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CLASSIFICATION OF

PSYCHIATRIC
DISORDERS

PRESENTER: DR. CAROLINE DIAS


CHAIRPERSON: DR. ANUPAMA

CLASSIFICATION:

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

PURPOSE:
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

PURPOSE:
CONTROL:
Knowledge of the course of disorder

Prevention of their recurrence and modification of


their courses with treatment

PURPOSE:
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

PROBLEMS UNIQUE TO CLASSIFYING


PSYCHIATRIC DISORDERS

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.

GOOD CLASSIFICATION:

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

DEFINITION OF MENTAL DISORDER:

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

HISTORY:

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

HISTORY:

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)

HISTORY:

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

HISTORY:

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

HISTORY:

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 manicdepressive 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

HISTORY:

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

HISTORY:

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

HISTORY:
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

HISTORY OF OFFICIAL
CLASSIFICATIONS
1840 US census
Idiocy (insanity)

1880 US census
Mania
Melancholia
Monomania
Paresis
Dementia
Dipsomania
Epilepsy

INTERNATIONAL CONGRESS OF MENTAL


SCIENCE - 1889

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 manic- depressive
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

MODERN HISTORY OF
CLASSIFICATION

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

MODERN HISTORY OF
CLASSIFICATION

DSM III 1980


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

DSM-III

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

DSM-III

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

MULTIAXIAL DIAGNOSIS

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

DSM IV

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

DSM IV-TR CLASSIFICATION:

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

DSM IV-TR CLASSIFICATION:

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

DSM IV-TR CLASSIFICATION:

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

CRITICISM:

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

DIMENSIONAL VS CATEGORICAL:

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

SEPARATE DISORDERS VS SUBTYPES:

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

LABORATORY TESTS AS A DIAGNOSTIC


CRITERIA

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

THE CLASSIFICATION OF MENTAL DISORDERS IN


THE INTERNATIONAL CLASSIFICATION OF DISEASES

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

ICD 10

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

CHARACTERISTICS OF ICD:

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

ICD 10 LIST OF CATEGORIES

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)

ICD 10 LIST OF CATEGORIES

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

DSM IV

Origin

International (WHO)

American
Psychiatric
Association

Comprehensiveness

Comprehensive
classification of all
diseases and related
health problems

Stand-alone
classification of
mental disorders

Presentation

Different versions for


clinical work research
and use in primary
care

A single document

Languages

Available in all widely


spoken languages

English version

Structure

Part of overall ICD


framework ,Single
axis in chapter V
,separate multiaxial
systems available

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

Worldwide
usage

Every country is obliged


to report basic morbidity
data to WHO using its
categories

Most frequently
used in
research work

Content

Guidelines and criteria do


not include social
consequences of
disorders

Diagnostic
criteria usually
include
significant
impairment in
social functions

COMPARISON OF DSMIV AND ICD10

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.

FOUR VERSIONS OF CLASSIFICATION


OF MENTAL DISORDERS IN ICD 10

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.

OTHER CLASSIFICATIONS

TheChinese Society of Psychiatry'sChinese


Classification of Mental Disorders currently CCMD-3
published by theChinese Society of
Psychiatry(CSP), is aclinical guideused
inChinafor the diagnosis ofmental disorders.
It is currently on a third version, theCCMD-3,
written in Chinese and English.
It is intentionally similar in structure and
categorization to theICDandDSM, the two most
well-known diagnostic manuals, though includes
some variations on their main diagnoses and around
40 culturally-related diagnoses

OTHER CLASSIFICATIONS

TheLatin 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)
TheFrench Classification of Child and
Adolescent Mental Disorders(CFTMEA)

FIRST DRAFT DIAGNOSTIC


CRITERIA FOR DSM 5

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

PROPOSED CHANGES TO DSM IV


DIAGNOSIS

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

NEW DSM 5 DIAGNOSIS

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
potentialharmonization of the corresponding
category sections forDSM-5(Somatic Symptom
Disorders)and ICD-11(Somatoform Disorders).

CONCLUSION

Adjust the classification to the settings in


which it will be used

internationally accepted classification to


facilitate communication

continue working on the reduction or


elimination of differences that might exist
between the different classifications

THANK YOU