CLASSIFICATION SYSTEM

PRESENTED BY: ABHISHIKTA MUKHERJEE

(MPHIL 1ST YEAR TRAINEE)
SUPERVISED BY: DR. SOMDEB MITRA
PRESENTATION DATE : 16/05/2015
NEED FOR PSYCHIATRIC NOSOLOGY:
CONCEPT OF NORMALITY:
 Communication
 Medical Model
 To understand the implication of
the diagnosis  Statistical Model

 to facilitate epidemiological  Utopian Model

studies  Subjective Model
 For estimates of prevalence rate  Social Model
and vital public health  Process Model
information such as morbidity and
mortality sequelae of disorder.  Continuum Model
DEFININING MENTAL DISORDER

 “ …a clinically recognizable set of symptoms or

behaviour associated in most cases with distress
and with interference with personal functions.
Social deviance or conflict alone, without
personal dysfunction, should not be included in
mental disorder as defined here.”
(World Health Organization, 1992, p. 5)
 “ …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
usually associated with significant distress or disability in
social, occupational, or other important activities. An
expectable or culturally acceptable 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.”
(American Psychiatric Association, 2013, p. 20)
SOME BASIC TERMINOLOGIES:

• NEUROSIS

• PSYCHOSIS

CONSEQUENCE OF
DISORDER :
 Impairment
 Disability
 Handicap
 Incapacity
APPROACHES TO CLASSIFICATION:
• Etiological approach: Paralacelsus developed a classificatory
system-Vensania, Insanity& Lunacy
• Descriptive Approach: Defines disorder based on clinical
description; Kraepelin’s classification
• Categorical approach: Determining the presence or absence of
a disorder depending upon prototypical description of a typical
case
• Dimensional Approach: classifies the mental disorders that
quantifies a person’s symptoms with numerical values on one or
more scales or continuum rather than assigning them to a
particular mental disorder category
HISTORY OF CLASSIFICATION OF MENTAL DISORDER

 500 B.C. : Ayurveda

 460-377 B.C. Hippocrates
 2nd century A.D. Galen
 980–1037 A.D Avicenna
 1759 Linnaeus’s ‘Genera Morborum’
 1840 Recording of mental illness in the US census
 1844 Psychiatry was first recognized as a medical specialty.
 Late 1800s Kraepelin (bipolar disorder-schizophrenia)
 1892 The Association of Medical Superintendents of American
Institutions for the Insane came to be known as American
Medico-Psychological Association
 1917 Statistical Manual for the Use of Institutions of the Insane
 1921 American Medico-Psychological Association then
became the American Psychological Association. (APA)
 1945 ‘Medical 203’ became ‘Nomenclature of Psychiatric
Disorders and Reactions in 1947
 1949 Mental disorders were first included in the sixth revision of
the ‘International Classification of Disease’
 1952 Introduction of ‘Diagnostic and Statistical Manual of
Mental Disorders’
 PRECURSOR TO RECENT ICD AND DSM

 The first version of ICD (1850s) organized diseases by anatomical site and
provided the conceptual basis for the subsequent International List of
Causes of Death.
 WHO integrated the classification of morbidity along with mortality.
 The International Classification of Diseases, Injuries, and Causes of Death,
came to be known as ICD-6 (WHO, 1948).
 DSM-I (APA,1952) 130 pages; 106 categories.
 Organic and functional disorders (e.g., “schizophrenic reaction” or
“depressive reaction”).
 The description of data were mostly prose paragraphs infused with
psychodynamic assumptions and added little to what meaning could be
derived from the name of the disorder.
 DSM-II (APA, 1968) 134 pages; 182 categories
 The term “reaction” was no longer used.
 maintained the general psychodynamic
orientation
 Similar to ICD 8(WHO, 1966) : psychoses;
neuroses, PDs and Mental Retardation.
 ICD 8 included miscellaneous category with
code .8 and .9
 Therefore to standardise the terms glossary of
terms was introduced.
 This made ICD an internationally used system
 DSM III(APA, 1980)494 pages; 265 categories
 descriptive approach
 Operational definition using observable sign and patient reported
symptoms
 number of signs and symptoms
 duration and course
 exclusion criteria
 description for the typical demographic profile
 introduction of Differential Diagnosis
 Multiaxial system

 DSM-III was part of a paradigm shift in psychiatry

 ICD-9 criteria were modified to be consistent with DSM-III
 DSM-III-R(APA, 1987)567 pages; 292 categories
 intended to correct the diagnostic criteria
 DSM IV (APA, 1994) 886 pages; 365 categories
 structured literature reviews, re analyses of
existing data sets, and field trials
 addition of “clinically significant distress or
impairment” across the diagnostic criteria
 DSM-IV-TR(APA, 2000) 936 pages; 365
categories
 To update the research findings
CURRENT APPROACHES:
 International Classification of Disease (ICD) by World Health
Organisation
 Diagnostic and Statistical Manual of Mental Disorders (DSM) by
American Psychological Association
 Psychodynamic Diagnostic Manual (PDM) by American
Psychoanalytic Association, International Psychoanalytic
Association, the Division of Psychoanalysis of the American
Psychological Association, the American Academy of
Psychoanalysis and Dynamic Psychiatry, and the National
Membership Committee on Psychoanalysis in Clinical Social Work
 Chinese Classification of Mental Disorders (CCMD) by Chinese
Society of Psychiatry
 Research Domain Criteria (RDoC) by National Institute of Mental
Health
ICD 10 (WHO, 1994)
 Chapter V of the book (F00-F99) is the Mental and behavioural
disorders
 Clinical descriptions and diagnostic guidelines, is intended for general
clinical, educational and service use. Diagnostic criteria for research
has been produced for research purposes.
 Diagnostic guidelines
 Provisional or Tentative diagnosis
 Numeric codes (001-999) of ICD-9 has been replaced by
alphanumeric coding scheme (A00-Z99)
 Further detail is then provided by means of decimal numeric
subdivisions at the four-character level.
 The term ‘neurotic’ is retained only as a part of the heading of the
block F40-F48.
 The term ‘psychotic’ is retained as a convenient descriptive term.
 List of Categories:
 F00-F09 Organic, including symptomatic, mental disorders
 F01Vascular dementia
 F02Dementia in other diseases classified elsewhere
 F03Unspecified dementia
 F04Organic amnesic syndrome, not induced by alcohol and other
substances
 F05Delirium, not induced by alcohol and other psychoactive substances
 F06Other mental disorders due to brain damage and dysfunction and
to physical disease
 F07Personality and behavioural disorder due to brain disease, damage
and dysfunction
 F09Unspecified organic or symptomatic mental disorder
None of which are induced by any psychoactive drug use.
F10--F19 Mental and behavioural disorders due to psychoactive
substance use.
The third character indicates the substance used. The psychoactive
substance in order of their classificatory codes are alcohol, opioids,
cannabinoid, sedatives, cocaine, stimulants including caffeine,
hallucinogen, tobacco, volatile solvent, and multiple substance use.
The fourth and fifth characters indicate the psychopathological
syndrome.
F1x.0 Acute intoxication
F1x.1 Harmful use
F1x.2 Dependence syndrome
F1x.3 Withdrawal state
F1x.4 Withdrawal state with delirium
F1x.5 Psychotic disorder
F1x.6 Amnesic syndrome
F1x.7 Residual and late-onset psychotic disorder
F1x.8 Other mental and behavioural disorders
F1x.9 Unspecified mental and behavioural disorder
F20-F29 Schizophrenia,
schizotypal and delusional
disorders
 F20 Schizophrenia
 F21 Schizotypal disorder
 F22 Persistent delusional
disorders
 F23 Acute and transient
psychotic disorders
 F24 Induced delusional
disorder
 F25 Schizoaffective disorders
 F28 Other nonorganic
psychotic disorders
 F29 Unspecified nonorganic
psychosis
F30-F39 Mood [affective] disorders
 F30 Manic episode
 F31 Bipolar affective disorder
 F32 Depressive episode
 F33 Recurrent depressive disorder
 F34 Persistent mood [affective]
disorders
 F38 Other mood [affective]
disorders
 F39 Unspecified mood [affective]
disorder
 F40-F48 Neurotic, stress-related and somatoform disorders
F40 Phobic anxiety disorders
F41 Other anxiety disorders
F42 Obsessive - compulsive disorder
F43 Reaction to severe stress, and adjustment disorders
F44 Dissociative [conversion] disorders
F45 Somatoform disorders
F48 Other neurotic disorders
F50-F59 Behavioural syndromes associated with physiological disturbances and
physical factors
F50 Eating disorders
F51 Nonorganic sleep disorders
F52 Sexual dysfunction, not caused by organic disorder or disease
F53Mental and behavioural disorders associated with the puerperium, not elsewhere
classified
F54Psychological and behavioural factors associated with disorders or diseases
classified elsewhere
F55 Abuse of non-dependence-producing substances
F59Unspecified behavioural syndromes associated with physiological disturbances
and physical factors
F60-F69 Disorders of adult personality F70-F79 Mental retardation
and behaviour  F70 Mild mental retardation
 F60 Specific personality disorders  F71 Moderate mental retardation
 F61 Mixed and other personality  F72 Severe mental retardation
disorders  F73 Profound mental retardation
 F62 Enduring personality changes,  F78 Other mental retardation
not attributable to brain damage  F79 Unspecified mental retardation
and disease
 F63 Habit and impulse disorders A fourth character may be used
 F64 Gender identity disorders to specify the extent of associated
 F65 Disorders of sexual preference behavioural impairment.
 F66 Psychological and behavioural
disorders associated with sexual
development and orientation
 F68 Other disorders of adult
personality and behaviour
 F69 Unspecified disorder of adult
personality and behaviour
The next two blocks cover only those disorders that are specific to
childhood and adolescence. A number of disorders placed in other
categories can and should be used for children and adolescents when
required. Like disorders of eating (F50.-), sleeping (F51.-)

F80-F89 Disorders of psychological development

 F80 Specific developmental disorders of speech and
language
 F81 Specific developmental disorders of scholastic skills
 F82 Specific developmental disorder of motor function
 F83 Mixed specific developmental disorders
 F84 Pervasive developmental disorders
 F88 Other disorders of psychological development
 F89 Unspecified disorder of psychological development
Disorders of childhood such as infantile autism
previously classified as psychoses, is now more
appropriately contained in this block.
F90-F98 Behavioural and emotional disorders with onset
usually occurring in childhood and adolescence
 F90 Hyperkinetic disorders
 F91 Conduct disorders
 F92 Mixed disorders of conduct and emotions
 F93 Emotional disorders with onset specific to childhood
 F94 Disorders of social functioning with onset specific to
childhood and adolescence
 F95 Tic disorders
 F98 Other behavioural and emotional disorders with
onset usually occurring in childhood and adolescence

F99 Mental disorder, not otherwise specified

 DSM 5 (APA, 2013 )
 947 pages; 22 chapters
 Section I : DSM 5 basics;
 Section II Diagnostic criteria and codes.
 Section III emerging measures and models; appendix.
 Notable changes in structure:
 Reorganization
 Introduction of spectra
 Elimination of multiaxial diagnosis
 Attention to developmental, gender-related, and cultural aspects of
disorder
 Emerging measures and models
 List of new disorders in DSM 5 some of which are:
 Disruptive mood dysregulation disorder
 Hoarding disorder
 Excoriation disorder
 Binge eating disorder
 Restless legs syndrome
 Some of the specific changes include:
 Neurodevelopmental disorder
 Schizophrenia Spectrum
 Bipolar Disorder
 Depressive disorder
 Anxiety Disorders
 Obsessive compulsive and related disorder
 Somatic symptom and related disorder
List of Categories:
 Neurodevelopmental Disorders
 Schizophrenia Spectrum and other psychotic disorder
 Bipolar and related disorder
 Depressive disorder
 Anxiety disorder
 Obsessive Compulsive and related disorder
 Trauma and stressor related disorder
 Dissociative disorder
 Somatic symptom and related disorder
 Feeding and eating disorder
 Elimination disorder
 Sleep wake disorder *
 Sexual dysfunctions
 Gender dysphoria
 Disruptive impulse control and conduct
disorder
 Substance related and addictive disorder
 Neurocognitive disorder
 Personality disorder
 Paraphilic disorder
 Other mental disorder
 Medication induced movement disorder and
other adverse effects of medication *
 Other condition that may be a focus of clinical
attention *
* Disorders classified elsewhere in ICD 10
 COMPARING ICD AND DSM

 Although there is similarity in the broad grouping of both ICD

and DSM; and also in the way symptoms are defined most of
the times there are several differences among the two, some
of which are listed below:
1. Difference in disorder groupings.
2. Few categories of DSM are not included in ICD.
3. Results of studies by Sorenson et al. and Steinberger et al.
provide preliminary evidence that the DSM 5 diagnoses more
people with a mental disorder than the ICD10
 Typical description of a disorder according to the two manuals
ICD 10: DSM 5:
 Brief introduction  List of Diagnostic criteria
of the disorder  Detailed diagnostic features
 Diagnostic  Associated features supporting the
guidelines diagnosis
 Inclusion exclusion  Prevalence rate
criteria  Development and course
 Differential  Risk and prognostic factors
Diagnosis  Culture related issues
 Gender related issues
 Functional consequence of the disorder
 Differential diagnosis
 Comorbidity

The current versions available for mental disorder classification are DSM 5 (APA, 2013)
and ICD 10 (chapter 5 “Mental and behavioural disorders”)(WHO, 1994);
ICD 11 (Chapter 7 “Mental, Behavioural, and Neurodevelopmental Disorders”)(WHO,
2018 due to come into effect in 2022).
 The Psychodynamic Diagnostic Manual
 Currently in its second version it consists of 837 pages and 3 parts.
 Part 1: classification of adult mental health disorders,
 Part 2: classification of child and adolescent mental health
disorders.
 Part 3: conceptual and research foundations for a
psychodynamically based classification system of mental health
disorders
 Part 3 consists (a) the history of psychoanalytically based nosology
and psychoanalytic therapy research, (b) recently developed
diagnostic measures for assessing psychotherapeutically induced
personality change, (c) research findings concerning the
effectiveness of psychodynamic psychotherapy and indications for
undertaking it, and (d) psychodynamic conceptualizations of
normal and abnormal development.
 Diagnosis is made on three axis as follows:
 P axis (Personality Patterns and Disorders) P101 to P115:
behavior patterns and levels of personality organization
 M axis (Profile of Mental Functioning) M201 to M208:
assign people to one of eight levels of functioning
 S axis (Symptom Patterns) S301-S313: description of 13
disorders with emphasis on their development, and how
people with the disorder tend to experience their
symptoms affectively, cognitively, somatically, and in their
interpersonal interactions.
 Diagnosis of young people begins with attention to the
adequacy of their basic functioning capacities MCA
followed by PCA and then SCA
 The Chinese Classification of Mental Disorders
• Currently in its third version
CCMD 3 written both in
Chinese and English.
• It has a similar structure and
categorisation to the ICD
and DSM,
• Additionally it contains
some diagnosis more
specific to Chinese culture
include
1. Koro(genital retraction),
2. Zou huo rum mo(qigong
deviation),
3. mental disorder due to
superstition or witchcraft
4. travelling psychosis.
 The Research Domain Criteria

 The RDoC system represents a fundamentally different approach to

mental illness, with the goal of identifying the basic brain and
behavioral processes that, together with sociocultural forces, give rise
to multiple dimensions that may become dysfunctional and constitute
psychopathology.
 The RDoC project is not intended for practical clinical use in the near
future. Rather, it provides a framework for research. It does not formally
incorporate any current ICD or DSM disorders
 Therefore from an RDoC perspective, the aim is to develop a
comprehensive literature about the convergent and interacting roles of
neurodevelopment and the environment as well as their relations with
biological, psychological, and social variables in the onset and course
of impairment in various functional domains.
The 4 domains are: Unit of analysis:
1. Negative Valence system 1. Genes
2. Molecules
2. Positive valence system 3. Cell
3. Cognitive system 4. Neural circuits
4. Systems for social process 5. Physiology
6. Behaviour
5. Arousal/Modulatory system 7. Self reports
Issues in Classification: How ICD and DSM deal with them
 ETIOLOGY:
 research has shown that psychopathology generally arises from
multiple biological, behavioral, psychosocial, and cultural factors,
all interacting in complex ways and filtered through an individual’s
lifetime of experience.
 Research also show that the outcome and interaction of these
factors are not definite or distinct disorder rather complex and
variable combinations of psychological problems

 DSM IV: Conversion disorder- …psychological factors are judged to

be associated with…
 ICD 10: dissociative disorder- …evidence of psychological
causation…
 DSM 5: Conversion disorder- evidence of incompatibility between
symptom and medical findings
 CATEGORIES AND DIMENSIONS:
 Mental disorder is not an all-or-none phenomenon, because we now
know that mental disorders are complex combinations of
psychological problems, which themselves are dimensional.
 Some include emotion, cognition, behaviour and physical symptoms
like sleep, physiological arousal. Most manifestations of mental
disorder are now being described along a number of these symptom
dimensions.
 ICD as the international system of classification of Disorders in general
it requires to imposes much stricter restrictions on classification. It is
therefore CATEGORICAL in its approach.
 DSM on the other hand is much more DIMENSIONAL in its approach for
ex Disorder of Intellectual Functioning suggests incorporating
dimensional information in a categorical system.
 THRESHOLD
 Once continua is divided into categories, setting threshold for
mental disorder classification poses another challenge.
 Firstly because the very definition of mental disorder remains a
subject of debate.
 Second, the multidimensional nature of mental illness
necessitates that thresholds be set for each component
dimension.
 Both DSM and ICD have adopt similar if not identical
approaches to using thresholds in mental-disorder diagnosis
 COMORBIDITY
 The way mental disorders are theoretically conceptualised one
would believe that each disorder is distinct from all others
 However, individuals diagnosed with one mental disorder have
substantially increased odds of meeting the criteria for at least
one other disorder, and many individuals can meet the
diagnostic criteria for three or more disorders (Kessler et al.,
1994).
 Yet again both ICD and DSM have dealt with this issue in a
similar manner. Both the manual encourage making more than
one diagnosis if and when required.
 Both the manual also have hierarchical categorical structures
where if the diagnosis for one disorder is met other comorbid
disorder need not be diagnosed as they can be well explained
by the preceding diagnosis.
 CRITICISM :
 In contrast to the view that classification is an essential, albeit insufficient and imperfect,
basis for clinical practice (Craddock and Mynors-Wallis, 2014; Tyrer, 2014), the use of
psychiatric classification is sometimes criticized as being inappropriate or even harmful.

 If the concept of mental disorder is itself disputed, then so will any

classifications thereof.
 The main Criticism arise from the view that:
1. distraction from understanding the unique personal difficulties
2. Labelling deviant behaviour as illness
3. Individuals do not fit neatly into the available categories.
4. Another core criticism is specificity of diagnosis.
 FURTHER STUDY

 DSM 5 contains an addition appendix dedicated to ‘conditions

for further study’ with the note “ these proposed criteria set are
not intended for clinical use…” rather these proposed criteria set
are presented for conditions on which future research is
encouraged. Some of these are as under:
1. Attenuated psychosis Syndrome
2. Depressive episode with short duration hypomania
3. Persistent complex bereavement disorder
4. Internet gaming disorder
5. Caffeine use disorder
 ICD 10 does not contain any such separate section. But it
does mention several points in the text where there is scope
for further study:
1. Several missing categories
2. Prodrome typical of schizophrenia
3. Neurasthenia
4. More specific guideline and criteria for adult personality
disorder