1. Diagnosis & Classification In Psychiatry
Dr. Mohammed Alblowi
SB-Psych
Consultation Liaison Psychiatry – Queen’s University
Neuropsychiatry – University of Western Ontario

2. Huge thanks to Dr. Ahmad AlHadi
Assistant Professor, Consultant Psychiatry and Psychotherapy
Director, SABIC Psychological Health Research & Applications Chair
College of Medicine, King Saud University

3. Objectives
To list the main classification systems for Diagnosis in psychiatry.
To discuss the differences between ICD & DSM
To describe the differences between primary and secondary psychiatric disorders.
To describe the differences between psychosis and neurosis.

4. Evolution of knowledge about a disease entity

5. Definition of mental disorder
A syndrome characterized by clinically significant disturbance in an individual's cognition, emotion regulation, or behavior that reflects a dysfunction in the psychological, biological, or developmental processes underlying mental functioning.
Mental disorders are associated with significant subjective distress or impairment in social, occupational, or other important activities.
An expectable or culturally approved response to a common stressor or loss, such as the death of a loved one, is not a mental disorder. Socially deviant behavior (e.g., political, religious, or sexual) and conflicts that are primarily between the individual and society are not mental disorders unless the deviance or conflict results from a dysfunction in the individual, as described above

6. Classifications of diseases WHO | International Classification of Diseases (ICD)

7. Diagnostic and Statistical Manual of Mental Disorders (DSM)
Published by APA: a common language and standard criteria for the classification of mental disorders.
The manual evolved from systems for collecting census and psychiatric hospital statistics.
Developed by the US Army, 1952.
Five revisions since it was first published.
The last major revision was the fourth edition ("DSM- IV"), published in 1994, although a "text revision" was produced in 2000.
DSM-5 was published in May 2013.
gradually including more mental disorders, although some have been removed and are no longer considered to be mental disorders, most notably homosexuality

8. Chapters in DSM-5

9. Similarities:
Both are diagnosis and categorizing manuals require two or more symptoms to make a diagnosis;
Both are NOT self diagnosis manuals; Intended for use by qualified health professionals, more specifically psychiatrists;
Both are officially recognized manuals used to categorize and diagnose mental disorders;
Attempts are on to further harmonize between the two systems of disease classification;

10. Differences: ICD Internationally, DSM used mainly in the USA;
ICD is larger manual, encompasses all types of diseases/disorders; Only chapter V is relevant for mental disorders.
DSM is purely for mental disorders;
ICD brought out of international collaboration;
ICD produced by a global health agency with a constitutional public health mission;
DSM issued by single national professional body-American Psychiatric Association;
ICD primary focus on classification is to help countries to reduce burden of mental disorders. Its development is global, multidisciplinary and multilingual; DSM primary constituency is U.S. Psychiatrists;
ICD approved by World Health Assembly comprising of member countries;
DSM approved by assembly of APA members;
ICD is low cost and available free on internet;
DSM is copyrighted and generates income for APA;

11. Con’t differences: DSM criteria very specific and detailed
ICD more of prototype descriptions with less detailed criteria and minimum background information to guide diagnosis;
DSM always been multi-axial except now.
ICD always been non-axial;
DSM used by licensed mental health professionals with advanced degrees;
ICD accessible to wide rage of health care professionals with wide educational backgrounds;
Conceptual differences; Ex: Bulimia nervosa is characterized by ’morbid dread of fatness’ while DSM requires ‘self evaluation’; PTSD is much broader in ICD-10 than DSM5;
Differences can cause problems in research comparisons;

12. Other classification:

13. Primary vs Secondary psychiatric disorders
Etiology : one diagnosable systemic medical disease, CNS disease or substance.
e.g. Depression due to SLE
Psychosis due to amphetamine
Etiology is: Multi-factorial
e.g. schizophrenia
Major depressive disorder
In medicine: like secondary HTN due to renal artery stenosis.
In medicine: like Essential hypertension
Clues suggestive of being secondary:
Disturbance of consciousness or vital signs
Presence of :
non-auditory hallucinations e.g. visual,
hard neurological signs
physical illness
old age onset
Clues suggestive of being primary :
Normal consciousness & vital signs.
Auditory hallucinations
soft neurological signs
Young age onset
DEFINITION OF “ORGANIC MENTAL DISORDERS”
During the past few decades, the advent of newer pharmacological treatments and advances in fields such as neuroimaging, genetics, and molecular biology, have resulted in a growing recognition of brain pathology as the basis for mental disorders. Indeed, the introduction to the Diagnostic and Statistical Manual of Mental Disorders Fourth Edition Text Revision (DSM-IV-TR; American Psychiatric Association, 2000) agrees that the term “mental disorder” unfortunately implies a distinction between “mental” disorders and “physical” disorders that is a reductionist anachronism of mind / body dualism, and admits that the term “mental disorder” persists in the title of the Manual because an appropriate substitute have not been found.
The term "organic," as used for many years pointed to defined pathological lesions and was contrasted with the term "functional" or physiological abnormalities that could not be detected by existing laboratory procedures. The DSM-IV (American Psychiatric Association, 1994) and DSM-IV-TR abandon the categories of organic and functional mental disorders. DSM-IV introduced the category Mental Disorders due to a general medical condition to designate psychopathological syndromes which are known to be symptomatic manifestations of a systemic medical or cerebral disorder. Disorders are included in this category if they meet the following criteria: (1) There is evidence from the history, physical examination, or laboratory findings that the disturbance is the direct physiological consequence of a general medical condition; (2) The disturbance is not better accounted for by another mental disorder; (3) The disturbance does not occur exclusively during the course of a delirium. The term general medical condition refers to conditions that are coded on Axis III and are listed outside the “mental disorders” chapter of ICD (American Psychiatric Association, 2000).
ICD – 10 maintains "organic" as a superordinate category. The block F00 – F09 is titled “Organic, including symptomatic, mental disorders”, and comprises “a range of mental disorders grouped together on the basis of their common, demonstrable etiology in cerebral disease, brain injury, or other insult leading to cerebral dysfunction” (World Health Organization, 1992). ICD-10 indicates that the dysfunction may be primary, as in diseases, injuries and insults that affect the brain directly or with predilection, or secondary, as in systemic disorders that involve the brain. ICD-10 uses the term symptomatic for those organic disorders in which cerebral involvement is secondary to a systemic extracerebral disease or disorder. ICD-10 states that use of the term “organic” does not imply that conditions elsewhere in the classification are “nonorganic” in the sense that they have no cerebral substrate, and that the term means simply that the syndrome so classified can be attributed to an independently diagnosable cerebral or systemic disease. ICD-10 recommends four criteria for classifying a syndrome as organic: (1) evidence of cerebral disease, damage, or dysfunction, or of systemic physical disease, known to be associated with one of the listed syndromes; (2) a temporal relationship (weeks or a few months) between the development of the underlying disease and the onset of the mental syndrome; (3) recovery from the mental disorder following removal or improvement of the underlying presumed cause; and (4) absence of evidence to suggest an alternative cause of the mental syndrome (such as a strong family history or precipitating stress).

14. Broad classification of psychiatric disorders
NEUROSIS
PSYCHOSIS
Intact insight & reality testing.
Good judgment.
Abnormal quantity of symptoms.
No psychotic features.
E.g. anxiety disorders
Impaired insight & reality testing.
Impaired judgment.
Abnormal quality of symptoms.
Presence of active/positive psychotic features like delusion and hallucinations & negative like poverty of thoughts & speech, lack of ambition, initiation and restricted affect.
E.g. schizophrenia

15. Diagnostic tree for cognitive impairment

17. Diagnostic tree for depression

18. Diagnostic tree for Anxiety