classification and diagnosis in psychiatry

د.وليد عزيز العميدي classification and diagnosis in psychiatry
There are major difficulties in classification and diagnosis in psychiatry :-
- What are psychiatrists talking about , i.e. what is a mental illness ? and when is a mental state abnormal ? how do you decide ?
- Psychiatric symptoms and signs are not specific .
- Delusions and hallucinations occur in schizophrenia , mania and severe depression .
- Depression can be the primary problem or part of another disorder .
- There are no reliable biological markers.
- Psychiatrists change their minds and cannot agree.
WHAT ARE MENTAL DISORDERS ? this term should include the following elements ( derived from DSM-IV ) :
- A behavioral or psychological syndrome.
- Associated with distress or disability.
- Associated with a risk of incurring death , pain or disability.
- Not culturally appropriate.
- The disorder is a manifestation of dysfunction in the individual .
- Not merely a conflict between the individual and society.
Mental disorders are diagnosed at different levels :
- Aetiological , e.g. general paralysis of the insane.
- Pathological , e.g. Alzheimer`s disease.
- Clinical symptoms , e.g. schizophrenia.
Some major divisions :
- Categorical VS. dimensional : for most areas of psychiatry a categorical approach to classification is taken ( this is schizophrenia , that is obsessive compulsive disorder , and so forth ) . this can lead to defining rather disparate symptoms and signs under the same rubric. Sometimes the person display a little anxiety , little depression and perhaps some phobic elements too , under these circumstances it may be more sensible to define the person`s symptoms along a series of axes rather than in a categorical manner .
- Organic VS. functional : clinically defined disorders for which no underlying neuropathology could be demonstrated known as functional disorders ( schizophrenia , anxiety disorders …..) . with sophisticated techniques of investigation , more of the biology of the functional disorders is now known (e.g. neurochemistry of depression ). As a result , the historical division between organic and functional has begun to appear unhelpful.
- Psychotic VS. neurotic : psychotic patients have delusions and hallucinations , and have lost the ability to test reality in the normal way . neurotic patients recognize their states as abnormal and do not suffer from delusions or hallucinations. The term neurotic has been omitted from the most recent major classifications.
The multi-axial approach : the term multi-axial is applied to schemes of classifications in which two or more separate sets of information ( such as symptoms , aetiology , and personality type ) are coded . multi-axial classification is now integral to DSM-IV and available within ICD-10 .
Current psychiatric classifications :
- The international classification of diseases ( ICD ) : is produced by the WHO as an aid to the collection of international statistics about disease . the system is revised every few years and the present edition is the tenth ( ICD 10 ) .
Mental disorders were included for the first time in 1948, in the 6th revision , the final version was published as ICD-10 by WHO in 1992 . all diagnostic codes start with the letter F and like the other chapters , it has ten major divisions , e.g. F20 schizophrenia , can be followed by a further number for the category within the group ( example : F20.1 , hebephrenic schizophrenia ) .
The main categories of ICD-10 :
F00 – F09 : organic including symptomatic mental disorders.
F10 – F19 : mental and behavioral disorders due to psychoactive substance use.
F20 – F29 : schizophrenia , schizotypal and delusional disorders.
F30 – F39 : mood (affective) disorders .
F40 – F49 : neurotic , stress related and somatoform disorders.
F50 – F59 : behavioral syndromes associated with physiological disturbances and physical factors.
F60 – F69 : disorders of adult personality and behavior .
F70 – F79 : mental retardation .
F80 – F89 : disorders of psychological development.
F90 – F99 : behavioral and emotional disorders with onset usually occurring in childhood or adolescence.

The axes in ICD-10 :
Axis I : current mental state diagnosis including personality disorder.
Axis II : Disabilities.
Axis III : Contextual factors.

Diagnostic and Statistical Manual ( DSM ) : in 1952 the American Psychiatric Association (APA) published the first edition of the diagnostic and statistical manual ( DSM-I ) as an alternative to the widely criticized ICD-6 .DSM-IV Textual Revision (DSM-IV-TR ) was published in 2000.


The categories of DSM-IV :
1- Disorders usually first diagnosed in infancy, childhood, or adolescence
a- Mental Retardation : mild , moderate , severe , profound
b- Learning disorders : reading disorder , mathematics disorder , disorders of written expression .
c- Motor skills disorders : developmental coordination disorder.
d- Communications disorder : expressive language disorder , mixed expressive-receptive language disorder , phonological disorder , stuttering .
e- Pervasive developmental disorder : autism , Rett`s disorder , Asperger`s disorder , childhood disintegrative disorder.
f- Attention deficit and and disruptive behavior disorders.
g- Feeding and eating disorders of infancy or early childhood : pica and rumination disorder.
h- Tic disorders : Tourette`s disorder.
i- Elimination disorders : enuresis , encopresis.
j- Other disorders of infancy , childhood or adolescence : separation anxiety disorder , selective mutism , reactive attachment disorder.

2- Delirium, dementia, and amnestic and other cognitive disorders:
a- Delirium .
b- Dementia : Alzheimer`s dementia , vascular dementia …
c- Amnestic disorders.
d- Other cognitive disorders.
3- Mental disorders due to a general medical condition not elsewhere classified.
4- Substance-related disorders : alcohol related disorders , amphetamines related disorders , caffeine related disorder……
5- Schizophrenia and other psychotic disorders : schizophrenia , schizoaffective disorder , schizophreniform disorder…..
6- Mood disorders : depressive disorders , bipolar disorders …..
7- Anxiety disorders : generalized anxiety disorders , panic disorders with or without agoraphobia , specific phobia , social phobia …….
8- Somatoform disorders : somatization disorder , hypochondriasis …..
9- Factitious disorders
10- Dissociative disorders : depersonalization , dissociative amnesia..
11- Sexual and gender identity disorders
12- Eating disorders : anorexia nervosa , bulimia nervosa..
13- Sleep disorders.
14- Impulse-Control Disorders Not Elsewhere Classified : kleptomania , pyromania..
15- Adjustment disorders
16- Personality disorders.
17- Other disorders that may be a focus of clinical attention.
The five axes of DSM-IV :
Axis I : Current mental state diagnosis ( definite or provisional ).
Axis II : personality disorders and mental retardation .
Axis III : physical disorders and conditions.
Axis IV : psychosocial or environmental factors contributing to the disorder.
Axis V : global assessment of functioning .

Aetiology : a number of models exists for the generation of mental disorders . In most cases these are multifactorial and no single paradigm suffices.
- Biological models : more and more is known about the biology of mental disorders , but attempts to view them all as organic are premature. Some mental disorders , e.g. Alzheimer`s disease , clearly have a physical substrate , but even here the person`s response to the organic deterioration of their brain is mediated through their personality , biography and social circumstances . biological factors may include family history , drug use , physical illness….
- Psychological models : psychological factors in the causation of mental disorders are of major importance and should not be submerged under the current wave of interest in biological factors. why does one person get clinically depressed following loss of his or her job , while another does not ? there may be some biological predisposition , such as family history , but it is more likely to be related to the person`s way of coping with stress and their previous experience of loss and rejection.
- Social factors : social stressors as poor housing , lack of confidant , noise , poverty , poor marital relationship have all been associated with poor mental health.
The bio-psycho-social model : for each case the relative contribution made by each of the three elements is very different , even if the same disorder is present.
The aetiological factors can also be divided into the following categories :
Predisposing : those factors which made it likely that this person might experience a particular problem ( e.g. a family history or disrupted childhood ).
Precipitating : those factors which indicate why this problem has happened now (e.g. loss of job , physical illness , loss of loved one).
Perpetuating : those factors which are likely to make resolution of the episode of illness less likely ( e.g. poor housing , unstable relationship , chronic physical illness )