Introduction to Diagnostic Classification in mental

disorders
• PRINCIPLES OF CLASSIFICATION OF MENTAL DISORDERS
• The development of classification system and their subsequent revisions reflect
the contemporary understanding of the mental illness. The classification of
psychiatric disorders has been primarily based on the clinical presentation of the
illness and its course, since we are not aware of their exact etiology and
pathophysiology. Clustering of different clinical symptoms in different areas of
psychological functioning, their severity, and the course often form the basis of
the categorization, as also historically used by Kraepelin. At the simplest, the
mental disorders are divided into organic and functional, and then into psychotic
and neurotic disorders.
• This dichotomy, though still used sometimes, is not valid in the current
classificatory systems. But for historical reasons and for understanding purpose, it
is important to understand these terms. If in a psychiatric patient there is an
evidence of a structural disturbance in brain on taking history, clinical examination
or investigations, the disorder is termed as ‘organic’. If there is no such evidence,
the illness is called ‘functional’. The functional illnesses are further broadly
categorised into psychoses (psychotic disorders) and neuroses (neurotic disorders)
• MODERN SYSTEMS OF CLASSIFICATION OF MENTAL DISORDERS
• There are currently two official classification systems which are
recognised internationally. Both have been in use now for more than 60
years. The two systems are the WHO’s International Classification of
Diseases (ICD) and American Psychiatric Association’s Diagnostic and
Statistical Manual of Mental Disorders (DSM). Both the systems have
undergone a number of revisions and also expansions since their initial
introduction. Though initially, there were many differences between the
two systems, their latest editions (ICD 11 and DSM V TR) with revisions in
their respective editions over the years, the two are now quite similar in
basic principle. Both are recognised internationally. DSM is the official
diagnostic system of USA and its latest version is of 2022, called DSM V-
TR (DSM V- Text Revision).WHO’s ICD11 has got acceptance all over the
world and is also the official diagnostic system globally.
• Pre–World War II
• In the United States, the initial stimulus for developing a classification of mental
disorders was the need to collect statistical information. What might be considered the
first official attempt to gather information about mental health in the United States
was the recording of the frequency of “idiocy/insanity” in the 1840 census. By the
1880 census, seven categories of mental health were distinguished: mania,
melancholia, monomania, paresis, dementia, dipsomania, and epilepsy.
• In 1917, the American Medico–Psychological Association, together with the National
Commission on Mental Hygiene, developed a plan adopted by the Bureau of the
Census for gathering uniform health statistics across mental hospitals. Although this
system devoted more attention to clinical usefulness than did previous systems, it was
still primarily an administrative classification. In 1921, the American Medico–
Psychological Association changed its name to the APA. It subsequently collaborated
with the New York Academy of Medicine to develop a nationally acceptable
psychiatric classification that would be incorporated within the first edition of the
American Medical Association’s Standard Classified Nomenclature of Disease. This
system was designed primarily for diagnosing inpatients with severe psychiatric and
neurological disorders.
• Post–World War II
• A much broader classification system was later developed by the U.S. Army (and modified by the
Veterans Administration) to better incorporate the outpatient presentations of World War II
servicemen and veterans (e.g., psychophysiological, personality, and acute disorders). At the same
time, the World Health Organization (WHO) published the sixth edition of ICD, which, for the first
time, included a section for mental disorders. ICD–6 was heavily influenced by the Veterans
Administration classification and included 10 categories for psychoses and psychoneuroses and seven
categories for disorders of character, behavior, and intelligence.
• The APA Committee on Nomenclature and Statistics developed a variant of the ICD–6 that was
published in 1952 as the first edition of DSM. DSM contained a glossary of descriptions of the
diagnostic categories and was the first official manual of mental disorders to focus on clinical use.
The use of the term “reaction” throughout DSM reflected the influence of Adolf Meyer’s
psychobiological view that mental disorders represented reactions of the personality to psychological,
social, and biological factors.
• In part because of the lack of widespread acceptance of the mental–disorder listings contained
in ICD–6 and ICD–7, WHO sponsored a comprehensive review of diagnostic issues, conducted by
the British psychiatrist Erwin Stengel. His report inspired many advances in diagnosis—especially
the need for explicit definitions of disorders as a means of promoting reliable clinical diagnoses.
However, the next round of revisions, which led to DSM–II and ICD–8, did not follow Stengel’s
recommendations to any great degree. DSM–II was similar to DSM but eliminated the term
“reaction.”
• Development of DSM–III
• As had been the case for the DSM and DSM–II, the development of the third edition (DSM–
III) was coordinated with the development of the next version of the ICD, ICD–9, which was
published in 1975 and implemented in 1978. Work began on DSM–III in 1974, with
publication in 1980.
• DSM–III introduced a number of important innovations, including explicit diagnostic criteria,
a multiaxial diagnostic assessment system, and an approach that attempted to be neutral with
respect to the causes of mental disorders. This effort was aided by extensive work on
constructing and validating the diagnostic criteria and developing psychiatric interviews for
research and clinical uses.
• ICD–9 did not include diagnostic criteria or a multiaxial system largely because the primary
function of this international system was to outline categories for the collection of basic health
statistics. In contrast, DSM–III was developed with the additional goal of providing precise
definitions of mental disorders for clinicians and researchers. Because of dissatisfaction across
all of medicine with the lack of specificity in ICD–9, a decision was made to modify it for use
in the United States, resulting in ICD–9–CM (for Clinical Modification).
• DSM–III–R and DSM–IV
• Experience with DSM, Third Edition (DSM–III) revealed inconsistencies in the
system and instances in which the diagnostic criteria were not clear. Therefore,
APA appointed a work group to revise DSM–III, which developed the revisions and
corrections that led to the publication of DSM–III–R in 1987.
• DSM–IV was published in 1994. It was the culmination of a six–year effort that
involved more than 1,000 individuals and numerous professional organizations.
Much of the effort involved conducting a comprehensive review of the literature to
establish a firm empirical basis for making modifications. Numerous changes were
made to the classification (e.g., disorders were added, deleted, and reorganized), to
the diagnostic criteria sets, and to the descriptive text. Developers of DSM–IV and
the 10th edition of the ICD worked closely to coordinate their efforts, resulting in
increased congruence between the two systems and fewer meaningless differences
in wording. ICD–10 was published in 1992.
• DSM–5
• The work on DSM-5 began in 2000, work groups were formed to create a
research agenda for the fifth major revision of DSM (DSM–5). These work
groups generated hundreds of white papers, monographs, and journal
articles, providing the field with a summary of the state of the science
relevant to psychiatric diagnosis and letting it know where gaps existed in
the current research, with hopes that more emphasis would be placed on
research within those areas. In 2007, APA formed the DSM–5 Task Force to
begin revising the manual as well as 13 work groups focusing on various
disorder areas. DSM–5 was published in 2013.
 DSM IV TR VS DSM-5
• New categories: Obsessive-Compulsive and Related Disorders, Trauma- and Stressor-Related
Disorders
• Transformed: Neurodevelopmental Disorders (Infancy, adolescence, childhood), Somatic
Symptom and Related Disorders
• Discontinued 5-Axis system
• NOS replaced by "Other Specified” or “Unspecified” and “Another Medical Condition"
instead of “General Medical Condition” NOTE: NOS DSM IV = 41 and

Other/Unspecified DSM-5 =65 (To match ICD-10)

• Axis 4 gone - might use V & (Z in ICD 10) codes
• Axis 5 gone - might use WHODAS from Section III
• List multiple diagnoses in order of attention or concern
 NEW DISORDERS IN THE
DSM-5
•Social (Pragmatic) Communication Disorder
•Disruptive Mood Dysregulation Disorder
•Premenstrual Dysphoric Disorder
•Hoarding Disorder
•Excoriation (Skin‐Picking) Disorder
•Disinhibited Social Engagement Disorder (split from Reactive Attachment
Disorder)
•Binge Eating Disorder
•Central Sleep Apnea
 NEW DISORDERS IN THE
DSM-5
•Sleep-Related Hypoventilation
•Rapid Eye Movement Sleep Behavior Disorder
•Restless Legs Syndrome
•Caffeine Withdrawal
•Cannabis Withdrawal
•Major Neurocognitive Disorder with Lewy Body Disease (Dementia Due to Other
Medical Conditions)
•Mild Neurocognitive Disorder
ELIMINATED DISORDERS IN THE
DSM-5

•Sexual Aversion Disorder

•Polysubstance-Related Disorder
COMBINED DISORDERS IN THE
DSM-5
• Specific Learning Disorder (Reading Disorder, Math Disorder, Disorder of Written
Expression)
• Delusional Disorder (Shared Psychotic Disorder, Delusional Disorder)
• Panic Disorder (Panic Disorder Without Agoraphobia Panic Disorder With Agoraphobia)
• Dissociative Amnesia (Dissociative Fugue and Dissociative Amnesia)
• Somatic Symptom Disorder (Somatization Disorder, Undifferentiated Somatoform
Disorder and Pain Disorder)
• Insomnia Disorder (Primary Insomnia and Insomnia Related to Another Mental
Disorder)
• Hypersomnolence Disorder (Primary Hypersomnia and Hypersomnia Related to
Another
Mental Disorder)
 COMBINED DISORDERS IN THE
DSM-5
• Non-Rapid Eye Movement Sleep Arousal Disorders (Sleepwalking Disorder and Sleep
Terror Disorder)
• Genito‐Pelvic Pain/Penetration Disorder (Vaginismus and Dyspareunia)
• Alcohol Use Disorder (Alcohol Abuse and Alcohol Dependence)
• Cannabis Use Disorder (Cannabis Abuse and Cannabis Dependence)
• Phencyclidine Use Disorder (Phencyclidine Abuse and Phencyclidine Dependence)
• Other Hallucinogen Use Disorder (Hallucinogen Abuse and Hallucinogen Dependence)
• Inhalant Use Disorder (Inhalant Abuse and Inhalant Dependence)
• DSM–5-TR
• The DSM-5-TR development effort started in Spring 2019 and involved more than
200 experts, the majority of whom were involved in the development of DSM-5.
These experts were given the task of conducting literature reviews covering the
past nine years and reviewing the text to identify out-of-date material. Four cross-
cutting review groups (Culture, Sex and Gender, Suicide, and Forensic) reviewed
all the chapters, focusing on material involving their specific expertise. The text
was also reviewed by a Work Group on Ethnoracial Equity and Inclusion to
ensure appropriate attention to risk factors such as racism and discrimination and
the use of non-stigmatizing language. Although the scope of the text revision did
not include conceptual changes to the criteria sets, some necessary clarifications
to certain diagnostic criteria were reviewed and approved by the DSM Steering
Committee, as well as the APA Assembly and Board of Trustees. DSM-5-TR was
published in March 2022.
• New additions of disorders include:
• Prolonged grief disorder: A disorder that applies to children,
adolescents, and adults, defined as intense yearning or longing, and
preoccupation with thoughts or memories of the deceased.
• Unspecified Mood Disorder: A diagnosis that was reinstated in the
DSM-5-TR. It refers to symptoms characteristic of Bipolar Related
Disorders and/or Depressive Disorders but do not meet the full criteria
for any of the disorders under those classes.
• Addition of other conditions that may be a focus of clinical attention
• The purpose of this addition is intended to improve documentation of the following
behaviors, which may provide additional information that affects the course, prognosis,
or treatment of an individual’s mental disorder:
• Suicidal Behavior
• Non-suicidal Self-Injury
• The names of the following disorders were updated according to their usage in
current literature and the International Classification of Diseases (ICD-11):
• Intellectual Developmental Disorder (Intellectual Disability), formerly Intellectual
Disability (Intellectual Developmental Disorder)
• Persistent Depressive Disorder, formerly Persistent Depressive Disorder (Dysthymia)
• Social Anxiety Disorder, formerly Social Anxiety Disorder (Social Phobia)
• There were changes to the diagnostic criteria and specifiers for the following diagnoses:
• The purpose of this addition was to clarify diagnostic criteria and differential diagnoses, remove
redundancy, and increase consistency within the DSM and with the International Classification of
Diseases (ICD-11):
• Attenuated Psychosis Syndrome; Other Specified Schizophrenia
• Autism Spectrum Disorder; Intellectual Disability
• Avoidant Restrictive Food Intake Disorder; Other Specified Feeding Disorder
• Bipolar and Related Disorders
• Delirium; Other Specified Delirium Disorder
• Depressive Disorders
• Gender Dysphoria
• Depressive Disorders
• Narcolepsy
• Other Specified Obsessive-Compulsive and Related Disorder
• Posttraumatic Stress Disorder
• Texts were updated for most disorders according to advances in current
literature and to increase adherence with principles of fairness, for example, the
impact of racism on diagnoses and language use (e.g., “desired gender” was
replaced with “experienced gender”). The text areas with the most changes
include:
• Prevalence
• Risk and Prognostic Factors
• Culture-Related Diagnostic Features
• Sex- and Gender-Related Diagnostic Features
• Association With Suicidal Thoughts or Behavior
• Comorbidity
• KEYWORDS USED IN PSYCHOPATHOLOGY
DIAGNOSIS
 It is the process of identifying and determining the nature of
a disease or disorder by its signs and symptoms, through the
use of assessment techniques (e.g., tests and examinations)
and other available evidence.

 It is the classification of individuals on the basis of a disease,

disorder, abnormality, or set of characteristics. Psychological
diagnoses have been codified for professional use, notably in
the DSM–IV–TR and DSM–5.

 It is the considered as the decision or statement itself that

results from this process or classification as in “She was
given a diagnosis of schizoaffective disorder.”
DIAGNOSTIC CRITERIA

Diagnostic criteria are a set of signs, symptoms, and

tests for use in routine clinical care to guide the care of
individual patients.
Diagnostic criteria are used to guide for the care of
individual patients. They are usually broad and must
reflect different features of a disease in order to
accurately identify as many people with the condition
as possible.
DIFFERENTIAL DIAGNOSIS

A differential diagnosis is the process of differentiating

between two or more disorder that share similar symptoms
ETIOLOGY

1. It is the causes and progress

of a disease or disorder.
2. It is also a branch of
medical and psychological
science which is concerned
with the systematic study of
the causes of physical and
mental disorders.
 EPIDEMIOLOGY

• EPIDEMIOLOGY
• It is the scientific study of the spread and control of diseases.

• It is the study of the incidence and distribution of specific diseases

and disorders. The epidemiologist also seeks to establish
relationships to such factors as heredity, environment, nutrition, or
age at onset.
 • Prevalence is defined as the number of instances of a
given disease or other condition in a given population at a
designated time (Last, 1983).
• Often, prevalence rates represent cross-sectional events,
noted at a single point in time for the state of the group
PREVALENCE under study (Jenicek and Cléroux, 1982; Feinstein, 1985).
This is called point prevalence. Period prevalence refers
to the number of cases that occur during a specified
period of time, e.g., 1 year. This is now rarely used. It
usually takes some time to conduct a study and find all
cases and in such cases it is generally possible to estimate
point prevalence (which can be called just “prevalence”).
• The prevalence rate is given as the number of cases for a
specified number of persons in the population (number of
cases at a specified time/number of persons in the
population at that time). Prevalence focuses on disease
status, and should not be confused with incidence.
 PROGNOSIS
• In medicine and mental health
science, prognosis is a prediction of
the course, duration, severity, and
outcome of a condition, disease, or
disorder.
• Prognosis may be given before any
treatment is undertaken, so that the
patient or client can weigh the
benefits of different treatment
options.
 SPECIFIER
• Specifiers are extensions to a diagnosis to further clarify a disorder or
illness.

• They allow for a more specific diagnosis. They are used extensively in
the Diagnostic & Statistical Manual of Mental Disorders (DSM-5)
primarily in the diagnosis of mood disorders.

• Specifiers are not mutually exclusive and more than one specifier may be
applied on a patient.
CLINICAL PICTURE

The clinical picture is the collection of findings of the

medical doctor during anamnesis (the medical interview) and
physical examination and possible further examination,
which is typical for a particular disease.