Classification of Diseases/Disorders are important to improve treatment and prevention efforts. Two important classification system used in the field of Mental Disorders are DSM -V and ICD -10. Here we will discuss Strengths and Weaknesses of both.

1. CLASSIFICATORY SYSTEMS:
ADVANTAGES & DISADVANTAGES
Ms Hemangi Narvekar
M.Phil. Clinical Psychology
National Institute for Empowerment of Persons with Multiple
Disabilities (NIEPMD), Chennai - 560029

2. CONTENTS
• Introduction
• The International Classification of Diseases (ICD)
• The Diagnostic and Statistical Manual of Mental Disorders (DSM)
• The International Classification of Functioning, Disability and
Health (ICF)
• Strengths & Weaknesses of Classification Systems
• References

3. INTRODUCTION
• Classification is the process by which the complexity of
phenomena is reduced by arranging them into categories
according to some established criteria for one or more
purposes.
• The ultimate purpose of classification of diseases/disorders is
to improve treatment and prevention efforts.
• The classification of disorders is based on knowledge of
etiology or pathophysiology.

4. INTRODUCTION
• There are two major classification systems for mental disorders: the DSM, used primarily in North
America, and the ICD, used worldwide under the auspices of the World Health Organization
(WHO).
• The mental and behavioural disorders section of the ICD is one of 17 components of a
comprehensive classification of all ‘diseases and related health problems’ and it has to meet the
needs of, and formally secure the approval of, nearly two hundred countries throughout the
world.
• The DSM on the other hand, is produced by a national professional association to meet the needs
of its own members, American Psychiatrists.

5. INTRODUCTION
• Both ICD and DSM are descriptive classifications that categorize mental disorders based
upon a constellation or syndrome of symptoms and signs.
• Structurally, both manuals group related mental disorders into either chapters (DSM) or
diagnostic blocks (ICD).
• The names and diagnostic descriptions for many of the mental disorders in the ICD are
similar to those in the DSM, a consequence of collaboration over the years and a shared
empirical pool from which both have drawn.

6. INTERNATIONAL CLASSIFICATION OF DISEASES (ICD)
• International classifications of mental disorders have existed for over one hundred years but were
poorly developed and had little influence before the late 1960s.
• The International Statistical Classification of Diseases and Related Health Problems, usually called
by the short-form name International Classification of Diseases (ICD), is the international "standard
diagnostic tool for epidemiology, health management and clinical purposes".
• The ICD is maintained by the World Health Organization (WHO) and is designed as a health care
classification system, providing a system of diagnostic codes for classifying diseases, including
nuanced classifications of a wide variety of signs, symptoms, abnormal findings, complaints, social
circumstances, and external causes of injury or disease.

7. ICD REVISIONS
ICD 1
(1893)
The
International
List of Causes of
Death
ICD 2
(1909)
Renamed as
International
Classification of
Causes of
Sickness and
Death
ICD 3
(1919)
ICD 4
(1929)
Transfer to
categories based
on etiology
ICD 5
(1938)
Comparability
between
successive ICD
versions
ICD 6
(1948)
Renamed as
International
Statistical
Classification of
Diseases

8. ICD REVISIONS
ICD 7
(1955)
ICD 8
(1965)
ICD 9
(1978)
Included narrative
MBD descriptions
similar to DSM II
language
Refined classification
and diagnosis of
mental disorders
ICD 10
(1992)
Detailed classification
of over 300 mental &
behavioural disorders
It has a full
alphabetical index &
annex lists other
disorders
ICD 11
(2007)
Each disease entity
will have definitions
that give key
Each ICD entity can
be seen from
different dimensions
or “parameters”.
ICD exists in 41
Languages in
electronic versions
and its expression in
multiple languages
will be systematically
pursued in ICD11

9. ICD 10
CODES CATEGORIES
F00-F09 Organic, including symptomatic, mental disorders.
F10-F19 Mental and behavioural disorders due to psychoactive substance use.
F20-F29 Schizophrenia, schizotypal and delusional disorders.
F30-F39 Mood (affective) disorders.
F40-F48 Neurotic, stress-related and somatoform disorders.
F50-F59
Behavioural syndromes associated with physiological disturbances and physical
factors.
F60-F69 Disorders of adult personality and behaviour.
F70-F79 Mental retardation.
F80-F89 Disorders of psychological development.
F90-F98
Behavioural and emotional disorders with onset usually occurring in childhood and
adolescence.
F99 Unspecified mental disorder.

10. ICD 10
Storage, retrieval, analysis and interpretation of data
Sharing and comparisons: Within populations, Between populations,
Compilation of international data
Health records
Tracking and trending of diseases
Better and more descriptive clinical information
Revised descriptions of “diseases”
Better fit for health information technology systems and electronic
health records

11. ADVANTAGES OF ICD
• Easier comparison of mortality and morbidity data
• Improved quality of data
• The greater level of detail in the new code sets includes laterality, severity, and complexity
of disease conditions, which will enable more precise identification and tracking of specific
conditions.
• Terminology and disease classification are now consistent with new technology and current
clinical practice.

12. ADVANTAGES OF ICD
• Injuries, poisonings and external causes are much more detailed in ICD-10-CM, including the
severity of injuries, and how and where injuries happened. Extensions are also used to
provide additional information for many injury codes.
• There are new concepts that did not exist in ICD-9-CM, such as under dosing, blood type, the
Glasgow Coma Scale, and alcohol level.
• Facilitates more precise diagnosis, which leads to better medical processes and outcomes.
• More Flexibility – Allows for addition of emerging diagnoses and procedures.
• Better patient care and research

13. DISADVANTAGES OF ICD
• The classification is complex and is hard to teach.
• Some subtypes which clinicians frequently use in practice are entirely absent (E.g. Seasonal
Affective Disorder, Postnatal Depression).
• New Training is required: The number of codes in ICD-10 is 150,000; while ICD-9 had 18,000
codes. This is a vast expansion.

14. DISADVANTAGES OF ICD
• Continued use of outdated and insufficient ICD-9 codes.
• No benefit from larger code set included in ICD-10.
• This classification is not suitable in cases where few or no information about
patient is available. In such case only symptoms of disease can be coded that
can be caused by several different medical condition that can be regularly
coded if we have enough information to confirm diagnosis.

15. The Diagnostic and Statistical Manual of
Mental Disorders (DSM)
• The Diagnostic and Statistical Manual of Mental Disorders (DSM), published by the American
Psychiatric Association (APA), offers a common language and standard criteria for the
classification of mental disorders.
• It is used, or relied upon, by clinicians, researchers, psychiatric drug regulation agencies,
health insurance companies, pharmaceutical companies, the legal system, and policy makers
together with alternatives such as the International Statistical Classification of Diseases and
Related Health Problems (ICD).
• Since the initial publication of the DSM, there have been five subsequent editions of this manual
published.

16. REVISIONS OF DSM
DSM I
(1952)
Divided psychological
pathology - neurotic,
psychotic, and
character disorders
DSM II
(1968)
A section on
behavioral
disorders of
childhood,
adolescence & on
Sexual deviations
DSM III
(1980)
Definition of the term “mental disorder”
Diagnostic criteria for each disorder
Multiaxial diagnostic format
Published reliability data from field trials
DSM-III-R
(1987)
Categories were renamed and
reorganized
It merely described the disorders
and did not talk about etiologies

17. MULTIAXIAL SYSTEM
MULTIAXIAL
SYSTEM
DESCRIPTION EXAMPLE
AXIS I
Mental disorder/s that have been diagnosed. A person can suffer from
more than one.
Includes all of the mental health conditions except personality disorders
and mental retardation
Bipolar disorder, Pathological
Gambling
AXIS II Personality disorders or mental retardation (intellectual disability)
Borderline personality disorder,
Moderate mental retardation
AXIS III General medical conditions High Blood Pressure, Asthma
AXIS IV Psychological and environmental factors
Death of a friend, Educational
problems, Housing problems,
Economic problems, Work difficulties
AXIS V
Global Assessment of functioning
Based on psychological wellness
A score of 1-10 indicates that
someone is severely unwell
A score of 91-100 indicates someone
has superior functioning

18. REVISIONS OF DSM
DSM IV
(1994)
The inclusion of a clinical significance criterion
which required symptoms cause “clinically
significant distress or impairment in social,
occupational, or other important areas of
functioning”.
DSM V
(2013)
Eliminated five "axis” diagnostic
system
Includes changes to many diagnostic
categories (e.g. personality disorders)
More emphasis on severity of
symptoms
Organized to follow the lifespan
DSM-IV-TR
(2000)
Each category of disorder has a
numeric code taken from the ICD
coding system
Use of Qualifiers

19. ADVANTAGES OF DSM
• Serves as a Guide Map
• Increase in diagnostic reliability
• Clarifies process of differential diagnosis
• Evidence-Based Treatment
• Consistency and Insurance Coverage
• Facilitates Research
• Legal Benefits

20. DISADVANTAGES OF DSM
Reliability
and Validity
Concerns
Diagnoses
Based on
Superficial
Symptoms
not causes
Differential
Diagnosis Cultural
Bias
Medicalization
and Financial
Conflicts of
Interest
Stigma

21. Critics say…
1. One underlying issue (e.g. severe childhood abuse) can lead to a very large number of diagnoses.
2. May lead to labeling people in ways that undermine identity and self-esteem, and lead to seeing
a disease rather than a person.
3. May lead to expectations about prognosis that become self-fulfilling prophecies (e.g. individuals
with schizophrenia in developing countries have substantially better outcomes than those in
developed countries).
4. The DSM makes the process of diagnosing psychological disorders seem scientific when, in fact,
diagnosis is highly subjective.

22. Critics say…
5. Including relatively minor problems such as caffeine-induced sleep disorder in the DSM will
cause people to liken these problems to serious disorders such as schizophrenia or bipolar
disorder.
6. It can lead to normal problems of living being turned into “diseases.” For example, a child
who displays the inattentive and hyperactive behavior normally seen in young children could
be diagnosed with attention-deficit/hyperactivity disorder by an overenthusiastic clinician.
7. The loss of the multiaxial system may compromise the richness of the diagnostic
assessment.

23. THE INTERNATIONAL CLASSIFICATION OF
FUNCTIONING, DISABILITY AND HEALTH (ICF)
• Traditional health indicators have mostly focused on mortality and morbidity.
• On the other hand, “disability” has been seen as an unrelated entity, either as a medical
issue of bodily impairments such as blindness and deafness or as an imposed restriction on
the individual that hinders him/her from taking part in daily life activities.
• ICF has brought these concepts into a comprehensive whole of multiple dimensions of
human functioning synthesizing biological, psychological, social and environmental aspects.
• ICF, thus, presents health and disability in a single spectrum.

24. ICF…
• The classification was first published for trial purposes in 1980 as the
International Classification of Impairments, Disabilities and Handicaps (ICIDH).
• Since its publication, the classification has been used in a variety of areas and
has specific applications in clinical diagnosis, rehabilitation assessment,
disability policy planning and survey research.
• Under the auspices of the World Health Organization (WHO), ICIDH was revised
and renamed THE INTERNATIONAL CLASSIFICATION OF FUNCTIONING, DISABILITY
AND HEALTH (ICF) in 2001.

25. ICF…
The ICF framework consists of two parts:
FUNCTIONING
& DISABILITY
Body Functions
& Structures
Activity &
Participation
CONTEXTUAL
FACTORS
Environmental
Factors
Personal
Factors
For each of these components, the ICF
provides a hierarchy of classifications
and codes. A person’s functioning is
conceived as a dynamic interaction
between health conditions and
environmental and personal factors.

26. ICF…
• Illustration of functioning associated with cataract• Interaction between ICF components

27. ICF…
• Functioning and disability are viewed as a complex interaction between the health condition
of the individual and the contextual factors of the environment as well as personal factors.
• The classification treats these dimensions as interactive and dynamic rather than linear or
static.
• It is applicable to all people, whatever their health condition. The language of the ICF is
neutral as to etiology, placing the emphasis on function rather than condition or disease.
• It also is carefully designed to be relevant across cultures as well as age groups and genders,
making it highly appropriate for heterogeneous populations.

28. ICF…
The chart gives some
possible examples of
disabilities that may be
associated with the three
levels of functioning linked
to a health condition.

30. ADVANTAGES
• ICF provides a common language and framework for the description of human functioning
and disability as an important component of health and social care. This standardization of
language supports:
improved communication between sectors and people with disabilities;
facilitates the comparison of data nationally and internationally;
establishes a culturally applicable tool covering the whole life span; and can be used in
service event data sets as well as survey questionnaires.

31. ADVANTAGES
• It offers a conceptual framework for information that is applicable to personal health care,
including prevention, health promotion, and the improvement of participation by removing or
mitigating societal hindrances and encouraging the provision of societal supports and
facilitators.
• A taxonomy for documentation of child functioning in: assessment, intervention & outcome
measurement .
• A framework for specifying the Child, the Environment and the Interaction in child-
environment interaction.
• ICF is also useful in Disability certification.

32. ADVANTAGES
• ICF can also be employed as a clinical instrument for evaluation, monitoring treatment
under special conditions, vocational evaluation, rehabilitation in evaluating the functional
abilities, capacity and performance of individuals, and in evaluating the outputs and
success of rehabilitation.
• It is also useful as a statistical instrument for collecting and recording data (prevalence and
incidence of disability, in studies of the population, in research or management of
information systems).

33. DISADVANTAGES
• The disadvantages of ICF are complicated terminology and subjectivity of the assessor.
• Wade and Halligan (2003) highlight the need to specify more about ‘the person’ (i.e. the
individual being considered) in their environment, their society, their body and their organ
and also include a section on the individuals choice: ‘free will’.
• The ICD (International Classification of Diseases and Related Health Problems) classifies
disease, the ICF looks at functioning. Therefore, the use of the two together would provide
a more comprehensive picture of the health of persons and populations.

34. STRENGTHS OF CLASSIFICATION SYSTEMS
• A major advantage of classification systems for mental disorders is that inappropriate behaviours
can be distinguished from functional ones.
• A range of mental disorders are arranged, organised and described in a particular manner and
order.
• Standardize the description and interpretation of mental disorders – provides clarity and
eliminates ambiguity.
• Psychologists and other mental health practitioners use these manuals as they provide a common
language for therapists, researchers, social agencies and health workers worldwide.
• This aids diagnosis, selection of appropriate treatments / therapies for the given conditions.
• It allows for consistent diagnoses and treatments from hospital to hospital, clinic to clinic, all
over the world.
• Serve as an educational tool for teaching psychopathology.

35. WEAKNESSES OF CLASSIFICATION SYSTEMS
• The Classification Systems ‘boxes people into one of the available categories, sometimes
inappropriately, and it does not accommodate the unique nature of the human condition.
• These classifications do not account for people who have ‘atypical’ symptoms or those that
do not clearly follow the ‘script.
• Critics claim that categorical systems reduce humans to one-dimensional sources of data
rather than encouraging practitioners to treat the whole person.
• Critics also see these systems as tools for social control – giving mental health professionals
control over people’s lives.

36. TO CONCLUDE…

37. REFERENCES
Book References
• American Psychiatric Association. (2013). Diagnostic and Statistical Manual for Mental Disorders (5th ed.).
Washington: APA.
• Woo, S.M.,& Keatinge, C. (2008). Diagnosis and Treatment of Mental Disorders Across the Life Span. New Jersey: John
Wiley and Sons, Inc.
• Johnstone,E.C., Owens,D.C., Lawrie, S.M., McIntosh, A.M., & Sharpe, M. (2010). Companion to Psychiatric studies (8th
ed.). Elsevier: Churchill Livingstone.
• Ahuja, N.(2011). A Short Textbook of Psychiatry (7th ed.). New Delhi: Jaypee Brothers Medical Publishers (P) LTD.
• Sadock, B.J., & Sadock, V.A. (2005). Comprehensive Textbook of Psychiatry Vol 1 (8th ed.). New York: Lippincott
Williams & Wilkins.

38. REFERENCES
Journal References
• Blashfield, R.K., Keeley, J.W., Flanagan, E. H., & Miles, S.R. (2014). The Cycle of Classification: DSM-I Through DSM-5. Annual Review
of Clinical Psychology, 10, 25-51. DOI: 10.1146/annurev-clinpsy-032813-153639
• Kawa, S., & Giordano, J. (2011). A brief historicity of the Diagnostic and Statistical Manual of Mental Disorders: Issues and implications
for the future of psychiatric canon and practice. Philosophy, Ethics, and Humanities in Medicine, 201-272.
• Kostanjsek, N. (2011). Use of The International Classification of Functioning, Disability and Health (ICF) as a conceptual framework and
common language for disability statistics and health information systems. BMC Public Health, 11(4), S3. doi: 10.1186/1471-2458-11-S4-
S3
• Švestková, O., Sládková, P., & Kotková, K. (2016). Application of international classification of functioning, disability and health (ICF),
functional health and disability. Cent Eur J Public Health, 24 (1), 83–85. http://dx.doi.org/10.21101/cejph.a4140

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41. THANK
YOU