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
[Link] use , thereby facilitating communication
amongst professionals
[Link] definition and delineation of the disorders
[Link] with ICD diagnostic system
4. Clear guidelines for compilation and reporting of
patient diagnostic data
[Link] collection of diagnostic term in one
source
[Link] 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
[Link] symptom complex
[Link] distinction between organic and nonorganic
mental disorder
[Link] 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
[Link] time for accumulation of research
[Link] of resources
[Link] in interpreting and resolving discrepant
research findings based on different criteria set
[Link] no of diagnostic errors due to lack of time
to learn the nuances
[Link] communication
[Link] 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
