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CLASSIFCTN (2).pptx
- 1. 27-06-2023 1
- 2. Diseases have existed as time immemorial and it is our understanding of the diseases that has changed over the time with advances This evolution of our knowledge is reflected in our classification systems. 27-06-2023 2
- 3. Syndrome Disease Disorder Syndrome- is a constellation of symptoms that are unique as a group. May contain some symptoms that occur in other syndromes. It is the particular combination of symptoms that makes the syndrome specific Etiology variable Disease - is a condition with specific etio- pathogenesis and has biomedical connotation. Disorder- is term midway b/w the above two in means of significance, consistency and correlates. Cource , outcome and prognosis known. 27-06-2023 3
- 4. Concept of Classification Every patient has three kind of characteristic:- Universal, shared with all others Shared with some but not others Unique, shared with no others Classification depends on B relative to A & C It is the process by which the complexity of phenomenon is reduced by arranging them into categories according to some established criteria for certain purposes. (kendel RE, criteria for assessing a classification in psychiatry ..west sussex, psychiatric diagnosis and classification 2002) 27-06-2023 4
- 5. Purpose of Classification Communication:- about the disorder, summarizing it Control :- refers to treatment and prevention, ultimate purpose of any classification. Comprehension :- cause of disorder, process in their development and maintenance. Desired as leads to more effective control. Comprehension is not served in the present systems due to limitation of the understandings of the psychiatric disorders. 27-06-2023 5
- 6. Importance of clearly defining a psychiatric disorder Influences the estimates of the psychiatric morbidity burden on the community Legal implication in criminal cases and disability benefits Lack of clarity leads to abuse of the diagnosis Lack of clear definition leads to reduce confidence in the discipline of psychiatry 27-06-2023 6
- 7. Ideally classification be based on knowledge of etiology or path physiology – improves T/t and prevention efforts. Psychiatry – defined and classified mostly on the basis of their clinical syndromes. 27-06-2023 7
- 8. Constituents for good classification Reliability :- shows how far errors of measurement have been excluded from assessment Improved by- operational diagnostic criteria, structured interviews It establishes ceiling for validity Validity :- how far a test measures actually, what it is supposed to measure Utility :- assessed by its impact on three domains : use, decision making and clinical outcome. Ease of use Applicability across settings and cultures. Meets need for various users : Clinicians, researchers 27-06-2023 9
- 9. Categorical v/s Dimensional Psychiatric disorders traditionally classified categorically Patients may not fit neatly into the available categories Problem of comorbidities Dimensional system solves problem assoc with boundaries and comorbidity But these not of great value in clinical practice, in terms of decision for t/t and disorder meriting t/t Pluralistic view- eg categorical for eating disorders etc and dimensional for GAD, PTSD. (haslam et al, categorical v/s dimensional model, 2003- Aust NZ J Psy) 27-06-2023 10
- 10. 27-06-2023 11
- 11. Classification systems DSM 5 ICD 11 27-06-2023 12
- 12. History ICD - WHO Used -Europe, Africa and Asia 1948 - ICD 6 ICD 7 1955 ICD 8 1965 ICD 9 1975 ICD 10 1992 ICD-11 2022 New Oxford Textbook of Psychiatry. Third Edition, Oxford University Press; 2020. DSM-I by APA- 1952 DSM-II 1968 DSM-III 1980 DSM-IV 1994 DSM-IV TR 2000 DSM-5 2013
- 13. ICD 11 • 2007- International advisory group • 2015 - Beta draft available publicly • May 2019- 72nd WHA • Implemented from 01 Jan 2022 • Chapter 06 Mental, Behavioural or Neurodevelopmental Disorders (MBND) Gaebel W, Stricker J, Kerst A. Changes from ICD-10 to ICD-11 and future directions in psychiatric classification Dialogues Clin Neurosci. 2020;22(1):7-15.
- 14. ICD 10 & ICD 11
- 15. 27-06-2023 16
Editor's Notes
- are unlikely to find single gene underpinnings for most mental disorders, which are more likely to have polygenetic vulnerabilities interacting with epigenetic factors (that switch genes on and off ) and environmental exposures to produce disorders. Biological or social mark that sets a person apart from others, is discrediting and disrupts interactions with others It is clear that a hierarchy was present that tended to suppress the significance of lower-order symptoms in the syndrome definitions in order to achieve such pure types. This hierarchical arrangement of disorders was implicit in the Kraepelinean classification tradition of ranking organic mental disorders, nuclear schizophrenia, manic-depressive illness, and neurotic illnesses from higher- to lowerorder conditions (16). It was followed by an explicit statement of Jaspers: “The principle of medical diagnosis is that all the disease-phenomena should be characterized within a single diagnosis…in any one person” we now have a plethora of comorbidity—because patients do not usually have only mood, somatic, or anxiety symptoms but tend to come with a mix from multiple symptom groups. Hence, we have heterogeneous conditions within single diagnostic groups, a remarkably high rate in specialty mental health settings of “not otherwise specified” (NOS) diagnoses that do not quite fit the existing criteria, as well as high rates of “subsyndromal” mixed anxietymood- somatic disorders in primary care settings
- Korsakoff’s syndrome illustrates the progression from symptom to syndrome to disease. Initially, confabulation and impressibility among alcoholics were recognised by Korsakoff as significant symptoms. Later the presence of disorientation for time and place, euphoria, difficulty in registration, confabulation and ‘tram-line’ thinking were identified as key features of this syndrome. Finally, the discovery that in the alcoholic amnestic syndrome there was always severe damage to the mammillary bodies confirmed that Korsakoff ’s psychosis (syndrome) is a true disease with a neuropathological basis.
- Taxonomy is the metatheory of classification including systematic study of carious strategies of classification. Classification is pointless in A and in C it is iimpossible.
- Classical taxonomic strategy: Monothetic approach -The candidate must meet exactly the set of necessary and sufficient criteria that define a given class (e.g., periodic table of elements). Numerical taxonomy: Polythetic approach - The candidate must meet a certain number of criteria to qualify for a diagnosis (e.g., diagnosis of schizophrenia in ICD-10 and DSM-IV). Prototype matching procedure: Polythetic approach - Diagnosis is made according to how close a candidate meets a prototype.
- Reliability- consistency of a set of measurements or of a measuring instrument, often used to describe a test. test retest, interrater Internal consistency reliability, assesses the consistency of results across items within a test. reliability is analogous to precision, while validity is analogous to accuracy. Validity (well-founded and applicable; sound and to the point; against which no objection can fairly be brought) Diagnostic validity is a complex multifaceted construct that has historically been adapted from the field of psychological testing and includes a number of different types of validity. These include the following: 1. Face validity whether the description of a category and its diagnostic criteria seem to accurately describe the disorder. 2. Descriptive validity whether the features of a category are unique to that category relative to other mental disorders. 3. Predictive validity The extent to which having a diagnosis predicts future clinical course, complications, and treatment response. 4. External or construct validity The extent to which the diagnosis correlates with expected external vali-dators, such as family history and neurobiological markers. Robins and Guze (1970) were 1st to advance formal methods of determining validity of a diagnosis. Clinical descriptions Laboratory studies Specification of exclusion criteria Follow up studies Family studies Utility if it provides nontrivial information about prognosis and likely treatment outcomes, and/or testable propositions about biological and social correlates
- Categorical- clear boundaries b/w entities or b/w disorder and the absence of them; widespread acceptance in psychiatry and other fields, and have generally been found to have improved inter-rater reliability Dimensional – lack of clear demarcation. dimensions are better suited to the portrayal of variation in populations than day-to-day decisions about the treatment of individuals. difference in the discriminative power may be rather small. Taxometric analysis -0 statistical method of examining wether the interrelationship among the defining feature of a disorder better fit a dim/catego model
- Classifcatory systems in 18th and 19th century were mainly for fatal diseases and mortality statistics Need was felt for morbidity statistics…assigned to WHO Post world war 2, WHO was established as specialized agency of UN in health . All members agreed collecting mortality statistics on causes of death and morbidity statistics of known medical and mental disorders to develop comparable national and international health statistics- ICD 6 : mental disorders subsection - Comprehensive classification of all “diseases and related health problems” Although APA contributed in icd 6 mental disorders sub section, it published a separate DSM I based on views mental disorders as psychobiological reactions to critical life and dev events. ICD 8 - 1965 : few-sentence descriptions, organic-functional dichotomy, psychotic-neurotic While publishing ICD 8 WHO noted disparity btw diff national nomenclatures and lists of mental disorders throughout the world and appointed a british psychiatrist Erwin Stengel to look into it His proposal of “operationalized definitions “ basd on observation tht could be reliably reported was not accepted in publishing ICD 8 nor DSM II in 1968 (based on psychoanalitical approach/theories of etiology) But this was later considered in publication of DSM III in 1980 DSM III- marked a paradigm shift from the psychoanalytical approach Explicit diagnostic criteria based on descriptive approach Introduced multi axial system DSM IV-TR (text revision) -to make the diagnostic codes consistent with the ICD Need was felt to bring greater international agreement on definitions and opeartionalised criteria fro mental disorders and this was implemented for ICD 10
- WHA world Health Assembly Advisory group- reviewed avlb evidence and proposed changes Beta draft avlbl for review and comments Additionally feedback from mental health professionals was obtained via field formative studies (global survey of psychiatrists attitude towards mental disorders classification- 4887 psychiatrists)
- Changes from ICD-10 to ICD-11 include the introduction of new diagnoses, the refinement of diagnostic criteria of existing diagnoses, and notable steps in the direction of dimensionality for some diagnoses.
- A classification therefore has only provisional value. It is a fiction which will discharge its function if it proves to be the most apt for the time