Week 4
Classification and Its Rules
Classification requires rules to organize categories.
Rule-makers:
o WHO (World Health Organization): Defines rules for ICD-10, ICD-11
o APA (American Psychiatric Association): Defines rules for DSM-5
Definition of Taxonomy
Taxonomy: The science or technique of classification.
In biology, it involves description, identification, naming, and classification of organisms.
Emphasizes ordered and meaningful categories.
Purpose of ICD (International Classification of Diseases)
Foundation for identifying global health trends and statistics.
International standard for reporting diseases and health conditions.
Defines diseases, disorders, injuries, and related health conditions in a comprehensive hierarchical
structure.
Enables:
o Easy storage, retrieval, and analysis of health data for evidence-based decisions.
o Sharing and comparing health information across hospitals, regions, and countries.
o Data comparison over time in the same location.
Uses include:
o Monitoring incidence and prevalence of diseases.
o Observing reimbursements and resource allocation.
o Tracking safety and quality guidelines.
o Counting deaths, diseases, injuries, symptoms, reasons for encounter, health status
factors, and external causes.
Purpose of DSM (Diagnostic and Statistical Manual of Mental Disorders)
Developed to improve communication about patient types in US mental hospitals.
Historically used in the US census to record frequency of terms like “idiocy/insanity”.
Define vs Explain
Term Meaning
Define To determine or fix boundaries or extent; clarify outline or form of something.
Explain To clarify cause or reason; to account for something.
Classification and diagnostic systems are used to define mental disorders, not to explain them.
Defining Mental Disorder: Challenges and Perspectives
No universally accepted precise boundaries for "mental illness".
Definitions may include:
o Statistical deviation from the norm.
o Social deviance or disruptive behavior.
o Experience of distress.
o Anatomical or physiological brain abnormalities.
o Functional difficulties or disabilities.
o Maladaptive behaviors.
Karl Jaspers’ perspective:
o Illness is partly an opinion of the patient and culturally influenced.
o Empirical approach: illness as statistical deviation.
o Consider patient’s subjective experience of being “sick”.
DSM-IV statement: Mental illness lacks a consistent operational definition covering all situations.
Evolution of DSM Editions
Edition Publication Pages Diagnoses Revenue
Date (APA)
DSM-I 1952 132 128 Unknown
DSM-II 1968 119 193 $1.27 million
DSM-III 1980 494 228 $9.33 million
DSM-III-R 1987 567 253 $16.65 million
DSM-IV 1994 886 383 $120 million
DSM-IV- 2000 943 383 Unknown
TR
DSM-5 2013 947 541 Unknown
Timeline shows parallel development of DSM and ICD editions.
Significant Advancements in DSM
Edition Key Advancements
DSM- - Atheoretical formulation and operationalized definitions for diagnostic criteria.
III - Multi-axial diagnoses recognizing complexity.
- Biopsychosocial model requiring diagnosis on multiple levels.
DSM- - Avoided strict brain-mind distinction (e.g., removed "Organic mental syndromes").
IV - Emphasized social and occupational functioning.
- Added criteria for clinically significant distress or impairment.
DSM-5 - Harmonized with ICD-11.
- Proposed new organization of categories based on 11 indicators including shared neural
substrates, genetic risk, biomarkers, symptom similarity, comorbidity, and treatment response.
DSM-IV-TR Multi-Axial Classification System (Pedersen, 2005)
Axis Description Example/Notes
I Clinical Disorders (focus of clinical attention) E.g., Bipolar I Disorder
II Personality Disorders / Mental Retardation E.g., Borderline Personality Disorder
III General Medical Conditions Includes ICD-9-CM codes
IV Psychosocial/Environmental Problems Family, social, occupational, legal issues
V Global Assessment of Functioning (GAF) Scale 0-100; current, highest, admission, discharge
Clinical Pearl: Axis I initiates therapy.
Sample DSM-IV-TR Multi-Axial Diagnosis Example
Axis Diagnosis/Condition
I 296.44 Bipolar I Disorder, manic episode with psychotic features
II 301.83 Borderline Personality Disorder
III 704.00 Alopecia
IV Unemployed
V GAF admission: 28
Why Multi-Axial System Is Outdated (Verywellmind, 2021)
DSM-5 eliminated the multi-axial system.
Combined first three axes into one.
Reason: To remove artificial distinctions between diagnoses.
Benefits: Streamlines information for clinicians, researchers, and insurance.
Application of Diagnostic Systems in Clinical Practice
Only professionally trained psychiatrists and some psychologists can diagnose mental disorders.
Types of clinical diagnoses:
o Primary diagnosis: Main condition causing current consultation.
o Provisional diagnosis: Partial match to criteria; pending further information.
o Differential diagnosis: Conditions with similar presentations; determined by hypothetical
deduction.
Why Occupational Therapists (OT) Use DSM/ICD?
To understand patient manifestations and problems.
To provide hints for problem identification and treatment planning.
To anticipate illness course and outcomes.
To facilitate communication with:
o Mental health professionals.
o Family members/caregivers.
o The patient.
Side Effects of DSM/ICD Use
Effect Description
Labeling Patient’s self-identity and behavior influenced by diagnostic label.
Effect
Stigmatization Social disapproval based on deviant characteristics.
Sick Role Patient gains certain rights (exemption from normal roles, not responsible for illness)
but also responsibilities (seek help, try to improve).
What Is OT Actually Treating? (Based on ICF Model)
Component Description
Health Condition Disorder or disease
Body Functions & Structures Impairments in mental and physical functions
Activity Limitations in performing tasks
Participation Restrictions in involvement in life situations
Contextual Factors Environmental and personal factors influencing functioning
OT theories such as PEO/PEOP and МОНО align with this model.
Suggested OT Thinking Process for Diagnosis and Referral
Step Considerations
What is the Review history of present illness, signs and symptoms, patient complaints, and
diagnosis? reports from others.
Aim of OT referral? Determine if concerns fall within OT domain and if OT can make a difference.
Competency check Assess if OT is competent to address referral.
Problem analysis Use cause-oriented and outcome-oriented reasoning.
What Should an OT Do?
Within OT Outside OT
Be familiar with diagnostic criteria Communicate effectively with mental health
professionals
Differentiate diagnoses sensitively Demonstrate professional judgment as an OT
Use a holistic approach to patient and illness Be competent with OT legitimate tools
Reference OT theories Ensure patient and relatives understand OT role
Formulate treatment plans from OT
perspective
DSM-5, ICD, and Case Definition in Research: Chronic Fatigue Syndrome (CFS) Example
DSM-5 not applicable for CFS (neurological condition).
ICD-11 codes CFS under Postviral fatigue syndrome (8E49) but criteria unclear.
ICD-10 CM codes CFS under R53.82 Chronic Fatigue, Unspecific; lacks clear criteria.
Other case definitions:
o 1991 Oxford criteria (UK use)
o 2003 Canadian Consensus Criteria (limited adoption)
o 2015 Institute of Medicine (IOM) criteria (focus on exertional intolerance; controversial)
Study uses Fukuda’s case definition (most common historically, used locally despite controversy).
Criticism of DSM-5 (Wikipedia, 2021)
Issues with validity and reliability.
Tendency for over-diagnosis.
Focus on superficial symptoms.
Concerns about medicalization and financial conflicts of interest.