Chapter 1

Classification of Psychiatric Disorders

1. Importance of Aetiology: The passage emphasizes that any meaningful classification of
psychiatric disorders should ideally be based on understanding their underlying causes.
Without knowing the root causes of these disorders, it's difficult to create precise
classifications that accurately capture the nature of the illnesses.
2. Pragmatic Approach: Since the exact causes of many mental illnesses remain unknown, the
passage suggests adopting a pragmatic approach to classification. This approach aims to
develop classification systems that are practical and useful for patient care, communication
among healthcare professionals, and conducting high-quality research.
3. Comparison to Physical Medicine: The passage draws a parallel between psychiatric
disorders and physical illnesses. It notes that in physical medicine, syndromes (clusters of
symptoms) existed long before the causes of these illnesses were understood. Over time, as
medical knowledge advanced, some syndromes were found to correspond to specific disease
entities with identifiable causes.
4. Evolution of Classification: The passage highlights how advancements in medical
knowledge, such as diagnostic techniques and understanding of disease mechanisms, have led
to changes in the classification of physical illnesses. Some syndromes were confirmed as true
diseases with identifiable causes, while others were redefined or discarded as knowledge
progressed.
5. Modern Approach to Classification: In modern medicine, including psychiatry, the
approach to classification often involves identifying syndromes based on symptom clusters.
This facilitates research and extends understanding of the disorders, with the ultimate goal of
identifying specific diseases with identifiable causes.
6. Challenges in Psychiatry: Unlike some physical illnesses with clear-cut causes, psychiatric
disorders often have multifactorial etiologies. These may involve a combination of genetic,
environmental, and psychological factors, making it challenging to identify discrete disease
entities based solely on symptom patterns.

Summary of Interview Schedules for Diagnosing

Mental Disorders
Diagnostic Interview Schedules (DIS): Developed to standardize diagnoses based on ICD
and DSM criteria.
SCID (Structured Clinical Interview for DSM-5):
 Semi-structured interview for clinicians or researchers.
 Different versions for specific uses (clinical, research, personality disorders).
 Allows for some clinical judgment during questioning.
 SCID-5-AMPD enables dimensional assessment of personality disorders.
CIDI (Composite International Diagnostic Interview):
 Standardized interview for lay interviewers.
 Rigid questioning with minimal interviewer judgment.
 Available as a computer-administered self-assessment tool.
  CIDI-5 in development for compatibility with DSM-5.
Advantages of Standardized Interviews:
 Easier and cheaper to administer than traditional clinical interviews.
Disadvantages:
 Limited clinical judgment may lead to less accurate diagnoses.
SCAN (Schedule for Clinical Assessment in Neuropsychiatry):
 Semi-structured interview for mental health professionals.
 Aims to capture a standardized clinical interview while minimizing subjectivity.
 Uses computer algorithms for diagnosis based on symptom ratings.
 Expensive due to requiring trained mental health professionals.
SCAN vs. CIDI:
 SCAN offers more clinical judgment, potentially leading to more accurate diagnoses.
 CIDI is cheaper due to the possibility of using lay interviewers.
Both SCID and SCAN may require adjustments for ICD-11 compatibility

Modern Classifications of Mental Disorders (DSM-5 &

ICD-11)
Comparison:
 Syndrome-based: Both classify based on co-occurring symptoms, not cause (etiology).
 Focus on symptoms: Neither classifies based on underlying biology or prognosis.
 Aetiology-free: Terms like "psychogenic" or "neurotic" are removed to avoid implying cause.
 Limitations:
o Not based on distinct disease entities.
o High co-morbidity (overlap) between disorders.
o Short-term diagnostic instability for many disorders.
o Lack of treatment specificity.
DSM-5 (American Psychiatric Association)
 Published: 2013
 Key Changes:
o Abandoned 5-axis system from DSM-IV.
o Removed bereavement exclusion for major depression.
o Added 14 new disorders.
 Controversies:
o Lack of transparency in development.
o Over-diagnosis of mood and anxiety disorders possible.
o Failure to remove oppositional defiant disorder.
ICD-11 (World Health Organization)
 Published: 2022
 Development Process:
o International working groups gathered feedback from mental health professionals.
o Evaluative field trials using case studies (vignettes).
o Reliability studies in 18 countries.
 Key Changes:
o Reduced number of personality disorder categories (based on severity).
o Moved acute stress disorder to "factors affecting health" (not a disorder).
o Added new conditions (gaming disorder, hoarding disorder, prolonged grief
disorder).
o Included section on boundaries between normal and abnormal functioning.
Additional Notes:
 ICD-11 intended to be published with DSM-5 but came later.
 Both have separate research criteria for some disorders.
 Chapter 2
What Is Psychopathology?
Philosophical Approaches to Defining Psychiatric
Disorder

1. Are mental disorders real like physical illnesses? (Realism)

  Most psychiatrists believe this. They think conditions like depression or schizophrenia have a
biological basis, just like a broken bone.
 The idea is that future research will identify genes, brain changes, or other markers to explain
these disorders.
 Critics argue that despite years of research, many disorders lack clear biological causes. They
also point out that social factors sometimes influence what gets included as a mental disorder
in diagnostic manuals.
2. Are mental disorders just invented categories? (Constructivism)
 This view argues that mental disorders are not real illnesses, but rather labels created by
society.
 It's like how fashion trends or music genres come and go. They are not inherent, but created
by humans.
 Some psychiatrists share this concern, worried that social or political pressures might
influence what gets labeled as a disorder (e.g., PTSD after wars).
3. Do the labels themselves matter more than the cause? (Pragmatism)
 This view focuses on using diagnoses that are helpful for treatment, even if we don't fully
understand the cause.
 The idea is to develop treatments based on the best knowledge we have now, rather than
waiting to find the exact cause.
 Critics argue that this approach might downplay the seriousness of mental illness and
discourage further research into causes.
The main question remains unanswered:
The text doesn't give a definitive answer. There's no consensus on whether mental disorders are
entirely biological, social constructs, or something in between.
The author (Kendler) leans towards a cautious version of the first view (realism):
 He believes mental disorders are real, but acknowledges our current knowledge might be
limited.
 He highlights historical examples of scientific theories being replaced, suggesting future
research might bring a clearer understanding.
 He compares mental disorders to conditions like heart disease, which are defined by a
combination of factors, not just a single cause.