1. Classification of Psychiatric Illness 1 Basic Classification of Psychiatric Illness Dr. Muhd. Najib Mohd. Alwi Dept. of Psychiatry najib@kck.usm.myclik.to/drnajib © MNMA Y2K2

2. Classification of Psychiatric Illness2 Objectives To understand the concept of mentalTo understand the concept of mentalillness To describe principles used in theTo describe principles used in the classification of psychiatric illness To know basic outline of ICD-10 andTo know basic outline of ICD-10 and DSM-IV and their main differences

3. Classification of Psychiatric Illness3 Definition of Mental Illness  ‘Illness’ has three definitions: Absence of health Absence of health Presence of suffering Presence of suffering Presence of pathological process – physical or psychological Presence of pathological process – physical or psychological  Can we then define mental illness along those lines?

4. Classification of Psychiatric Illness4 Definition of Mental Illness ABSENCE OF HEALTH WHO defines health as: ‘a state of complete physical, mental and social well-being, and not merely the absence of disease or infirmity’  … almost impossible to achieve ‘mental health’ then?

5. Classification of Psychiatric Illness5 Definition of Mental Illness PRESENCE OF SUFFERING  … may explain a group of people who comes to seek treatment  BUT in mental illness, some patients may not realise that they have problem e.g. some manic or schizophrenic patients…

6. Classification of Psychiatric Illness6 Definition of Mental Illness PRESENCE OF PATHOLOGICAL PROCESS  Most mental disorders have no demonstrable physical pathology… and thus ? not ILLNESSES. A view strongly advocated by the ‘anti-psychiatry movement’ (Szasz etc.) A view strongly advocated by the ‘anti-psychiatry movement’ (Szasz etc.) … true only until lately though!!!  In the last decade, more and more evidence are emerging – genetic, biochemical and even some structural and functional imaging on quite a number of psychiatric conditions (including Schizophrenia!)

7. Classification of Psychiatric Illness7

8. 8 Definition of Mental Illness  Perhaps the best way forward, and most widely used is to define mental illness as the PRESENCE OF PSYCHOPATHOLOGY.  i.e. evident disturbance in psychological functions: Perception Perception Memory Memory Learning Learning Emotion Emotion Thinking Thinking Partially or in full

9. Classification of Psychiatric Illness9 Why Classify?  The purpose of classification is to identify groups of patients who share similar clinical features or disorders: To formulate treatment plan To formulate treatment plan To predict likely outcome To predict likely outcome To communicate with other professionals regarding the illness To communicate with other professionals regarding the illness To enable research to be conducted with comparable groups of patients To enable research to be conducted with comparable groups of patients

10. Classification of Psychiatric Illness10 What Does The Patient Have?  Disease: refers to objective pathology  Illness: is subjective awareness of distress  Sickness: refers to a loss of capacity to fill normal social roles

11. Classification of Psychiatric Illness11 Ways of Classifying Disorders  In medicine, generally this can be by: Aetiology e.g. pneumococcal pneumonia Aetiology e.g. pneumococcal pneumonia Pathology e.g. hepatitis Pathology e.g. hepatitis Symptoms e.g. migraine Symptoms e.g. migraine  For psychiatry, very few psychiatric disorders have a well known physical aetiology e.g. Alzheimer Disease OR exact pathology; the rest are mainly based on symptoms clusters or SYNDROMES only

12. Classification of Psychiatric Illness12 Criticism Against Classification  Allocating patients to a diagnostic category distracts from the understanding of their unique personal difficulties  Individual patients do not fit neatly into the available categories Proper use of classification however, can certainly give consideration of patients’ unique qualities, and yet improve treatment plan and perhaps predict prognosis better

13. Classification of Psychiatric Illness13 History of Psychiatric Classification  Greek physician Galen divided mental disorders: Frenzy (fever, madness, sleep problems) Frenzy (fever, madness, sleep problems) Melancholy (depression) Melancholy (depression) Fatuities (dementia) Fatuities (dementia) Memory loss (amnesic syndrome) Memory loss (amnesic syndrome)  Falret (1854) described folie circulaire (MDP)  Kraepelin (1897) distinguished between manic depressive psychosis and dementia praecox (schizophrenia)  Many more classification was proposed since then until modern times…

14. Classification of Psychiatric Illness14 History of Psychiatric Classification  Until recently, three main categories of mental disorders: Psychosis Psychosis Neurosis Neurosis Behaviour disorders Behaviour disorders (Mental retardation) (Mental retardation)

15. Classification of Psychiatric Illness15 Neurosis vs Psychosis  “Neurosis” : first described by Cullen (1772) first described by Cullen (1772) (all) diseases affecting the nervous system (apart from delirium = febrile condition) (all) diseases affecting the nervous system (apart from delirium = febrile condition) Includes psychosis! Includes psychosis!  “Psychosis” : 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 as a whole! He accepted the term neurosis for mental disorders as a whole!

16. Classification of Psychiatric Illness16 Neurosis vs Psychosis  With time, the term neurosis narrowed and later – psychosis and neurosis are accepted as separate and independent group of disorders

17. Classification of Psychiatric Illness17 Neurosis vs Psychosis  Modern usage: Psychosis Psychosis Severe forms of mental disorders (e.g. organic mental disorders, schizophrenia and affective disorders)Severe forms of mental disorders (e.g. organic mental disorders, schizophrenia and affective disorders) Greater severity of illnessGreater severity of illness Lack of insightLack of insight Inability to distinguish between subjective experience and reality (hallucinations & delusions)Inability to distinguish between subjective experience and reality (hallucinations & delusions) Neurosis Neurosis Mental disorders that are generally less severe than psychosisMental disorders that are generally less severe than psychosis Characterized by symptoms closer to normal experience e.g. anxiety, phobiaCharacterized by symptoms closer to normal experience e.g. anxiety, phobia Examples: generalized anxiety disorder, simple phobia, somatoform disorder etc.Examples: generalized anxiety disorder, simple phobia, somatoform disorder etc.

18. Classification of Psychiatric Illness18 Neurosis vs Psychosis  Problems with this dichotomy: Insight is difficult to define Insight is difficult to define Conditions included together has little in common Conditions included together has little in common Less informative to classify a disorder as psychosis or neurosis than to classify a particular disorder under the two categories Less informative to classify a disorder as psychosis or neurosis than to classify a particular disorder under the two categories  For these reasons, the distinction between neurosis and psychosis was abandoned in DSM-III and ICD-10

19. Classification of Psychiatric Illness19 Neurosis vs Psychosis  Currently, the term “psychotic disorders” is retained in DSM-IV and ICD-10 for conditions not yet certain of diagnosis or not characteristic 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 retained in ICD-10 as a heading: ‘Neurotic, stress-related, and somatoform disorders’ ‘Neurotic, stress-related, and somatoform disorders’

20. Classification of Psychiatric Illness20 Types of Classification  Categorical: represent discreet entities Based on symptom patterns, and the course and outcome of the different disorders. Based on symptom patterns, and the course and outcome of the different disorders. Includes implicit hierarchy: Includes implicit hierarchy: Organic Disorders → Schizophrenia → Affective Disorders → Anxiety Disorders → others etc.Organic Disorders → Schizophrenia → Affective Disorders → Anxiety Disorders → others etc. The higher level diagnosis have precedent over the lower oneThe higher level diagnosis have precedent over the lower one This principle is used in both ICD-10 and DSM- IVThis principle is used in both ICD-10 and DSM- IV

21. Classification of Psychiatric Illness21 O S S A N P P M D A O-Organic mental disorders (F0) S-Substance (psychoactive) use related disorders (F1) S-Schizophrenia-type disorders (F2) A-Affective and mood disorders (F3) N-Neurotic,stress related and somatoform disorders (F4) P-Physiological and physical disorders (F5) P-Personality disorders (F6) M-Mental retardation (F7) D-Developmental disorders (F8) A-Adolescent and childhood disorders (F9) Categories of ICD-10 (Chapter V)

22. Classification of Psychiatric Illness22 Categories 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

23. Classification of Psychiatric Illness23 Types of Classification  Dimensional: classifies patients based on three different dimensions rather than separate categories: Psychoticism Psychoticism Neuroticism Neuroticism Introversion-Extroversion Introversion-Extroversion  The proponents argues there is no evidence to support the existence of the discrete categories of mental disorders  Patients are given scores which locates them on each of these axes, using multivariate analysis  Difficult to apply in clinical practice e.g. high scores on psychoticism doesn’t mean the patient is ‘psychotic’!

24. Classification of Psychiatric Illness24 Types of Classification  Multiaxial Approach : schemes of classifications in which two or more separate sets of information (e.g. symptoms and aetiology) are coded  More comprehensive but also more complicated  Enable identification of conditions with similar clinical presentation / aetiology  Principles have been used for both ICD-10 and DSMIV

25. Classification of Psychiatric Illness25 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 Diagnosis

26. Classification of Psychiatric Illness26 DSM-IV Multiaxial Diagnosis  Axis I: consists of all mental disorders except those listed under Axis II, and other conditions that may be a focus of clinical attention.  Axis II: consists of personality disorders and mental retardation. The habitual use of a particular defense mechanism can be indicated on Axis II.

27. Classification of Psychiatric Illness27  Axis III: lists any physical disorder or general medical condition that is present in addition to the mental disorder. The identified physical condition may be: causative (e.g., hepatic failure causing delirium) causative (e.g., hepatic failure causing delirium) interactive (e.g., gastritis secondary to alcohol dependence), interactive (e.g., gastritis secondary to alcohol dependence), an effect (e.g., dementia and human immunodeficiency virus [HIV]-related pneumonia), an effect (e.g., dementia and human 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 disorder, a mental disorder due to a general condition is listed on Axis I and the general medical condition is listed on both Axis I and III.

28. Classification of Psychiatric Illness28 Axis IV: Psychosocial and Environmental Problems Problems with primary support group Problems related to the social environment Educational problems Occupational problems Housing problems Economic problems Problems with access to health care services Problems related to interaction with the legal system/crime Other psychosocial and environmental problems

29. Classification of Psychiatric Illness29 Axis V: Global Assessment of Functioning

30. Classification of Psychiatric Illness30

31. Example of DSM-IV multiaxial diagnosis Axis I296.23Major depressive disorder, single episode, severe without psychotic features 305.00Alcohol abuse Axis II301.6Dependent personality disorder Frequent use of denial Axis IIIDiabetes Mellitus Axis IVThreat of job loss Axis VGAF = 35(current)

32. Classification of Psychiatric Illness32

33. Classification of Psychiatric Illness33 International Classification of Diseases (ICD)  Mental disorders didn’t enter the ICD until 1948 (ICD-6)  ICD-8 (1968) : based on the British version, too many categories, added glossary  ICD-9 (1978) : very similar to ICD-8  ICD-10 (1992) : under Chapter V

34. Classification of Psychiatric Illness34 ICD-10  International effort based on multicentre research programme and collaborative studies  Close collaboration with APA  resemble DSMIV  Several versions are available: clinical description, research criteria, primary care, multiaxial systems  Available in widely spoken languages

35. Classification of Psychiatric Illness35 The Diagnostic and Statistical Manual (DSM)  DSM-I (1952) was published by the APA because of dissatisfaction with ICD-6 (1948) : a simple glossary, influence of psychoanalytic concepts  DSM-II (1968) : American National Glossary to ICD-8 (1968), combined with Kraepelin ideas.  DSM-III (1980) : precise operational criteria (including inclusion/exclusion criteria), multiaxial classification, less relying on psychoanalytical concepts

36. Classification of Psychiatric Illness36 DSM-IV (1994)  Revised edition of DSM-III and later DSM- IIIR Very meticulously undergone literature review Very meticulously undergone literature review Research / field trials done before final version was published Research / field trials done before final version was published  Technically compatible with ICD-10 Can be cross-referred with ICD-10 Can be cross-referred with ICD-10

37. Classification of Psychiatric Illness37 ICD-10 DSM IV UK, Europe e.t.c USA More than one version (CDDG, DCR, PHC e.t.c) One Version only MultiaxialMultiaxial HierarchicalHierarchical Diagnostic guidelines Precise Operational criteria No Global Assessment of Functioning Global Assessment of Functioning Atheoretical with regard to causes Has NOS (not otherwise specified) categories Comparison ICD-10 vs DSM-IV

38. Classification of Psychiatric Illness38 Summary  Described the concept of mental illness – difficult to define  Issues around psychosis and neurosis dichotomy  Principals of classification of mental disorders  Introduction to ICD-10 and DSM-IV