Transcript Classification in Psychiatry

Classification in Psychiatry
Professor Shmuel Fennig, M.D
Shalvata Mental Health Center
Hod Hasharon
Goals of a Classification
System
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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 Normal?
Average
SupraThreshold
Ideal
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
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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”.
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What is Abnormal?
Possible definitions:
 Statistical deviation
 Violation of social norms
 Subjective distress
 Disability or dysfunction
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Abnormal behavior does not necessarily
indicate mental illness
Definition of a Mental Disorder
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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
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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?
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Sign/symptom
Syndrome
Disorder
Disease
Illness
From syndrome to disease
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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
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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
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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
First Step II
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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.
First Step II
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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
Second Step
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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
Mental disorder
functional
organic
substance
Medically
DD of Psychosis with Mood
Disorder
Psychosis
medical
Symptoms of sc
Lasting 1 m.
substance
Depression or mania
Duration long
Duration short
sz
At least two weeks
In the absence of Mood
schizoaffective
Mental disorder
affective
psychotic
Non-psychotic
Non-affective
psychotic
Non-psychotic
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
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Definitions of Depression
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Symptoms
Episodes
Disorders
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Major Depressive Disorder
Bipolar Disorder
Dysthymia
Depressive Disorder NOS (e.g. subthreshold
depression)
Symptoms of Depression
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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
Symptoms of Depression,
cont.
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Physical Symptoms
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Weight loss or
weight gain
Psychomotor
agitation or
retardation
Insomnia or
hyposomnia
Fatigue or loss of
energy
Depressive Episodes
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Major Depressive Episode
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Depressed mood or loss of interest or
pleasure in most activities, plus 5 of 9
symptoms
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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
DSM-III Paradigm Shift
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Descriptive
Non-etiologic focus
Diagnostic criteria
Multiaxial system
Multiple diagnoses
Splitting
Reliability
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
Categorical vs. Dimensional
Systems
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Categorical
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Dimensional
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Presence/absence of a disorder
 Either you are anxious or you
are not anxious.
DSM is categorical
Rank on a continuous quantitative
dimension
 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
Categorical and Dimensional
Systems
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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
Assessment Issues: Reliability
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Reliability
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Consistency of
measurement
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Interrater reliability
– Extent to which
clinicians agree on
the diagnosis.
Diagnosis
Kappa
Bipolar Disorder
Major Depression
Schizophrenia
Alcohol Abuse
Anorexia
Bulimia
Panic Disorder
Social Phobia
.84
.64
.65
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.75
.86
.58
.47
What’s in DSM-IV
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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
Multiaxial System
Clinical Disorders
AXIS I:
Other Conditions That May Be a Focus of Clinical Attention
DSM-IV Name
Panic Disorder with Agoraphobia, Moderate
Diazepam Dependence, Mild
Diagnostic Code
300.21
304.10
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AXIS II: Personality Disorders
DSM-IV Name
Diagnostic Code
Avoidant Personality Disorder
301.82
Dependent Personality
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Features___________
AXIS III: General Medical Conditions
ICD-9-CM name
Mitral Valve Prolapse
ICD-9-CM code
424.0
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Multiaxial System
Axis IV: Psychosocial and Environmental Problems
Check:
Specify: Marital
Problems with primary support group X
Discord
Problems related to the social environment
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Specify:___________
Educational problems
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Specify:_____________________________
Occupational problems Specify: Excessive Work Absences X
Housing problems
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Specify:________________________________
Economic problems
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Specify:_______________________________
Problems with access to health care services
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Specify:__________
Problems related to the legal system/crime
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Specify:___________
Other psychosocial and environmental problems 
Diagnostic Approach
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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
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Determine specific primary disorder(s)
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Multiple diagnoses
Some hierarchies
“Not better accounted for…”
Diagnostic Approach
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Distinguishing Adjustment Disorder from Not
Otherwise Specified (NOS) – e.g. response to
stressor
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Establishing boundary with no mental
disorder - i.e. clinical significance/cultural
sanction, i.e. bereavement
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Add subtypes/specifiers
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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
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Autism
Attention Deficit-Hyperactivity Disorder
Conduct Disorders
Mental Retardation (Axis II)
Tourette’s
Delirium, Dementia and Cognitive Disorders
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Delirium
Dementia of the Alzheimer’s Type
Vascular Dementia
Amnestic Disorder
Diagnostic Groupings and Examples
Substance Related Disorders
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Alcohol Dependence
Cannabis Abuse
Hallucinogen-Induced Psychotic Disorder
Opiate Withdrawal
Psychotic Disorders
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Schizophrenia
Delusional Disorder
Mood Disorders
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Major Depressive Disorder
Bipolar Disorder
Dysthymia
Diagnostic Groupings and
Examples
Anxiety Disorders
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Panic Disorder with Agoraphobia
Post-Traumatic Stress Disorder
Obsessive-Compulsive Disorder
Somatoform Disorders
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Somatization Disorder
Hypochondriasis
Factitious Disorders and Malingering
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Factitious Disorder (Munchhausen’s)0
Malingering
Diagnostic Groupings and
Examples
Dissociative Disorders
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Dissociative Identity Disorder
Depersonalization Disorder
Eating Disorders
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Anorexia Nervosa
Bulimia Nervosa
Sleep Disorders
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Narcolepsy
Sleep Terror Disorder
Sexual, Gender Identity Disorders
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Premature Ejaculation
Paraphilias
Diagnostic Groupings and
Examples
Adjustment Disorders
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Adjustment Disorder with Mixed Anxiety and
Depressed Mood
Personality Disorders (Axis II)
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Borderline Personality Disorder
Obsessive-Compulsive Personality Disorder
Impulse Control Disorders
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Trichotillomania
Pathological Gambling
Other Conditions (Including “V Codes”)
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Relational Problems
Sexual Abuse of a Child
Bereavement
DSM-IV Text
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Essential Features
Associated Features (including physical
exam and lab findings)
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Recording Procedures
Age, Gender, and Culture Features
Prevalence, Course, Familial Pattern
Differential Diagnosis
DSM-IV Appendices
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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
Controversies
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Brainless vs. Mindless Psychiatry
“Inventing” New Diagnoses
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e.g. Premenstrual Dysphoric Disorder
Social Labeling
Cultural Relativism
Primary Care vs. Sepciality Focus
Conceptual Tensions:
Past and Present
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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
Assessment Issues: Validity
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Construct validity
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Extent to which
diagnosis is related to,
or predictive of, a
network of diagnostic
hypotheses.
Validity of DSM
diagnostic categories
varies.