Classification in psychiatry

classification, approches, history, dsm, icd

1. CLASSIFICATION IN PSYCHIATRY DR.R.G.ENOCH MD Psychiatry I Year GMKMCH, Salem

2. Definition Advantages of Classification Key terms Approaches to Classification Historical Development DSM ICD ICD 11 Other Classification Systems Classification of sleep disorders

3. Definition Classification also known as  psychiatric nosology  or  psychiatric taxonomy , a process by which complex phenomena are reduced by rearranging into categories based on shared characteristics.

4. ADVANTAGES OF CLASSIFICATION Organization of disorders into diagnostic classes To allow mental health practitioners and researchers to communicate more effectively with each other To arrive at a diagnosis that has important predictive power To distinguish between one diagnosis from another Structure for teaching phenomenology and differential diagnosis Psychoeducation of patients and their families Health care epidemiologists to determine the incidence and prevalence of disorders

5. KEY TERMS Syndrome – It is a cluster of symptoms that can result from different disease processes. Disorder - It is a derangement or abnormality of  function Disease – it is a definite pathological process having a characteristic set of signs and symptoms Diagnosis - is simply the opinion, by someone with expertise in the matter, that a given disorder is present (or absent) in a patient, or the procedure to decide whether or not a certain disease or disorder is present (or absent). categorical - it is either present or absent dimensional - a certain point in a continuum.

6. KEY TERMS Diagnostic Classification - is the listing of diagnoses grouped by relatedness (for example, infectious, autoimmune diseases, cancer, or injuries in medicine, or anxiety, affective or psychotic disorders in psychiatry). Diagnostic Criteria - are the rules that need to be followed for making a diagnosis. Reliability - Once made, a diagnosis is reliable if the same conclusion about can be reached by two independent observers ( inter-rater reliability ) or the same diagnosis is achieved when examined more than once within a reasonable time period ( test–retest reliability ). Validity - Finally, a diagnosis is valid, if it picks out a “real” entity, based on etiology and pathophysiology .

7.   Mental Disorder As defined in the DSM-5 Manual, 1. “A mental disorder is a syndrome characterized by clinically significant disturbance in an individual’s cognition, emotion regulation, or behavior 2. that reflects a dysfunction in the psychological, biological or developmental processes underlying mental functioning. 3. Mental disorders are usually associated with significant distress or disability in social, occupational, or other important activities. 4. An expectable or culturally approved response to a common stressor or loss, such as the death of a loved one, is not a mental disorder. 5. Socially deviant behavior (e.g., political, religious, or sexual) and conflicts that are primarily between the individual and society are not mental disorders unless the deviance or conflict results from a dysfunction in the individual, as described above.”

8. APPROACHES TO CLASSIFICATION Etiological Descriptive Categorical Dimensional

9. ETIOLOGICAL APPROACH It tends to find “reason” for the set of symptoms. The reasons could be biological, psychological, or social. However, the etiological approach is difficult to use for psychiatric disorders since the etiology is usually multifactorial . Interplay of genetic and environmental factors is implicated in development of most disorders. Role of each factor can be hardly quantified with certain degree of precision. Also, it may be unclear whether a factor causes the disorder or merely unmasks it in susceptible individuals. 16th century Swiss physician Paracelsus developed a classification system. He divided psychotic presentations into three types of disorders based on presumed etiology VESANIA : Disorders caused by poisons - Substance-induced disorders INSANITY : Diseases caused by heredity - Schizophrenia and bipolar disorder LUNACY : Periodical condition. Influenced by the phases of Moon. Has no analogous condition today

10. DESCRIPTIVE APPROACH Descriptive approach to classification defines disorders based on clinical descriptions of presenting symptoms. It has proved to be of greater utility. This approach advanced by the work of the nineteenth century psychiatrist Emil Kraepelin ( Kraepelin , 1992). Forms the basis for the current DSM and ICD classification system.

11. CATEGORICAL APPROACH It involves the assessment of whether an individual has a disorder on the basis of symptoms and characteristics that is described as typical of the disorder. This approach is the classification strategies used in DSM and ICD. The DSM names the disorders and describes them in specific terms. The ICD identifies symptoms that indicate the presence of a disorder.

12. Thoughts, feelings and behaviour can be organised into categories representing disorders All or nothing principle. This approach considers illness as being either present or absent. there are no “in between” diagnoses. (so the individual either has a diagnosable metal disorder or does not have a diagnosable disorder.) This system used to classify and diagnose metal disorders is both valid and reliable ( this classification system actually organises metal disorders into discrete and distinct disorders and that the classification system produces the same diagnosis each time it is used In the same situation) CATEGORICAL APPROACH

13. CATEGORICAL APPROACH Strengths for using this approach include: Helps communication Allows diagnosis Weaknesses for using this approach include : Lots of overlap between symptoms which can make diagnosis tricky Stigma and labelling

14. DIMENSIONAL APPROACH Symptoms of disorder exist on a dimension which is a continuum from normal to severely ill Dimensionality can be envisaged in terms of number of symptoms (e.g., five out of eight symptoms to diagnose major depressive disorder) and severity of each symptom group (mild, moderate and severe). This approach classifies the mental disorders that quantifies a person’s symptoms with numerical values on one or more scales or continuums, rather than assigning them to a mental disorder category. Diagnosis then becomes not a process of deciding the presence or absence of a symptom or disorder but rather the degree to which a particular characteristic is present. The dimensional approach suggests that symptoms may be present in normal as well as in ill.

15. ADVANTAGES OF DIMENSIONAL APPROACH 1. Comorbid disorders can be easily represented. Individual who presents with depression, anxiety, and social avoidance using the DSM-5 categorical system, criteria might be met for three diagnoses. A dimensional approach may simply indicate that the person has elevated values on the depression, anxiety and social avoidance dimensions 2. Dimensional approach avoids setting of a particular thresholds for distinguishing between pathology and normality. Categorically individual has major depressive disorder only if the threshold of five depressive symptoms is met or exceeded. Dimensional approach might say that the person is high on the depression dimension 3. More detailed information on each symptom

16. 4. It takes into account a wider range of factors. (More than categorical approaches)  5. A profile is created instead of labelling . 6. Dimensions can be helpful in indicating the severity of the disorder. The range of appropriate treatments is related to the severity of the disorder. 7. Facilitate research into the underlying etiology and pathophysiology of mental disorders. 8. Research studies using dimensional scales have greater power to detect differences in groups

17. DISADVANTAGES OF DIMENSIONAL APPROACH 1.Clinicians are accustomed to thinking in terms of diagnostic categories 2.Existing knowledge base about the presentation, etiology, epidemiology, course, prognosis, and treatment is based on these categories. 3.Decisions about the management of individual patients are easier to make if the patient is thought of as having a particular disorder 4.The value of dimensions in terms of communicating information from one clinician to another is likely to be quite limited. one clinician communicates with another by saying something like, ‘this is a bad case of depression and so far intractable to treatment,’ not by saying, ‘on dimensional scales x, y, and z the patient has such and such scores

18. The previous editions of DSM strictly used a categorical approach. In the present DSM 5 and ICD -10 there is an integration of the dimensional approach along with the categorical approach.

19. HISTORICAL DEVELOPMENT 460 – 377 BC In Ancient Greece,  Hippocrates  and his followers are generally credited with the first classification system . 6 Conditions -mania, melancholia, epilepsy, hysteria, phrenitis  and Scythian disease ( transvestism ). They held that they were due to different kinds of imbalance in four humors . 1624–1689 – Thomas Sydenham – the "English Hippocrates", emphasized careful clinical observation and diagnosis and developed the concept of a  syndrome . Rejected single dysfunction was the root cause. Each disease has an uniform presentation in different individuals. 18th century - Boissier de Sauvages  developed an extremely extensive psychiatric classification. It was only a part of his classification of 2400 medical diseases. Nosologia methodica

20. 19th century - The diagnosis of "moral insanity" coined by  James Prichard  also became popular; meaning disordered emotions or behavior. 1808 The term "psychiatry" (" Psychiatrie ") was coined by German physician  Johann Christian Reil  , from the Greek psychē : "soul or mind" and iatros : "healer or doctor" 1840 Recording of mental illness in the United States census that included, besides physical illnesses, a category for idiocy/insanity and normals 1844 Association of Medical Superintendents of American Institutions for the Insane formed

21. 1856 – 1926 German psychiatrist  Emil Kraepelin  advanced a new system. In all he proposed 15 categories The three main categories are D ementia precox Mood disorder Paranoia 1886 – 1950 Adolf Meyer – introduction of Krapelin’s classification in US. He eventually gave his own classification based on the notion of reaction types – disorders are reaction of the individual to environment stressors.

22. 1880 Census, “mania, melancholia, monomania, paresis, dementia, dipsomania, and epilepsy ” 1917 together with the National Commission on Mental Hygiene, the precursor of the APA developed a “Statistical Manual for the Use of Institutions for the Insane,” 1921 American Psychiatric Association. 1930 The term “stress” emerged from  endocrinology work 1945   William C. Menninger  advanced a classification scheme for the US army, called Medical 203 . This system was adopted by the Veterans Administration in the United States and strongly influenced the DSM

23. 1946 Mental disorders were first included in the sixth revision of the International Classification of Diseases  (ICD-6) 1952 Introduction of its first edition of DSM 1967 Present State Examination by John Wing 1950s to the early 1970s .The  Feighner Criteria developed at Washington University in St. Louis, Missouri The criteria are named after a famous psychiatric paper published in 1972 of which John Feighner was the first listed author. The development of the criteria had been led by a trio of psychiatrists Eli Robins, Samuel Guze  and George Winokur . Fourteen conditions were defined, including primary affective disorders (such as depression), schizophrenia, anxiety neurosis, antisocial personality disorder and  homosexuality  

24. 1970 Research Diagnostic Criteria (RDC) led by Robert Spitzer at Columbia University Some of the criteria were based on the earlier  Feighner Criteria, although many new disorders were included DSM-III  was based on many of the RDC descriptions. [3]

25. Present State Examination John Wing produced a simple descriptive categorisation of the four leading symptoms of chronic schizophrenia, i.e. flatness of affect, poverty of speech, incoherence of speech,and delusions Sections dealing with neurotic symptoms were added in the second and third versions. Reliability studies were done in the the fourth and the fifth editions. In all its versions, the P.S.E. has been a systematically arranged interview schedule, containing all the symptoms which are relevant to a present mental state examination. Present State Examination later became the SCAN in 1990 in 10 th Ed The SCAN system (Schedules for Clinical Assessment in Neuropsychiatry) is a set of instruments and manuals aimed at classifying the psychopathology and behavior associated with the major psychiatric disorders . This approach emphasises gathering clinical data along with social and environmental influences.

26. Schedule for Affective Disorders and Schizophrenia  ( SADS ) It is a collection of psychiatric diagnostic criteria and symptom rating scales originally published in 1978.  It is organized as a semi-structured diagnostic interview . The structured aspect is that the screening questions are about the same set of disorders regardless of the presenting problem. The diagnoses covered by the interview include schizophrenia, schizoaffective disorder, major depressive disorder, bipolar disorder, anxiety disorders and a limited number of other fairly common diagnoses. The SADS was developed by the same group of rearchers as the Research Diagnostic Criteria (RDC).

27. Systems of classifications in Psychiatry. ICD by WHO DSM by APA Chinese Classification of Mental Disorders [CCMD] Latin American Guide for Psychiatric Diagnosis The Research Domain Criteria [ RDoC ] by NIMH

28. DSM

29. DSM-I (1952) 132 Pages 106 Diagnosis Mental disorders as “reactions ” to psychological, social and biological factors. Definitions were simple, brief paragraphs with prototypical descriptions. It was influenced by the Medical 203 DSM-II (1968) 134 pages 182 diagnosis Rationale – to conform to the system used in ICD Almost similar to DSM I “Reaction” terminology dropped, Users encouraged to record multiple psychiatric diagnoses (in order of importance) and associated physical conditions. Meyer and Meninger developed both the editions.

30. DSM-III (1980) 494 Pages 265 Diagnosis Rationale – to conform to the newest ICD Reflected a shift from a theoretical paradigm to a medical model. Coincided with ICD-9 . Goal was to introduce reliability. Influenced by research – oriented psychiatrists who felt psychodynamic orientation to be unscientific.  DSM-III-R (1987) 567 Pages 292 Diagnosis Rationale – to increase the reliability and validity Categories were renamed and reorganized, and significant changes in criteria were made. Controversial diagnoses, such as pre-menstrual dysphoric disorder, masochistic personality disorder, and Ego- dystonic homosexuality" was removed Influence – Robert Spitzer

31. DSM-IV (1994) 886 Pages 365 Diagnosis Rationale – to conform with ICD 10 Inclusion of a clinical significance criterion. New disorders introduced (e.g., Acute Stress Disorder, PTSD, Bipolar II Disorder, Asperger’s Disorder), others deleted (e.g., Cluttering, Passive-Aggressive Personality Disorder).  Allen Francis was the Chairman. DSM-IV-TR (2000) 936 Pages 365 Diagnosis – none added The text sections giving extra information on each diagnosis were updated, as were some of the diagnostic codes to maintain consistency with the ICD. Influence – John Wakefield The DSM-IV-TR was organized into a five-part axial system.

32. Axis I : All psychological diagnostic categories Axis II :  Personality disorders and mental retardation Axis III : General medical condition; acute medical conditions and physical disorders Axis IV : Psychosocial and environmental factors contributing to the disorder Axis V : Global Assessment of Functioning or Child Global Assessment of Functioning [ cGAF ]

33. DSM 5 The DSM-5 task force was officially convened in August 2007. Chair – David Kupfer The first step was to name several workgroups with responsibility for specific diagnostic areas, each led by a member of the task force. For the ensuing 5-year period (2008 to 2013) the task force and workgroups met frequently both in person and via teleconference, reviewing the evidence base related to current diagnoses as well as that for potential new ones. DSM-5 would become a second “paradigm shift” for psychiatric diagnosis (DSM-III has been viewed as the first), by incorporating a dimensional approach.

34. The Process of Approving/Disapproving Changes or New Diagnoses in DSM-5. Several levels of clearance and approval of the new proposals. The first premise was that any changes to DSM-IV or proposals for new diagnoses had to be evidence-based . Committee recommendations went to an “independent” body called the “Scientific Advisory Committee CPHC, “ Clinical Public Health Committee ” reviewed proposals keeping in mind potential practical or public-health implications of proposed changes. The SAC and CPHC recommendations then went to the full task force for final debate. These final recommendations were then forwarded to the APA Board of Trustees for their review.

35. DSM 5 947 pages Approved by the Board of Trustees of the APA on December 1, 2012 Released on 18th May2013 . The DSM-5 is the first major edition of the manual in twenty years. 22 Chapters DSM-IV - 17 Chapters It is notable that The DSM-5 is identified with Hindu rather than Roman numerals. Incremental updates will be identified with decimals (DSM-5.1,DSM-5.2, etc.). A new edition will be signified by whole number changes (DSM-5,DSM-6, etc .)

36. INSIDE DSM- 5 Divided into three sections. Section I - DSM 5 basics Section II - Diagnostic criterion and codes Section III - Emerging measures and models and an Appendix.  

37. INSIDE DSM- 5   Section I •Introduction •Historical back ground •Development of DSM-5 •Harmonization with ICD system. •Dimensional approach   Section II - Diagnostic criterion and codes

38. INSIDE DSM- 5 Section III - Emerging Measures and Models •Assessment measures •Cultural formulation •Alternative DSM-5 model for personality disorders •“Criteria Sets for Conditions for Further Study” Appendix •Highlights of changes from DSM-IV to DSM-5 •Glossary of technical terms •Glossary of cultural concepts of distress •Alpha & numeric listings of diagnoses and codes •List of advisors and contributors

39. Key Changes in DSM-5 DELETION OF THE MULTIAXIAL SYSTEM. The five-axis frame of DSM-III and IV was eliminated in DSM-5. This makes DSM-5 closer to the structure of the ICD-10 diagnostic system.   STRUCTURE AND GROUPING OF DISORDERS. The removal of PTSD and acute stress disorders from the anxiety disorders category in DSM-IV and their placement in a new chapter called Trauma and Stress Related Disorders (TSRD). Obsessive-compulsive disorder was also moved out of the anxiety disorders chapter and also placed in a new chapter called Obsessive-Compulsive and Related Disorders. This group also includes “body dysmorphic disorder,”“ trichotillomania ” (hair pulling disorder), a new diagnosis “hoarding disorder,” as well as “skin-picking” disorder.

40. New Disorders IN DSM 5 Social Communication Disorder Disruptive Mood Dysregulation Disorder Premenstrual Dysphoric Disorder Hoarding Disorder Excoriation (Skin‐Picking) Disorder Disinhibited Social Engagement Binge Eating Disorder Central Sleep Apnea Sleep-Related Hypoventilation Rapid Eye Movement Sleep Behavior Disorder Restless Legs Syndrome Caffeine Withdrawal Cannabis Withdrawal Major Neurocognitive Disorder with Lewy Body Disease Mild Neurocognitive Disorder

41. Eliminated Disorders in DSM 5 Sexual Aversion Disorder Polysubstance ‐Related Disorder

42. NEURODEVELOPMENTAL DISORDERS. Mental Retardation was renamed Intellectual Disability (Intellectual Developmental Disorder). Autism Spectrum Disorder replaces Autism, Asperger Syndrome and Pervasive Developmental Disorder NOS in DSM-IV. NEUROCOGNITIVE DISORDERS. These disorders were previously referred in DSM-IV as “dementia, delirium, amnestic , and other cognitive disorders.” In DSM-5, they are headed by “delirium.”

43. SCHIZOPHRENIA SPECTRUM This included removal of special consideration for “bizarre” delusions and “special” hallucinations under Criterion A (characteristic symptoms). Rewording of negative symptoms in efforts to provide more clarity (“affective flattening” was changed to “ restricted affect ”; “ alogia or avolition ” were changed to “ avolition / asociality ”). The second change is the addition of a requirement in Criterion A that the individual must have at least one of these three symptoms: delusions, hallucinations, and disorganized speech. The DSM-IV subtypes of schizophrenia (i.e., paranoid, disorganized, catatonic,undifferentiated , and residual types) are eliminated due to their limited diagnostic stability, low reliability, and poor validity.

44. BIPOLAR DISORDER Inclusion of “ increased energy/activity ” as a criterion a symptom of mania/hypomania. Also addition of “mixed features” specifiers for mania, hypomania, and depression The complete list of “ specifiers ” for bipolar and related disorders include “anxious distress,” “manic or hypomanic episode with mixed features,” “depressive episode with mixed features,” “with rapid cycling,” “with melancholic features,” “with atypical features,” “with psychotic features,” “with catatonia,” “with seasonal pattern.”

45. DEPRESSIVE DISORDERS. Included here are “ Disruptive Mood Dysregulation Disorde r,” a new disorder intended to decrease the “excess” of diagnoses of bipolar disorder observed in children and adolescents. “Major Depressive Disorder,” remains virtually identical to the DSM-IV category No more bereavement exclusion for diagnosing MDD. Bereavement is now recognized as a severe psychosocial stressor that can precipitate a major depressive episode in a vulnerable individual List of “ specifiers ,” “with anxious distress “with mixed features,” “with melancholic features” and “with atypical features.”

46. PTSD Qualifying traumatic events are now explicit as to whether they were experienced directly, witnessed or experienced indirectly . Four symptom clusters instead of three namely -Re-experiencing -Arousal -Avoidance -Persistent negative alterations in cognition and mood. Acute Stress Disorder Requires being explicit as to whether qualifying traumatic events were experienced directly, witnessed, or experienced indirectly. Criterion A2 regarding subjective reaction has been eliminated  

47. ANXIETY DISORDERS OCD and PTSD have been omitted and made into separate categories. Separation anxiety and selective mutism are included in anxiety disorders. Anxiety disorders no longer need age >18 for diagnosis. 6-month duration used to be limited to individuals under age 18, but is now extended to all ages Panic disorder and Agoraphobia are unlinked . The co-occurrence of these two disorders is now coded with two diagnoses. This change was made because there is a substantial number of individuals with agoraphobia who do not experience panic symptoms. Social anxiety disorder - Formerly called Social Phobia, but now called Social Anxiety Disorder . Generalized specifier has been deleted and replaced with a “ performance only ” specifier .

48. Separation anxiety disorder Formerly in the section “Disorders Usually First diagnosed in Infancy, Childhood, or Adolescence.” Now, classified as an anxiety disorder. Includes symptoms in adulthood as well as childhood. SUBSTANCE USE DISORDERS. Substance abuse and substance dependence were consolidated into a single disorder called “substance use disorder.” A continuum or dimension was created that includes “mild,” “moderate,” or “severe” substance use. One of the DSM-IV abuse criteria was removed (“legal consequences such as multiple arrests”), and a new criterion, “ craving ,” was added.

49. SOMATIC SYMPTOM AND RELATED DISORDERS . This new category replaced the somatoform disorders category from DSM-IV. The symptoms to be “medically unexplained” was removed from DSM-5. Somatization Disorder, Pain Disorder, and Undifferentiated Somatoform Disorder were all merged into a new diagnosis called “Somatic Symptom Disorder.” Hypochondriasis became “ Illness Anxiety Disorder .” “Conversion Disorder” was significantly revised and the term “ Functional Neurological Symptom Disorder ” was added to the title OBSESSIVE COMPULSIVE AND RELATED DISORDERS New chapter. New disorders include hoarding disorder, excoriation(skin picking)disorder, Substance/Medication induced obsessive –compulsive and related disorders and obsessive-compulsive disorders due to another medical condition, Trichotillomania (hair-pulling disorder), Body Dysmorphic disorder Specifiers for Obsessive-Compulsive and Related Disorders - “with poor insight” specifier has been refined to allow a distinction between those with good or fair insight, poor insight, and “absent insight/delusional ”

50.   SLEEP–WAKE DISORDERS. This group includes a large number of categories and subcategories, starting with Insomnia Disorder, Hypersomnolence Disorder, Narcolepsy (various subtypes)

51. Alternative DSM-5 model for personality disorders The current approach to personality disorders appears in Section II of DSM-5, and an alternative model developed for DSM-5 is presented here in Section III . For example, the typical patient meeting criteria for a specific personality disorder frequently also meets criteria for other personality disorders. In the alternative model, the essential criteria to define any personality disorder are: a) moderate or greater impairment in personality functioning and b) the presence of pathological personality traits.  In addition, a new diagnosis called Personality Disorder-Trait Specific was established, replacing Personality Disorder Not Otherwise Specified in DSM-IV.

52. Conditions for Further Study Attenuated Psychosis Syndrome Depressive Episodes With Short-Duration Hypomania Persistent Complex Bereavement Disorder Caffeine Use Disorder Internet Gaming Disorder Neurobehavioral Disorder Associated With Prenatal Alcohol Exposure Suicidal Behavior Disorder Nonsuicidal Self-Injury

53. I C D

54. ICD Represents International Statistical Classification of Diseases and Related Health Problems. Can be defined as a system of categories to which morbid entities are assigned according to established criteria. Used to translate diagnoses of diseases from words into an alphanumeric code .

55. Purpose and uses Identification of health trends and statistics globally. It is the international standard for defining and reporting diseases and health conditions. ICD allows the counting of deaths as well as diseases, injuries, symptoms, reasons for encounter, factors that influence health status, and external causes of disease. Easy storage, retrieval and analysis of health information for evidence-based decision making; Sharing and comparing health information between hospitals, regions, settings and countries; and Data comparisons in the same location across different time periods. It is the diagnostic classification standard for all clinical and research purposes.  

56. EVOLUTION OF ICD 1855 William Farr first medical statistician of the General Register Office of England and Wales submitted his Report on nomenclature and statistical classification of diseases 1893 “Bertillon Classification of Causes of Death,” introduced by the French physician Jacques Bertillon 1900 an international conference revised what was then called the “ International Classification of Causes of Death ,” and agreed to hold revisions of the system every 10 years. 1948 the recently created WHO , an agency of the United Nations, assumed responsibility for the ICD.

57. 1949 The sixth revision, published in, involved significant changes. Included morbidity in addition to mortality, title was changed to International Statistical Classification of Diseases, Injuries, and Causes of Death. It included a section on mental disorders . 1965 Eighth Revision 1975 Nineth Revision well-known convention of using a dagger (†) marking the underlying disease and an asterisk (*) to mark its manifestations was issued in this revision. However, the most important single event for classification in psychiatry was the inclusion of a glossary and brief descriptions of the categories included in the fifth chapter (mental disorders), a procedure that was not part of the other chapters 1989 Tenth Revision 1990 ICD-10 was endorsed by the Forty-third World Health Assembly and came to use in WHO Member States as from 1994 . 2000 India adopted this classification

58. DSM ICD National classification of the United States Official World classification Focus on psychiatrists and psychologists Designed to be used by and useful for the different health professionals Developed to fulfill the particular information needs of the US health system Created with the idea of being useful for different health systems around the world Property of the APA Free of charge and open access Operational criteria Clinical descriptions US, Anglophone perspective Multilingual and multicultural Advantages for research Advantages for clinical use Different formats, one version Multiple versions and formats for multiple users

59. ICD 10 Much larger than ICD-9 ICD-10 has 21 chapters against 17 Chapters in ICD-9 Numeric codes ( 001-999 ) were used in ICD-9 where as an alphanumeric coding, (A00-Z99) has been adopted in ICD-10. It enlarged the number of categories available for the classification.

60. Volumes of ICD-10 Volume 1: Main classifications Volume 2: Instruction/ Guidance to users Volume 3: Alphabetical Index

61. Basic coding guidelines The basic ICD is a single coded list of three character categories, each of which can be further divided into up to 10 four-character subcategories . Tenth Revision uses an alphanumeric code with a letter in the first position and a number in the second, third and fourth positions. Some three-character categories have been left vacant for future expansion / Revision Codes U00–U49 are to be used by WHO for the provisional assignment of new diseases of uncertain etiology. Codes U50–U99 may be used in research The fourth character follows a decimal point. Possible code numbers therefore range from A00.0 to Z99.9. Fill fourth position with X , when sub-division is not there, so that the codes are of a standard length for data-processing.

62. Multi Axial System Axis I , clinical syndromes (psychiatric disorders including personality disorders and somatic diseases); Axis II , disabilities; Axis III , environmental/circumstantial and personal life-style/life management factors.

63. List of Blocks of Chapter V: Mental and Behavioral Disorders from ICD-10 F00 - F09 Organic including Symptomatic Mental Disorders F10 - F19 Mental and Behavioral Disorders due to Psychoactive Substance Use F20 - F29 Schizophrenia, Schizotypal and Delusional Disorders F30 - F39 Mood (Affective) Disorders F40 - F49 Neurotic, Stress-Related and Somatoform Disorders F50 - F59 Behavioral Syndromes Associated with Physiological Disturbances and Physical Factors F60 - F69 Disorders of Adult Personality and Behavior F70 - F79 Mental Retardation F80 - F89 Disorders of Psychological Development F90 - F98 Behaviroal and Emotional Disorders with Onset usually occurring in childhood and Adolescence F99 Unspecified Mental Disorders

64. (F00–F09) Organic, including symptomatic, mental disorders • (F00) Dementia in Alzheimer's disease • (F01) Vascular dementia (F02)Dementia in other diseases classified elsewhere • (F03) Unspecified dementia • (F04) Organic amnesic syndrome, not induced by alcohol and other psychoactive substances • (F05) Delirium, not induced by alcohol and other psychoactive substances • (F06) Other mental disorders due to brain damage and dysfunction and to physical disease • (F07) Personality and behavioural disorders due to brain disease, damage and dysfunction • (F09) Unspecified organic or symptomatic mental disorder

65. F10--F19 Mental and behavioural disorders due to psychoactive substance use F10.-Mental and behavioural disorders due to use of alcohol F11.-Mental and behavioural disorders due to use of opioids F12.-Mental and behavioural disorders due to use of cannabinoids F13.-Mental and behavioural disorders due to use of sedatives or hypnotics F14.-Mental and behavioural disorders due to use of cocaine F15.-Mental and behavioural disorders due to use of other stimulants, including caffeine F16.-Mental and behavioural disorders due to use of hallucinoeens F17.-Mental and behavioural disorders due to use of tobacco F18.-Mental and behavioural disorders due to use of volatile solvents F19.-Mental and behavioural disorders due to multiple drug use and use of other psychoactive substances

66. Four- and five-character categories may be used to specify the clinical conditions, as follows: F1 x .0 Acute intoxication F1 x .1 Harmful use F1 x .2 Dependence syndrome F1 x .3 Withdrawal state F1 x .4 Withdrawal state with delirium F1 x .5 Psychotic disorder F1 x .6 Amnesic syndrome F1 x .7 Residual and late-onset psychotic disorder F1 x .8 Other mental and behavioural disorders

67. F20-F29 Schizophrenia, schizotypal and delusional disorders F20 Schizophrenia F20.0 Paranoid schizophrenia F20.1 Hebephrenic schizophrenia F20.2 Catatonic schizophrenia F20.3 Undifferentiated schizophrenia F20.4 Post-schizophrenic depression F20.5 Residual schizophrenia F20.6 Simple schizophrenia F20.8 Other schizophrenia F20.9 Schizophrenia, unspecified F21 Schizotypal disorder F22 Persistent delusional disorders F23 Acute and transient psychotic disorders F24 Induced delusional disorder F25 Schizoaffective disorders F28 Other nonorganic psychotic disorders F29 Unspecified nonorganic psychosis

68. F30-F39 Mood [affective] disorders F30 Manic episode F31 Bipolar affective disorder F32 Depressive episode F33 Recurrent depressive disorder F34 Persistent mood [affective] disorders F38 Other mood [affective] disorders F39 Unspecified mood [affective] disorder

69. F40-F48 Neurotic, stress-related and somatoform disorders F40 Phobic anxiety disorders F41 Other anxiety disorders F42 Obsessive - compulsive disorder F43 Reaction to severe stress, and adjustment disorders F44 Dissociative [conversion] disorders F45 Somatoform disorders F48 Other neurotic disorders  

70. F50-F59 Behavioural syndromes associated with physiological disturbances and physical factors F50 Eating disorders F51 Nonorganic sleep disorders F52 Sexual dysfunction, not caused by organic disorder or disease F53Mental and behavioural disorders associated with the puerperium , not elsewhere classified F54Psychological and behavioural factors associated with disorders or diseases classified elsewhere F55 Abuse of non-dependence-producing substances F59Unspecified behavioural syndromes associated with physiological disturbances and physical factors

71. F60-F69 Disorders of adult personality and behaviour F60 Specific personality disorders F60.0 Paranoid personality disorder F60.1 Schizoid personality disorder F60.2 Dissocial personality disorder F60.3 Emotionally unstable personality disorder .30 Impulsive type .31 Borderline type F60.4 Histrionic personality disorder F60.5 Anankastic personality disorder F60.6 Anxious [avoidant] personality disorder F60.7 Dependent personality disorder F60.8 Other specific personality disorders F60.9 Personality disorder, unspecified F61 Mixed and other personality disorders F62 Enduring personality changes, not attributable to brain damage and disease F63 Habit and impulse disorders F64 Gender identity disorders F65 Disorders of sexual preference

72. F70-F79 Mental retardation F70 Mild mental retardation F71 Moderate mental retardation F72 Severe mental retardation F73 Profound mental retardation F78 Other mental retardation F79 Unspecified

73. F80-F89 Disorders of psychological development F80 Specific developmental disorders of speech and language F81 Specific developmental disorders of scholastic skills F82 Specific developmental disorder of motor function F83 Mixed specific developmental disorders F84 Pervasive developmental disorders F88 Other disorders of psychological development F89 Unspecified disorder of psychological development

74. F90-F98 Behavioural and emotional disorders with onset usually occurring in childhood and adolescence F90 Hyperkinetic disorders F91 Conduct disorders F92 Mixed disorders of conduct and emotions F93 Emotional disorders with onset specific to childhood F94 Disorders of social functioning with onset specific to childhood and adolescence F95 Tic disorders F98 Other behavioural and emotional disorders with onset usually occurring in childhood and adolescence F99 Unspecified mental disorder

75. Mental Disorders in ICD-11 Included in Chapter 7 M ajor reasons for reviewing ICD-10 include to improve the consistency and uniformity of the diagnostic information provided by the clinical descriptions and to adapt to new demands from users and conditions of use. The environmental components and the context in which classification is used have undergone profound changes with the passage of time.  

76. The Definition of Mental Disorder Will Not Change in ICD-11 Major changes in the definition of mental disorder are not expected in ICD-11 and therefore, the ICD-10 definition will be maintained: “A clinically recognizable set of symptoms or behaviors associated in most cases with distress and with interference with personal functions.” While the emphasis will be on categories, ICD-11 may also consider dimensions at least in a few situations, where simple measurements may be feasible. “ Specifiers ” and “Qualifiers” in ICD-11. ICD will not use coded “ specifiers ” because of the limits of the coding system. Therefore, if some features of a disorder are deemed important to be highlighted, noncoded “ qualifiers ” will be added

77. List of Blocks of Chapter 7 Mental and Behavioral Disorders of ICD-11 Neurodevelopmental disorders Schizophrenia and other primary psychotic disorders Mood disorders Anxiety and fear-related disorders Obsessive-compulsive and related disorders Disorders specifically associated with stress Dissociative disorders Bodily distress disorder Feeding and eating disorders Elimination disorders Disorders due to substance use Impulse control disorders Disruptive behavior and dissocial disorders Personality disorders Paraphilic disorders Factitious disorders Neurocognitive disorders Mental and behavioral disorders associated with disorders or diseases classified elsewhere

78. Standard Format for ICD-11 Clinical Descriptions and Diagnostic Guidelines Category Name Brief Definition: containing a summary statement (100–125 words) of the common essential features of the disorder Inclusion Terms Exclusion Terms Essential (Required) Features: relatively explicit guidance regarding features needed to confidently make the diagnosis Boundary with Normality (Threshold): specifying those aspects of the disorder that are indicative of its pathological character Boundary with Other Disorders (Differential Diagnosis): this section provides guidance to the clinician about how to make this differentiation Coded Qualifiers/Subtypes Course Features: information on temporal patterns like age of onset, persistence, duration, likely progression overtime, etc. Associated Clinical Presentations: information about features that are important and help to recognize variations in presentation but also highlights areas where clinical intervention might be important Culture-Related Feature: brief information regarding cultural considerations for diagnosis Developmental Presentations Gender-Related Features

79. The World Health Organization World Mental Health Composite International Diagnostic Interview (WHO WMH-CIDI)  The WHO WMH-CIDI is a comprehensive, fully-structured interview designed to be used by trained lay interviewers for the assessment of mental disorders according to the definitions and criteria of ICD-10 and DSM-IV. It is intended for use in epidemiological and cross-cultural studies as well as for clinical and research purposes. 

80.   The   Chinese Classification of Mental Disorders   Published by the Chinese Society of Psychiatry (CSP) Is a clinical guide used in China for the diagnosis of mental disorders. It is currently on a third version, the  CCMD-3 , written in Chinese and English. It is similar in structure and categorisation to the ICD and DSM Diagnoses that are more specific to Chinese or Asian culture include: Koro  or  Genital retraction syndrome : excessive fear of the genitals (and also breasts in women) shrinking or drawing back into the body. Zou huo ru mo  or  qigong deviation  perception of uncontrolled flow of energy in the body. Mental disorders due to superstition or witchcraft. Travelling psychosis The CCMD-3 lists several "disorders of sexual preference" including ego- dystonic homosexuality.

81. The   Research Domain Criteria  ( RDoC ) Developed by Bruce Cuthbert and Thomas Insel of the US National Institute of Mental Health in 1970. It is a research framework fo r new ways of studying mental disorders " RDoC is an attempt to create a new kind of taxonomy for mental disorders by bringing the research approaches in genetics, neuroscience, and behavioral science to the problem of mental illness." RDoC is conceived as a dimensional system

82. SLEEP DISORDER CLASSIFICATIONS Three different nosologies provide classification systems for sleep disorders: (1) DSM, (2) the International Classification of Sleep Disorders (ICSD), and (3) ICD ICSD-3 is more comprehensive ICSD-3 includes 60 specific diagnoses within the seven major categories, as well as an appendix Insomnia Sleep-related breathing disorders Isolated symptoms and normal variants Central disorders of hypersomnolence Circadian rhythm sleep-wake disorders Parasomnias Sleep-related movement disorders Other sleep disorders 

83. CONCLUSION DSM and ICD are essential clinical tools; the former has emphasized diagnostic validity, and the latter has emphasized clinical utility. Clinical utility is however reliant on diagnostic validity, and there is considerable overlap between the two. RDoC provides a useful focus on the individual-level causal mechanisms that are relevant to vulnerability to mental disorder. In their day-to-day clinical work for the near future, clinicians are likely to continue to use DSM and ICD. However, our hope is that advances in work on endophenotypes and exophenotypes will ultimately lead to improved classification systems, and in turn to better individualized care as well as improved global mental health.

84. References Kaplan and Sadocks Comprehensive textbook of Psychiatry – 10 th edition Kaplan and Sadocks Synopsis of Psychiatry – 11 th edition Postgraduate Textbook of Psychiatry - Ahuja

85. Thank you