8/4/2019 Approach to Classification
1/52
APPROACH TO CLASSIFICATION
OF MENTAL DISORDERS
8/4/2019 Approach to Classification
2/52
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.
8/4/2019 Approach to Classification
3/52
Classification, is a systematic arrangement
of the world in order to master the otherwise
chaotic entities and structures, and
corresponds to the structure of humanthinking.
8/4/2019 Approach to Classification
4/52
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
aetiologyTo relate findings of clinical research to
patients seen in everyday practices
8/4/2019 Approach to Classification
5/52
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
8/4/2019 Approach to Classification
6/52
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.
8/4/2019 Approach to Classification
7/52
Ancient classification
In Ancient Greece, Hippocrates and his
followers are generally credited with the
first classification system for mental
illnesses, includingmania, melancholia, paranoia, phobias an
d Scythian disease (transvestism). They
held that they were due to different kindsof imbalance in four humors.
8/4/2019 Approach to Classification
8/52
Ancient classification
Senile deterioration
Melancholia & hysteria
Oldest systematic
classification in Ayur - veda
3000 B.C.
2600 B.C.
1400 B.C.
8/4/2019 Approach to Classification
9/52
Ancient classification :18th Cent.
Philippepinel (1745 1826)
functional disorders of nervous system
4 types Mania,
Melancholia,
Dementia,
Idiotism
Father of modern psychiatry.
8/4/2019 Approach to Classification
10/52
Ancient classification :19th Cent.
Karlludwig kahlbaum1828-1899)
distinguished organic &
non organic mental disorder.
Wilhelmgriesinger(1818-1868)
Mental diseases are brain diseases
8/4/2019 Approach to Classification
11/52
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.
8/4/2019 Approach to Classification
12/52
Ancient classification :20th Cent.
Eugen bleuler- Combined Kraepelin &
Meyerian approaches.
Psycho- pathological processes.
Sigmund Freud 1856- 1939
psychoanalytical- psychoanalytical processes
classified neurosis
8/4/2019 Approach to Classification
13/52
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 ofPsychoanalysis (Division 39) of the AmericanPsychological Association, the American Academy ofPsychoanalysis and Dynamic Psychiatry, and the National Membership Committee on Psychoanalysis in Clinical
Social Work.
Chinese Classification of Mental
Disorders (CC
MD) underCP
S
8/4/2019 Approach to Classification
14/52
APPROACHES TO CLASSIFICATION
Categorial vs dimensional
Descriptivevs etiological
Prototypal Approach
8/4/2019 Approach to Classification
15/52
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
8/4/2019 Approach to Classification
16/52
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.
8/4/2019 Approach to Classification
17/52
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.
8/4/2019 Approach to Classification
18/52
Catogorical vs dimensional
CategoricalCategorical
Presence/absence of a disorderPresence/absence of a disorder
E.g.,E.g., Either anxious or notanxious.Either anxious or notanxious.
DSM isDSM is categoricalcategorical DimensionalDimensional
Rank on a continuous quantitative dimensionRank on a continuous quantitative dimension
How anxious are youHow anxious are you on a scale of 1 to 10?on a scale of 1 to 10?
Dimensional systems may better capture anDimensional systems may better capture anindividuals functioning but the categoricalindividuals functioning but the categorical
approach has advantages for research andapproach has advantages for research and
understandingunderstanding
8/4/2019 Approach to Classification
19/52
Etiological APPROACH
Etiological approach was the first
approach towards the classification in
psychiatry.
Psychiatric disorders are divided into three
The One Caused By Poisons (Substance-
induced)
Due To Heredity (Schizophrenia And MoodDisorder)
The Lunacy (Due To Changing Moon)
8/4/2019 Approach to Classification
20/52
DESCRIPTIVE APPROACH
Based on the clinical description of the
presenting symptom.
Current classification system is based on
these category
8/4/2019 Approach to Classification
21/52
Prototypal Approach
There are imperfect but recognizablecombinations of characteristics that clustertogether.
These imperfect clusters define abnormalbehavior.
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
8/4/2019 Approach to Classification
22/52
Organizing principles ofcontemporary classification
Organic and functional
Neurosis and psychosis
Categories, dimensional and multiple axes
Hierarchies of diagnosis
comorbidity
8/4/2019 Approach to Classification
23/52
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 variousneuropsychiatric symptoms (lishman 1998)
The organic and functional dichotomy has 2main implication for classification
8/4/2019 Approach to Classification
24/52
Organic and functional
In philosophical dimension linked with
concepts of mind and body
Functional disorders have no biological basis,
while psychological and social factors areirrelevant for organic disorders
Mindless and brainless controversy
In practical way organic defines disordersaetiologically where as other psychiatric
disorders are purely descriptive.
8/4/2019 Approach to Classification
25/52
Neurosis and psychosis
Concepts and classification based on
concepts ofNeurosis and psychosis were
important in past.
But still in clinical practice these terms areused frequently.
8/4/2019 Approach to Classification
26/52
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.
8/4/2019 Approach to Classification
27/52
psychosis
The term broadly means conditions which
are usually severe including,
hallucinations, delusions or unusual or
bizarre behaviors especially when a moreprecise diagnosis cannot yet be made.
Psychotic disorders NOS
Psychotic symptomsAntipsychotic drugs
8/4/2019 Approach to Classification
28/52
neurosis
Introduced by William Cullen in 1769 to
refer to "disorders of sense and motion"
caused by a "general affection of
the nervous systemNeurosis is a class of functional mental
disorders involving distress.
In ICD-10 it is used as neurotic stressrelated and somatoform disorders
8/4/2019 Approach to Classification
29/52
Categorical classification
Traditionally psychiatric disorders are
classified by dividing them into categories
which represent discrete clinical entities.
They are defined in terms of symptompattern and course.
This help in diagnosis & management.
Problems based on reliability, validity andco morbidity.
8/4/2019 Approach to Classification
30/52
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 theindividual need treatment or not,
8/4/2019 Approach to Classification
31/52
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 personto propose such system for use in
psychiatry.
Multi-axial classification is integral toDSM-4 TR and now available within ICD-
10 also.
8/4/2019 Approach to Classification
32/52
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.
8/4/2019 Approach to Classification
33/52
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
8/4/2019 Approach to Classification
34/52
Comorbidity
Two different circumstance of comorbidity.
Disorder that are currently considered distinct
but are probably causally related.
Disorders that are causally unrelated.
8/4/2019 Approach to Classification
35/52
ValidityofDiagnosticsystem
Validity: the degree to which the category reflects the disorderit seeks to describe.
Constructvalidity:whetherthesymptomschosenascriteriaforadisorderareconsistentlyassociatedwiththedisorder.
Descriptivevalidity: Theextenttowhichthediagnosticclassificationprovidessignificantinformationabouttheindividualsplacedinthe
category. Frequentcriticism.
Predictivevalidity:extenttowhichadiagnosisisabletopredictthecourseofthedisorderandtheefficacyofdifferenttypesoftreatment
8/4/2019 Approach to Classification
36/52
Reliabilityofdiagnosticsystems:
Reliability: The extent to which differentclinicians agree in identifying a disorder.
Validity and reliability are often at oddswith each other. DSM-IV accused ofsacrificing validity for increased reliability.
NB: Research methods trade off betweenreliability and validity when using either labor field experiments.
8/4/2019 Approach to Classification
37/52
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
8/4/2019 Approach to Classification
38/52
ICD
1977 ICD 9 with clinical modification codes- vol. 1&2 diagnostic codes
codes- vol. 3 procedure codes
ICD - 10 Worked underNorman sartorius
Pub. In 1992.
Mental disorders in chap.. V (F). Subdivision upto 5 digits.
Inclusion & exclusion terms with glossary
8/4/2019 Approach to Classification
39/52
Icd-10 codes
F00-F09 - Organic, including symptomatic,mental disorders Dementia, Delirium, Organic
amnesia..
F10-F19 - Mental and behavioural disordersdue psychoactive substances Alcohol,
cocaine, tobacco
F20-F29 - Schizophrenia, schizotypal anddelusional disorders
F30-F39 - Mood [affective] disorders Manic,Bipolar, depressive
8/4/2019 Approach to Classification
40/52
Icd-10 codes
F40-F48 - Neurotic, stress-related andsomatoform disorders Dissociative- Phobia,
OCD, Adjustment , Dissociative
F50-F59 - Behavioural syndromes associatedwith physiological factors physiological
disturbances and physical factors - Eating
disorders, sleep disorder, sexual dysfunctions
8/4/2019 Approach to Classification
41/52
Icd-10 codes
F60-F69 - Disorders of adult personality and
behaviour.
F70-F79 - Mental retardation
F80-F89 - Disorders of psychologicaldevelopment speech and language, pervasive
development disorder
F90-F98 - Behavioural and emotional disorderswith onset usually occurring in childhood and
adolescence
F-99 - Unspecified mental disorders.
8/4/2019 Approach to Classification
42/52
DSM
1917- APA developsadiagnosticsystem
listing 59 mental disorders.
1943- GeneralWilliam Menninger,new
classificationsystem, Medical 203.
1950 - APA CommitteeonNomenclature
produced 1stdraft of the Diagnostic&
Statistical Manual ofMental Disorders(DSM).1952 DSM I: 106 diagnosis
Robertspitzer DSM III
- neurosis & homeosexuality controversy.
8/4/2019 Approach to Classification
43/52
8/4/2019 Approach to Classification
44/52
DSM 4 TR CATAGORIES
1. Disordersusuallyfirstdiagnosedininfancy,childhoodoradolescence
2. Delirium,Dementia&amnestic,&othercognitivedisorders
3. Mentaldisordersduetoageneralmedicalcondition
4. Substancerelateddisorders
5. Sc
hizo
phr
enia&
othe
rpsy
ch
oticdis
orde
rs6. Mooddisorders
7. Anxietydisorders
8/4/2019 Approach to Classification
45/52
DSM 4 TR CATAGORIES CONT
8. Somatoformdisorders9. Factitiousdisorders
10. Dissociativedisorders
11.Sexual& Genderidentitydisorders
12.Eatingdisorders13.Sleepdisorders
14.Impulsecontroldisordersnotelsewhereclassified
15.Adjustmentdisorders
16.Personalitydisorders17.Otherconditionsthatmaybeafocusofclinicalattention
18.Additionalcodes
8/4/2019 Approach to Classification
46/52
ThefiveaxesoftheDSM-IV-TR.
AxisIClinical syndromes.
other conditions that may be a focus of clinical attention
AxisIIPersonality disorders, Mental retardation.
(Life long deeplyingrained, inflexible & maladaptive)AxisIIIGeneral medical condition. (Any medical
condition thatcouldeffectthepatients mental state.)
AxisIV Psychosocial & environmental problems.
(Stressfulevents thathave occurred within the
previous year)
AxisVglobal assessment functioning. (How wellthe
patientperformed duringtheprevious year)
8/4/2019 Approach to Classification
47/52
The axes in ICD10
The axes in ICD10 are as follow:
AxisI
C
urrent mental state diagnosisincluding personality disorder
AxisIIDisabilities
AxisIIIContextual factors.
8/4/2019 Approach to Classification
48/52
Problems classification
Stigma & labelling
Distracts from understanding individual
Individuals do not fit into Categories
8/4/2019 Approach to Classification
49/52
Current and future issues in classification
No national approach in classification
Uncertain categories and atypical
disorders
The subthreshold disorder and clinical
significance.
8/4/2019 Approach to Classification
50/52
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 arrangedisorders by more than common symptoms.
ICD Global Practice Network
ICDRevisionPlatformINCLUDES ICD 10 PLUS ICD 11DRAFT ICD ONTOLOGY
8/4/2019 Approach to Classification
51/52
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
8/4/2019 Approach to Classification
52/52
C l i c k t o e d i t c o m p a n y s l o g a n .