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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 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 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 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. 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 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 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 Definitions of Depression Symptoms Episodes Disorders Major Depressive Disorder Bipolar Disorder Dysthymia Depressive Disorder NOS (e.g. subthreshold depression) 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 Symptoms of Depression, cont. Physical Symptoms Weight loss or weight gain Psychomotor agitation or retardation Insomnia or hyposomnia Fatigue or loss of energy 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 DSM-III Paradigm Shift • • • • • • • 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 Categorical Dimensional 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 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 Reliability Consistency of measurement 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 .75 .75 .86 .58 .47 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 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 ___.__ ____________________________________ AXIS II: Personality Disorders DSM-IV Name Diagnostic Code Avoidant Personality Disorder 301.82 Dependent Personality ___.__ Features___________ AXIS III: General Medical Conditions ICD-9-CM name Mitral Valve Prolapse ICD-9-CM code 424.0 ___.__ ____________________________________ Multiaxial System Axis IV: Psychosocial and Environmental Problems Check: Specify: Marital Problems with primary support group X Discord Problems related to the social environment Specify:___________ Educational problems Specify:_____________________________ Occupational problems Specify: Excessive Work Absences X 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 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. 2. 3. 4. 5. Autism Attention Deficit-Hyperactivity Disorder Conduct Disorders Mental Retardation (Axis II) Tourette’s Delirium, Dementia and Cognitive Disorders 1. 2. 3. 4. Delirium Dementia of the Alzheimer’s Type Vascular Dementia Amnestic Disorder Diagnostic Groupings and Examples Substance Related Disorders 1. 2. 3. 4. Alcohol Dependence Cannabis Abuse Hallucinogen-Induced Psychotic Disorder Opiate Withdrawal Psychotic Disorders 1. 2. Schizophrenia Delusional Disorder Mood Disorders 1. 2. 3. Major Depressive Disorder Bipolar Disorder Dysthymia Diagnostic Groupings and Examples Anxiety Disorders 1. 2. 3. Panic Disorder with Agoraphobia Post-Traumatic Stress Disorder Obsessive-Compulsive Disorder Somatoform Disorders 1. 2. Somatization Disorder Hypochondriasis Factitious Disorders and Malingering 1. 2. Factitious Disorder (Munchhausen’s)0 Malingering Diagnostic Groupings and Examples Dissociative Disorders 1. 2. Dissociative Identity Disorder Depersonalization Disorder Eating Disorders 1. 2. Anorexia Nervosa Bulimia Nervosa Sleep Disorders 1. 2. Narcolepsy Sleep Terror Disorder Sexual, Gender Identity Disorders 1. 2. Premature Ejaculation Paraphilias Diagnostic Groupings and Examples Adjustment Disorders 1. Adjustment Disorder with Mixed Anxiety and Depressed Mood Personality Disorders (Axis II) 1. 2. Borderline Personality Disorder Obsessive-Compulsive Personality Disorder Impulse Control Disorders 1. 2. Trichotillomania Pathological Gambling Other Conditions (Including “V Codes”) 1. 2. 3. Relational Problems Sexual Abuse of a Child 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 Controversies Brainless vs. Mindless Psychiatry “Inventing” New Diagnoses e.g. Premenstrual Dysphoric Disorder Social Labeling Cultural Relativism Primary Care vs. Sepciality Focus 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 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.