Classification in Psychiatry Professor Shmuel Fennig, M.D Shalvata Mental Health Center Hod Hasharon

Goals of a Classification System Communication: among clinicians, between science and practice Clinical: facilitate identification treatment, and prevention of mental disorders Research: test treatment efficacy and understand etiology Education: teach psychopathology Information Management: measure and pay for care

What is abnormal? Your uncle consumes a quart of whiskey each day; he has trouble remembering the names of people around him Your friend complains of many physical problems and sees 2-3 doctors each week

What is abnormal? Your neighbor sweeps, washes, and scrubs his driveway daily Your cousin is pregnant and she is dieting so that she will not get “ too fat ”.

What is Abnormal? Possible definitions: Statistical deviation Violation of social norms Subjective distress Disability or dysfunction Abnormal behavior does not necessarily indicate mental illness

Definition of a Mental Disorder Clinically significant …. Behavioral or psychological …. Pattern or syndrome …. Associated with …. Present Distress OR …. Disability/impairment Or …. With significantly increased risk of …. Suffering death, pain, disability or an important loss of freedom

Definition of a Mental DisorderII This syndrome or pattern … Must not be merely an expectable/culturally sanctioned response to particular event (death of a loved one) Considered a manifestation of a behavioral, psychological or biological dysfunction in the individual Neither deviant behavior (e.g political. Releigeous or sexual) nor conflicts between individual and society are mental disorders Unless they represent a dysfunction in the individual

What is Pathology? Sign/symptom Syndrome Disorder Disease Illness

From syndrome to disease Syndrome – a set of signs and symptoms that co-occure at a greater than chance frequency Disorder – conjunction of a syndrome with a clinical course Disease – conjunction of etiology and pathology. True disease: symptoms, pathology, pathophysiology and underlying causes are known as well as the relationship between them Illness- the psychosocial aspect of being sick

Psychiatric Diagnosis Step I: Normal vs. Abnormal -Concepts of health and disease Step II: how to build a diagnosis What is DSM IV and how does it work? Controversies/Polemics/Hype

First Step Determine that this is a Dis-Order: what are the boundaries between “ this ” what is presented, and normal behavior Symptoms cause a subjective distress and/or a clinically significant disturbance. Discuss: Homosexuality, Grief vs. Pathological Grief, Fetishism, Voyerism, transverstism, Exhibitionism

Second Step Determine what are the symptoms and signs and their temporal relationship: are the symptoms cluster belong to psychosis, affective disorder, cognitive impairement, etc Course Axis: II personality, mental retardation, axis III, stressors (Axis IV), GAF

Another Practical approach to Mental Disorders Organic (medical or substance) vs. non organic Psychotic vs. non psychotic If Psychotic with or without affective symptoms Or Affective with or without psychotic symptoms Severe Mental Disorders vs. “ Soft Psychiatry

A Brief Look at Etiology of Mental Disorders Models of Psychopathology Biological Psychodynamic Cognitive Learning Humanistic Diathesis-Stress

Categorical vs. Dimensional Systems Categorical Categorical Presence/absence of a disorder Presence/absence of a disorder Either you are anxious or you are not anxious. Either you are anxious or you are not anxious. DSM is categorical DSM is categorical Dimensional Dimensional Rank on a continuous quantitative dimension Rank on a continuous quantitative dimension How anxious are you on a scale of 1 to 10? How anxious are you on a scale of 1 to 10? Dimensional systems may better capture an individual’s functioning but the categorical approach has advantages for research and understanding Dimensional systems may better capture an individual’s functioning but the categorical approach has advantages for research and understanding

Categorical and Dimensional Systems DSM-IV is a categorical system: categories may share features (criteria) and may share members (both diagnoses in the same individual) Dimensional: no discrete categories. Pathology represent a statistical deviation from the norm. Combination of the two: severity, GAF

What ’ s in DSM-IV Systematic framework for diagnosis (including multiaxial system) Names and codes (from ICD-9cm) Diagnostic criteria Detailed text Appendices to expand educational/practical utility Primary Care version

Diagnostic Approach Presenting symptom - e.g. depressed mood Rule out disorder due to general medical condition – e.g. due to hypothyroidism Rule out disorder due to direct effects of a substance - e.g. alcohol induced, reserpine induced Determine specific primary disorder(s) Multiple diagnoses Some hierarchies “ Not better accounted for …”

Diagnostic Approach Distinguishing Adjustment Disorder from Not Otherwise Specified (NOS) – e.g. response to stressor Establishing boundary with no mental disorder - i.e. clinical significance/cultural sanction, i.e. bereavement Add subtypes/specifiers severity (mild moderate, severe – with or without psychotic features) treatment relevant (melancholic, a typical, etc.) longitudinal course (with/without full interepisode recovery, seasonal pattern)

Diagnostic Groupings and Examples Disorders Usually Evident in Infancy, Childhood or Adolescence 1. Autism 2. Attention Deficit-Hyperactivity Disorder 3. Conduct Disorders 4. Mental Retardation (Axis II) 5. Tourette ’ s Delirium, Dementia and Cognitive Disorders 1. Delirium 2. Dementia of the Alzheimer ’ s Type 3. Vascular Dementia 4. Amnestic Disorder

Diagnostic Groupings and Examples Substance Related Disorders 1. Alcohol Dependence 2. Cannabis Abuse 3. Hallucinogen-Induced Psychotic Disorder 4. Opiate Withdrawal Psychotic Disorders 1. Schizophrenia 2. Delusional Disorder Mood Disorders 1. Major Depressive Disorder 2. Bipolar Disorder 3. Dysthymia

Anxiety Disorders 1. Panic Disorder with Agoraphobia 2. Post-Traumatic Stress Disorder 3. Obsessive-Compulsive Disorder Somatoform Disorders 1. Somatization Disorder 2. Hypochondriasis Factitious Disorders and Malingering 1. Factitious Disorder (Munchhausen ’ s)0 2. Malingering Diagnostic Groupings and Examples

Dissociative Disorders 1. Dissociative Identity Disorder 2. Depersonalization Disorder Eating Disorders 1. Anorexia Nervosa 2. Bulimia Nervosa Sleep Disorders 1. Narcolepsy 2. Sleep Terror Disorder Sexual, Gender Identity Disorders 1. Premature Ejaculation 2. Paraphilias

Diagnostic Groupings and Examples Adjustment Disorders 1. Adjustment Disorder with Mixed Anxiety and Depressed Mood Personality Disorders (Axis II) 1. Borderline Personality Disorder 2. Obsessive-Compulsive Personality Disorder Impulse Control Disorders 1. Trichotillomania 2. Pathological Gambling Other Conditions (Including “ V Codes ” ) 1. Relational Problems 2. Sexual Abuse of a Child 3. Bereavement

DSM-IV Text Essential Features Associated Features (including physical exam and lab findings) Recording Procedures Age, Gender, and Culture Features Prevalence, Course, Familial Pattern Differential Diagnosis

DSM-IV Appendices Decision Trees for Differential Diagnosis Criteria Sets and Axes Provided for Further Study Glossary of Technical Terms Alphabetical and Numerical Listings Codes for Selected General Medical Conditions Cultural Formulation and Glossary