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The dsmiv and_icd10_classification_systems_(background)
1. THE DSM AND ICD
PSYCHIATRIC
CLASSIFICATION SYSTEMS
2. FACILITATES CHARACTERIZATION,
COMMUNICATION AND RESEARCH
COMPLEXITY OF PHENOMENA ARE
REDUCED
TWO VIEWS:
DIMENSIONALIZERS – DIMENSIONS OF
FUNCTIONING,DIFFERENT
PSYCHIATRIC D/O
CATEGORIZERS – SPECIFIC GROUPS
OF SYMPTOMS – REFLECT
PSYCHIATRIC SYNDROMES
3. IMPORTANCE OF CLASSIFICATION FOR
PSYCHIATRIC DIAGNOSIS
DISTINGUISH BET DIFF PSYCHIATRIC
DIAGNOSIS
COMMON LANGUAGE AMONGST HEALTH
PROFESSIONALS ENSURES
RELIABILITY,COMMUNICATION AND
STATISTICAL REPORTING
EFFECTIVE TREATMENT
STANDARD FRAME OF REFERENCE
TEACHING-INTERNATIONAL REFERENCE
SYSTEMS
4. IMPORTANCE OF CLASSIFICATION
CONT.
PUBLIC ACESS – IMPROVES COMMUNICATION
IMPROVES RELIABILITY OF PSYCHIATRIC
DIAGNOSIS IN RESEARCH SETTINGS
UNDERSTANDING OF CAUSES AND
PROCESSES OF MENTAL DISORDERS
5. TWO MOST ACCEPTED PSYCHIATRIC
CLASSIFICATIONS
DIAGNOSTIC AND STATISTICAL
MANUAL OF MENTAL DISORDERS
(DSM IV TR)
INTERNATIONAL CLASSIFICATION OF
DISEASES (ICD 10)
CLINICAL DESCRIPTIONS BASED ON
PHENOMENOLOGICAL APPROACHES
7. HISTORY AND BACKGROUND
FIRST DSM – AMERICAN PSYCHIATRIC
ASSOCIATION COMMITTEE
DSM II – 1968
DSM III – 1980
REVISED DSM III – 1987
DSM III-R – 1987
DSM IV – 1994
DSM-IV-TR – 2000
8. HISTORY AND BACKGROUND
WHO – ICD-6
SECTION ON MENTAL DISORDERS
APA – VARIANT OF ICD-6
DSM-1 – FIRST OFFICIAL MANUAL OF
CLINICAL MENTAL DISORDERS
PSYCHOBIOLOGICAL VIEW
9. HISTORY AND BACKGROUND
DSM-II CORRELATED WITH ICD-8
DSM-III CORRELATED WITH 1CD-9
DSM-III
– EXPLICIT DIAGNOSTIC CRITERIA
– MULTI-AXIAL SYSTEM
– DESCRIPTIVE MEDICAL
NOMENCLATURE
10. HISTORY AND BACKGROUND
DSM-III-R – EMPIRICAL RESEARCH
DSM-IV – SYSTEMATIC REVIEWS AND
FOCUSED FIELD TRIALS
GOAL – INCREASE PRACTICALITY AND
CLINICAL UTILITY
DSM IV-TR – NOS CATEGORY
11. DSM IV-TR
OFFICIAL CODING SYSTEM IN USA
ATHEORETICAL APPROACH TO CAUSES
DESCRIBES MANIFESTATIONS AND
DESCRIPTIONS OF CLINICAL FEATURES
OF MENTAL D/O
SPECIFIC DIAGNOSTIC CRITERIA
CRITERIA INCREASE RELIABILITY
12. DSM IV-TR
SYSTEMATIC DESCRIPTIONS:
AGE
CULTURE
GENDER FEATURES
PREVALENCE, INCIDENCE
RISK , COURSE
COMPLICATIONS
PREDISPOSING FACTORS
FAMILIAL PATTERNS
DIFFERENTIAL DIAGNOSIS
LAB FINDINGS
PHYSICAL EXAMINATION SIGNS AND SYMPTOMS
14. DSM IV-TR ORGANIZATIONAL
PLAN
16 MAJOR DIAGNOSTIC CLASSES
OTHER CONDITIONS THAT MAY BE FOCUS
OF CLINICAL ATTENTION
11 APPENDICES
DIFFERENTIAL DX
GLOSSARY
CHANGES IN DSM-IV-TR
CLASSIFICATION WITH ICD-10
CULTURAL FORMULATION, ETC
15. AIMS OF DSM IV-TR
CLEAR DIAGNOSTIC CATEGORIES
DX, COMMUNICATION, STUDY AND TREAT
DIAGNOSTIC CRITERIA FOR RESEARCH
PURPOSES
RECORD KEEPING, DATA COLLECTION
REPORTING TO 3RD PARTIES – GOVN, PRIVATE
INSURERS
SUBTYPES
SPECIFIERS
INCREASED SPECIFICITY
16. AIMS OF DSM IV-TR
CLINICAL DECISIONS
RX SETTING
MODE OF RX
DURATION OF RX
17. SEVERITY AND COURSE
SPECIFIERS
MILD, MODERATE, SEVERE ONLY WHEN
FULL CRITERIA MET
INTENSITY OF S AND S
IMPAIRMENT IN OCCUPATIONAL AND
FUNCTIONAL IMPAIRMENT
MR
CONDUCT D/O
MANIC EPISODE
MAJOR DEPRESSIVE EPISODE
18. SEVERITY AND COURSE
SPECIFIERS
PARTIAL REMISSION – FULL CRITERIA
PREVIOUSLY MET
FULL REMISSION – NO LONGER S AND S,
STILL CLINICALLY RELEVANT
PARTIAL AND FULL REMISSION FOR:
MANIC EPISODE
MAJOR DEPRESSIVE EPISODE
SUBSTANCE DEPENDANCE
PRIOR HISTORY – USEFUL TO NOTE HX OF
CRITERIA PREVIOUSLY MET BUT NOW
RECOVERED
19. RECURRENCE
FULL CRITERIA NO LONGER MET
PARTIAL, FULL REMISSION,
RECOVERY
DO NOT MEET FULL THRESHOLD OF
D/O ACCORDING TO SPECIFIED
CRITERIA
20. NOS CATEGORIES
DIVERSITY OF CLINICAL
PRESENTATION
4 SITUATIONS:
– CRITERIA NOT MET FOR SPECIFIC D/O EG
ATYPICAL, MIXED PICTURE
– DOES NOT CONFORM TO DSM IV
CLASSIFICATION BUTCLINICAL
SIGNIFICANT DISTRESS
– AETIOLOGY UNCERTAIN
– INSUFFICIENT DATA, INCONSISTENT
INFORMATION
21. MULTIAXIAL ASSESSMENT
5 AXES
– I – CLINICAL D/O, OTHER CONDITIONS
FOCUS OF CLINICAL ATTENTION
– II – PERSONALITY D/O
– III – GMC
– IV – PSYCHOSOCIAL, ENVIRONMENTAL
– V – GAF
22. MULTIAXIAL ASSESSMENT
DIFFERENT DOMAINS OF
INFORMATION
PLAN RX AND PREDICT OUTCOME
ORGANIZING, COMMUNICATING
CLINICAL INFORMATION
CAPTURES COMPLEXITY OF CLINICAL
SITUATION
HETEROGENEITY OF PATIENT
BIOPSYCHOSOCIAL MODEL
23. AXIS I
PRINCIPAL DX
AXIS II CAN ALSO BE PRINCIPAL
DIAGNOSIS – MUST BE FOLLOWED BY
‘PRINCIPAL DX’ OR ‘REASON FOR VISIT’
25. AXIS III
GMC RELEVANT TO MENTAL D/O
NO LINK BUT INCLUDED IF:
OVERALL UNDERSTANDING OF PT
AXIS I PSYCHOLOGICAL
REACTION TO AXIS II
THOROUGHNESS OF EVALUATION
ENHANCES COMMUNICATION BETWEEN
HEALTH PROFESSIONALS
PROGNOSTIC AND RX IMPLICATION
26. AXIS IV
PYCHOSOCIAL AND ENVIRONMENTAL
PROBLEMS THAT AFFECT DX ,RX AND PX:
– PROBLEMS WITH PRIMARY SUPPORT
GROUPS
– PROBLEMS RELATED TO SOCIAL
ENVIRONMENT
– EDUCATIONAL PROBLEMS
– HOUSING PROBLEMS
– ECONOMIC PROBLEMS
– PROBLEMS WITH ACCESS TO HEALTH
CARE SERVICES
27. AXIS IV
– PROBLEMS RELATED TO ACCESS TO
HEALTH CARE SERVICES
– PROBLEMS RELATED TO INTERACTION
WITH LEGAL SYSTEM/CRIME
– OTHER PSYCHOSOCIAL AND
ENVIRONMENTAL PROBLEMS
28. AXIS V
GLOBAL ASSESSMENT OF FUNCTIONING
CLINICIANS JUDGEMENT – OVERALL
LEVEL OF FUNCTIONING
PLANNING RX
PREDICTING OUTCOME
GAF SCALE
29. GAF SCALE
TRACKS CLINICAL PROGRESS
SOCIAL,OCCUPATIONAL AND
PSYCHOLOGICAL FUNCTIONING
2 COMPONENTS – SYMPTOM SEVERITY
AND FUNCTIONING
REFLECTS WORSE OF 2
CURRENT PERIOD S/T ADMISSION,
DISCHARGE ETC
30. ADVANTAGES DSM IV-TR
WIDESPREAD USE – EASE OF
COMMUNICATION
CLEAR DEFINITION AND
DELINEATIONS
COMPATIBILITY WITH ICD10
REPORTING DIAGNOSTIC DATA
COLLECTION OF DIAGNOSTIC DATA
31. ADVANTAGES CONT
CATEGORICAL MODEL – VALID
THRESHOLDS FOR CASE
IDENTIFICATION WITH CLEAR
BOUNDARIES BETWEEN CLASSES
MULTIAXIAL EVALUATION PROMOTES
COMPREHENSIVE BIOPSYCHOSOCIAL
APPROACH
33. FORENSIC SETTING
RISK OF INFORMATION MISUSED
INSUFFICIENT TO ESTABLISH MI,
COMPETENCY AND CRIMINAL
RESPONSIBILITY
NO IMPLICATIONS FOR DEGREE OF
CONTROL OVER BEHAVIOURS
ASSOCIATED WITH MI
FACILITATES LEGAL DECISIONS
35. ETHNIC AND CULTURAL
IMPLICATIONS
CHALLENGING IF PT AND CLINICIAN FROM
DIFFERENT BACKGROUNDS
INCORRECTLY DIAGNOSE
PSYCHOPATHOLOGY
INCORRECT PERSONALITY DIAGNOSTIC
CRITERIA ACROSS DIFFERENT CULTURAL
SETTINGS
ALLOWANCES MADE BY DSM
DISCUSSES CULTURAL
VARIATIONS
CULTURE BOUND SYNDROMES
CULTURAL FORMULATION
37. CATEGORICAL APPROACH
CATEGORIES OF MENTAL ILLNESS NOT
MUTUALLY EXCLUSIVE
INDIVIDUALS ARE HETEROGENOUS
NO CONSIDERATION OF PATIENTS
NARRATIVE HISTORY
38. LIMITATIONS OF DSMIV-TR
CONT
NOT USEFUL FOR RESEARCH – HINDERS
INVESTIGATIONS INTO AET, PATHOPHYS,
GENETICS
NOT RELIABLE INTERCLINICIAN TOOL
PATIENTS NOT INCORPORATED IN RX
CHOICES
COMPLICATED-284 POTENTIAL DX
LESS VALIDITY- BEREAVEMENT
CONCEPTUAL INCONSISTENCY
39. LIMITATIONS OF DSM IV-TR
INCONSISTENCIES WITH REMISSION
STATUS
EXCUSION OF PSYCHODYNAMIC AND
PSYCHOSOCIAL PERSPECTIVES
UNCERTAINTY OF INTERPRETING
‘CLINICALLY SIGNIFICANT’ CRITERIA
MULTIAXIAL SYSTEM- TIME CONSUMING,
NOT USED
AXES IV, V- DUBIOUS RELIABILITY AND
VALIDITY
41. HISTORY AND BACKGROUND
1853 – INTERNATIONAL STATISTICAL
CONGRESS – W. FARR
REVISED OVER NEXT DECADES
1946 – WHO – INTERNATIONAL LIST OF
CAUSES IF MORBIDITY
1948 – 6TH REVISION
1975 – 9TH REVISION-BEGINNING OF ICD
9TH REVISION – DESCRIPTIONS OF
CATEGORIES OF CHAPTER V – MENTAL D/O
42. HX AND BACKGROUND
1989 – 10TH REVISION
ALPHANUMERICAL CODING SCHEME
OF 1 LETTER FOLLOWED BY 3
NUMBERS
INCREASE IN NUMBER OF
CATEGORIES, SEPARATE CHAPTERS
43. ICD 10
CHAPTER V – MENTAL D/O
CHAPTER VI – NEUROLOGICAL D/O
CHAPTER XIX – CLASSIFICATION OF
INJURIES – POISONING
CHAPTER XVIII – S AND S, ABN CLINICAL
AND LAB FINDINGS
CATEGORIES DENOTED BY LETTER
1ST NO – MAIN GROUP
2ND NO – CATEGORY WITHIN GROUP
4TH CHARACTER – FURTHER SUBDIVISION
F32.2 – SEVERE DEPRESSIVE EPISODE
WITHOUT PSYCHOTIC SYMPTOMS
44. ICD 10
SCZ – 5TH CHARACTER – SPECIFY
COURSE
F20.01 – PARANOID SCZ, EPISODIC
WITH PROGRESSIVE DEFICIT
DIFFERENT VERSIONS – FLEXIBILITY
AND ACCEPTIBILITY TO VARIOUS USERS
45. ICD 10
CLINICAL DESCRIPTIONS AND DIAGNOSTIC
GUIDELINES FOR GENERAL CLINICAL,
EDUCATIONAL AND SERVICE USE
DIAGNOSTIC CRITERIA FOR RESEARCH
PRIMARY CARE VERSION
MULTIAXIAL VERSION
46. CLINICAL DESCRIPTIONS…
EACH CATEGORY ACCOMPANIED BY
GLOSSARY OF BRIEF DEFINITIONS
FURTHER DEFINED SET OF CRITERIA
CRITERIA LESS PRECISE THAN DSM
ALLOWS CLINICIANS TO USE IN DAILY
PRACTICE
47. DIAGNOSTIC CRITERIA FOR RESEARCH
TWO NB ANNEXES
CULTURE SPECIFIC D/O
PROVISIONAL CRITERIA FOR UNCERTAIN
NOSOLOGICAL STATUS – BIPOLAR D/O II
48. MULTIAXIAL VERSION
ADULT PSYCHIATRY – 3 AXES
CATEGORIZE CLINICAL SYNDROME
LEVEL OF FUNCTIONAL CAPACITY/
DISABILITY
CATEGORIES OF IMPORTANCE IN
THE UNDERSTANDING OF THE D/O
49. MULTIAXIAL VERSION
MENTAL D/O OF CHILDHOOD
6 AXES:
CLINICAL PSYCHIATRIC SYNDROMES
SPECIFIC D/O OF PSYCHOLOGIC DEVELOPMENT
INTELLECTUAL LEVEL
MEDICAL CONDITIONS
ASSOCIATED ABNORMAL PSYCHOSOCIAL
SITUATION
GLOBAL ASSESSMENT OF PSYCHOSOCIAL
DISABILITY
50. PRIMARY CARE VERSION
FEWER CATEGORIES
GENERAL PRACTITIONER, PRIMARY
HEALTH CARE STAFF,
PSYCHIATRISTS, OTHERS
2 CARDS
WAY THAT CONDITION IS RECOGNIZED
AND DIAGNOSED
ADVICE ON MX
51. ADVANTAGES OF ICD 10
SIMPLICITY OF STRUCTURE AND USE
USED BY SPECIAL GROUPS, STILL
COMPATIBLE WITH ORIGINAL
CLASSIFICATION
COMPATIBILITY WITH NATIONAL AND
OTHER WIDELY USED CLASSIFICATIONS
DIFFERENCES KEPT TO MINIMUM
CONTINUITY OVER TIME
BASED ON INTERNATIONAL CONSENSUS
52. ADVANTAGES OF ICD 10
BASED ON INTERNATIONAL CONSENSUS
SEVERAL VERSIONS – ALL COMPATIBLE
WITH EACH OTHER
SEVERAL LANGUAGES
ADDITIONAL PUBLICATIONS FACILITATE ITS
USE
RESPONSIVE TO NEEDS OF PRACTICE
CATEGORIES FOR DIAGNOSIS
FREQUENTLY USED BUT NOSOLGY
UNCERTAIN
53. ADVANTAGES OF ICD 10
AVOIDS ‘SOCIAL FUNCTIONING’ AS
DIAGNOSTIC INDICATOR
RECENTLY INTRODUCED DX OF PUBLIC
HEALTH INTERES MILD COGNITIVE D/O
TERMINOLOGY EASY TO USE
SIGNIFICANT EXPANSION OF ACUTE
PSYCHOTIC D/O-DEVELOPING COUNTRIES
CATEGORICAL CLASSIFICATION
54. LIMITATIONS OF ICD 10
CATEGORICAL CLASSIFICATION-DISCRETE
ENTITY VIEW OF PSYCH D/O
55. LIMITATIONS OF CURRENT OPERATIONAL
APPROACHES TO DIAGNOSIS
FOCUS ON EPISODE RATHER THAN LIFETIME
EXPERIENCE
HIERARCHIES LEAD TO LOSS OF INFO
BOUNDARIES BET CATEGORIES ARE
ARBITRARY
BOUNDARIES BET CATEGORIES REQUIRE
SUBSTANTIAL SUBJECTIVE JUDGEMENT
DIAGNOSTIC CATEGORIES ARE UNHELPFUL IN
DETERMINING SEVERITY
56. LIMITATIONS OF CURRENT OPERATIONAL
APPROACHES TO DIAGNOSIS
SUBCLINICAL CASES NOT ACCOMODATED
FULLY
NOS CATEGORIES HIGHLY HETEROGENOUS
INCREASED GAPS BETWEEN RESEARCH
FINDINGS AND DEFINITIONS OF CURRENT
DIAGNOSTIC SYSTEMS – SACRIFICES VALIDITY
FOR RELIABILITY
57. DIFFERENCES BETWEEN DSM AND ICD
DSM IV-TR ICD10
PRODUCED BY APA WHO
ONE GROUP OF DISEASES, DIRECT NUMBER OF CLASSIFICATIONS
INTEREST TO PARTICULAR – EVEN CLASSIFICATION OF
PROFESSIONAL GROUP REASON FOR CONTACT
NATIONAL DIAGNOSTIC STATUTORY RESPONSIBILITY
CLASSIFICATION FOR RELIABLE REPORTING OF
DISEASES AND HEALTH
STATES TO THE WORLD
POPULATION
SINGLE SET OF OPERATIONAL INTERRELATED VERSIONS
DIAGNOSTIC CRUTERIA FOR ALL ADDRESSING DIFFERENT
USERS USERS IN SPECIFIC CONTEXTS
58. DIFFERENCES BETWEEN DSM AND ICD 10
DSM IV-TR ICD10
DEFINITIONAL DIFFERENCES- DX OF HARMFUL USE FOCUSES
SUBSTANCE D/O=FOCUS ON ON DAMAGE TO USER’S
NEGATIVE CONSEQUENCES PHYSICAL AND MENTAL HEALTH
ACUTE STRESS D/O-DX ONLY WIDER RANGE OF RESPONSES-
FOR SEVERE DISSOCIATIVE MILD ANXIETY TO SEVERE
REACTIONS DISSOCIATION
DIFFERENCES IN DIAGNOSTIC MINIMUM 3/12
CRITERIA-DURATION,
FREQUENCY ETC-DELUSIONAL
D/O-3/12
DIFFERENCES IN HYPOCHONDRIASIS
EXCLUSIONARY CRITEIA-
HYPOCHONDRIASIS
CONCEPTUAL DIFFERENCES OF CONCEPTUAL DIFFERENCES OF
DISORDERS DISORDERS
64. DEVELOPMENTAL ISSUES
REFINE PSYCHIATRIC ASSESSMENT
TECHNIQUE ACROSS
DEVELOPMENTAL STAGES
METHODS TO INTEGRATE
DEVELOPMENTAL ASSESSMENTS
INTO DIAGNOSTIC PROCESSING
65. DEFINING MENTAL ILLNESS
FACILITATING DIAGNOSTIC PROCESSES IN
NON-PSYCHIATRIC SETTINGS
APPLICABILITY OF CRITERIA ACROSS
DIFFERENT CULTURAL SETTINGS
VALIDATINGDIAGNOSTIC CRITERIA
INCREASING COMPATIBILITY BETWEEN
DSM V AND ICD 10
DIMENSIONAL APPROACH MORE SUPERIOR
66. PERSONALITY DISORDERS
DIMENSIONAL MODEL MAY BE SUPERIOR,
MORE RELIABLE, SPECIFIC AND CLINICALLY
INFORMATIVE
SHOULD THERE BE INDEPENDENCE AND
DISTINCTIVENESS BETWEEN AXIS I AND
AXIS II PERSONALITY D/O
BOTH FREQUENTLY CO-EXIST
AXIS II OFTEN A SIGNIFICANT
COMPLICATING FACTOR TO AXIS I
68. PROPOSED CHANGES TO DSM IV-TR
DX
ELIMINATE ASPERGERS SYNDROME
AS SEPARATE D/O
MERGE UNDER AUTISM SPECTRUM D/
O
SEVERITY CAN BE RATED- SEVERE,
MODERATE, MILD
69. PROPOSED NEW DSM V DX
COMPLEX POST TRAUMATIC STRESS D/O
DEPRESSIVE PERSONALITY D/O
NEGATIVISTIC ( PASSIVE-AGGRESSIVE ) PD
POST TRAUMATIC EMBITTERMENT D/O
RELATIONAL D/O
PD AND MR AS AXIS I D/O
SLUGGISH COGNITIVE TEMPERAMENT
70. REFERENCES
KAPLAN AND SADDOCK’S COMPREHENSIVE TEXTBOOK OF
PSYCHIATRY, 9TH EDITION 2009
KAPLAN AND SADDOCK’S SYNOPSIS OF PSYCHIATRY,10TH
EDITION
DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL
DISORDERS:DSM IV TR- APA 2000
A RESEARCH AGENDA FOR DSM V. KUPFER,D;
FIRST,M;REGIER,D
FIRST M.HARMONISATION OF ICD-11 AND DSM- V:
OPPORTUNITIES AND CHALLENGES.BJP 2009;195:382-390
JABLENSKY A.TOWARDS ICD-11 AND DSM-V:ISSUES BEYOND
HARMONISATION.BJP 2009;195:379-381
CRADDOCK,MICHAEL O.RETHINKING PSYCHOSIS.WORLD
PSYCHIATRY 2007;6(2):84-91
71. REFERENCES
DISTINGUISHING BETWEEN VALIDIDTY AND UTILITY
OF PSYCHIATRIC DIAGNOSIS. KWNDELL
R,JABLESKY A.AMJ 2003;160:4-12
CLINICAL UTILITY AS A CRITERION FOR REVISING
PSYCHIATRIC DIAGNOSIS. FIRST M,WILLIAMS
J,USTUN B, PEELE R. AMJ 2004;161;946-954
AMERICAN ASSOCIATION OF COMMUNITY
PSYCHIATRIST’S VIEWS ON GENERAL FEATURES
OF DSM-IV. BELL C,SOWERS W, THOMPSON K.
PSYCHIATRIC SERVICES,2008;59:687-689