1. Classification in Psychiatry
Professor Shmuel Fennig, M.D
Shalvata Mental Health Center
Hod Hasharon

3. Goals of a Classification System
Communication: among clinicians, between science and practice
Clinical: facilitate identification treatment, and prevention of mental disorders
Research: test treatment efficacy and understand etiology
Education: teach psychopathology
Information Management: measure and pay for care

5. What is Normal?
Average
Supra-Threshold
Ideal

6. What is abnormal?
Your uncle consumes a quart of whiskey each day; he has trouble remembering the names of people around him
Your friend complains of many physical problems and sees 2-3 doctors each week

7. What is abnormal?
Your neighbor sweeps, washes, and scrubs his driveway daily
Your cousin is pregnant and she is dieting so that she will not get “too fat”.

8. What is Abnormal? Possible definitions: Statistical deviation
Violation of social norms
Subjective distress
Disability or dysfunction
Abnormal behavior does not necessarily indicate mental illness

9. Definition of a Mental Disorder
Clinically significant ….
Behavioral or psychological….
Pattern or syndrome….
Associated with….
Present Distress OR ….
Disability/impairment Or….
With significantly increased risk of….
Suffering death, pain, disability or an important loss of freedom

10. Definition of a Mental DisorderII
This syndrome or pattern…
Must not be merely an expectable/culturally sanctioned response to particular event (death of a loved one)
Considered a manifestation of a behavioral, psychological or biological dysfunction in the individual
Neither deviant behavior (e.g political. Releigeous or sexual) nor conflicts between individual and society are mental disorders
Unless they represent a dysfunction in the individual

11. What is Pathology?
Sign/symptom
Syndrome
Disorder
Disease
Illness

12. From syndrome to disease
Syndrome – a set of signs and symptoms that co-occure at a greater than chance frequency
Disorder – conjunction of a syndrome with a clinical course
Disease – conjunction of etiology and pathology. True disease: symptoms, pathology, pathophysiology and underlying causes are known as well as the relationship between them
Illness- the psychosocial aspect of being sick
Most psychiatric illnesses and many medical illnesses are not disease in the strict sense of the word.
Understanding the syndrome and cause facilitate the discovery of etiology. For example the separation of Down Syndrome from the rest of Mental Disorders facilitate the discovery of the Trisomy 21.
A similar relation is seen between the disorder dementia paralytica and the discovery of the causative agent of the disease syphilis: Treponema Pallidum

13. Psychiatric Diagnosis
Step I: Normal vs. Abnormal -Concepts of health and disease
Step II: how to build a diagnosis
What is DSM IV and how does it work?
Controversies/Polemics/Hype

14. First Step
Determine that this is a Dis-Order: what are the boundaries between “this” what is presented, and normal behavior
Symptoms cause a subjective distress and/or a clinically significant disturbance. Discuss: Homosexuality, Grief vs. Pathological Grief, Fetishism, Voyerism, transverstism, Exhibitionism
In DSM-III there was “ego-dystonic homosexuality” and DSM-III-R excluded it totally. This exempliffied a social change in the american society and to view homosexuality as a normal variant of human behavior.
1973- Declassification
1987- Eliminatrion at all

15. 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.

16. 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 disress or danger

17. 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

18. Mental disorder
functional
organic
substance
Medically

19. DD of Psychosis with Mood Disorder
At least two weeks
In the absence of Mood
schizoaffective

20. Mental disorder
affective
Non-affective
psychotic
Non-psychotic
psychotic
Non-psychotic

21. 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

22. Definitions of Depression
Symptoms
Episodes
Disorders
Major Depressive Disorder
Bipolar Disorder
Dysthymia
Depressive Disorder NOS (e.g. subthreshold depression)

23. 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

24. Symptoms of Depression, cont.
Physical Symptoms
Weight loss or weight gain
Psychomotor agitation or retardation
Insomnia or hyposomnia
Fatigue or loss of energy

25. 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

26. A Brief Look at Etiology of Mental Disorders
Models of Psychopathology
Biological
Psychodynamic
Cognitive
Learning
Humanistic
Diathesis-Stress

27. DSM-III Paradigm Shift
Descriptive
Non-etiologic focus
Diagnostic criteria
Multiaxial system
Multiple diagnoses
Splitting
Reliability

28. 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

29. Categorical vs. Dimensional Systems
Presence/absence of a disorder
Either you are anxious or you are not anxious.
DSM is categorical
Dimensional
Rank on a continuous quantitative dimension
How anxious are you on a scale of 1 to 10?
Dimensional systems may better capture an individual’s functioning but the categorical approach has advantages for research and understanding

30. 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

31. Assessment Issues: Reliability
Diagnosis
Kappa
Bipolar Disorder
.84
Major Depression
.64
Schizophrenia
.65
Alcohol Abuse
.75
Anorexia
Bulimia
.86
Panic Disorder
.58
Social Phobia
.47
Reliability
Consistency of measurement
Interrater reliability
Extent to which clinicians agree on the diagnosis.

32. What’s 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

33. Multiaxial System AXIS I: Clinical Disorders
Other Conditions That May Be a Focus of Clinical Attention
Diagnostic Code DSM-IV Name
Panic Disorder with Agoraphobia, Moderate
Diazepam Dependence, Mild
___.__ ____________________________________
AXIS II: Personality Disorders
Avoidant Personality Disorder
___.__ Dependent Personality Features___________
AXIS III: General Medical Conditions
ICD-9-CM code ICD-9-CM name
Mitral Valve Prolapse

34. Multiaxial System Axis IV: Psychosocial and Environmental Problems
Check:
X Problems with primary support group 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 Specify:_______
Axis V: Global Assessment of Functioning Scale Code: 55 (current)

35. 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…”

36. 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)

37. Diagnostic Groupings and Examples
Disorders Usually Evident in Infancy, Childhood or Adolescence
Autism
Attention Deficit-Hyperactivity Disorder
Conduct Disorders
Mental Retardation (Axis II)
Tourette’s
Delirium, Dementia and Cognitive Disorders
Delirium
Dementia of the Alzheimer’s Type
Vascular Dementia
Amnestic Disorder

38. Diagnostic Groupings and Examples
Substance Related Disorders
Alcohol Dependence
Cannabis Abuse
Hallucinogen-Induced Psychotic Disorder
Opiate Withdrawal
Psychotic Disorders
Schizophrenia
Delusional Disorder
Mood Disorders
Major Depressive Disorder
Bipolar Disorder
Dysthymia

39. Diagnostic Groupings and Examples
Anxiety Disorders
Panic Disorder with Agoraphobia
Post-Traumatic Stress Disorder
Obsessive-Compulsive Disorder
Somatoform Disorders
Somatization Disorder
Hypochondriasis
Factitious Disorders and Malingering
Factitious Disorder (Munchhausen’s)0
Malingering

40. Diagnostic Groupings and Examples
Dissociative Disorders
Dissociative Identity Disorder
Depersonalization Disorder
Eating Disorders
Anorexia Nervosa
Bulimia Nervosa
Sleep Disorders
Narcolepsy
Sleep Terror Disorder
Sexual, Gender Identity Disorders
Premature Ejaculation
Paraphilias

41. Diagnostic Groupings and Examples
Adjustment Disorders
Adjustment Disorder with Mixed Anxiety and Depressed Mood
Personality Disorders (Axis II)
Borderline Personality Disorder
Obsessive-Compulsive Personality Disorder
Impulse Control Disorders
Trichotillomania
Pathological Gambling
Other Conditions (Including “V Codes”)
Relational Problems
Sexual Abuse of a Child
Bereavement

42. 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

43. 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

44. Controversies Brainless vs. Mindless Psychiatry
“Inventing” New Diagnoses
e.g. Premenstrual Dysphoric Disorder
Social Labeling
Cultural Relativism
Primary Care vs. Sepciality Focus

45. DSM-IV and ICD-10 Atheorethical Descriptive Axis (not in ICD)
Explicit rules when information is insufficient
Associated features
Heirarchy
Multiple Diagnoses

46. 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

47. Hippocrates and Psychiatric Diagnosis
Axis I
Phrenitis (fever)
Mania (w/o fever)
Melancholia
Epilepsy
Hysteria
Axis II
Choleric
Sanguine
Melancholic
Phlegmatic

48. 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.

49. Descriptive Approach to Psychiatric Classification
Relies on descriptions of presenting symptomatology
Many discrete categories - e.g. Boissier de Sauvages
Course e.g. Esquirol, Morel, Kahlbaum
Symptoms and course e.g. Kraeplin
Adopted by DSM III

50. Etiological Approach to Psychiatric Classification
Organized around presumed pathogenic processes
Historical example: Paracelsus (16th cen.)
Vesania (poisons)
Lunacy (phases of the moon)
Insanity (heredity)
Relatively few diagnostic categories