Module 2

DSM- V and ICD-10

The Classification
• The first attempt to classify was by the Greek physician Hippocrates in 400
BC, who believed that mental illness stemmed from imbalances of a
person's black bile, yellow bile, phlegm, and blood.
• Different imbalances resulted in particular symptoms which could be split
into the following categories: Mania, Melancholy(sadness with no obvious
reason), Phrenitis (brain inflammation), Insanity, Disobedience, Paranoia,
Panic, Epilepsy, and Hysteria.
• Inspired by botanical taxonomy (the classification of plants), a French
physician called François Boissier published a system of classifying illness in
1763. This classification included mental illnesses, subdivided into four
categories: 1) Hallucinations, 2) Morositates, 3) Deliria, and 4) Folies
Anomales.
• The 19th century saw more attempts to classify mental illness. In
Germany, Karl Kahlbaum published his 'Classification of Psychiatric
Diseases and Mental Disturbances' (1863), positing a system which
classified mental illnesses by their symptoms.
• Rejecting the tradition of labelling a symptom as a particular illness,
he conceptualised psychiatric diagnoses as clusters of symptoms:
mania as a symptom of a disorder instead of a disorder in itself.
• Kahlbaum employed many terms that we still use today including
Dysthymia, Cyclothymia, Catatonia, Paranoia, and Hebephrenia.
• Inheriting Kahlbaum's ideas, Emil Kraeplin, in the late 19th and early
20th century, proposed a system in which a disorder was defined not
only by the symptoms that constitute it, but also by the patterns and
course in which it presents. Famously, he differentiated between
Psychotic Disorders and Affective Disorders, providing the
foundations for what we now refer to as Schizophrenia and Bipolar
Disorder.
• Today, the two most widely established systems of psychiatric
classification are the Diagnostic and Statistical Manuel of Mental
Disorders (DSM) and the International Classification for Diseases
(ICD). Despite each being as widely used as the other, the ICD and the
DSM conceptualise and classify mental disorders in different ways.
• DSM:- The Diagnostic and Statistical Manual of Mental Disorders is a
publication for the classification of mental disorders using a common
language and standard criteria.
• ICD:- The International Classification of Diseases is the international
"standard diagnostic tool for epidemiology, health management and
clinical purposes." Its full official name is International Statistical
Classification of Diseases and Related Health Problems.
Why classification ?
• To distinguish one psychiatric diagnosis from another, so that
clinicians can offer the most effective treatment.
• To provide a common language among health care professionals.
• And to explore the still unknown causes of many mental disorders.
DSM
• DSM is intended to serve as a practical, functional, and flexible guide for organizing
information that can aid in the accurate diagnosis and treatment of mental disorders.
• It is a tool for clinicians, an essential educational resource for students and practitioners,
and a reference for researchers in the field.
• DSM has been used by clinicians and researchers from different orientations (biological,
psychodynamic, cognitive, behavioral, interpersonal, family/systems), all of whom strive for
a common language to communicate the essential characteristics of mental disorders
presented by their patients.
• The information is of value to all professionals associated with various aspects of mental
health care, including psychiatrists, other physicians, psychologists, social workers, nurses,
counselors, forensic and legal specialists, occupational and rehabilitation therapists, and
other health professionals.
• The criteria are concise and explicit and intended to facilitate an objective assessment of
symptom presentations in a variety of clinical settings—inpatient, outpatient, partial
hospital, consultation- liaison, clinical, private practice, and primary care—as well in general
community epidemiological studies of mental disorders.
History of DSM
• In 1918, the American Medico-Psychological Association (presently
the American Psychological Association, or APA) issued the Statistical
Manual for Use of Institutions for the Insane. It did not catch on.
• In 1928, the American Psychiatric Association issued another edition
but it was too narrowly focused. It looked primarily at neuroses and
psychoses.
• By World War II, the military had its own nomenclature system.
• The World Health Organization (WHO) issued the International
Classification of Diseases-6 (ICD-6); it contained a section on mental
disorders but it needed modification for use in the United States.
DSM-I
• The ​APA published the Diagnostic and Statistical Manual of Mental
Disorders in 1952; it was based off of the ICD-6 and the military
system.
• The first DSM contained about 60 disorders and was based on
theories of abnormal psychology and psychopathology.
• Problems: DSM was criticized for its reliability and validity. The major
limitation of the DSM was that the concept had not been scientifically
tested. Also, all of the disorders listed were considered to be
reactions to events occurring in an individual’s environment. Another
problem was that there really was no distinction between abnormal
and normal behavior. Despite this, it gained acceptance.
DSM-II
• The ​DSM-II was published in 1968 but still had criticism over its
validity and reliability. Changes in the DSM-II included eleven major
diagnostic categories, with 185 total diagnoses for mental disorders.
Additionally, increased attention was given to children and
adolescents in the DSM-II. For example the diagnostic category of
Behavior Disorders of Childhood-Adolescence was presented for the
first time.
• In 1974, the seventh printing of the DSM-II no longer listed
homosexuality as a disorder.
 DSM-III
• The DSM-III was published in 1980. This dramatically changed the field of psychology.
• The five part multiaxial diagnostic system, still used today, first appeared in DSM-III.
• DSM-III provided specific diagnostic criteria for 265 diagnoses.
• Dr. Robert L. Spitzer was appointed to lead the changes to the DSM in 1974. He was
largely involved in creating the discrete diagnostic categories of the DSM-III, as opposed
to a dimensional model of diagnosis.
• As with the DSM-II, many significant changes were made in the third edition of the
DSM. For example, previously many of the anxiety disorders were lumped together as
one diagnosis of Anxiety Neurosis. The DSM-III broke that broad diagnosis down to
include many different anxiety disorders such as generalized anxiety disorder (GAD),
panic disorder, agoraphobia, and social phobia. In fact, the term “neurosis” was
removed from the DSM-III altogether. Furthermore, social issues came into play with
the development of the DSM-III. Racism was considered as a mental disorder to be
added, but after much deliberation and research was not included. Post-traumatic
stress disorder was added to the DSM at this time. Also, the DSM-II category of “sexual
orientation disturbance” was changed to “ego-dystonic homosexuality.”
DSM-III-R
• The revision for DSM-III was published in 1987.
• 297 diagnoses
DSM-IV
• The DSM-IV was published in 1994.
• This edition was more research based as far as criteria and diagnoses
are concerned.
• 365 diagnoses.
DSM-IV-TR
• The newest revision of the DSM was published in 2000.
• This volume is heavily research based and includes information about
the etiologies of the disorder.
 DSM-V
• The newest revision, DSM-V, will be available in 2012, with final approved
edition expected May 2013.
• Join effort between the American Psychiatric Association, the National Institute
of Mental Health, the World Health Organization, and the World Psychiatric
Association.
• Efforts began in 2000, and have involved 13 conferences with international
involvement.
• Some of the proposed changes include:
• Modifications of various disorder spectrums, such as including Asberger’s disorder within
the autism spectrum;
• Modiciations of terminology, such as replacing use of “mental retardation” with
“intellectual disability”;
• Improved methods of assessment.
• Large scale inclusion of new criteria to all aspects, with some proposed removals and
integrations.
History of ICD
• The International Classification of Disease (ICD) system was created for the
accurate tracking of diseases within a population.
• Across the years, it has become an integral part of the payment
infrastructure of the US health care system along with the Current
Procedural Terminology (CPT) coding system for medical procedures.
• International statistical classification of diseases and related health
problems in short “ICD” is the international standard diagnostic tool for
epidemiology, health management and clinical purposes.
• ICD is designed as health care classification system which provides the
diagnostic codes for classifying diseases including classification of wide
variety of signs, symptoms, abnormal findings, complaints, social
circumstances and external cause of injury or disease.
• In 1860, Florence nightingale →made first model of systemic
collection of hospital data.
• In 1893, French physician, Jacques Bertillon→ introduced Bertillon
classification of cause of death
• In 1898, American public health association→ recommended revision
of ICD system every 10 years.
• The revision followed minor changes until 6th version of ICD→
morbidity and mortality condition and section on mental disorders
• WHO →responsibility for preparing and publishing the ICD revisions
every 10 years.
• The ICD -10 was formed in 1893, as the Bertillon classification of
international list of causes of death.
• The work on ICD -10 started in 1983 → approved in 1990 at 43rd
world health assembly (WHA)
Cause of death
• THE CAUSES OF DEATH to be entered on the medical certificate are all
those diseases, morbid conditions or injuries which are either
resulted or contributed to death and circumstances of accident or
violence , which produced any such injuries.
• UNDERLYING CAUSE OF DEATH
• a) Diseases or injury which initiated the sequence of events leading
directly to death
• b) The circumstances of the accident or violence which produced the
fatal injury.
ICD-11
• The world health organization is currently revising the ICD towards
ICD-11.
• The development is taking place on an internet based workspace
called " icat " platform
• The draft of the ICD -11 system → submitted to WHO’s world health
assembly (WHA)→ by 2017 and a final version → in 2018. ICD -11
Advantages and limitations
Advantages:
• 1) fast aggregation of health data
• 2) To know the real time information about current health situation
• 3) Wider analysis of community health
• 4) Global health assessment
Limitations:
• 1) discussion is limited to classified diseases
• 2) common term descriptions of diseases
• 3) covers the most common diseases
• 4) country specific modifications of certain diseases
Uses of DSM
• 1. Standardization
Beyond the standardization of billing and coding, the DSM provides a
number of important benefits to both the therapist and the client.
Standardization of diagnoses helps to ensure that clients receive
appropriate, helpful treatment regardless of geographic location, social
class or ability to pay. It provides a concrete assessment of the issues
and assists in developing specific goals of therapy, as well as a standard
of measure in assessing the effectiveness of treatment
• 2. Research Guidance
In addition, the DSM helps guide research in the mental health field.
The diagnostic checklists help ensure that different groups of
researchers are actually studying the same disorder—although this may
be more theoretical than practical, as so many disorders have such
widely varying symptoms.
• 3. Therapeutic Guidance
For the therapist, the DSM eliminates much of the guesswork. Proper
diagnosis and treatment of mental illness remain an art, but the DSM
diagnostic criteria serve as a sort of guide map. In the age of brief
therapy, a clinician may see a specific client only a handful of times,
which may not be long enough to delve fully into the client's
background and issues. Using the diagnostic criteria contained in the
DSM, the therapist can develop a quick frame of reference, which is
then refined during individual sessions.
Disadvantages of DSM
1. Oversimplification
Many critics of the DSM see it as an oversimplification of the vast
continuum of human behavior. Some worry that by reducing complex
problems to labels and numbers, the scientific community risks losing
track of the unique human element.
2. Misdiagnoses and Over-Diagnoses
Possible risks include misdiagnosis or even over-diagnosis, in which
vast groups of people are labeled as having a disorder simply because
their behavior does not always line up with the current "ideal."
3. Labeling and stigmatizing
Other risks involve the possibility of stigmatization. Although mental
health disorders are not viewed in the negative light that they once
were, specific disorders can be perceived as labels. Some therapists
take great care to avoid attaching labels to their clients, although for
insurance reasons, a specific diagnosis may be required.
Uses of ICD
• The ICD is the foundation for the identification of health trends and
statistics globally.
• It is the international standard for defining and reporting diseases and
health conditions.
• These entities are listed in a comprehensive way so that everything is
covered.
• ICD allows the counting of deaths as well as diseases, injuries,
symptoms, reasons for encounter, factors that influence health status,
and external causes of disease.
• It organizes information into standard groupings of diseases, which
allows for:
• easy storage, retrieval and analysis of health information for
evidence-based decision- making;
• sharing and comparing health information between hospitals,
regions, settings and countries; and
• data comparisons in the same location across different time periods.
• It is the diagnostic classification standard for all clinical and research
purposes.
These include
• monitoring of the incidence and prevalence of diseases,
• observing reimbursements and resource allocation trends, and
• keeping track of safety and quality guidelines.