APPROACH TO CLASSIFICATION

OF MENTAL DISORDERS

Introduction

The classification of illnesses (nosology) has always been an integral part of the theory and practice of medicine. Nosology is the study and practice of classification in medicine. The basic purpose of classification is data reduction or condensation of information.

Classification, is a systematic arrangement of the world in order to master the otherwise chaotic entities and structures, and corresponds to the structure of human thinking.

PURPOSE OF CLASSIFICATION To enable clinicians to Communicate with one another about the diagnoses given to their patient. To understand the implication of these diagnosis in terms of their symptoms, prognosis, treatment, and sometimes aetiology To relate findings of clinical research to patients seen in everyday practices

PURPOSE OF CLASSIFICATION cont. To facilitate epidemiological studies and the collection of reliable statistics. To ensure that research can be conducted with compariable group of subjects

HISTORY OF CLASSIFICATION

Psychiatric illnesses were widely recognized in the ancient world. Melancholia and hysteria were identified in Egypt and Sumeria as early as 2600 BC. In India a psychiatric nosology was contained within the medical classification system of the Ayur-Veda, written about 1400 BC.

Ancient classification

In Ancient Greece, Hippocrates and his followers are generally credited with the first classification system for mental illnesses, including mania, melancholia, paranoia, phobias an d Scythian disease (transvestism). They held that they were due to different kinds of imbalance in four humors.

Ancient classification Senile deterioration Melancholia & hysteria Oldest systematic classification in Ayur - veda
3000 B.C. 2600 B.C. 1400 B.C.

Ancient classification :18th Cent. Philippe pinel (1745 1826)

functional disorders of nervous system 4 types
Mania, Melancholia, Dementia, Idiotism

Father of modern psychiatry.

Ancient classification :19th Cent. Karl ludwig kahlbaum1828-1899)

distinguished organic & non organic mental disorder.

Wilhelm griesinger (1818-1868)

Mental diseases are brain diseases

Ancient classification :20th Cent. Emil kraepelin(1856- 1926)

classified on basis of cause, course outcomes manic depressive psychosis dementia praecox were main. Based on clinical features.

Adolf meyer (1866 1952)

Disorder is pathological reaction to environmental stresses.

Ancient classification :20th Cent. Eugen bleuler - Combined Kraepelin & Meyerian approaches.
Psycho- pathological processes.

Sigmund Freud 1856- 1939

psychoanalytical- psychoanalytical processes classified neurosis

CURRENT CLASSIFICATIONS

THE ICD-10 CLASSIFICATION OF MENTAL AND BEHAVIORAL DISORDERS (WHO) DSM -4 TR CLASSIFICATON (APA) Psychodynamic Diagnostic Manual (PDM) 2006
American Psychoanalytic Association, the International Psychoanalytical Association, the Division of Psychoanalysis (Division 39) of the American Psychological Association, the American Academy of Psychoanalysis and Dynamic Psychiatry, and the National Membership Committee on Psychoanalysis in Clinical Social Work.

Chinese Classification of Mental Disorders (CCMD) under CPS

APPROACHES TO CLASSIFICATION Categorial vs dimensional Descriptive vs etiological Prototypal Approach

CATEGORICAL APPROACH

The categorical approach divides illnesses into a numbers of separate and mutually exclusive categories ADVANTAGE:
 Categories are familiar  Easy to understand and use  They provide a prelude to action

CATEGORICAL APPROACH

CONT

They are formed on the basis of either distinct combination of symptoms or demonstrably distinct etiologies. Main problem in this approach is that, some conditions merge with each other.

DIMENSIONAL APPROACH

THE MAIN ADVENTAGE OF THIS APPROACH IS:

 Dimensional: no discrete categories.  It does not distort the perception of Individuals lying in each other in different categories  It provides more Information because finer distinctions are possible.  It is more flexible.

Catogorical vs dimensional


Categorical


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

Dimensional


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

Etiological APPROACH

Etiological approach was the first approach towards the classification in psychiatry. Psychiatric disorders are divided into three
 The One Caused By Poisons (Substanceinduced)  Due To Heredity (Schizophrenia And Mood Disorder)  The Lunacy (Due To Changing Moon)

DESCRIPTIVE APPROACH

Based on the clinical description of the presenting symptom. Current classification system is based on these category

Prototypal Approach
There are imperfect but recognizable combinations of characteristics that cluster together. These imperfect clusters define abnormal behavior. Assumptions:
 No people share all of the features of the prototype.  All people share most of the features of the prototype.  Medical tradition:
 Categorical in intention  Prototypal in practice

Organizing principles of contemporary classification Organic and functional Neurosis and psychosis Categories, dimensional and multiple axes Hierarchies of diagnosis comorbidity

Organic and functional

Organic disorders are those which arise from a demonstrable cerebral or systematic pathological process: the core disorders are dementia, delirium and the various neuropsychiatric symptoms (lishman 1998) The organic and functional dichotomy has 2 main implication for classification

Organic and functional

In philosophical dimension linked with concepts of mind and body

 Functional disorders have no biological basis, while psychological and social factors are irrelevant for organic disorders  Mindless and brainless controversy  In practical way organic defines disorders aetiologically where as other psychiatric disorders are purely descriptive.

Neurosis and psychosis

Concepts and classification based on concepts of Neurosis and psychosis were important in past. But still in clinical practice these terms are used frequently.

psychosis

Suggested by Feuchterleben in his book Principles Of Medical Psychology (1845) Severe mental disorder (PAST) In modern usage it refers to severe psychiatric disorders, including schizophrenia, some organic and affective disorders. Lack of insight, inability to distinguish between subjective experience and external reality.

psychosis

The term broadly means conditions which are usually severe including, hallucinations, delusions or unusual or bizarre behaviors especially when a more precise diagnosis cannot yet be made. Psychotic disorders NOS Psychotic symptoms Antipsychotic drugs

neurosis

Introduced by William Cullen in 1769 to refer to "disorders of sense and motion" caused by a "general affection of the nervous system Neurosis is a class of functional mental disorders involving distress. In ICD-10 it is used as neurotic stress related and somatoform disorders

Categorical classification

Traditionally psychiatric disorders are classified by dividing them into categories which represent discrete clinical entities. They are defined in terms of symptom pattern and course. This help in diagnosis & management. Problems based on reliability, validity and co morbidity.

Dimensional classification

Dimensional classification does not use separate categories but categorize the subject by means of scores on two or more dimensions. Kretschmer, Eysenck support this concepts. Problems difficult to determine if the individual need treatment or not,

Multiaxile approach

It represent the schemes of classification in which two or more separate set of information are coded. Essen moller was probably the first person to propose such system for use in psychiatry. Multi-axial classification is integral to DSM-4 TR and now available within ICD10 also.

Hierarchies of diagnosis

Categorical system includes an implicit hierarchy of categories of disorders. There are clinical evidence for an inbuilt hierarchy of significance between disorder. E.g., schizophrenia take precedence over mood disorders.

Comorbidity

Recently emphasis are on dual diagnosis rather than hierarchies. (comorbidity) Three reasons:
1. Research shows co morbidity are very common 2. It encourage the clinician to focus on all the various disorders which are present. 3. Diagnostic rule in current DSM encourage multiple diagnosis

 Disorders that are clinically considered distinct

Comorbidity

Two different circumstance of comorbidity.

 Disorder that are currently considered distinct but are probably causally related.  Disorders that are causally unrelated.

Validity of Diagnostic system

Validity: the degree to which the category reflects the disorder it seeks to describe.
 Construct validity: whether the symptoms chosen as criteria for a disorder are consistently associated with the disorder.  Descriptive validity: The extent to which the diagnostic classification provides significant information about the individuals placed in the category. Frequent criticism.  Predictive validity: extent to which a diagnosis is able to predict the course of the disorder and the efficacy of different types of treatment

Reliability of diagnostic systems: Reliability: The extent to which different clinicians agree in identifying a disorder.

Validity and reliability are often at odds with each other. DSM-IV accused of sacrificing validity for increased reliability. NB: Research methods trade off between reliability and validity when using either lab or field experiments.

History of official classification

1840 US census, idiocy & insanity. 1880 revised , 5 new categories. 1893 1st international list of causes of death. 1900 ICD 1 1900 1929 4th & 5th revision of ICD. 1949 ICD 6 with section on mental disorder. 1972 ICD 8 with glossary

ICD

1977 ICD 9 with clinical modification

codes- vol. 1&2 diagnostic codes codes- vol. 3 procedure codes

ICD - 10
     Worked under Norman sartorius Pub. In 1992. Mental disorders in chap.. V (F). Subdivision upto 5 digits. Inclusion & exclusion terms with glossary

Icd-10 codes

F00-F09 - Organic, including symptomatic,

mental disorders Dementia, Delirium, Organic amnesia..

F10-F19 - Mental and behavioural disorders

due psychoactive substances Alcohol, cocaine, tobacco

F20-F29 - Schizophrenia, schizotypal and

delusional disorders

F30-F39 - Mood [affective] disorders Manic,

Bipolar, depressive

Icd-10 codes

F40-F48 - Neurotic, stress-related and

somatoform disorders Dissociative- Phobia, OCD, Adjustment , Dissociative

F50-F59 - Behavioural syndromes associated

with physiological factors physiological disturbances and physical factors - Eating disorders, sleep disorder, sexual dysfunctions

Icd-10 codes

F60-F69 - Disorders of adult personality and behaviour. F70-F79 - Mental retardation F80-F89 - Disorders of psychological
development speech and language, pervasive development disorder

F90-F98 - Behavioural and emotional disorders

with onset usually occurring in childhood and adolescence

F-99 - Unspecified mental disorders.

DSM

1917- APA develops a diagnostic system listing 59 mental disorders. 1943- General William Menninger, new classification system, Medical 203. 1950 - APA Committee on Nomenclature produced 1st draft of the Diagnostic & Statistical Manual of Mental Disorders(DSM). 1952 DSM I : 106 diagnosis Robert spitzer DSM III - neurosis & homeosexuality controversy.

DSM 4 TR CATAGORIES
1. Disorders usually first diagnosed in infancy, childhood or adolescence 2. Delirium, Dementia & amnestic, & other cognitive disorders 3. Mental disorders due to a general medical condition 4. Substance related disorders 5. Schizophrenia & other psychotic disorders 6. Mood disorders 7. Anxiety disorders

DSM 4 TR CATAGORIES

CONT

8. Somatoform disorders 9. Factitious disorders 10. Dissociative disorders 11.Sexual & Gender identity disorders 12.Eating disorders 13.Sleep disorders 14.Impulse control disorders not elsewhere classified 15.Adjustment disorders 16.Personality disorders 17.Other conditions that may be a focus of clinical attention 18.Additional codes

The five axes of the DSM-IV-TR.

 Axis I Clinical syndromes.
other conditions that may be a focus of clinical attention

 Axis II Personality disorders, Mental retardation. (Life long deeply ingrained, inflexible & maladaptive)  Axis III General medical condition. (Any medical condition that could effect the patients mental state.)  Axis IV Psychosocial & environmental problems. (Stressful events that have occurred within the previous year)  Axis V global assessment functioning. (How well the patient performed during the previous year)

The axes in ICD10

The axes in ICD10 are as follow:

 Axis I Current mental state diagnosis including personality disorder  Axis II Disabilities  Axis III Contextual factors.

Problems classification

Stigma & labelling Distracts from understanding individual Individuals do not fit into Categories

Current and future issues in classification

No national approach in classification Uncertain categories and atypical disorders The subthreshold disorder and clinical significance.

Towards icd 11 and dsm 5

The DSM-5 Work Groups (DSM-5 website) DSM-5 Task Force

 whether advances in neuroscience, brain imaging and genetics suggested a framework that would arrange disorders by more than common symptoms.

ICD Global Practice Network ICD Revision Platform INCLUDES

 ICD 10 PLUS

ICD 11DRAFT

ICD ONTOLOGY

REFERENCE
 Synopsis of psychiatry  New oxford textbook of psychiatry  Shorter oxford textbook of psychiatry  Comprehensive textbook of psychiatry 8th  Fish psychopathology  ICD 10 (clinical discription and diagnostic guidelines)  DSM 4 TR  Wikipedia.com  dsm5.com  Icd10plus.com

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