UNIT- 1

Current classification systems

Classification organizes phenomena into categories to group similar items and
distinguish different ones. In psychiatry, the ideal approach would be to classify
disorders based on their causes (etiology). However, due to the unclear aetiologies of
most psychiatric disorders, the current method is syndromal, focusing on clusters of
symptoms and signs. This mirrored early medical practices when etiology was also
unknown. The main goals of classifying psychiatric disorders are to:
1. Facilitate communication about diagnoses.
2. Aid in understanding the causes of disorders.

Definition of a Psychiatric Disorder

A psychiatric disorder can be understood as a disturbance in Cognition (thought),
Conation (action), or Affect (feeling), or a disequilibrium among these areas.
A psychiatric disorder or mental disorder is a clinically significant psychological or
behavioural syndrome that causes significant (subjective) distress, (objective)
disability or loss of freedom; and which is not merely a socially deviant behaviour or
an expected response to a stressful life event (e.g. loss of a loved one).

NORMAL MENTAL HEALTH

According to the World Health Organization (WHO), health is defined as complete
physical, mental, and social well-being, not just the absence of disease or
infirmity. Defining normal mental health is complex, but it generally includes
several key traits that are more commonly found in individuals considered to be
mentally healthy-
1. Reality Orientation: Ability to perceive and interpret the world accurately.
2. Self-Awareness and Self-Knowledge: Understanding of one’s own
thoughts, feelings, and behaviors.
3. Self-Esteem and Self-Acceptance: Having a positive view of oneself and
accepting one’s strengths and weaknesses.
4. Voluntary Control over Behavior: Capability to manage one’s actions
deliberately.
5. Ability to Form Affectionate Relationships: Capacity to develop
meaningful and caring relationships with others.
6. Pursuit of Productive and Goal-Directed Activities: Engagement in
activities that are purposeful and aim towards achieving goals.

Reliability and validity

 Reliability can different observers agree that the behaviour they observe fits
into a given diagnostic entity.
 Validity. Does the classification tell us something important or basic about the
disorder
 Robins and Guze's criteria for validating of a psychiatric diagnosis
Robins and Guze's (1970) were the first to propose formal criteria to do establish the
validity of a medical diagnosis. The five criteria were-
1. Clinical Description: This phase involves a detailed and comprehensive
description of the symptoms and clinical features of the disorder. This description
should be specific enough to differentiate the disorder from other conditions and to
capture its unique aspects.
2. Laboratory Studies: In this phase, researchers look for biological markers
(Chemical, physiological, radiological findings, etc) or physiological markers
(Reliable (inter-rater and intra- rater) and reproducible) associated with the
disorder. This might involve neuroimaging, biochemical tests, or other laboratory
measures that could provide evidence supporting the diagnosis.
3. Exclusion of Other Disorders: This phase involves ruling out other possible
diagnoses that could explain the symptoms. It ensures that the diagnosis in
question is not attributable to other psychiatric or medical conditions.
4. Follow-Up Study: This phase involves tracking patients over time to see if the
diagnosis remains consistent and if the symptoms and course of the disorder align
with the initial diagnosis. It helps in understanding the prognosis and stability of
the disorder.
5. Family Study: In this phase, researchers investigate the occurrence of the
disorder within families to assess any genetic or familial patterns. This helps in
understanding the hereditary aspects and potential genetic underpinnings of the
disorder.

Classification in Psychiatry
Accurate diagnosis is crucial for evidence-based management but can
sometimes result in stigmatization and reduction of a patient to merely a case
number, overshadowing their individual needs.

Need for Classification in Mental Health

1. To Communicate:
Classification systems in mental health establish a standardized nomenclature,
facilitating clear and consistent communication among healthcare professionals. This
common language is essential for accurate diagnosis and treatment, especially when
multiple professionals are involved in a patient’s care.
2. To Discuss the Nature, Cause, and Treatment:
By providing a structured framework, classification systems enable professionals to
discuss the nature of mental health disorders, including their symptoms and
diagnostic criteria. This structure also aids in understanding the causes—biological,
psychological, and social factors—and in developing targeted treatments and
interventions, improving patient outcomes.
3. For Insurance Purposes:
Classification systems play a crucial role in mental health insurance. They provide a
standardized method for coding diagnoses, which is essential for processing claims
and ensuring that patients receive the coverage and care they need. This system
helps streamline reimbursement processes and supports the allocation of resources.
 4. For Epidemiological Studies:
Classification systems enable the objective assessment of mental health disorders
across various clinical settings and communities. This uniformity is vital for conducting
epidemiological studies that track the prevalence and trends of mental health
disorders, providing valuable data for public health initiatives.
5. For Research:
In research, classification systems offer a structured approach to understanding
mental health disorders. They facilitate the identification of research trends, support
the development of evidence-based treatments, and contribute to the overall
advancement of knowledge in the field of mental health.

Historical Evolution:
 Psychiatry has seen significant evolution in classification systems, influenced by
growing research in various domains (epidemiology, symptomatology,
prognosis, treatment, and causation theories).
 Early attempts at classification can be traced back to Ayurveda, Plato (4th
century BC), and Asclepiades (1st century BC).
The historical classification of mental disorders has evolved significantly over time.
Two notable early classifications were:
1. Organic vs. Functional
The first major classification of mental illness was based on the distinction between
disorders, arising from the diseases of the brain and those with no such obvious
biases
Organic Disorders: These were believed to have a clear, identifiable physical cause.
The term "organic" suggested that the disorder was due to some identifiable biological
or physical abnormality. Examples might include conditions caused by brain injury,
infections, or neurological diseases. They can be acute, sub-acute or chronic.
Functional Disorders: These were considered to have no identifiable physical cause
and were thought to arise from psychological or functional disturbances. The term
"functional" implied that the disorder's origins were more related to psychological
factors or disturbances in mental functioning rather than physical abnormalities. It can
be broadly classified as neurosis and psychosis
This distinction was useful in its time but has largely been replaced or refined
with more nuanced understandings in modern psychiatry. Advances in
neuroscience have shown that even disorders once classified as "functional" can
have underlying biological components.
2. Neurosis vs. Psychosis
Neurosis: This term was used to describe mental disorders that involved distressing
symptoms but where the individual retained insight into their condition. People with
neuroses often experienced anxiety, depression, or obsessive-compulsive behaviors,
but they were generally able to maintain contact with reality and function in everyday
life.
Psychosis: This term refers to more severe mental disorders where individuals lose
contact with reality. Psychotic disorders are characterized by symptoms such as
delusions, hallucinations, and disorganized thinking. Psychosis can be a feature of
various mental illnesses, including schizophrenia and severe bipolar disorder.
They lack insight about their condition. The entire personality is being disordered due
to the condition. Construct a false environment out of his dissorted subjective
environment
In contemporary psychiatry, these terms have largely been replaced by more
specific diagnostic categories and criteria, as outlined in classification systems
like the DSM-5 and ICD-11.

Types of classification systems used in psychiatry:

Categorical Classification
 Behaviors are grouped into clear categories like "normal" and "abnormal."
 Abnormal behavior is classified into distinct, non-overlapping types (like illnesses or
diseases).
Example: Diagnosing conditions like cancer or diabetes involves specific categories;
similarly, mental disorders are diagnosed as specific types.

Advantages of Categorical Classification:

 Provides clear diagnostic criteria and categories.
 Facilitates communication among clinicians and researchers.
 Useful for clinical decision-making and treatment planning.

Limitations of Categorical Classification:

 May oversimplify complex mental health conditions.
 Can lead to diagnostic overlaps and comorbidities.
 Might not capture the full spectrum or nuances of disorders
Dimensional Classification
 Behavior is seen as a result of different intensities across several traits
(dimensions) like mood, emotional stability, and trust.
 Everyone shares the same traits but differs in intensity.
Example: Instead of labeling someone with a disorder, their mood or anxiety level
might be measured on a spectrum.

Advantages of Dimensional Classification:

 Provides a more nuanced understanding of mental health conditions.
 Captures variations in severity and symptom intensity.
 Reflects the complexity and continuum of mental disorders.

Limitations of Dimensional Classification:

 Can be more complex to implement and interpret in clinical practice.
 May lack the clear-cut diagnostic criteria seen in categorical systems.
 Requires extensive research and validation to establish reliable dimensions.

Current Major Classifications:

 International Classification of Diseases
 Diagnostic and Statistical Manual of Mental Disorders
They are referred to as categorical classificatory systems because:
 Diagnostic and Statistical Manual of Mental Disorders
The Diagnostic and Statistical Manual of Mental Disorders, published by the
American Psychiatric Association (APA), DSM I – was published in 1952 is a
comprehensive tool used to diagnose mental disorders.
 Rigid and elaborate definitions of disorder, suitable for both clinical practises
and research. Less user of friendly than ICD.
 Global Use: Predominantly used in the United States and Australia, but also
influences diagnostic practices in many Western countries.
 Content: DSM-5 is 947 pages long and contains 541 diagnostic criteria spread
across 22 chapters.
 DSM-I (1952)
 DSM-IV-TR (2000): Introduced a multiaxial classification system.
 DSM V (2013): Elimination of the Multiaxial System

Key Changes in DSM-5

1. Elimination of the Multiaxial System:
o DSM-IV-TR: Used a multiaxial system to assess different aspects of
mental health on separate axes.
o DSM-5: Abolished this system in favor of a single-axis diagnostic system
that integrates all mental disorders into one comprehensive list within 22
chapters.
2. Revised Diagnostic Criteria:
o Updates: DSM-5 revised criteria for several disorders, added new ones,
and removed some considered less clinically useful.
o Dimensional Assessments: Emphasizes that mental disorders exist on a
spectrum rather than being strictly categorical.
3. Autism Spectrum Disorder (ASD):
o Previous Diagnoses: DSM-IV-TR included multiple separate autism
diagnoses.
o DSM-5: Consolidated these into a single diagnosis of Autism Spectrum
Disorder to provide a more unified understanding.
4. Bereavement Exclusion:
o DSM-IV-TR: Had a bereavement exclusion for Major Depressive Disorder
(MDD), which prevented MDD diagnosis within two months of a loved
one's death.
o DSM-5: Removed this exclusion, allowing for the diagnosis of MDD even
in the context of bereavement if symptoms meet the criteria for
depression.
5. Cultural Considerations:
o Incorporation: DSM-5 places greater emphasis on cultural factors in
diagnosing and treating mental disorders.
 o Guidance: Provides guidance on considering cultural context and
influences when making diagnoses.

International Classification of Diseases,

The ICD is used by many countries globally as the standard diagnostic system
for medical conditions, including mental disorders. It is particularly prevalent in
countries in Europe, Asia, Africa, and Latin America.
The ICD was first used to classify causes of death.
In 1900, the ICD-1.
 Developed by the World Health Organization (WHO) to cover all diseases and
health issues, including psychiatric disorders.
 Psychiatric disorders are categorized under 'Mental and Behavioural Disorders'
(MBDs) with alphanumeric codes ranging from F00 to F99.
 ICD-10 is available in various versions, tested globally across over 50 countries.
Some versions include:
o Clinical Descriptions and Diagnostic Guidelines (CDDG)
o Diagnostic Criteria for Research (DCR)
o Multi-axial Classification Version
o Primary Care Version

Principal Differences Between ICD-10 and ICD-9:

1. Size and Number of Categories:
o ICD-9: Chapter V (mental disorders) had 33-character categories (codes
290-319).
o ICD-10: Chapter V (F) includes 103-character categories, allowing for
more detailed classification.
2. Coding System:
o ICD-9: Utilized a numeric coding system (001-999).
o ICD-10: Employs an alphanumeric coding scheme with a letter followed
by two numbers (e.g., A00-Z99), allowing for more categories and greater
specificity.
3. Detail and Subdivisions:
o ICD-9: Limited in detail.
o ICD-10: Offers further detail with decimal numeric subdivisions at the
four-character level.

General Principles
Core Classification: Central system for various disease and health classifications.
Some categories use additional characters for specificity, while others are condensed.
Multiaxial Presentation: Includes systems for different practices, including child
psychiatry and research.
Additional Classifications: Covers impairments, disabilities, medical procedures,
and reasons for patient encounters.
Feature ICD-10 DSM-5
Name International Classification of Diagnostic and Statistical
Diseases, 10th Edition Manual of Mental Disorders,
5th Edition
Purpose Global classification system for Classification system
all diseases and health specifically for mental health
conditions disorders
Developed by World Health Organization American Psychiatric
(WHO) Association (APA)
Geographic Use Used internationally for a Primarily used in the United
broad range of health States and some other
conditions countries
Diagnosis Alphanumeric codes are used Numeric codes specifically for
Codes for all health conditions mental disorders
Updates Updated periodically by WHO; Updated by APA; DSM-5 is the
ICD-11 is the latest version latest version, with possible
updates through DSM-5-TR
Diagnostic Less detailed criteria for Detailed diagnostic criteria for
Criteria mental disorders compared to mental disorders
DSM-5
Comorbidity Generally not as detailed in Provides detailed criteria for
terms of comorbidity comorbid conditions

Clinical formulation
Clinical formulation - Case history + MSE + provisional diagonisis…… differentiatial
diagnosis
Psychological Assessment/ testing
Final Diagnosis

Case History
When a patient's history is incomplete due to lack of insight or willingness, it's
important to gather information from their relatives or friends. This should be done
with the patient's consent unless they are unable to give it.
 their relationship with the patient,
 their living arrangement with the patient, and
 the length of time they've spent together.
Additionally, the reliability of the informants' information should be evaluated based
on their relationship with the patient, their observational skills, familiarity with the
patient, and their level of concern. Referral sources, like letters from general
practitioners or specialists, can also offer valuable insights into the patient's condition
1. Identification data
Name, Age, Sex, Marital Status, Education, Occupation, Income, Residential Address,
Office Address, Religion, Socioeconomic Background, Source of Referral, Identification
Marks (for medicolegal cases)
 2. Presenting (chief) complaints
When documenting presenting (chief) complaints, record both the patient's and, if
relevant, the informant's accounts of the issues. Note if the patient has no complaints
due to lack of insight. Use the patient's exact words and include the duration of each
complaint. Key details to record are:
Onset, Duration, Course, Predisposing Factors, Precipitating Factors,
Perpetuating/Relieving Factors
3. History of present illness
4. Past Psychiatric History:
5. Past Medical History:
6. Treatment History
7. Family history
Family Structure:
Family History of Illnesses:
Current Social Situation:
1. Personal and social history
 Perinatal History:
 Childhood History:
 Educational History:
 Play History:
 Puberty:
 Menstrual and Obstetric History:
 Occupational History:
 Sexual and Marital History:
2. Premorbid Personality (PMP)
[Relationships with family members, friends, and colleagues; introverted/extroverted;
ease of forming and maintaining social relationships.]
3. Alcohol and substance history
4. Physical Examination
Patients should be referred to a physician for detailed check-ups

Mental Status Examination (MSE)

Mental status examination is a standardized format in which the clinician records the
psychiatric signs and symptoms present at the time of the interview.
1. General Appearance and Behaviour
Examining a patient's general appearance and behavior, while considering their
sociocultural background and personality, is crucial, especially for uncooperative
patients.

 General Appearance
 Attitude towards Examiner
 Comprehension
 Gait and Posture
 Motor Activity
 Social Manner
 Rapport
 Hallucinatory Behaviour
2. Speech
 Rate and Quantity
 Volume and Tone
 Relevant or Irrelevant
 Coherent or Incoherent
3. Mood and Affect
Mood refers to the enduring emotional tone that colors a person's overall experience,
while affect is the immediate, observable expression of emotion.
Mood is assessed through its quality, stability, reactivity, and persistence, whereas
affect is evaluated based on its quality, range, depth, and appropriateness.
4. Thought
Normal thinking is characterized by a goal-directed flow of ideas that are rationally
connected and lead to realistic conclusions. In clinical examination, thought is
evaluated under "stream and form" and "content":

 Stream
This refers to the speed and continuity of thinking:
 Flight of ideas: Rapid shifting from one topic to another, often seen in mania.
 Retardation of thinking: Slowness in thought processes, common in
depression.
 Perseveration: Repetition of the same thought or idea, even when it's no
longer relevant.
 Thought block: Sudden interruption in the flow of thought, often associated
with schizophrenia

 Form
This looks at the logical organization of ideas:
 Loosening of association: Ideas are disconnected, making speech illogical
(e.g., schizophrenia).
 Derailment: Thoughts shift abruptly, losing coherence.
 Neologisms: Inventing new words with no understood meaning.
 Clang associations: Linking words based on their sound rather than meaning
(e.g., rhyming).

 Content
This refers to the specific themes or topics of their thoughts:
 Delusions: False, fixed beliefs not aligned with reality (e.g., paranoia,
grandeur).
 Depressive cognitions: Negative self-view, feelings of hopelessness.
 Suicidal ideas: Thoughts about self-harm or ending one’s life.
 Phobias: Intense, irrational fears of specific situations or objects.
 Anxieties: Excessive worries about real or imagined scenarios.
 Somatic symptoms: Preoccupation with physical health without medical
evidence.

 Possession
This evaluates whether the person feels in control of their thoughts:
 Obsessions: Recurrent, intrusive thoughts causing distress.
 Compulsions: Repetitive behaviors driven by obsessive thoughts.
 Thought insertion: Belief that external forces are implanting thoughts into
their mind.
  Thought withdrawal: Belief that thoughts are being removed from their mind.
 Thought broadcast: Belief that others can hear their thoughts.
5. Perception
Perception involves recognizing and interpreting sensory experiences based on prior
knowledge. It is assessed through:
 Hallucinations: These are perceptions without external stimuli, categorized by
type (auditory, visual, olfactory, gustatory, tactile), nature (elementary vs.
complex), and whether they feel external or internal (pseudohallucinations).
Important details include the content, frequency, source, and whether they are
command hallucinations or occur during specific states of consciousness
(hypnagogic, hypnopompic).
 Illusions and Misinterpretations: Assess whether distorted perceptions are
visual, auditory, or of other types, occur in clear consciousness, and if reality-
checking steps were taken.
 Depersonalization/Derealization: These are disturbances in self and
environmental perception, often described as ‘as-if’ experiences.
 Somatic Passivity Phenomena: This involves sensations imposed by an
external force, considered a Schneiderian first-rank symptom.
 Others: Include autoscopy, abnormal vestibular sensations, and sense of
presence.
6. Cognition (Higher Mental Functions)
Assessment of cognitive functions, crucial for diagnosing organic psychiatric disorders,
involves:

Consciousness: Determine the patient's level of alertness and responsiveness,

ranging from conscious to coma, and use tools like the Glasgow Coma Scale if needed.

Orientation: Evaluate the patient's awareness of time, place, and person, noting that
disorientation in time often precedes disorientation in place and person.

Attention: Assess the ability to focus and sustain attention using tasks like digit span
tests.

Concentration: Measure concentration by tasks requiring serial subtraction or

counting backward.

Memory: Test immediate retention, recent memory, and remote memory with tasks
such as recalling digits, recent events, and personal history.

Intelligence: Evaluate logical thinking, rational action, and environmental interaction

through questions about general knowledge, simple calculations, and reading/writing
tests.

Abstract Thinking: Assess the ability to understand and manipulate concepts

through proverb interpretation and identifying similarities and differences between
objects, noting responses for concreteness or abstraction, which may indicate
conditions like schizophrenia.
 7. Judgement
Judgment is the ability to accurately assess and respond appropriately to situations,
evaluated through:
 Social Judgment: Observed during interactions and the interview, reflecting
personal judgment and decision-making in real-life contexts.
 Test Judgment: Assessed by presenting hypothetical scenarios (e.g., a house
on fire, a man lying on the road, or a sealed envelope found on the street) and
evaluating the patient's responses.
Judgment is rated as Good/Intact/Normal or Poor/Impaired/Abnormal based on these
evaluations.
8. Insight
Insight is rated on a 6-point scale from one to six.
1. Complete denial of illness.
2. Slight awareness of being sick and needing help, but denying it at the same
time.
3. Awareness of being sick, but it is attributed to external or physical factors.
4. Awareness of being sick, due to something unknown in self.
5. Intellectual Insight: Awareness of being ill and that the symptoms/failures in
social adjustment are due to own particular irrational feelings/thoughts; yet
does not apply this knowledge to the current/future experiences.
6. True Emotional Insight: It is different from intellectual insight in that the
awareness leads to significant basic changes in the future behaviour

Provisional Diagnosis:
A provisional diagnosis is a preliminary diagnosis made based on the current evidence
and symptoms presented by the patient. It's not definitive but serves as a working
diagnosis while further investigation is conducted.
It helps guide initial treatment and management decisions while additional tests and
evaluations are completed. The provisional diagnosis may be revised as more
information becomes available.

Differential Diagnosis:
Differential diagnosis is the process of distinguishing a particular disease or condition
from others that present with similar clinical features. It involves considering a list of
possible conditions that could explain the patient's symptoms.
The goal is to systematically rule out or confirm each potential condition to arrive at
the correct diagnosis. This process ensures that other possible explanations for the
symptoms are considered and tested.

Psychological Assessments/Testing
Type of Assessment: Specify any standardized tests or psychological assessments
used (e.g., personality assessments, cognitive tests).
 Laboratory Tests: To analyze biological samples and assess physiological
conditions.
 Diagnostic Standardized Interviews: Structured interviews to evaluate
specific symptoms and conditions.
 Family Interviews: To gather information about family history and dynamics.
 Psychological Tests: To assess mental and emotional functioning.
Results: Summarize key findings from the tests, including scores, patterns, and any
significant insights.
Interpretation: Discuss how these results support or contradict the provisional
diagnosis and contribute to understanding the client’s condition.

Final Diagnosis
The final diagnosis is the conclusive identification of a disease or condition, based on
comprehensive evidence collected through various diagnostic methods. It represents
the ultimate conclusion reached by healthcare professionals after ruling out other
possible conditions.
Process:
 Initial Evaluation: Begins with the provisional diagnosis, which is based on
initial symptoms and findings.
 Diagnostic Testing: Involves conducting various tests, imaging studies, and
possibly consultations with specialists.
 Differential Diagnosis: Continues to be refined as tests and evaluations help
to confirm or exclude other potential conditions.
 Synthesis of Information: Combines all the clinical findings, test results, and
patient history to arrive at the final diagnosis.
Purpose:
The final diagnosis guides treatment and management plans. It helps formulate a
specific treatment regimen, determine a prognosis, and plan follow-up care.