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  • ClassificationClassification, , nosologynosologyinin psychiatrypsychiatry

    SandorSandor FeketeFekete

    Dept.ofDept.of PsychiatryPsychiatry, , UniversityUniversity ofof PecsPecs

    httphttp://://psychiatry.pote.hupsychiatry.pote.hu

    AreAre thethe diagnosisdiagnosis, , andand classificationclassificationreallyreally necessarynecessary inin psychiatrypsychiatry??

    WhatWhat is is normalnormal oror pathologicalpathological humanhumanbehaviourbehaviour

    CanCan thethe pathologicalpathological, , thethe diagnosisdiagnosis be be justjusta a labellabel oror stigma? (stigma? (socialsocial deviancydeviancy modelmodel) ) -- / / seesee antipsychiatryantipsychiatry/ /

    symptomssymptoms, , outcomeoutcome, , familyfamily clusteringclustering arearedifferentdifferent inin thesethese disordersdisorders//syndromssyndroms alsoalsothethe biologicalbiological backgroundbackground, , specificspecificresponsesresponses inin treatmenttreatment

    The The FundamentalFundamental PurposePurpose ofof DiagnosisDiagnosisandand ClassificationClassification

    The The purposepurpose ofof diagnosisdiagnosis andand classificationclassification is is totoisolateisolate a a groupgroup ofof discretediscrete diseasedisease entitiesentities, , eacheach ofofwhichwhich is is characterizedcharacterized byby a a distinctdistinct pathophysiologypathophysiologyandand//oror etiologyetiology. . IdeallyIdeally, , allall diseasesdiseases inin medicinemedicinewouldwould be be defineddefined inin termsterms ofof etiologyetiology. . ForFor most most illnessesillnesses, , howeverhowever, , wewe dodo notnot knowknow oror understandunderstandexactlyexactly thethe specificspecific etiologyetiology

    ForFor most most diseasesdiseases, , howeverhowever, , ourour understandingunderstandingis is atat thethe levellevel ofof pathophysiologypathophysiology ratherrather thanthanetiologyetiology. .

    Most Most ofof thethe disordersdisorders oror diseasesdiseases diagnoseddiagnosed ininpsychiatrypsychiatry areare syndromessyndromes: : collectionscollections ofof symptomssymptomsthatthat tendtend toto occuroccur togethertogether. .

    DiagnosisDiagnosis, , classificationclassification ininpsychiatrypsychiatry

    PsychiatryPsychiatry triestries consistentlyconsistently andandcomprehensivelycomprehensively formalizeformalize thethe diagnosticdiagnosticprocessesprocesses forfor thethe disordersdisorders withinwithin itsits domaindomain. .

    ThisThis precisionprecision andand structurestructure areare particularlyparticularlyimportantimportant inin psychiatrypsychiatry becausebecause itit lackslacksrecognizedrecognized etiologiesetiologies forfor manymany disordersdisorders andandlacklack specificspecific laboratorylaboratory diagnosticdiagnostic teststests asaswellwell. .

    diagnosisdiagnosis reliesrelies largelylargely onon thethepatientpatientss presentingpresenting symptomssymptoms andand historyhistory..WithoutWithout suchsuch structurestructure, , thethe diagnosticdiagnosticprocessprocess couldcould becomebecome confusedconfused andand fuzzyfuzzy. .

    PurposesPurposes ofof DiagnosisDiagnosis inin PsychiatryPsychiatry

    DiagnosisDiagnosis helpshelps toto simplifysimplify ourour thinkingthinking andandreducereduce thethe complexitycomplexity ofof clinicalclinical

    PsychiatricPsychiatric diagnosesdiagnoses facilitatefacilitate communicacommunica--tiontion betweenbetween cliniciansclinicians. .

    DiagnosesDiagnoses helphelp toto predictpredict thethe outcomeoutcome ofof thethedisorderdisorder

    DiagnosesDiagnoses areare oftenoften usedused toto decidedecide onon ananappropriateappropriate treatmenttreatment..

    DiagnosisDiagnosis areare usedused toto assistassist inin thethe searchsearch forforpathophysiologypathophysiology andand etiologyetiology

    OtherOther PurposesPurposes ofof DiagnosisDiagnosis

    DiagnosesDiagnoses areare usedused toto monitor monitor treatmenttreatment andand totomakemake decisionsdecisions aboutabout reimbursementreimbursement

    DiagnosesDiagnoses areare usedused byby attorneysattorneys inin malpracticemalpracticesuitssuits andand inin otherother litigationlitigation..

    DiagnosesDiagnoses areare usedused byby healthhealth carecareepidemiologistsepidemiologists toto determinedetermine thethe incidenceincidenceandand prevalenceprevalence ofof variousvarious diseasesdiseasesthroughoutthroughout thethe worldworld..

    DiagnosesDiagnoses areare usedused toto makemake decisionsdecisions aboutaboutinsuranceinsurance coveragecoverage..

  • fMRIfMRI AnteriorAnterior CingulCingulaarr CortexCortex(ACC)(ACC)

    DSM IV APA (1994) DSM IV APA (1994) classifiesclassifiesmentalmental disordersdisorders

    The The AmericanAmerican PsychiatricPsychiatric AssociationAssociationhas has formulatedformulated a a manualmanual thatthat summarizessummarizesallall thethe diagnosesdiagnoses usedused inin psychiatrypsychiatry, , specfiesspecfies thethe symptomssymptoms thatthat must be must be presentpresent toto makemake a a givengiven diagnosisdiagnosis andandorganizesorganizes thesethese diagtnosisdiagtnosis togethertogether intointo a a classificationclassification systemsystem -- DiagnDiagn. . AndAnd StatistStatistManualManual forfor mentalmental DisordersDisorders (DSM)(DSM)

    DSM IV APA (1994) DSM IV APA (1994) classifiesclassifiesmentalmental disordersdisorders

    DSMDSM--IV is IV is largelylargely descriptivedescriptive andandatheoreticalatheoreticalDSMDSM--IV IV makesmakes useuse ofof a a novelnovel multiaxicalmultiaxicalsystemsystem forfor recordingrecording diagnosesdiagnoses-- ((characterizingcharacterizing patientspatients inin multiplemultiple waysways-- evaluatingevaluating allall aspectsaspects ofof patientpatientss healthhealth

    andand socialsocial backgroundbackgroundThe The fivefive axesaxes onon whichwhich informationinformation shouldshouldbe be recordedrecorded areare asas followsfollows: :

    ParalellyParalelly -- thethe ICD ICD systemsysteminternationalinternational, WHO , WHO supportedsupported, ,

    ratherrather usedused inin EuropeEurope -- ICD10ICD10

    -- notnot multiaxialmultiaxial systemsystem

    -- more more formalformal diagnosticdiagnostic categoriescategories

    -- listlist certaincertain categoriescategories preferedprefered byby oneone ororanotheranother nationalnational schoolschool. .

    -- More More forfor statisticalstatistical reasonsreasons

    DiagnosticDiagnostic criteriacriteria forfor DysthymicDysthymic DisorderDisorder

    DepressedDepressed moodmood -- forfor atat leastleast 2 2 yearsyears -- thethe mildmild, , chronicchronic depressiondepression, , lowlow moodmood, , anhedoniaanhedoniaPresencePresence ofof twotwo ((oror more) more) ofof thethe followingfollowing::(1) (1) poorpoor appetiteappetite oror overeatingovereating(2) (2) insomniainsomnia oror hypersomniahypersomnia(3) (3) lowlow energyenergy oror fatiguefatigue(4) (4) lowlow selfself--esteemesteem(5) (5) poorpoor concentrationconcentration oror makingmaking decisionsdecisions(6) (6) feelingfeeling ofof hopelessnesshopelessness

    SymptomlessSymptomless periodsperiods less less thanthan twotwo monthsmonthsNo major No major depressivedepressive, no , no manicmanic episodeepisode, , notnot otherother psychoticpsychotic

    conditionsconditionsDistressDistress oror impairmentimpairment inin socialsocial, , occupationaloccupational functioningfunctioning

  • AxisAxis II is is forfor thethe major major clinicalclinical syndromessyndromes..

    AxisAxis IIII is is forfor specificspecific developmentaldevelopmentaldisordersdisorders ((forfor childrenchildren andand adolescentsadolescents andand, , inin somesome casescases, , forfor adultsadults), ), andand personalitypersonalitydisordersdisorders ((forfor adultsadults, , andand occasionallyoccasionally forforchildrenchildren andand adolescentsadolescents). ).

    AxisAxis IIIIII is is forfor physicalphysical disordersdisorders ororconditionsconditions thatthat thethe clinicanclinican considersconsiderspotentiallypotentially relevantrelevant toto understandingunderstanding orormanagementmanagement ofof thethe patientpatient..

    AxisAxis IVIV, , maymay be be usedused toto recordrecord thethe degreedegree ofofseverityseverity ofof psychosocialpsychosocial stressorsstressors thatthat thetheclinicianclinician considersconsiders significantsignificant inin precipititatingprecipititating ororexacerbatingexacerbating, , thethe patientpatientss disorderdisorder..

    AxisAxis VV maymay be be usedused toto recordrecord thethe clinicanclinicanssjudgmentjudgment regardingregarding thethe highesthighest levellevel ofof adaptiveadaptivefunctioningfunctioning demonstrateddemonstrated byby thethe patientpatient duringduringthethe pastpast yearyear. .

    AxisAxis I: I: ClinicalClinical DisordersDisorders andand OtherOtherConditionsConditions ThatThat MayMay Be a Be a FocusFocus ofof

    ClinicalClinical AttentionAttention-- DisordersDisorders usuallyusually firstfirst diagnoseddiagnosed inin infancyinfancy, ,

    childhoodchildhood, , oror adolescenceadolescence-- DeliriumDelirium, , dementiadementia, , andand amnesticamnestic andand otherother

    cognitivecognitive disordersdisorders-- MentalMental disordersdisorders duedue toto a a generalgeneral medicalmedical

    conditioncondition-- SubstanceSubstance--relatedrelated disordersdisorders-- SchizophreniaSchizophrenia andand otherother psychoticpsychotic disordersdisorders-- MoodMood disordersdisorders-- AnxietyAnxiety disordersdisorders

  • AxisAxis I: I: ClinicalClinical DisordersDisorders andand OtherOtherConditionsConditions ThatThat MayMay Be a Be a FocusFocus ofof

    ClinicalClinical AttentionAttention

    -- SomatoformSomatoform disordersdisorders-- FactitiousFactitious disordersdisorders-- DissociativeDissociative disordersdisorders-- SexualSexual andand gendergender identityidentity disordersdisorders-- EatingEating disordersdisorders-- SleepSleep disordersdisorders-- ImpulseImpulse--controlcontrol disordersdisorders notnot elsewhereelsewhere classifiedclassified-- AdjustmentAdjustment disordersdisorders-- OtherOther conditionsconditions thatthat maymay be a be a focusfocus ofof clinicalclinical

    attentionattention

    AxisAxis II: II: PersonalityPersonality DisordersDisorders andandMentalMental RetardationRetardation

    ParanoidParanoid personalitypersonality disorderdisorderSchizoidSchizoid personalitypersonality disorderdisorder AASchizotypalSchizotypal personalitypersonality disorderdisorder

    AntisocialAntisocial personalitypersonality disorderdisorderBorderlineBorderline personalitypersonality disorderdisorder BBHistrionicHistrionic personalitypersonality disorderdisorderNarcissisticNarcissistic personalitypersonality disorderdisorder

    AvoidantAvoidant personalitypersonality disorderdisorderDependentDependent personalitypersonality disorderdisorder CCObsessiveObsessive--compulsivecompulsive personalitypersonality disorderdisorder

    MentalMental retardationretardation

    Personality:Personality: a repertoire of coping devices ora repertoire of coping devices ordefenses that defenses that allows allows us to us to maintain an equilibrium maintain an equilibrium between our internal drives and the world aroundbetween our internal drives and the world aroundusus

    Personality traits:Personality traits: results of development thatresults of development thathas been influencedhas been influencedby culture and societyby culture and societyby the childby the child--rearing practices of the familyrearing practices of the familyby genetically determined temperamental by genetically determined temperamental

    factorsfactorsPersonality disorders :Personality disorders : the the personality traits arepersonality traits are

    inflexible and inflexible and madaptivemadaptive, causing significant , causing significant impairmentimpairment in social or occupational functioningin social or occupational functioningand/and/orsubjectiveorsubjective distressdistress

    Pathological personality Pathological personality structuresstructures

    NEUROTIC:NEUROTIC: integrated identityintegrated identityhighhigh--level defensive operations level defensive operations (repression) (repression) maintained reality testingmaintained reality testing

    BORDERLINE:BORDERLINE: identity diffusionidentity diffusionprimitive defensive operations primitive defensive operations maintained reality testingmaintained reality testing

    PSYCHOTIC:PSYCHOTIC: diffusion or lack of integration of diffusion or lack of integration of identityidentity primitive defensive primitive defensive operations (depersonalization) operations (depersonalization) (denial) (denial) impaired reality testingimpaired reality testing

    AxisAxis IV: IV: PsychosocialPsychosocial andandEnvironmentalEnvironmental ProblemsProblems

    ProblemsProblems withwith primaryprimary supportsupport groupgroupProblemsProblems relatedrelated toto thethe socialsocial environmentenvironmentEducationalEducational problemsproblemsOccupationalOccupational problemsproblemsHousingHousing problemsproblemsEconomicEconomic problemsproblemsProblemsProblems withwith accessaccess toto healthhealth carecare servicesservicesProblemsProblems relatedrelated toto interactioninteraction withwith thethe legallegal

    systemsystem//crimecrimeOtherOther psychosocialpsychosocial andand environmentalenvironmental problemsproblems

  • AdvantagesAdvantages andand DisadvantagesDisadvantages ofof thetheDSM DSM 2828III/IV III/IV ApproachApproach I.I.

    DSM IV DSM IV substantiallysubstantially improvedimproved thethe reliabilityreliabilityofof diagnosisdiagnosis. . ReliabilityReliability, a , a biometricbiometric conceptconcept, , refersreferstoto thethe abilityability ofof twotwo observersobservers toto agreeagree onon whatwhat theytheyseesee. .

    The DSM IV The DSM IV approachapproach has has clarifiedclarified thethediagnosticdiagnostic processprocess andand facilitatedfacilitated historyhistory takingtaking. .

    DSM IV DSM IV alsoalso clarifiedclarified andand facilitatedfacilitated thetheprocessprocess ofof differenctialdifferenctial diagnosisdiagnosis. .

    AdvantagesAdvantages andand DisadvantagesDisadvantages ofof thetheDSM IV DSM IV ApproachApproach II.II.

    DSM IV DSM IV maymay sacrificesacrifice validityvalidity forfor reliabilityreliability. . WhereasWhereasreliabilityreliability refersrefers toto thethe capacitycapacity ofof individualsindividuals toto agreeagree ononwhatwhat theythey seesee, , validityvalidity refersrefers toto thethe capacirtycapacirty toto makemakeusefuluseful predictionspredictions. .

    InIn particularparticular, , thethe validityvalidity ofof a a medicalmedical diagnosticdiagnostic systemsystemrefersrefers toto itsits abilityability toto predictpredict prognosisprognosis andand outcomeoutcome, , responseresponse toto treatmenttreatment, , andand ultimatelyultimately etiologyetiology..

    The The increasedincreased precisionprecision sometimessometimes givesgives clinicansclinicansandand researchersresearchers a a falsefalse sensesense ofof certaintycertainty aboutabout whatwhattheythey areare doingdoing. .

    ComparisonComparison ofof BNOBNO--10 10 andand DSMDSM--IVIV

    criteriacriteria BNOBNO--1010 DSMDSM--IVIV

    originorigin EuropeanEuropean NorthNorth AmericanAmerican

    MainMain purposepurpose StatisticsStatistics ResearchResearch, , clinicalclinical

    axisaxis NonNon--multiaxialmultiaxial MultiaxialMultiaxial

    EmpiricalEmpirical basisbasis moderatemoderate StrongStrong

    categoriescategories NotNot veryvery exactexact QuiteQuite clearclear, , somesome categoriescategoriesareare arbitraryarbitrary

  • BPRS - Bief Psychiatrc Rating Scale

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