable to do usual activities because of sleeping pills. Interestingly, gambling

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disorder is now included in this category. In DSM-IV-TR, it used to be under
the category of impulse control disorder.

Neurocognitive disorders
Patients with these disorders suffer from disturbances in cognitive aspects of
thinking, usually involving memory. There are two major disorders that fall
under this category, namely dementia and delirium. Dementia is a cognitive
disorder that may be caused by biological illnesses such as Alzheimer’s
disease or stroke. Memory impairment is usually permanent for patients
with dementia. On the other hand, delirium is usually a temporary cognitive
disturbance caused by illnesses or chronic ingestion of illicit drugs and
alcohol.

Personality Disorders
People suffering for personality disorders have disturbances on how they
perceive oneself and other people. These disturbances cause significant
functional impairments that affect a person’s daily activities. A common
example of a personality disorder is antisocial personality disorder wherein
an individual lacks regard for moral and social norms, including the thoughts
and feelings of other people. People with antisocial personality disorder
commonly violate the law and commit crimes, without guilt or remorse for
what they have committed. This causes significant lifestyle impairment since
they cannot abide by rules and regulations. There are ten distinct types of
personality disorders that are grouped into clusters. Each cluster will be
discussed in a separate module towards the end of this course.

Paraphilic Disorders
Patient suffering from paraphilia usually generate unusual sources of sexual
arousal or interest that involves hurting, injuring, or forcing someone to do
an act against his will. Some examples of disorders under this category
include pedophilic disorder, sexual sadism disorder and exhibitionistic
disorder.

Other Disorders
These are mental disturbances that do not fit any of the other categories of
DSM-V.
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Comparison of DSM IV-TR and DSM-V Disorder Categories

Fig. 9 Note. Chapters in DSM-IV-TR and DSM-V. Adapted from Abnormal

Psychology (p. 70), by A. M. Kring, S. L. Johnson, G.C. Davidson, & J.M. Neale,
2012, Essex County, MA: John Wiley & Sons Inc. Copyright year 2012 by John
Wiley & Sons Inc.

Course Module
International Classification of Diseases (ICD)
International Classification of Diseases
The International Classification of Diseases is a broad diagnostic guideline for
all diseases, not limited to mental health disorders. Its tenth edition was
published in 1992 by the World Health Organization and is the most recent
edition. Mental and Behavioral disorders are a special subsection of the ICD.
Diseases are also classified into different categories in order to group
together illnesses with similar disease presentation, etiology and
management (See Fig. 12). Similar to DSM, disorders are also described
based on symptoms and duration of abnormality. Both DSM and ICD share a
similar criterion for all mental health illnesses in that the presence of a
disorder should cause significant impairment or distress. Also, medical
illnesses that may cause similar symptoms should have been ruled out.

Diagnostic Disease classification

Code

F00-F09 Organic, including symptomatic, mental

disorders

F10-F19 Mental and behavioral disorders due to

psychoactive substance abuse

F20-F29 Schizophrenia, schizotypal and delusional

disorders

F30-F39 Mood (affective disorders)

F40-F49 Neurotic, stress-related and somatoform

disorders

F50-F59 Behavioral syndromes associated with

physiological disturbances and physical factors

F60-F69 Disorders of adult personality and behavior

F70-F79 Mental retardation

F80-F89 Disorders of psychological development

F90-F98 Behavioral and emotional disorders with onset

usually occurring in childhood and adolescence

F99 Unspecified mental disorder

Fig. 10 ICD-10 Classification of Mental and Behavioral Disorders

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Comparison of DSM and ICD classification

ICD and DSM also have important differences. First, DSM was published by a
Psychiatric Association and is more commonly used in the United States. ICD
on the other hand have been published by the WHO and is more universal.
Moreover, ICD and DSM have differences in categorization of certain
illnesses. For example, in ICD, somatoform disorders are combined with
anxiety disorders. On the other hand, these are separate categories in the
latest DSM version.

To differentiate ICD and DSM, let us examine how both classification systems
described their criteria in diagnosing Generalized Anxiety Disorders.

ICD-10 Criteria for Generalized Anxiety Disorder

A. A period of at least six months with prominent tension, worry, and

feelings of apprehension, about every day events and problems.
B. At least four of the following symptoms are present, one of which
must be from (1):
1. Palpitations or pounding heart; sweating; trembling or shaking; dry
mouth.
2. Difficulty breathing; feeling of choking; chest pain or discomfort;
nausea or abdominal distress; feeling dizzy, faint or light-headed;
feeling that objects are unreal (‘derealisation’) or that one’s self is
distant or ‘not really here’ (depersonalization); fear of losing control,
going crazy, or passing out.

Fig.11 ICD-10 Criteria for Generalized Anxiety Disorder

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 DSM-V Criteria for Generalized Anxiety Disorder

A. Excessive anxiety and worry (apprehensive expectation), occurring more

days than not for at least 6 months, about a number of events or activities
(such as work or school performance).
B. The individual finds it difficult to control the worry.
C. The anxiety and worry are associated with three (or more) of the following
six symptoms (with at least some symptoms present for more days than not
for the past six months):
 restlessness or feeling keyed up or on edge;
 being easily fatigued
 difficulty concentrating or mind going blank;
 irritability;
 muscle tension;
 sleeping disturbance (difficulty falling or staying asleep, or
restless, unsatisfying sleep)
D. The anxiety, worry or physical symptoms cause clinically significant
distress or impairment in social, occupational, or other important areas of
functioning
E. The disturbance is not attributable to the physiological effects of a
substance of another medical condition.
F. The disturbance is not better explained by another psychological disorder.

Fig.12 DSM-V Criteria for Generalized Anxiety Disorder

Notice the distinction how ICD and DSM described their criteria for
diagnosing generalized anxiety disorder. Both have specific clusters of
symptoms, which distinguish the behavior from normality (See Fig.11 and
Fig.12)

Activities and Exercises

Create a reviewer for this module that includes the following:

 Enumerate and define the classification systems for mental illnesses.
 Enumerate the similarities and differences between the two
classification systems
 Familiarize yourself with disease categories in both classification
systems and list down similarities and differences.
Take your short quiz and submit before deadline.
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Glossary
categorical classification - one of the approaches in patient assessment,
wherein a patient is either a member of a category or not.

delirium - is a temporary cognitive disturbance caused by illnesses or chronic

ingestion of illicit drugs and alcohol.

dementia - is a permanent cognitive disorder that may be caused by

biological illnesses such as Alzheimer’s disease or stroke

diagnosis - a particular illness that is inferred from a cluster of symptoms and

problems.

Diagnostic and Statistical Manual of Mental disorders - is a diagnostic system

of mental illnesses that was published by the American Psychiatric
Association (APA), which is the standard guide for clinicians in the United
States.

dimensional classification- one of the approaches in patient assessment,

wherein the patient is not categorized, rather placed in a continuum.

dysphoria - a state of unease or generalized dissatisfaction with a certain

condition

encopresis - is a condition wherein the patient defecates in places other than

the toilet

enuresis- is a condition that causes individuals to urinate in places other than

the toilet.

Global Assessment of Functioning (GAF)- is an objective measure of the

patient’s psychosocial, occupational and educational impairment.

International Classification of diseases - is a broad diagnostic guideline for all

diseases, not limited to mental health disorders that was published by the
World Health Organization

Course Module
 metamphetamine - a prohibited drug derived from amphetamine

multiaxial classification system- a classification system that was previously

used in DSM-IV-TR to diagnose illnesses.

paraphilia - a condition wherein a person has a sexual desire for unusual

objects causing them to engage in unusual sexual activities.

pathophysiology - the abnormal biologic processes associated with disease

or injury.

prototype - is a designated entity that ideally fits the categorical description

of a certain disease classification.

References
ABC Photo Archives. (n.d.). Bruce Jenner Trains For And Competes In The 1976
Montreal Summer Olympic Games [Photograph found in Disney ABC
Television Group]. In Getty Images. Retrieved from
http://www.gettyimages.com/license/479837454 (Originally
photographed 1976, June 4)
Anadolou Agency/ Getty Images. (2016). [Photograph found in Getty
Images]. In The Guardian News. Retrieved from
https://www.theguardian.com/commentisfree/2016/aug/20/omran
-picture-turning-point-syria-war-aleppo-david-nott (Originally
photographed 2016)
Butcher, J. N., Hooley, J. M., & Mineka, U. (2014). Abnormal psychology (16th
ed.). Upper Saddle River, New Jersey: Pearson.
Dalal, P. K., & Sivakumar, T. (2009). Moving towards ICD-11 and DSM-V:
Concept and evolution of psychiatric classification. Indian Journal of
Psychiatry, 51(4), 310–319. http://doi.org/10.4103/0019-
5545.58302
DSM-V. (2013, May 28). In PsychCentral. Retrieved from
http://pro.psychcentral.com/dsm-5-changes-feeding-eating-
disorders/004412.html#
Field, M., & Cartwright-Hatton, S. (2015). Essential abnormal & clinical
psychology (1st ed.). Thousand Oaks, California: SAGE Pulication.
Grunnitus Studios. (n.d.). [Photograph found in Photo Researchers, Inc]. In
Encyclopedia of Mental Disorders. Retrieved from
http://www.minddisorders.com/Br-Del/Catatonic-disorders.html
Jeremy Gillitizer. (2014). In New Health Advisor. Retrieved from
http://www.newhealthadvisor.com/Anorexia-Before-and-After.html
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Kring, A. M., Johnson, S. L., Davidson, G. C., & Neale, J. M. (2012). Abnormal
psychology (12th ed.). Essex County, MA: John Wiley & Sons.
Leibovitz, A. (2015, July). Vanity Fair Cover [Photograph found in Vanity
Fair]. In Vanity Fair. Retrieved from
http://www.vanityfair.com/hollywood/2015/06/caitlyn-jenner-
bruce-cover-annie-leibovitz (Originally photographed 2015)
Osborne, R. E., Lafuze, J., & Perkins, D. V. (2016). Case analyses for abnormal
psychology: Learning to look beyond the symptoms. New York, NY:
Routledge.
PsychSearch. (2012). DSM books. Retrieved from
http://www.psychsearch.net/psychiatrys-bible-the-dsm-is-doing-
more-harm-than-good/
Puri, B. K., Hall, A. D., & Ho, R. (2014). Revision notes in psychiatry (3rd ed.).
Boca Raton, FL: Taylor & Francis.
Stern, T. A., Fava, M., Wilens, T. E., & Rosenbaum, J. F. (2016). Massachusetts
General Hospital Comprehensive Clinical Psychiatry (2nd ed.). St.
Louis,Missouri: Elsevier.

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