PRESENTER: DR. CAROLINE DIAS CHAIRPERSON: DR.

ANUPAMA

Defn : Process by which complexity of phenomena is reduced by arranging them into categories according to some established criteria for one or more purposes
At present , consists of specific mental disorders which are grouped into various classes on the basis of some shared phenomenological characteristics Ultimate purpose is to improve treatment and prevention efforts

COMMUNICATION: Enables users to communicate with each other about the disorders with which they deal

Used as standard shorthand way of summarizing a great deal of information

Disorder indicates the specific features that the patient has To be effective, a high level of agreement among users is necessary

CONTROL: Knowledge of the course of disorder

Prevention of their recurrence and modification of their courses with treatment

COMPREHENSION: Should provide comprehension or understanding of the causes of mental disorder and the processes involved in their development and maintenance

Not an end in itself but is desired in a classification because it usually leads to more effective treatment and prevention

Relies on the patient's own subjective report of symptoms and the doctor's observation of patient behavior to arrive at a diagnosis.
Lacks objective and independent criteria for sorting out psychiatric disorders. Manifested by a quantitative deviation in behavior, ideation and emotion from a normative concept and it is difficult to define normal human behavior. Symptoms are highly nonspecific and quite unstable over time.

Reliability : It shows as to how far errors of measurement have been excluded from assessment. Validity: How far a test actually measures what it is supposed to measure, meaning the nature of reality Utility: The clinical utility of a classificatory system can be assessed empirically by taking into account its impact on three domains: Use, decision making process and clinical outcome Ease of use. Applicability across settings and cultures. Meet needs of various users: Clinicians, researchers and users of mental health services

Henry Brill (chairman of the APA committee on nomenclature and statistics)delineated 6 advantages of the then current nomenclature i.e. DSM II

1.Widespread use , thereby facilitating communication amongst professionals 2.Clear definition and delineation of the disorders 3.Compatibility with ICD diagnostic system 4. Clear guidelines for compilation and reporting of patient diagnostic data 5.Comprehensive collection of diagnostic term in one source 6.Ease of use

Lack of conceptual clarity can contribute to abuses of psychiatric diagnoses as a means of controlling or stigmatizing socially undesirable behavior
Also it reduces confidence in the profession as an authority regarding diagnostic issues and controversies In contrast to medical disorders, mental disorders are manifested by a quantitative deviation in behavior, ideation and emotion from a normative concept Debates are grounded in ambiguities

First DSM to offer definition in DSM III 1973, Robert Spitzer to justify the removal of homosexuality from the DSM : in order for a mental or psychiatric condition to be considered a psychiatric disorder, it must either regularly cause subjective distress or regularly be associated with generalized impairment in social effectiveness or functioning Ignored the concept of dysfunction

New definition was developed for DSM III and subsequently modified in the DSM-III-R and DSM-IV-TR DSM IV-TR : A clinically significant behavioral or psychological syndrome or pattern that occurs in an individual and that is associated with present distress or disability or with a significantly increased risk of suffering, death, pain, disability or an important loss of freedom

Karl Menninger and colleagues presented a compendium of classification from ancient times to the modern era According to them first description of mental illness appeared about 3000 BC senile deterioration in Prince Ptah-Hotep The syndromes of Melancholia and Hysteria appeared in Sumerian and Egyptian literature 2600 BC

Ebers papyrus 1500 BC-both senile deterioration and alcoholism were described
India 1400 BC classification of Psychiatric disorder in Ayurveda

Hippocrates- 460-370 BC introduced the concept of psychiatric illness His writings described acute mental disturbance with fever( delirium) and without fever( mania), chronic disturbance without fever(melancholia), Hysteria and Scythian disease (similar to transvestism) Caelius Aurelianus- described homosexuality- 5th century

Mental deficiency and dementia Swiss Renaissance physician Felix Platter (1536 1614)

Thomas Sydenham (1624 -1689) attributed all illness to the single pathogenic process of either a disturbance of humoral balance or a disrurbance in the tension in the solid tissues believed that each illness had a specific cause

Philippe Pinel (1745-1826) recognized 4 clinical types Mania, melancholia, dementia and Idiotism. Reacted against specific etiology and went back to Hippocrates classification

By 19th century regarded as manifestation of physical pathology and scientists searched for specific lesions parallel to the investigation of bodily diseases Benedict Augustin Morel first to use the course of illness as a basis for classification

Karl Ludwig Kahlbaum 1828-1899 introduced concepts 1.Temporary symptom complex 2.The distinction between organic and nonorganic mental disorder 3.Considering the patients age at the time of onset and the characteristic development of the disorder as basis of classification

Wilhelm Griesinger coined mental diseases are brain diseases.

19th century Kraeplin 3 approaches- clinical descriptive, somatic and course of disorder
Mental illnesses as organic disease entitities , brought manic and depressive disturbance into manic-depressive psychosis and differentiated it on basis of periods of remission from chronic deteriorating illness called dementia precox

He recognised paranoia distinct from dementia Precox, delirium from dementia and included concept of psychogenic neuroses and psychopathic personalities

Kraeplins approach was to search for that combination of clinical features that would best predict outcome Bleuler based his classification on an inferred psychopathological process such as a disturbance in the associative process in schizophrenia J C Prichard 1835 first noted personality disorders with the introduction on the concepts of moral insanity and imbecility

1891- August Koch coined psychopathic personality and psychopathic constitutional inferiority

Sigmund Freud divided neuroses into actual neuroses and psychoneuroses

Then neurosis synonymous with psychoneurosis

Neurosis had following subtypes: Anxiety neurosis, Anxiety Hysteria, Obsessive compulsive neurosis and hysteria In 1935, reactive depression added by American Medical Associations Standard Classified Nomenclature of Disease

Hagop S Akiskal and William McKinney : despite the advances in the understanding of mental disorders in the past 50 years, the major categories of mental disorders in the standard classification systems are based primarily on the concepts of Kraeplin and Bleuler organic mental disorders, affective disorders and schizophrenia and Freud neuroses and personality disorders

 1840

US census Idiocy (insanity)

1880

US census

Mania Melancholia Monomania Paresis Dementia Dipsomania Epilepsy

Mania Melancholia Periodical insanity Progressive systematic insanity Dementia Organic and senile dementia General paresis Insane neurosis Toxic insanity Moral and impulsive insanity Idiocy etc

1923 in order to conduct a special census for pts in hospitals for mental disease, Bureau of Census + APA + National Committee for Mental Health classification system with 22 disorders which was used till 1935 This classification inadequate for world war II psychiatric casualties Hence after WW II military services and the veteran administration developed their own system

1948 WHO revised the International List of Causes of Death 6th revision came to be known as the Manual of the International Classification of Diseases, Injuries, and Causes of Death (ICD 6) It contained for the first time a classification of mental disorders entitled mental, psychoneurotic and personality disorders.

Contained 10 categories of psychosis, 9 of psychoneurosis, 7 of disorders of character ,behavior and intelligence

Absence of dementia, PDs and adjustment disorders rendered it unsatisfactory Only Finland, New Zealand , Peru, Thailand and UK made official use of it

In 1951 US Public Health Service commissioned a work group party, with representation from APA to develop an alternative to ICD 6. was prepared by George Raines and based heavily on veteran administration classification and published in 1952- DSM I with 106 diagnoses It replaced other outdated systems APA became the only medical specialty in charge of its official specialty classification of medical disorders

The definitions in it reflected the acceptance of psychoanalytical concepts eg. Schizophrenic reaction
Not accepted universally throughout the country

ICD-6 was unsatisfactory and WHO sponsored an international effort to improve and make it acceptable to all member nations. Task was co-ordinated by the United States Public Health Service ICD-7- 1955 was identical to ICD-6

ICD 8 was approved in 1966 and became effective in 1968

based on ICD-8 DSM II 1968 had 182 disorders in 10 major categories In contrast to DSM I which discouraged multiple diagnoses, DSM II encouraged clinician to diagnose every disorder even if one was causally related to the other

The word disease was limited to certain categories in mental retardation and organic brain syndromes sections and illness appeared only in the manicdepressive conditions Mixed reactions to DSM II Child psychiatrist were pleased that it had a special category for children and adolescents It removed the term reaction Other glossaries were prepared- Glossary of Mental Disorder in Great Britain

Inconsistencies in definition occurred eg schizophrenia and epidemiological studies also varied between countries
ICD 9 in 1978 with minor changes

1972 Feighners criteria/Washington University criteria with specific inclusion and exclusion criteria for 15 disorders Spitzer and Joseph Fleiss concluded that reliability of the psychiatric diagnosis was poor Research Diagnostic Criteria were developed along with a semi-structured diagnostic interview that evaluated these criteria The criteria for almost every disorder originally defined in the Washington University Criteria were modified in the RDC

DSM III 1980 DSM III R 1987 DSM IV 1994 DSM IV TR - 2000

First to specify inclusion and exclusion criteria and expanded the number of disorders defined with specific criteria Brought the reliable diagnostic approach to clinical community Diagnostic reliability became better and communication between clinicians improved

Enabled to study boundaries of disorder

First to introduce multiaxial evaluation system which promoted a biopsychosocial approach towards assessment

Narrowing of definition of Schizophrenia which brought the American and European systems closer towards the diagnosis of this disorder Assumed a descriptive approach where etiological perspectives were not included and disorders were grouped based on common clinical features Included for the first time a definition of mental disorder

Axis I : clinical disorders

Axis II: personality disorders, mental retardation, prominent maladaptive personality traits not meeting criteria for specific disorder and defense mechanisms Axis III: general medical condition

Axis IV: psychosocial and environmental problems

Axis V : GAF scale

Published among criticism that it was published within a short period of time

Mark Zimmerman argued the problems of the period being too short 1.Insufficient time for accumulation of research 2.Expenditure of resources 3.Difficulty in interpreting and resolving discrepant research findings based on different criteria set 4.Increased no of diagnostic errors due to lack of time to learn the nuances 5.Impeded communication 6.Frustration in patients to have their diagnoses changed

To bridge the gap between DSM IV and V DSM IV TR 365 disorders in 17 sections

Goals: To update and correct the information in the text

To update the ICD 9 codes that had been changed

Disorders usually first diagnosed in infancy, childhood or adolescence Delirium , dementia, and amnestic and other cognitive disorders Mental disorders due to a general medical condition not elsewhere classified Substance related disorders Schizophrenia and other psychotic disorders Mood disorders Anxiety disorders Somatoform disorders Factitious disorders

Dissociative disorders Sexual and gender identity disorders Eating disorders Sleep disorders Impulse control disorders not elsewhere classified Adjustment disorders Personality disorders Other conditions that may be focus of clinical attention Appendix diagnoses: proposed criteria for 20 specific disorders that were not included in the official classification but are included so that research can be conducted on their reliability, validity and potential clinical utility

Multiple disorders: Principal diagnosis in DSM IV TR reason for clinical services

Disorder severity: After full criteria for disorder are met, severity ratings based on number and intensity of symptoms and impairment in socio occupational functioning can be used. Eg: mental retardation, major depression

Remission status: Symptoms of disorder present but full criteria not met partial remission No symptoms present full remission Specific guidelines for this only in manic and major depressive episodes and substance dependence Eg. Symptom free interval of 2 months for depression and mania but 1 month for substance dependence

Diagnostic uncertainty: Diagnosis can be deferred Specific diagnosis can be rendered and identified as provisional When some information is available , not enough to diagnose a specific disorder but enough to know which class of disorder is present, then diagnosis is not otherwise specified

Narrowly focused evaluation based on criteria and neglecting the patients life story Signs and symptoms are accorded greater significance than coping style

Multiaxial classification takes into the above perspective but is not taken actually into clinical practice Poor agreement between clinical assessments
Gap between researchers and clinicians diagnostic practices

Research community not unified in its opinion Personality disorder researchers favor replacing categorical with dimensional approach In absence of clear cut superiority of a dimensional approach , the DSM IV TRs categorical system, which is the traditional method of medical classification, seems appropriate at this time because its more useful in clinical practice

Criticism over increasing number of disorders which is indicative of a lack of scientific progress Disorders being created Debate between lumpers favour broader categories and splitters favour subclassication

Lack of universal applicability Challenges in applying scales to individuals with visual impairment, literacy problems, and compromised cognitive capacity Inclusion of an objective test as a criterion should be accompanied by a demonstration that the new proposal is more valid or clinically useful than the prior set of criteria

One of the 21 chapters (chapter V) of WHOs ICD Separate chapters relevant to psychiatry Chapter VI: neurological disorders Chapter XVIII: symptoms, signs and abnormal clinical and laboratory findings not classified elsewhere such as , hallucinations Chapter XIX: injuries , poisoning and consequences of external causes Chapter XX : external causes of morbidity and mortality Chapter XXI: factors influencing health status and contacts with health services

1853, the first International Statistical Congress held in Brussels asked William Farr and Marc dEspine of Geneva to prepare a uniform nomenclature of causes of death applicable in all countries The Congress adopted a list of 138 categories and revisions were made till 1886 A few years later the International Statistical Institute which replaced the International Statistical Congress requested that the committee prepare a comprehensive classification of the causes of death J. Bertillon The International Health Conference in New York in 1946, requested the preparation of an International List of causes of Morbidity Sixth revision 1948, seventh revision - 1965

Important event in the field of psychiatry was the decision on the 1975 conference to incorporate brief descriptions of the categories included in the chapter V in ICD 9
no other chapter has such a glossary Adopted in 1989 Geneva Constructed using alphanumeric coding scheme of one letter followed by three numbers Only 25 letters have been used , one letter U being reserved for changes necessary between revisions

Two chapters that were considered supplementary in the ICD-9 were incorporated into the ICD-10 as ordinary chapters: The classification of external causes of injury, and the classification of factors influencing health status and contact with health services. The latter decision made it easier to create the third axis for the multiaxial presentation of the ICD-I0 for use in psychiatry order of chapters was modified as little as possible from the ICD-9 every effort was made to ensure that the fourdigit categories (e.g., F20.0, simple schizophrenia) had a title that described the group of conditions in full and could stand alone

Based on international consensus

Produced in several versions

Was finalized taking results of field texts into account It was developed in several languages simultaneously It is accompanied by additional publications that facilitate its use Classification relied on a network of collaborating centers of excellence

Organic ,including symptomatic, mental disorders (F00 F09) Mental and behavioral disorders due to psychoactive substance use (F10 F19) Schizophrenia ,schizotypal and delusional disorders (F20 F29) Mood (affective) disorders (F30 F39) Neurotic, stress related and somatoform disorders (F40 F48) Behavioral syndromes associated with physiological disturbances and physical factors (F50 F59)

Disorders of adult personality and behavior (F60 F69) Mental retardation (F70 F79)

Disorders of psychological development (F80 F89)

Behavioural and emotional disorders with onset usually occurring in childhood and adolescence (F90 F98) Unspecified mental disorder (F99)

ICD 10 Origin International (WHO)

DSM IV American Psychiatric Association

Comprehensiveness

Comprehensive classification of all diseases and related health problems

Different versions for clinical work research and use in primary care Available in all widely spoken languages Part of overall ICD framework ,Single axis in chapter V ,separate multiaxial systems available

Stand-alone classification of mental disorders

A single document

Presentation

Languages Structure

English version Multiaxial

Used in

Most frequently used across the world for clinical work and training purposes

Designed, at least in the first instance, for use by American health professionals Most frequently used in research work

Worldwide usage

Every country is obliged to report basic morbidity data to WHO using its categories

Content

Guidelines and criteria do not include social consequences of disorders

Diagnostic criteria usually include significant impairment in social functions

Depressive personality disorder is not included in ICD10 and is only incorporated in the section of DSMIV entitled Criteria sets and axes provided for further study. Passiveaggressive personality disorder was included in DSMIII but excluded from the subsequent edition, and has never been incorporated into the ICD 10 Brief depressive disorder is a new addition to ICD10 but only appears in the appendix of DSMIV system. Schizotypal disorder is classified with the schizophrenic disorders in ICD10 and with the personality disorders in DSMIV.

The Clinical Descriptions and Diagnostic Guidelines (CDDG) The Diagnostic Criteria for Research (DCR) The Multiaxial Presentation of the ICD 10 for use in Adult Psychiatry - Axis 1: clinical syndrome ( physical or mental disorder and personality disorder) - Axis 2: level of functional capacity of the person - Axis 3:describe the situation important for the understanding of the disorder

#Multiaxial version of mental disorders of childhood 6 axes. Axis 1: clinical psychiatric syndromes Axis 2:specific disorders of psychological development Axis 3:intellectual level Axis 4:medical condition Axis 5:abnormal psychosocial situations Axis 6:global assessment of psychosocial disability

The Classification of Mental Disorders for use in Primary Health Care most widely used version of the classification, aside from the clinical version fewer categories than the other versions The selection of categories three sets of criteria the categories had to refer to conditions of public health importance (i.e., they had to be frequent and severe in consequences unless treated) had to be defined by criteria that met with wide international agreement they had to be categories describing conditions for which there was an effective treatment.

The Chinese Society of Psychiatry's Chinese Classification of Mental Disorders currently CCMD-3 published by the Chinese Society of Psychiatry (CSP), is a clinical guide used in China for the diagnosis of mental disorders. It is currently on a third version, the CCMD-3, written in Chinese and English. It is intentionally similar in structure and categorization to the ICD and DSM, the two most well-known diagnostic manuals, though includes some variations on their main diagnoses and around 40 culturally-related diagnoses

 The

Latin American Guide for Psychiatric Diagnosis (GLDP) Diagnostic Classification of Mental Health and Developmental Disorders of Infancy and Early Childhood (DC:0-3) The Research Diagnostic criteria-Preschool Age (RDC-PA) The French Classification of Child and Adolescent Mental Disorders(CFTMEA)

New categories for LD and single category ASD. Also to replace term MR to intellectual disability Replacing substance abuse and dependence category with addiction and related disorders New category of behavioral addictionsgambling New suicide scales New risk syndromes category earlier stages New temper dysregulation with dysphoria (TDD) within mood disorders Improved criteria for eating disorders

Asperger syndrome- merge it with ASD and also rate the severity of ASD
ADHD-age to increase from 7 to 12 years

More accurate subtyping for bipolar disorder and stringent criteria for diagnosis in children with a new diagnosis TDD proposed
Merger of dissociative trance disorder with dissociative identity disorder Hypersexual disorder new category

ODD- symptoms into categories : defiant behavior , angry mood , vindictiveness . Also change in frequency

PD: dimensional rather than categorical approach

Pica to be reclassified in Eating disorders

PTSD: criteria changes Schizophrenia: deletion Somatoform disorder: abridged somatization disorder and multisomatoform disorder

Absexual Complex PTSD Depressive personality disorder Negativistic personality disorder Relational disorder Sluggish cognitive tempo Binge eating

ICD-11 2014 Beta draft with proposed changes coming out in May 2012 on the website potential harmonization of the corresponding category sections for DSM-5 (Somatic Symptom Disorders) and ICD-11(Somatoform Disorders).

 Adjust

the classification to the settings in which it will be used accepted classification to facilitate communication working on the reduction or elimination of differences that might exist between the different classifications

internationally

continue