CLASSIFICATION
Significant Terms
• Classification - the activity of forming groups.
• Diagnosis - the process by which individuals are assigned to
already existing groups.
• Taxonomy - the study of how groups are formed; a meta-level
concept that looks at different theoretical ways in which
classifications can be organized, studied, and changed.
HISTORY: Classification of Mental D/o
• 3000 B.C. – Eygptian account of dementia
• Manovikara - early classification of mental disorders was
found in the Ayurveda, an ancient Indian system of medicine
(Menninger, Mayman, & Pruyser, 1963)
• Ancient Greek and Egyptian writings refer to disorders
remarkably similar to concepts of hysteria, paranoia, mania,
and melancholia
HISTORY: Classification of Mental D/o
• 20th century - classification was a prominent theme in the
study of psychopathology
• 1948 - classification of mental disorders became part of the
International Classification of Diseases (ICD 6)
• After WWII (1952) - American psychiatry saw a need to
systematize a single classification system: DSM
PURPOSE OF
CLASSIFICATION
Purpose of Classification
• Classification involves creating and defining the boundaries
of concepts (Sartorius, 1990).
• Through this process, diagnostic entities are defined
(Kendell, 1975) and the boundaries of the discipline are
ultimately established.
Purpose of Classification
1. providing a nomenclature for practitioners
2. serving as a basis for organizing and retrieving information
3. describing the common patterns of symptom presentation;
4. providing the basis for prediction
5. forming the basis for the development of theories
6. serving sociopolitical functions
Purpose of Classification
NOMENCLATURE
• list of names or terms of the categories within a classification
system
• allows clinicians to talk to each other about the “things” in their
world—patients and clients who seek the care of mental health
professionals
Purpose of Classification
INFORMATION RETRIEVAL
• a classification shapes the way information is organized,
thereby influencing all aspects of clinical practice and research
(e.g. etiology, treatment, prognosis)
Purpose of Classification
DESCRIPTIVE BASIS
• a classification establishes the descriptive basis for a science
of psychopathology
• when phenomena are systematically organized into categories,
the science is in the position to transform accounts of
individual cases into principles and generalizations
Purpose of Classification
PREDICTION
• most pragmatic from the perspective of clinicians
• a classification that is useful for prediction is a system in which
there is strong evidence that patients with different
diagnoses respond differentially to a specific treatment
Purpose of Classification
DEVELOPMENT OF THEORIES
• by providing systematic descriptions of phenomena, a
classification establishes the foundations for the
development of theories
Purpose of Classification
SOCIOPOLITICAL FUNCTION
• a classificatory system exists in a context of groups and
individuals that stand to benefit from the classification (e.g.
identifying a subset of the population that need treatment)
• however, some authors have argued that the classification of
mental disorders serves the objective of maintaining the social
power of the majority by marginalizing and stigmatizing those
people who fall under the domain of “mental illness” (e.g., Kirk&
Kutchins, 1992; Kutchins & Kirk, 1997)
HISTORY OF CLASSIFICATION
HISTORY: KRAEPLIN
• German psychiatrist
• Nine published editions of Kraepelin’s classifications
(Menninger et. al., 1963)
• 6th edition - two chapters established a fundamental
distinction between psychotic and mood disorders that forms a
linchpin of contemporary classifications: (1) dementia praecox
(now called schizophrenia), which included hebephrenia,
catatonia, and paranoia; and (2) manic-depressive insanity
CLASSIFICATION SYSTEMS
HISTORY: DSM & ICD EARLY ED.
ICD
• official classification of medical disorders is known as the
Manual of International Statistical Classification of
Diseases, Injuries, and Causes of Death (ICD), published by
the WHO
• End of 19th century - International Statistical Institute
commissioned Jacques Bertillon to generate a classification of
causes of death; The Bertillon Classification of Causes of Death
• Early 1900 – adopted as official international classification of
medical disorders; name changed to The International
Classification of Causes of Death
HISTORY: DSM & ICD EARLY ED.
ICD
• after World War II - the WHO met to generate a sixth revision
of this classification: expanded the classification beyond
causes of death and to include all diseases regardless of
whether those diseases led to death or not (i.e., morbidity as
well as mortality)
• 1948 – the Manual of International Statistical Classification of
Diseases, Injuries, and Causes of Death, Sixth Revision (ICD-6;
1948).
• Because it focused on all diseases, ICD-6 added a section
devoted to mental disorders
HISTORY: DSM & ICD EARLY ED.
DSM
• 1952 - American Psychiatric Association published its first
official classification of mental disorders (DSM-I; 1952)
• reason: there were four different classifications of
psychopathology in use in the United States during World War
II, a situation that American psychiatry found embarrassing; the
United States created its own nomenclature rather than using
ICD-6 (Grob, 1991)
• other countries generally locally created their own classification
system instead of using the ICD-6 as the official system
HISTORY: DSM & ICD EARLY ED.
• only 5 countries adopted the ICD-6 classification of mental
disorders: Finland, New Zealand, Peru, Thailand, and the United
Kingdom
• 1959 – Erwin Stengel documented the widespread differences
that existed the terminology from country to country
• the variation in classifications from one country to another meant
there was a failure for these systems to become useful
nomenclatures; there were quite variable beliefs about the
etiologies of the disorders being classified;
• Stengel suggested a classification that simply provided operational
definition without etiology (ICD 8)
HISTORY: DSM & ICD EARLY ED.
DSM
• 1968 – DSM II was published containing short prose definitions
of the basic categories in the system
CRITICISMS OF DSM I & II
CRITICISMS OF DSM I & II
DSM
• 1950 -1960: concerns about the reliability of psychiatric
diagnoses surfaced (Masserman and Carmichael, 1938; Ash,
1949; and Beck,1962)
• U.K./U.S. Diagnostic Project - found major differences in
diagnostic practice between Britain and the United States
(Cooper et. al., 1972; Kendell, Cooper, Gourlay, Sharpe, &
Gurland, 1971); Americans were overinclusive while British
psychiatrists were more specific in the use of schizophrenia
CRITICISMS OF DSM I & II
DSM
• reliability studies of the 1960s and 1970s were interpreted as
indicating that clinicians had problems achieving high levels
of agreement for any area of psychopathology; although
modern commentators of this literature suggested that the
criticisms of diagnostic reliability during this era were
overstated (Kirk & Kutchins, 1992).
• antipsychiatry movement; Szasz (1961) went so far as to argue
that mental illness was a myth
CRITICISMS OF DSM I & II
THREE MAJOR CRITICISMS OF PSYCHIATRIC
CLASSIFICATION
• unreliable
• based on the medical model
• labeling and stigmatizing effects of psychiatric diagnoses
(Goffman, 1959, 1963; Scheff, 1966, 1975)
What is the Rosenhan experiment’s influence and relevance to
contemporary mental health services?
HISTORY: The Neo-Kraepelinians
• 1970s - small, but effective, group of researchers emerged in
North American psychiatry: the Neo-Kraeplinians which
sought to reaffirm psychiatry as a branch of medicine
• emphasized the importance of diagnosis and classification
• reaction to the antipsychiatrists and the psychoanalytic
dominance of North American psychiatry
• included emphasizing the medical roots of psychiatry, such
that psychiatry provides treatment for people who are sick
with mental illness
HISTORY: The Neo-Kraepelinians
• represent a disease process (e.g., schizophrenia) belonged
to psychiatry, whereas other areas could be assigned to
ancillary professions such as psychology, social work, and
nursing.
• neo-Kraepelinians believed that psychiatry should be
founded on scientific knowledge
• reaffirm the medical and biological aspects of psychiatry
TAXONOMIC ISSUES
Classification of Syndromes,
Disorders, or Diseases
• symptom - self-reported issues
• signs - issues observed by others
• syndrome - signs and symptoms that frequently co-occur
(*note that the concept of a syndrome does not include any
assumptions about the cause of the condition or why those
symptoms belong together. It is a purely descriptive notion)
• disorder - provides an additional level of description beyond
that of a syndrome; a pattern of symptoms and signs that
includes an implied impact on the functioning of the
individual; its etiology is still unclear
Classification of Syndromes,
Disorders, or Diseases
• disease - a condition where the etiology is known, and the
path from the causal agent to the symptoms and signs it
causes is clear
• 1800s - general paresis was the most common single
disorder represented in mental asylums; syndrome:
symptoms included grandiose delusions and excitable
behavior; disorder: once course (excitable, grandiose
behavior but progressed to degenerative muscle movements,
paralysis) and outcome (and eventually death) were known;
disease: it was later on discovered as syphilitic infection and
was treated with penicillin
Classification of Disorders versus
Classification of Individuals
DSM-IV position:
• A common misconception is that a classification of mental
disorders classifies people, when actually what are being
classified are disorders that people have.
• The reason being is to try to avoid stigma .
• To emphasize the value of beneficence so that no or minimal
harm was done by assigning psychiatric diagnoses to
individual human beings.
DEFINITION OF MENTAL D/O
• neither DSM-I nor DSM-II provided any definition of a mental
disorder
• DSM-III - attempt to define this concept: “mental disorders
are a subset of medical disorders” (Spitzer, Sheehy, &
Endicott, 1977, p. 4).
• “A mental disorder is a medical disorder whose
manifestations are primarily signs or symptoms of a
psychological (behavioral) nature, or if physical, can be
understood only using psychological concepts” (p. 18).
DEFINITION OF MENTAL D/O
• Wakefield’s approach to mental disorders, termed harmful
dysfunction, considered mental disorders as “failures of
internal mechanisms to perform naturally selected
functions” resulting in impairment (Wakefield, 1999)
• distress, or harm, is included either by definition (feelings of
depression, anxiety, etc.) or through the criterion of clinical
signifcance
• clinical significance - judgment made by the clinician that
the severity of the dysfunction present in the disorder justifies
treatment
DEFINITION OF MENTAL D/O
• clinical significance is not an objectively defined concept
but rather requires a subjective decision by a clinician
regarding when a set of symptoms warrants clinical
attention
• for a classification system that has argued its strength in
objectivity and freedom from clinical bias, the explicit
inclusion of subjectivity in the definition of a mental disorder
is a problem
• 1995 - Lilienfeld and Marino criticized Wakefield’s
evolutionary basis of mental disorders, arguing that mental
disorders do not have defined properties and are not
necessarily evolutionary dysfunctions (e.g. snake phobia)
DEFINITION OF MENTAL D/O
• The current definition posed in DSM-5 reflects the logic of
Wakefield’s harmful-dysfunction concept, but it is more
lenient regarding the cause of the dysfunction
• DSM-5 definition includes the phrase “clinically significant
disturbance,” but the definition does not clarify the meaning
of this phrase (p. 20).
DIMENSIONS VERSUS CATEGORIES
DIMENSIONS VS CATEGORIES
• Most classifications of psychopathology employ categories
• Psychiatry, being the dominant profession in MH, has been
trained in the tradition associated with medical and
biological classification.
• Both biological and medical classificatory systems are
categorical
• Human’s natural cognitive mechanism that favor
categorical concepts (i.e. children seem to learn about the
natural world through category formation)
DIMENSIONS VS CATEGORIES
• DSM-III - majority of diagnoses contained exclusionary
criteria specifying that a respective disorder could not be
diagnosed if it occurred in the presence of another disorder
(APA, 1980)
• DSM-III-R (APA, 1987) - as expressed at the time by “it is
clear that the classic Kraepelinian model in which all
psychopathology is comprised of discrete and mutually
exclusive diseases must be modified or rejected” (Maser
and Cloninger (1990)
DIMENSIONS VS CATEGORIES
• the categorical approach has been increasingly questioned as
evidence has accumulated that the so-called categorical
disorders like major depressive disorder and anxiety
disorders, and schizophrenia and bipolar disorder seem to
merge imperceptibly both into one another and into
normality . . . with no demonstrable natural boundaries”
(First, 2003, p. 661).
DIMENSIONS VS CATEGORIES
• “DSM-5 remains a categorical classification of separate
disorders” (APA,2013,[Link])
• dimensional classification: ASD, schizophrenia spectrum
d/o, level of severity for substance use d/o, 5-domain trait
dimensional model of maladaptive personality functioning
DIMENSIONS VS CATEGORIES
• the authors of DSM-5 further suggested that “dimensional
approaches to diagnosis . . . will likely supplement or
supersede current categorical approaches in the coming
years” (APA, 2013, 13)
• dimensional proposals for DSM-5 were only to develop
“supplementary dimensional approaches to the
categorical definitions what would also relate back to the
categorical definitions” (Helzer et al., 2008, p116)