Classification in Psychiatry

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

3. 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

5. What is Normal? Average Supra-Threshold Ideal

6. 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

7. 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”.

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

9. 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

10. 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

11. What is Pathology? • Sign/symptom • Syndrome • Disorder • Disease • Illness

12. 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

13. 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

14. 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

15. First Step II • The boundaries from normality: Sex • Paraphilia as an example: recurrent, intensely sexually arousing fantasies, sexual urges or sexual behaviors that involve nonhuman objects, the suffering of self or partner, children or non consenting partner.

16. First Step II • To qualify as a DSM-IV diagnosis these patterns must have existed at least six months and they have cause clinically significant impairment in social, occupational or some other important area of functions, subjective disress or danger

17. 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

18. Mental disorder functional organic substance Medically

19. DD of Psychosis with Mood Disorder At leasttwo weeks In the absence of Mood schizoaffective

20. Mental disorder affective Non-affective Non-psychotic psychotic Non-psychotic psychotic

21. 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

22. Definitions of Depression • Symptoms • Episodes • Disorders • Major Depressive Disorder • Bipolar Disorder • Dysthymia • Depressive Disorder NOS (e.g. subthreshold depression)

23. Symptoms of Depression • Mood Symptoms - Depressed mood or irritability - Loss of interest or pleasure in most activities - Feelings of worthlessness or guilt - Thoughts of death or a desire to die • Cognitive Symptoms - Difficulty thinking, concentrating, or making decisions

24. Symptoms of Depression, cont. • Physical Symptoms • Weight loss or weight gain • Psychomotor agitation or retardation • Insomnia or hyposomnia • Fatigue or loss of energy

25. Depressive Episodes • Major Depressive Episode • Depressed mood or loss of interest or pleasure in most activities, plus 5 of 9 symptoms • Most of the day, nearly every day for a minimum of 2 weeks • Combinations of symptoms may vary significantly from individual to individual • Significant functional impairment or interference • Manic, Mixed, and Hypomanic Episodes

26. DSM-III Paradigm Shift • Descriptive • Non-etiologic focus • Diagnostic criteria • Multiaxial system • Multiple diagnoses • Splitting • Reliability

27. DSM-III Advantages • Improved reliability • Facilitated communication within and between research and clinical communities • Wide use by clinicians, researchers, educators, trainees • Promoted emphasis on empirical data • Methodological and content innovations

28. Categorical vs. Dimensional Systems • Categorical • Presence/absence of a disorder • Either you are anxious or you are not anxious. • DSM is categorical • Dimensional • Rank on a continuous quantitative dimension • How anxious are youon 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

29. 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

30. Assessment Issues: Reliability • Reliability • Consistency of measurement • Interrater reliability • Extent to which clinicians agree on the diagnosis.

31. 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

32. Multiaxial System AXIS I: Clinical Disorders Other Conditions That May Be a Focus of Clinical Attention Diagnostic Code DSM-IV Name 300.21 Panic Disorder with Agoraphobia, Moderate 304.10 Diazepam Dependence, Mild ___.__ ____________________________________ AXIS II: Personality Disorders Diagnostic Code DSM-IV Name 301.82 Avoidant Personality Disorder ___.__ Dependent Personality Features___________ AXIS III: General Medical Conditions ICD-9-CM code ICD-9-CM name 424.0 Mitral Valve Prolapse ___.__ ____________________________________

33. Multiaxial System Axis IV: Psychosocial and Environmental Problems Check: X Problems with primary support group Specify: Marital Discord Problems related to the social environment Specify:___________ Educational problems Specify:_____________________________ X Occupational problems Specify: Excessive Work Absences Housing problems Specify:________________________________ Economic problems Specify:_______________________________ Problems with access to health care services Specify:__________ Problems related to the legal system/crime Specify:___________ Other psychosocial and environmental problems Specify:_______ Axis V: Global Assessment of Functioning Scale Code: 55 (current)

34. 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…”

35. 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)

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

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

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

39. Diagnostic Groupings and Examples • Dissociative Disorders • Dissociative Identity Disorder • Depersonalization Disorder • Eating Disorders • Anorexia Nervosa • Bulimia Nervosa • Sleep Disorders • Narcolepsy • Sleep Terror Disorder • Sexual, Gender Identity Disorders • Premature Ejaculation • Paraphilias

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

41. 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

42. 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

43. Controversies • Brainless vs. Mindless Psychiatry • “Inventing” New Diagnoses • e.g. Premenstrual Dysphoric Disorder • Social Labeling • Cultural Relativism • Primary Care vs. Sepciality Focus

44. Conceptual Tensions: Past and Present • Phenomenology vs. course vs. etiology • Descriptive vs. theoretical • Categorical vs. dimensional • Symptom vs. syndrome vs. disease • Reliability vs. validity vs. clinical utility • Lumping vs. splitting • Clinical vs. research vs. administrative purposes

45. Assessment Issues: Validity • Construct validity • Extent to which diagnosis is related to, or predictive of, a network of diagnostic hypotheses. • Validity of DSM diagnostic categories varies.