Classification-of-Psychiatric-Disorders

2.  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

3. 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

4. CONTROL:
 Knowledge of the course of disorder
 Prevention of their recurrence and modification of
their courses with treatment

5. 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

6.  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.

7.  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

8.  Henry Brill (chairman of the APA committee on
nomenclature and statistics)delineated 6 advantages
of the then current nomenclature i.e. DSM II
1.Widespread use , thereby facilitating communication
amongst professionals
2.Clear definition and delineation of the disorders
3.Compatibility with ICD diagnostic system
4. Clear guidelines for compilation and reporting of
patient diagnostic data
5.Comprehensive collection of diagnostic term in one
source
6.Ease of use

9.  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

10.  First DSM to offer definition in DSM III
 “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

11.  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

12.  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

13.  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)

14.  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

15.  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
1.Temporary symptom complex
2.The distinction between organic and nonorganic
mental disorder
3.Considering the patient’s age at the time of onset
and the characteristic development of the disorder
as basis of classification

16.  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
manic-depressive 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

17.  Kraeplin’s 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

18.  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 Association’s Standard Classified
Nomenclature of Disease

19.  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

20.  1840 US census
Idiocy (insanity)
 1880 US census
Mania
Melancholia
Monomania
Paresis
Dementia
Dipsomania
Epilepsy

21.  Mania
 Melancholia
 Periodical insanity
 Progressive systematic insanity
 Dementia
 Organic and senile dementia
 General paresis
 Insane neurosis
 Toxic insanity
 Moral and impulsive insanity
 Idiocy etc

22.  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

23.  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

24.  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

25.  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

26.  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

27.  1972 –Feighner’s 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

28.  DSM III – 1980
 DSM III R – 1987
 DSM IV – 1994
 DSM IV TR - 2000

29.  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

30.  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

31.  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

32.  Published among criticism that it was published
within a short period of time
 Mark Zimmerman argued the problems of the period
being too short
1.Insufficient time for accumulation of research
2.Expenditure of resources
3.Difficulty in interpreting and resolving discrepant
research findings based on different criteria set
4.Increased no of diagnostic errors due to lack of time
to learn the nuances
5.Impeded communication
6.Frustration in patients to have their diagnoses
changed

33.  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

34.  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

35.  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

36.  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

37. 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

38. 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

39.  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

40.  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 TR’s categorical system, which
is the traditional method of medical classification,
seems appropriate at this time because its more
useful in clinical practice

41.  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

42.  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

43.  One of the 21 chapters (chapter V) of WHO’s 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

44.  1853, the first International Statistical Congress held
in Brussels asked William Farr and Marc d’Espine 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

45.  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

46.  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 four-
digit categories (e.g., F20.0, simple
schizophrenia) had a title that described the
group of conditions in full and could stand alone

47.  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

48.  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)

49.  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)

50. 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

51. 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

52.  Depressive personality disorder is not included in
ICD−10 and is only incorporated in the section of
DSM−IV entitled ‘Criteria sets and axes provided
for further study’.
 Passive−aggressive personality disorder was
included in DSM−III but excluded from the
subsequent edition, and has never been
incorporated into the ICD 10
 Brief depressive disorder is a new addition to
ICD−10 but only appears in the appendix of DSM−IV
system.
 Schizotypal disorder is classified with the
schizophrenic disorders in ICD−10 and with the
personality disorders in DSM−IV.

53.  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

54. #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

55.  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.

56.  The Chinese Society of Psychiatry's Chinese
Classification of Mental Disorders currently
CCMD-3
 published by the Chinese Society of
Psychiatry (CSP), is a clinical guide used
in China for the diagnosis of mental disorders.
 It is currently on a third version, the CCMD-3,
written in Chinese and English.
 It is intentionally similar in structure and
categorization to the ICD and DSM, the two most
well-known diagnostic manuals, though includes
some variations on their main diagnoses and
around 40 culturally-related diagnoses

57.  The Latin 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)
 The French Classification of Child and
Adolescent Mental Disorders(CFTMEA)

58.  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 addictions’-
gambling
 New suicide scales
 New ‘risk syndromes’ category – earlier stages
 New ‘temper dysregulation with dysphoria’
(TDD) within mood disorders
 Improved criteria for eating disorders

59.  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

60.  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

61.  Absexual
 Complex PTSD
 Depressive personality disorder
 Negativistic personality disorder
 Relational disorder
 Sluggish cognitive tempo
 Binge eating

62.  ICD-11 2014
 Beta draft with proposed changes coming out in
May 2012 on the website
 potential ”harmonization” of the corresponding
category sections for DSM-5 (Somatic Symptom
Disorders) and ICD-11(Somatoform Disorders).

63.  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