Classification of Psychiatric Illness 1 Basic Classification of Psychiatric Illness Dr. Muhd. Najib...

Classification of Psychiatric IllnesClassification of Psychiatric Illnesss

11

Basic Classification of Basic Classification of Psychiatric IllnessPsychiatric Illness

Dr. Muhd. Najib Mohd. AlwiDr. Muhd. Najib Mohd. AlwiDept. of PsychiatryDept. of [email protected]@kck.usm.my

clik.to/drnajibclik.to/drnajib

© MNMA Y2K2© MNMA Y2K2


22

ObjectivesObjectives

•To understand the concept of mentalTo understand the concept of mentalillnessillness

•To describe principles used in theTo describe principles used in theclassification of psychiatric illnessclassification of psychiatric illness

•To know basic outline of ICD-10 andTo know basic outline of ICD-10 andDSM-IV and their main differencesDSM-IV and their main differences


33

Definition of Mental IllnessDefinition of Mental Illness

‘‘IllnessIllness’ has three definitions:’ has three definitions: Absence of healthAbsence of health Presence of sufferingPresence of suffering Presence of pathological process – physical Presence of pathological process – physical

or psychologicalor psychological Can we then define mental illness along Can we then define mental illness along

those lines?those lines?


44


ABSENCE OF HEALTHABSENCE OF HEALTH

WHO defines health as:WHO defines health as:

‘‘a state of complete physical, mental and a state of complete physical, mental and social well-being, and not merely the social well-being, and not merely the absence of disease or infirmity’absence of disease or infirmity’

… … almost impossible to achieve ‘mental almost impossible to achieve ‘mental health’ then?health’ then?


55


PRESENCE OF SUFFERINGPRESENCE OF SUFFERING … … may explain a group of people who may explain a group of people who

comes to seek treatmentcomes to seek treatment

BUT in mental illness, some patients may BUT in mental illness, some patients may not realise that they have problem e.g. not realise that they have problem e.g. some manic or schizophrenic patients…some manic or schizophrenic patients…


66


PRESENCE OF PATHOLOGICAL PROCESSPRESENCE OF PATHOLOGICAL PROCESS Most mental disorders have no demonstrable Most mental disorders have no demonstrable

physical pathology… and thus ? not ILLNESSES.physical pathology… and thus ? not ILLNESSES. A view strongly advocated by the ‘anti-psychiatry A view strongly advocated by the ‘anti-psychiatry

movement’ (Szasz etc.)movement’ (Szasz etc.)

… … true only until lately though!!!true only until lately though!!!

In the last decade, more and more evidence are In the last decade, more and more evidence are emerging – genetic, biochemical and even some emerging – genetic, biochemical and even some structural and functional imaging on quite a number structural and functional imaging on quite a number of psychiatric conditions (including of psychiatric conditions (including SchizophreniaSchizophrenia!) !)


77


88


Perhaps the best way forward, and most Perhaps the best way forward, and most widely used is to define mental illness as the widely used is to define mental illness as the PRESENCE OF PSYCHOPATHOLOGYPRESENCE OF PSYCHOPATHOLOGY..

i.e. evident disturbance in psychological i.e. evident disturbance in psychological functions:functions: PerceptionPerception MemoryMemory LearningLearning EmotionEmotion ThinkingThinking

Partially Partially or in fullor in full


99

Why Classify?Why Classify?

The The purposepurpose of classification is to identify of classification is to identify groups of patients who share similar groups of patients who share similar clinical features or disorders:clinical features or disorders: To To formulateformulate treatmenttreatment plan plan To To predictpredict likely likely outcomeoutcome To To communicatecommunicate with other professionals with other professionals

regarding the illnessregarding the illness To enable To enable researchresearch to be conducted with to be conducted with

comparable groups of patientscomparable groups of patients


1010

What Does The Patient Have?What Does The Patient Have?

DiseaseDisease: refers to objective pathology: refers to objective pathology IllnessIllness: is subjective awareness of distress: is subjective awareness of distress SicknessSickness: refers to a loss of capacity to fill : refers to a loss of capacity to fill

normal social rolesnormal social roles


1111

Ways of Classifying DisordersWays of Classifying Disorders

In medicine, generally this can be by:In medicine, generally this can be by: AetiologyAetiology e.g. pneumococcal pneumoniae.g. pneumococcal pneumonia PathologyPathology e.g. hepatitise.g. hepatitis SymptomsSymptoms e.g. migrainee.g. migraine

For psychiatry, very few psychiatric disorders For psychiatry, very few psychiatric disorders have a well known physical aetiology e.g. have a well known physical aetiology e.g. Alzheimer Alzheimer Disease OR exact pathology; the rest Disease OR exact pathology; the rest are mainly based on are mainly based on symptoms clusterssymptoms clusters or or SYNDROMESSYNDROMES only only


1212

Criticism Against ClassificationCriticism Against Classification

Allocating patients to a diagnostic category Allocating patients to a diagnostic category distracts from the understanding of their unique distracts from the understanding of their unique personal difficultiespersonal difficulties

Individual patients do not fit neatly into the Individual patients do not fit neatly into the available categoriesavailable categories

Proper use of classification however, can Proper use of classification however, can certainly give consideration of patients’ unique certainly give consideration of patients’ unique qualities, and yet improve treatment plan and qualities, and yet improve treatment plan and perhaps predict prognosis betterperhaps predict prognosis better


1313

History of Psychiatric ClassificationHistory of Psychiatric Classification

Greek physician Galen divided mental disorders:Greek physician Galen divided mental disorders: FrenzyFrenzy (fever, madness, sleep problems)(fever, madness, sleep problems) MelancholyMelancholy (depression)(depression) FatuitiesFatuities (dementia) (dementia) MemoryMemory lossloss (amnesic syndrome) (amnesic syndrome)

Falret (1854) described Falret (1854) described folie circulairefolie circulaire (MDP) (MDP) Kraepelin (1897) distinguished between Kraepelin (1897) distinguished between manic manic

depressive psychosisdepressive psychosis and and dementia praecoxdementia praecox (schizophrenia)(schizophrenia)

Many more classification was proposed since then until Many more classification was proposed since then until modern times…modern times…


1414

History of Psychiatric ClassificationHistory of Psychiatric Classification

Until recently, three main categories of Until recently, three main categories of mental disorders:mental disorders: PsychosisPsychosis NeurosisNeurosis Behaviour disordersBehaviour disorders (Mental retardation)(Mental retardation)


1515

Neurosis vs PsychosisNeurosis vs Psychosis

““NeurosisNeurosis” :” : first described by Cullen (1772)first described by Cullen (1772) (all) diseases affecting the nervous system (apart (all) diseases affecting the nervous system (apart

from delirium = febrile condition)from delirium = febrile condition) Includes psychosis!Includes psychosis!

““PsychosisPsychosis” :” : first described by Feuchterleben (1845)first described by Feuchterleben (1845) term used for “severe mental disorders”term used for “severe mental disorders” He accepted the term neurosis for mental disorders He accepted the term neurosis for mental disorders

as a whole!as a whole!


1616


With time, the term neurosis With time, the term neurosis narrowednarrowed and and later – psychosis and neurosis are later – psychosis and neurosis are accepted as accepted as and independent and independent group of disordersgroup of disorders


1717

Neurosis vs PsychosisNeurosis vs Psychosis Modern usage:Modern usage:

PsychosisPsychosis • Severe forms of mental disorders (e.g. organic mental Severe forms of mental disorders (e.g. organic mental

disorders, schizophrenia and affective disorders)disorders, schizophrenia and affective disorders)• Greater severity of illnessGreater severity of illness• Lack of insightLack of insight• Inability to distinguish between subjective experience and Inability to distinguish between subjective experience and

reality (hallucinations & delusions)reality (hallucinations & delusions)

NeurosisNeurosis• Mental disorders that are generally less severe than Mental disorders that are generally less severe than

psychosispsychosis• Characterized by symptoms closer to normal experience e.g. Characterized by symptoms closer to normal experience e.g.

anxiety, phobiaanxiety, phobia• Examples: generalized anxiety disorder, simple phobia, Examples: generalized anxiety disorder, simple phobia,

somatoform disorder etc.somatoform disorder etc.


1818


Problems with this dichotomy:Problems with this dichotomy: InsightInsight is difficult to define is difficult to define Conditions included together has Conditions included together has little in little in

commoncommon Less informativeLess informative to classify a disorder as to classify a disorder as

psychosis or neurosis than to classify a psychosis or neurosis than to classify a particular disorder under the two categoriesparticular disorder under the two categories

For these reasons, the distinction between For these reasons, the distinction between neurosis and psychosis was neurosis and psychosis was abandonedabandoned in in DSM-III and ICD-10DSM-III and ICD-10


1919


Currently, the term “psychotic disorders” is Currently, the term “psychotic disorders” is retained in DSM-IV and ICD-10 for conditions retained in DSM-IV and ICD-10 for conditions not yet certain of diagnosis or not characteristic not yet certain of diagnosis or not characteristic of any:of any: Psychotic disorders NOS (DSM-IV)Psychotic disorders NOS (DSM-IV) Acute or Transient Psychotic Disorders (ICD-10)Acute or Transient Psychotic Disorders (ICD-10)

The term “neurosis” is not used in DSM-IV, but The term “neurosis” is not used in DSM-IV, but retained in ICD-10 as a heading:retained in ICD-10 as a heading: ‘‘Neurotic, stress-related, and somatoform disorders’Neurotic, stress-related, and somatoform disorders’


2020

Types of ClassificationTypes of Classification

CategoricalCategorical: represent discreet entities: represent discreet entities Based on symptom patterns, and the course Based on symptom patterns, and the course

and outcome of the different disorders.and outcome of the different disorders. Includes implicit Includes implicit hierarchyhierarchy::

• Organic Disorders Organic Disorders →→ Schizophrenia Schizophrenia → Affective → Affective Disorders → Anxiety Disorders → others etc.Disorders → Anxiety Disorders → others etc.

• The higher level diagnosis have precedent over The higher level diagnosis have precedent over the lower onethe lower one

• This principle is used in both ICD-10 and DSM-This principle is used in both ICD-10 and DSM-IVIV


2121

OO-Organic mental disorders (F0) SS-Substance (psychoactive) use related disorders (F1)SS-Schizophrenia-type disorders (F2)AA-Affective and mood disorders (F3)NN-Neurotic,stress related and somatoform disorders (F4)PP-Physiological and physical disorders (F5)PP-Personality disorders (F6)MM-Mental retardation (F7)DD-Developmental disorders (F8)AA-Adolescent and childhood disorders (F9)

Categories of ICD-10 (Chapter V)Categories of ICD-10 (Chapter V)


2222

Categories of DSM-IVCategories of DSM-IV

Factitious disorders Dissociative disorders Sexual and gender identity

disorders Eating disorders Sleep disorders Impulse-control disorders

not elsewhere classified Adjustment disorders Personality disorders Other conditions that may

be a focus of clinical attention

Disorders first diagnosed in childhood

Delirium, dementia & other cognitive disorders

Mental disorders due to GMC not elsewhere classified

Substance-related disorders Schizophrenia and other

psychotic disorders Mood disorders Anxiety disorders Somatoform disorders

Disorders first diagnosed in childhood

Delirium, dementia & other cognitive disorders

Mental disorders due to GMC not elsewhere classified

Substance-related disorders Schizophrenia and other

psychotic disorders Mood disorders Anxiety disorders Somatoform disorders


2323


DimensionalDimensional: classifies patients based on three different : classifies patients based on three different dimensions rather than separate categories:dimensions rather than separate categories:

PsychoticismPsychoticism NeuroticismNeuroticism Introversion-ExtroversionIntroversion-Extroversion

The proponents argues there is no evidence to support The proponents argues there is no evidence to support the existence of the discrete categories of mental the existence of the discrete categories of mental disordersdisorders

Patients are given scores which locates them on each of Patients are given scores which locates them on each of these axes, using multivariate analysisthese axes, using multivariate analysis

Difficult to apply in clinical practice e.g. high scores on Difficult to apply in clinical practice e.g. high scores on psychoticism doesn’t mean the patient is ‘psychotic’!psychoticism doesn’t mean the patient is ‘psychotic’!


2424


Multiaxial ApproachMultiaxial Approach : schemes of : schemes of classifications in which two or more separate classifications in which two or more separate sets of information (e.g. symptoms and sets of information (e.g. symptoms and aetiology) are codedaetiology) are coded

More comprehensive but also more complicatedMore comprehensive but also more complicated Enable identification of conditions with similar Enable identification of conditions with similar

clinical presentation / aetiologyclinical presentation / aetiology Principles have been used for both ICD-10 and Principles have been used for both ICD-10 and

DSMIVDSMIV


2525

ICD-10 (child)

I - Clinical syndrome

II - Developmental disorder

III - Intellectual level

IV - Medical conditions

V - Social Situations

VI - Global assessment of functioning

ICD-10 (adult)

I - Clinical diagnosis (mental and physical)

II – Disabilities

III - Contextual factors

DSM IV

I - Clinical syndromes

II - Developmental disorder, personality disorder or mental retardation

III - Physical disorders

IV - Severity of psychosocial stressor

V - Global assessment of functioning

Multiaxial DiagnosisMultiaxial Diagnosis


2626

DSM-IV Multiaxial DiagnosisDSM-IV Multiaxial Diagnosis

Axis IAxis I: consists of all mental disorders : consists of all mental disorders except those listed under Axis II, and except those listed under Axis II, and other conditions that may be a focus of other conditions that may be a focus of clinical attention.clinical attention.

Axis IIAxis II: consists of personality disorders : consists of personality disorders and mental retardation. The habitual and mental retardation. The habitual use of a particular defense mechanism use of a particular defense mechanism can be indicated on Axis II.can be indicated on Axis II.


2727

Axis IIIAxis III: lists any physical disorder or general : lists any physical disorder or general medical condition that is present in addition to medical condition that is present in addition to the mental disorder. The identified physical the mental disorder. The identified physical condition may be:condition may be: causative (e.g., hepatic failure causing delirium)causative (e.g., hepatic failure causing delirium) interactive (e.g., gastritis secondary to alcohol interactive (e.g., gastritis secondary to alcohol

dependence),dependence), an effect (e.g., dementia and human an effect (e.g., dementia and human

immunodeficiency virus [HIV]-related pneumonia),immunodeficiency virus [HIV]-related pneumonia), or unrelated to the mental disorder.or unrelated to the mental disorder.

When a medical condition is causally related to a mental When a medical condition is causally related to a mental disorder, a mental disorder due to a general condition disorder, a mental disorder due to a general condition is listed on Axis I and the general medical condition is is listed on Axis I and the general medical condition is listed on both Axis I and III.listed on both Axis I and III.


2828

Axis IV: Psychosocial and Environmental Axis IV: Psychosocial and Environmental ProblemsProblems

Problems with primary support groupProblems related to the social environmentEducational problemsOccupational problemsHousing problemsEconomic problemsProblems with access to health care servicesProblems related to interaction with the legal system/crimeOther psychosocial and environmental problems


2929

Axis V: Global Assessment of FunctioningAxis V: Global Assessment of Functioning


3030

Example of DSM-IV multiaxial Example of DSM-IV multiaxial diagnosisdiagnosis

Axis I 296.23 Major depressive disorder, single episode, severe without psychotic features305.00 Alcohol abuse

Axis II 301.6Dependent personality disorder

Frequent use of denialAxis III Diabetes MellitusAxis IV Threat of job lossAxis V GAF = 35 (current)


3232


3333

International Classification of International Classification of Diseases (ICD)Diseases (ICD)

Mental disorders didn’t enter the ICD until Mental disorders didn’t enter the ICD until 1948 (ICD-6)1948 (ICD-6)

ICD-8 (1968) : based on the British ICD-8 (1968) : based on the British version, too many categories, added version, too many categories, added glossaryglossary

ICD-9 (1978) : very similar to ICD-8ICD-9 (1978) : very similar to ICD-8 ICD-10 (1992) : under Chapter VICD-10 (1992) : under Chapter V


3434

ICD-10ICD-10

International effort based on International effort based on multicentre research multicentre research programme and collaborative programme and collaborative studiesstudies

Close collaboration with APA Close collaboration with APA resemble DSMIV resemble DSMIV

Several versions are Several versions are available: clinical description, available: clinical description, research criteria, primary research criteria, primary care, multiaxial systemscare, multiaxial systems

Available in widely spoken Available in widely spoken languageslanguages


3535

The Diagnostic and Statistical The Diagnostic and Statistical Manual (DSM)Manual (DSM)

DSM-I (1952) was published by the APA DSM-I (1952) was published by the APA because of dissatisfaction with ICD-6 (1948) : a because of dissatisfaction with ICD-6 (1948) : a simple glossary, influence of psychoanalytic simple glossary, influence of psychoanalytic conceptsconcepts

DSM-II (1968) : American National Glossary to DSM-II (1968) : American National Glossary to ICD-8 (1968), combined with Kraepelin ideas.ICD-8 (1968), combined with Kraepelin ideas.

DSM-III (1980) : precise operational criteria DSM-III (1980) : precise operational criteria (including inclusion/exclusion criteria), multiaxial (including inclusion/exclusion criteria), multiaxial classification, less relying on psychoanalytical classification, less relying on psychoanalytical conceptsconcepts


3636

DSM-IV (1994)DSM-IV (1994)

Revised edition of DSM-III and later DSM-Revised edition of DSM-III and later DSM-IIIRIIIR Very meticulously undergone literature reviewVery meticulously undergone literature review Research / field trials done before final Research / field trials done before final

version was publishedversion was published Technically compatible with ICD-10Technically compatible with ICD-10

Can be cross-referred with ICD-10Can be cross-referred with ICD-10


3737

ICD-10ICD-10 DSM IVDSM IV

UK, Europe e.t.cUK, Europe e.t.c USAUSA

More than one version (CDDG, More than one version (CDDG, DCR, PHC e.t.c)DCR, PHC e.t.c)

One Version onlyOne Version only

MultiaxialMultiaxial MultiaxialMultiaxial

HierarchicalHierarchical HierarchicalHierarchical

Diagnostic guidelinesDiagnostic guidelines Precise Operational criteriaPrecise Operational criteria

No Global Assessment of No Global Assessment of FunctioningFunctioning

Global Assessment of Global Assessment of FunctioningFunctioning

Atheoretical with regard to Atheoretical with regard to causescauses

Atheoretical with regard to Atheoretical with regard to causescauses

Has NOS (not otherwise Has NOS (not otherwise specified) categoriesspecified) categories

Has NOS (not otherwise Has NOS (not otherwise specified) categoriesspecified) categories

Comparison ICD-10 vs DSM-IVComparison ICD-10 vs DSM-IV


3838

SummarySummary

Described the concept of mental illness – Described the concept of mental illness – difficult to definedifficult to define

Issues around psychosis and neurosis Issues around psychosis and neurosis dichotomydichotomy

Principals of classification of mental Principals of classification of mental disordersdisorders

Introduction to ICD-10 and DSM-IVIntroduction to ICD-10 and DSM-IV

Date post:	14-Dec-2015
Category:	Documents
Upload:	tucker-perk
View:	223 times
Download:	2 times

Classification of Psychiatric Illness 1 Basic Classification of Psychiatric Illness Dr. Muhd. Najib...

Documents