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
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
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
19. DD of Psychosis with Mood
Disorder
Psychosis
medical substance
Symptoms of sc
Lasting 1 m.
Depression or mania
Duration short
sz
Duration long
At least two weeks
In the absence of Mood
schizoaffective
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
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. DimensionalCategorical vs. Dimensional
SystemsSystems
CategoricalCategorical
Presence/absence of a disorderPresence/absence of a disorder
Either you are anxious or youEither you are anxious or you
are not anxious.are not anxious.
DSM isDSM is categoricalcategorical
DimensionalDimensional
Rank on a continuous quantitativeRank on a continuous quantitative
dimensiondimension
How anxious are youHow anxious are you on a scaleon a scale
of 1 to 10?of 1 to 10?
Dimensional systems may betterDimensional systems may better
capture an individual’s functioningcapture an individual’s functioning
but the categorical approach hasbut the categorical approach has
advantages for research andadvantages for research and
understandingunderstanding
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: ReliabilityAssessment Issues: Reliability
Diagnosis Kappa
Bipolar Disorder .84
Major Depression .64
Schizophrenia .65
Alcohol Abuse .75
Anorexia .75
Bulimia .86
Panic Disorder .58
Social Phobia .47
ReliabilityReliability
Consistency ofConsistency of
measurementmeasurement
Interrater reliabilityInterrater reliability
– Extent to whichExtent to which
clinicians agree onclinicians agree on
the diagnosis.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 CodeDSM-IV Name
300.21Panic Disorder with Agoraphobia, Moderate
304.10Diazepam Dependence, Mild
__._______________________________________
AXIS II: Personality Disorders
Diagnostic CodeDSM-IV Name
301.82Avoidant Personality Disorder
___.__Dependent Personality Features___________
AXIS III: General Medical Conditions
ICD-9-CM codeICD-9-CM name
424.0Mitral Valve Prolapse
__._______________________________________
33. Multiaxial System
Axis IV: Psychosocial and Environmental Problems
Check:
XProblems with primary support groupSpecify: Marital
Discord
Problems related to the social environment
Specify:___________
Educational problems
Specify:_____________________________
XOccupational 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
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
1. Autism
2. Attention Deficit-Hyperactivity Disorder
3. Conduct Disorders
4. Mental Retardation (Axis II)
5. Tourette’s
Delirium, Dementia and Cognitive Disorders
1. Delirium
2. Dementia of the Alzheimer’s Type
3. Vascular Dementia
4. Amnestic Disorder
40. Diagnostic Groupings and
Examples Adjustment Disorders
1. Adjustment Disorder with Mixed Anxiety and
Depressed Mood
Personality Disorders (Axis II)
1. Borderline Personality Disorder
2. Obsessive-Compulsive Personality Disorder
Impulse Control Disorders
1. Trichotillomania
2. Pathological Gambling
Other Conditions (Including “V Codes”)
1. Relational Problems
2. Sexual Abuse of a Child
3. 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: ValidityAssessment Issues: Validity
Construct validityConstruct validity
Extent to whichExtent to which
diagnosis is related to,diagnosis is related to,
or predictive of, aor predictive of, a
network of diagnosticnetwork of diagnostic
hypotheses.hypotheses.
Validity of DSMValidity of DSM
diagnostic categoriesdiagnostic categories
varies.varies.
Notes de l'éditeur
Most psychiatric illnesses and many medical illnesses are not disease in the strict sense of the word.
Understanding the syndrome and cause facilitate the discovery of etiology. For example the separation of Down Syndrome from the rest of Mental Disorders facilitate the discovery of the Trisomy 21.
A similar relation is seen between the disorder dementia paralytica and the discovery of the causative agent of the disease syphilis: Treponema Pallidum
In DSM-III there was “ego-dystonic homosexuality” and DSM-III-R excluded it totally. This exempliffied a social change in the american society and to view homosexuality as a normal variant of human behavior.
1973- Declassification
1987- Eliminatrion at all