Approach to Classification

8/4/2019 Approach to Classification

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APPROACH TO CLASSIFICATION

OF MENTAL DISORDERS


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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.


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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.


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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


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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


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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.


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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.


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Ancient classification

Senile deterioration

Melancholia & hysteria

Oldest systematic

classification in Ayur - veda

3000 B.C.

2600 B.C.

1400 B.C.


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Ancient classification :18th Cent.

Philippepinel (1745 1826)

functional disorders of nervous system

4 types Mania,

Melancholia,

Dementia,

Idiotism

Father of modern psychiatry.


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Karlludwig kahlbaum1828-1899)

distinguished organic &

non organic mental disorder.

Wilhelmgriesinger(1818-1868)

Mental diseases are brain diseases


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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.


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Eugen bleuler- Combined Kraepelin &

Meyerian approaches.

Psycho- pathological processes.

Sigmund Freud 1856- 1939

psychoanalytical- psychoanalytical processes

classified neurosis


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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


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APPROACHES TO CLASSIFICATION

Categorial vs dimensional

Descriptivevs etiological

Prototypal Approach


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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


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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.


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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.


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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


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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)


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DESCRIPTIVE APPROACH

Based on the clinical description of the

presenting symptom.

Current classification system is based on

these category


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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


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Organizing principles ofcontemporary classification

Organic and functional

Neurosis and psychosis

Categories, dimensional and multiple axes

Hierarchies of diagnosis

comorbidity


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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


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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.


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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.


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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.


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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


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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


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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.


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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,


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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.


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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.


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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


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Comorbidity

Two different circumstance of comorbidity.

Disorder that are currently considered distinct

but are probably causally related.

Disorders that are causally unrelated.


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ValidityofDiagnosticsystem

Validity: the degree to which the category reflects the disorderit seeks to describe.

Constructvalidity:whetherthesymptomschosenascriteriaforadisorderareconsistentlyassociatedwiththedisorder.

Descriptivevalidity: Theextenttowhichthediagnosticclassificationprovidessignificantinformationabouttheindividualsplacedinthe

category. Frequentcriticism.

Predictivevalidity:extenttowhichadiagnosisisabletopredictthecourseofthedisorderandtheefficacyofdifferenttypesoftreatment


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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.


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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


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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


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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


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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


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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.


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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.


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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


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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


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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)


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The axes in ICD10

The axes in ICD10 are as follow:

AxisI

C

urrent mental state diagnosisincluding personality disorder

AxisIIDisabilities

AxisIIIContextual factors.


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Problems classification

Stigma & labelling

Distracts from understanding individual

Individuals do not fit into Categories


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Current and future issues in classification

No national approach in classification

Uncertain categories and atypical

disorders

The subthreshold disorder and clinical

significance.


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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


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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


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C l i c k t o e d i t c o m p a n y s l o g a n .

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Approach to Classification