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

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

What is Normal? Average Supra-Threshold Ideal

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

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”.

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

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

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

What is Pathology? Sign/symptom Syndrome Disorder Disease Illness

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

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

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

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 disress 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 functional organic substance Medically

DD of Psychosis with Mood Disorder 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

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

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 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

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 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.

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

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 301.82 Avoidant Personality Disorder ___.__ Dependent Personality Features___________ AXIS III: General Medical Conditions ICD-9-CM code ICD-9-CM name 424.0 Mitral Valve Prolapse

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)

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 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

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

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

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

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

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

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

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

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

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.

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

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