This document discusses classification in psychiatry and the goals and challenges of developing a psychiatric classification system. It addresses what constitutes normal versus abnormal behavior and the definition of a mental disorder. It describes the multiaxial system used in the DSM and provides examples of diagnostic groupings. It also discusses issues regarding reliability and validity in psychiatric diagnosis and controversies surrounding classification.

1. Classification in Psychiatry
Professor Shmuel Fennig, M.D
Shalvata Mental Health Center
Hod Hasharon

3. Goals of a Classification
System
 Communication: among clinicians, between
science and practice
 Clinical: facilitate identification treatment, and
prevention of mental disorders
 Research: test treatment efficacy and
understand etiology
 Education: teach psychopathology
 Information Management: measure and pay
for care

5. What is Normal?
Average
Supra-
Threshold Ideal

6. What is abnormal?
Your uncle consumes a quart of
whiskey each day; he has trouble
remembering the names of people
around him
Your friend complains of many physical
problems and sees 2-3 doctors each
week

7. What is abnormal?
Your neighbor sweeps, washes, and
scrubs his driveway daily
Your cousin is pregnant and she is
dieting so that she will not get “too fat”.

8. What is Abnormal?
Possible definitions:
 Statistical deviation
 Violation of social norms
 Subjective distress
 Disability or dysfunction
 Abnormal behavior does not necessarily
indicate mental illness

9. Definition of a Mental Disorder
 Clinically significant ….
 Behavioral or psychological….
 Pattern or syndrome….
 Associated with….
 Present Distress OR ….
 Disability/impairment Or….
 With significantly increased risk of….
 Suffering death, pain, disability or an
important loss of freedom

10. Definition of a Mental DisorderII
 This syndrome or pattern…
 Must not be merely an expectable/culturally
sanctioned response to particular event (death of a
loved one)
 Considered a manifestation of a behavioral,
psychological or biological dysfunction in the
individual
 Neither deviant behavior (e.g political. Releigeous or
sexual) nor conflicts between individual and society
are mental disorders
 Unless they represent a dysfunction in the individual

11. What is Pathology?
 Sign/symptom
 Syndrome
 Disorder
 Disease
 Illness

12. From syndrome to disease
 Syndrome – a set of signs and symptoms that
co-occure at a greater than chance frequency
 Disorder – conjunction of a syndrome with a
clinical course
 Disease – conjunction of etiology and
pathology. True disease: symptoms,
pathology, pathophysiology and underlying
causes are known as well as the relationship
between them
 Illness- the psychosocial aspect of being sick

13. Psychiatric Diagnosis
 Step I: Normal vs. Abnormal -Concepts
of health and disease
 Step II: how to build a diagnosis
 What is DSM IV and how does it work?
 Controversies/Polemics/Hype

14. First Step
 Determine that this is a Dis-Order: what
are the boundaries between “this” what
is presented, and normal behavior
 Symptoms cause a subjective distress
and/or a clinically significant
disturbance. Discuss: Homosexuality,
Grief vs. Pathological Grief, Fetishism,
Voyerism, transverstism, Exhibitionism

15. First Step II
 The boundaries from
normality: Sex
 Paraphilia as an
example: recurrent,
intensely sexually
arousing fantasies,
sexual urges or sexual
behaviors that involve
nonhuman objects, the
suffering of self or
partner, children or non
consenting partner.

16. First Step II
 To qualify as a DSM-IV
diagnosis these
patterns must have
existed at least six
months and they have
cause clinically
significant impairment in
social, occupational or
some other important
area of functions,
subjective disress or
danger

17. Second Step
 Determine what are the symptoms and
signs and their temporal relationship:
are the symptoms cluster belong to
psychosis, affective disorder, cognitive
impairement, etc
 Course
 Axis: II personality, mental retardation,
axis III, stressors (Axis IV), GAF

18. Mental disorder
Medically
organic functional
substance

19. DD of Psychosis with Mood
Disorder
Psychosis
medical substance
Symptoms of sc
Lasting 1 m.
Depression or mania
Duration short
sz
Duration long
At least two weeks
In the absence of Mood
schizoaffective

20. Mental disorder
Non-affectiveaffective
psychotic Non-psychotic psychotic Non-psychotic

21. Another Practical approach to
Mental Disorders
Organic (medical or substance) vs. non
organic
Psychotic vs. non psychotic
If Psychotic with or without affective
symptoms
Or Affective with or without psychotic
symptoms
Severe Mental Disorders vs. “Soft Psychiatry

22. Definitions of Depression
 Symptoms
 Episodes
 Disorders
 Major Depressive Disorder
 Bipolar Disorder
 Dysthymia
 Depressive Disorder NOS (e.g. subthreshold
depression)

23. Symptoms of Depression
 Mood Symptoms
- Depressed mood or
irritability
- Loss of interest or
pleasure in most
activities
- Feelings of worthlessness
or guilt
- Thoughts of death or a
desire to die
• Cognitive Symptoms
- Difficulty thinking,
concentrating, or making
decisions

24. Symptoms of Depression,
cont.
 Physical Symptoms
 Weight loss or
weight gain
 Psychomotor
agitation or
retardation
 Insomnia or
hyposomnia
 Fatigue or loss of
energy

25. Depressive Episodes
 Major Depressive Episode
 Depressed mood or loss of interest or
pleasure in most activities, plus 5 of 9
symptoms

Most of the day, nearly every day for a
minimum of 2 weeks

Combinations of symptoms may vary
significantly from individual to individual
 Significant functional impairment or
interference
 Manic, Mixed, and Hypomanic Episodes

26. DSM-III Paradigm Shift
• Descriptive
• Non-etiologic focus
• Diagnostic criteria
• Multiaxial system
• Multiple diagnoses
• Splitting
• Reliability

27. DSM-III Advantages
• Improved reliability
• Facilitated communication within and
between research and clinical communities
• Wide use by clinicians, researchers,
educators, trainees
• Promoted emphasis on empirical data
• Methodological and content innovations

28. Categorical vs. DimensionalCategorical vs. Dimensional
SystemsSystems
 CategoricalCategorical
 Presence/absence of a disorderPresence/absence of a disorder
 Either you are anxious or youEither you are anxious or you
are not anxious.are not anxious.
 DSM isDSM is categoricalcategorical
 DimensionalDimensional
 Rank on a continuous quantitativeRank on a continuous quantitative
dimensiondimension
 How anxious are youHow anxious are you on a scaleon a scale
of 1 to 10?of 1 to 10?
 Dimensional systems may betterDimensional systems may better
capture an individual’s functioningcapture an individual’s functioning
but the categorical approach hasbut the categorical approach has
advantages for research andadvantages for research and
understandingunderstanding

29. Categorical and Dimensional
Systems
 DSM-IV is a categorical system:
categories may share features (criteria)
and may share members (both
diagnoses in the same individual)
 Dimensional: no discrete categories.
Pathology represent a statistical
deviation from the norm.
 Combination of the two: severity, GAF

30. Assessment Issues: ReliabilityAssessment Issues: Reliability
Diagnosis Kappa
Bipolar Disorder .84
Major Depression .64
Schizophrenia .65
Alcohol Abuse .75
Anorexia .75
Bulimia .86
Panic Disorder .58
Social Phobia .47
 ReliabilityReliability
 Consistency ofConsistency of
measurementmeasurement
 Interrater reliabilityInterrater reliability
– Extent to whichExtent to which
clinicians agree onclinicians agree on
the diagnosis.the diagnosis.

31. What’s in DSM-IV
 Systematic framework
for diagnosis (including
multiaxial system)
 Names and codes (from
ICD-9cm)
 Diagnostic criteria
 Detailed text
 Appendices to expand
educational/practical
utility
 Primary Care version

32. Multiaxial System
AXIS I:Clinical Disorders
Other Conditions That May Be a Focus of Clinical Attention
Diagnostic CodeDSM-IV Name
300.21Panic Disorder with Agoraphobia, Moderate
304.10Diazepam Dependence, Mild
__._______________________________________
AXIS II: Personality Disorders
Diagnostic CodeDSM-IV Name
301.82Avoidant Personality Disorder
___.__Dependent Personality Features___________
AXIS III: General Medical Conditions
ICD-9-CM codeICD-9-CM name
424.0Mitral Valve Prolapse
__._______________________________________

33. Multiaxial System
Axis IV: Psychosocial and Environmental Problems
Check:
XProblems with primary support groupSpecify: Marital
Discord
Problems related to the social environment
Specify:___________
Educational problems
Specify:_____________________________
XOccupational problems Specify: Excessive Work Absences
Housing problems
Specify:________________________________
Economic problems
Specify:_______________________________
Problems with access to health care services
Specify:__________
Problems related to the legal system/crime
Specify:___________
Other psychosocial and environmental problems

34. Diagnostic Approach
 Presenting symptom - e.g. depressed mood
 Rule out disorder due to general medical
condition – e.g. due to hypothyroidism
 Rule out disorder due to direct effects of a
substance - e.g. alcohol induced, reserpine
induced
 Determine specific primary disorder(s)
 Multiple diagnoses
 Some hierarchies
 “Not better accounted for…”

35. Diagnostic Approach
 Distinguishing Adjustment Disorder from Not
Otherwise Specified (NOS) – e.g. response to
stressor
 Establishing boundary with no mental
disorder - i.e. clinical significance/cultural sanction,
i.e. bereavement
 Add subtypes/specifiers
 severity (mild moderate, severe – with or without
psychotic features)
 treatment relevant (melancholic, a typical, etc.)
 longitudinal course (with/without full interepisode
recovery, seasonal pattern)

36. Diagnostic Groupings and
Examples
 Disorders Usually Evident in Infancy,
Childhood or Adolescence
1. Autism
2. Attention Deficit-Hyperactivity Disorder
3. Conduct Disorders
4. Mental Retardation (Axis II)
5. Tourette’s
 Delirium, Dementia and Cognitive Disorders
1. Delirium
2. Dementia of the Alzheimer’s Type
3. Vascular Dementia
4. Amnestic Disorder

37. Diagnostic Groupings and Examples
 Substance Related Disorders
1. Alcohol Dependence
2. Cannabis Abuse
3. Hallucinogen-Induced Psychotic Disorder
4. Opiate Withdrawal
 Psychotic Disorders
1. Schizophrenia
2. Delusional Disorder
 Mood Disorders
1. Major Depressive Disorder
2. Bipolar Disorder
3. Dysthymia

38.  Anxiety Disorders
1. Panic Disorder with Agoraphobia
2. Post-Traumatic Stress Disorder
3. Obsessive-Compulsive Disorder
 Somatoform Disorders
1. Somatization Disorder
2. Hypochondriasis
 Factitious Disorders and Malingering
1. Factitious Disorder (Munchhausen’s)0
2. Malingering
Diagnostic Groupings and
Examples

39. Diagnostic Groupings and
Examples
 Dissociative Disorders
1. Dissociative Identity Disorder
2. Depersonalization Disorder
 Eating Disorders
1. Anorexia Nervosa
2. Bulimia Nervosa
 Sleep Disorders
1. Narcolepsy
2. Sleep Terror Disorder
 Sexual, Gender Identity Disorders
1. Premature Ejaculation
2. Paraphilias

40. Diagnostic Groupings and
Examples Adjustment Disorders
1. Adjustment Disorder with Mixed Anxiety and
Depressed Mood
 Personality Disorders (Axis II)
1. Borderline Personality Disorder
2. Obsessive-Compulsive Personality Disorder
 Impulse Control Disorders
1. Trichotillomania
2. Pathological Gambling
 Other Conditions (Including “V Codes”)
1. Relational Problems
2. Sexual Abuse of a Child
3. Bereavement

41. DSM-IV Text
 Essential Features
 Associated Features (including physical
exam and lab findings)
 Recording Procedures
 Age, Gender, and Culture Features
 Prevalence, Course, Familial Pattern
 Differential Diagnosis

42. DSM-IV Appendices
 Decision Trees for Differential
Diagnosis
 Criteria Sets and Axes Provided for
Further Study
 Glossary of Technical Terms
 Alphabetical and Numerical Listings
 Codes for Selected General Medical
Conditions
 Cultural Formulation and Glossary

43. Controversies
 Brainless vs. Mindless Psychiatry
 “Inventing” New Diagnoses
 e.g. Premenstrual Dysphoric Disorder
 Social Labeling
 Cultural Relativism
 Primary Care vs. Sepciality Focus

44. Conceptual Tensions:
Past and Present
• Phenomenology vs. course vs. etiology
• Descriptive vs. theoretical
• Categorical vs. dimensional
• Symptom vs. syndrome vs. disease
• Reliability vs. validity vs. clinical utility
• Lumping vs. splitting
• Clinical vs. research vs. administrative
purposes

45. Assessment Issues: ValidityAssessment Issues: Validity
 Construct validityConstruct validity
 Extent to whichExtent to which
diagnosis is related to,diagnosis is related to,
or predictive of, aor predictive of, a
network of diagnosticnetwork of diagnostic
hypotheses.hypotheses.
 Validity of DSMValidity of DSM
diagnostic categoriesdiagnostic categories
varies.varies.