KLASIFIKASI DALAM PSIKIATRI

Sumber: PPDGJ 3, ICD X, DSM IV,

Tujuan Sistem Klasifikasi

Komunikasi: diantara para klinisi , ilmuwan dan praktisi Klinisi : memfasilitasi identifikasi terapi dan pencegahan gangguan mental Periset : menguji efikasi terapi dan pemahaman etiologi Edukasi: mengajarkan psikopatologi Manajemen Informasi : mengukur dan menghitung anggaran perawatan

Apa yang dimaksud dengan Normal?

Average

SupraThreshold

Ideal

Apa yang disebut Abnormal?

Definisi : Deviasi Statistik Melanggar norma sosial Distress subyektif Disabilitas atau disfungsi Perilaku abnormal tidak selalu merupakan indikasi gangguan mental

Gangguan Jiwa-Definisi

Secara klnis bermakna Behavioral atau psikologik. Pola atau sindrom . Terkait dengan . Ada Distress ATAU . Disabilitas/Hendaya ATAU . Terdapat peningkatan risiko . Membuat penderitaan, kematian, sakit, disabilitas, atau kehilangan kebebasan

Definisi Gangguan Mental II

Sindroma atau pola perilaku Tidak diharapkan secara kultur/norma budaya ketika individu menemui kejadian tertentu (kematian , atau kehilangan sesuatu yang dicintai ) Adanya manifestasi disfungsi perilaku, psikologik, atau biologik Adanya perilaku menyimpang (politik, religi, seksual) ataupun konflik antara individu dan masyarakatnya Disfungsi individu

Patologi ?

Tanda/ Simtom Sindrom Gangguan Sakit Penyakit

Dari Sindroma ke Penyakit

Sindroma serangkaian tanda dan simtom yang sering terjadi bersamaan Gangguan conjunction sindroma dengan perjalanan klinis Penyakit conjunction etiologi dan patologi. Penyakit sesungguhnya : simtom, patologi, patofisiologi dan penyebab yang mendasari dan yang diketahui adanya relasi diantara semuanya Illness/kesakitan- aspek psikososial dari si sakit

Diagnosis Psikiatri

Langkah I: Normal vs. Abnormal Konsep kesehatan dan penyakit Langkah II: cara membangun diagnosis Apa yang tertera dalam PPDGJ 3/ICD 10/DSM IV dan cara menyusunnya Kontroversi/Polemik /Hype

Langkah Pertama

Kenali - Dis-Order: tidak dalam aturan/runutan , cara ia muncul dalam perilaku Simtom menimbulkan distress subyektif dan/atau secara bermakna mengganggu. Discuss: Homosexuality, Grief vs. Pathological Grief, Fetishism, Voyerism, transverstism, Exhibitionism

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.

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

distress or danger

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

Mental disorder

organic

functional

substance

Medically

DD of Psychosis with Mood Disorder

Psychosis Symptoms of sc Lasting 1 m. Depression or mania

medical

substance

Duration long

Duration short

sz

At least two weeks In the absence of Mood schizoaffective

Mental disorder

affective

Non-affective

psychotic

Non-psychotic

psychotic

Non-psychotic

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

Definitions of Depression

Symptoms Episodes Disorders

Major Depressive Disorder Bipolar Disorder Dysthymia Depressive Disorder NOS (e.g. subthreshold depression)

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

Symptoms of Depression, cont.

Physical Symptoms

Weight loss or weight gain Psychomotor agitation or retardation Insomnia or hyposomnia Fatigue or loss of energy

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

DSM-III Paradigm Shift

Descriptive Non-etiologic focus Diagnostic criteria Multiaxial system Multiple diagnoses Splitting Reliability

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

Categorical vs. Dimensional Systems

Categorical

Dimensional

Presence/absence of a disorder Either you are anxious or you are not anxious. DSM is categorical
Rank on a continuous quantitative dimension How anxious are you on a scale of 1 to 10?

Dimensional systems may better capture an individuals functioning but the categorical approach has advantages for research and understanding

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

Assessment Issues: Reliability

Diagnosis

Kappa

Reliability

Consistency of measurement

Interrater reliability
Extent to which clinicians agree on the diagnosis.

Bipolar Disorder Major Depression Schizophrenia Alcohol Abuse Anorexia Bulimia Panic Disorder Social Phobia

.84 .64 .65 .75 .75 .86 .58 .47

Whats 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

Multiaxial System

AXIS I: Clinical Disorders Other Conditions That May Be a Focus of Clinical Attention
Diagnostic Code DSM-IV Name 300.21 Panic Disorder with Agoraphobia, Moderate 304.10 Diazepam Dependence, Mild ___.__ ____________________________________

AXIS II: Personality Disorders

Diagnostic Code DSM-IV Name 301.82 Avoidant Personality Disorder ___.__ Dependent Personality Features___________

AXIS III: General Medical Conditions

ICD-9-CM code 424.0 ICD-9-CM name Mitral Valve Prolapse ___.__

Multiaxial System
Axis IV: Psychosocial and Environmental Problems Check:
Specify: Marital Discord Problems related to the social environment Specify:___________ Educational problems Specify:_____________________________ X Occupational 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 X Problems with primary support group

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

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)

Diagnostic Groupings and Examples

Disorders Usually Evident in Infancy, Childhood or Adolescence

1. 2. 3. 4. 5.

Autism Attention Deficit-Hyperactivity Disorder Conduct Disorders Mental Retardation (Axis II) Tourettes

1. 2. 3. 4.

Delirium, Dementia and Cognitive Disorders

Delirium Dementia of the Alzheimers Type Vascular Dementia Amnestic Disorder

Diagnostic Groupings and Examples

1. 2. 3. 4.

Substance Related Disorders

Alcohol Dependence Cannabis Abuse Hallucinogen-Induced Psychotic Disorder Opiate Withdrawal

1. 2.

Psychotic Disorders
Schizophrenia Delusional Disorder

1. 2. 3.

Mood Disorders
Major Depressive Disorder Bipolar Disorder Dysthymia

Diagnostic Groupings and Examples

1. 2. 3.

Anxiety Disorders
Panic Disorder with Agoraphobia Post-Traumatic Stress Disorder Obsessive-Compulsive Disorder

1.
2.

Somatoform Disorders
Somatization Disorder Hypochondriasis

1. 2.

Factitious Disorders and Malingering

Factitious Disorder (Munchhausens)0 Malingering

Diagnostic Groupings and Examples

1. 2.

Dissociative Disorders Eating Disorders

Dissociative Identity Disorder Depersonalization Disorder Anorexia Nervosa Bulimia Nervosa

1. 2.

1. 2.

Sleep Disorders
Narcolepsy Sleep Terror Disorder

1. 2.

Sexual, Gender Identity Disorders

Premature Ejaculation Paraphilias

Diagnostic Groupings and Examples

Adjustment Disorders

1.

Adjustment Disorder with Mixed Anxiety and Depressed Mood

1. 2.

Personality Disorders (Axis II)

Borderline Personality Disorder Obsessive-Compulsive Personality Disorder

1. 2.

Impulse Control Disorders

Trichotillomania Pathological Gambling

1. 2. 3.

Other Conditions (Including V Codes)

Relational Problems Sexual Abuse of a Child Bereavement

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

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

Controversies

Brainless vs. Mindless Psychiatry Inventing New Diagnoses

e.g. Premenstrual Dysphoric Disorder

Social Labeling Cultural Relativism Primary Care vs. Sepciality Focus

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

Assessment Issues: Validity

Construct validity

Extent to which diagnosis is related to, or predictive of, a network of diagnostic hypotheses. Validity of DSM diagnostic categories varies.