• Classification is fundamental to the quantitative study of any phenomenon
• It is recognised as the basis of all scientific knowledge
• In the study of health and illness, a classification necessary

• A system of categories to which morbid entities are assigned according to some established criteria WHO 1977

• Labelling: Stigmatisation; Increases personal difficulties
• However, no matter whether the Pt is given a Dx, he is suffering from those difficulties
• A diagnostic term can have different meaning to different people
• Not justifiable to make arbitrary cut-off point between normal and abnormal (eg. Neurosis can just be qualitative variation from normal)
• Individual Pt cannot fit neatly into available categories (as described in textbooks)
• Putting into a category distracts from the understanding of the problem unique to the individual

• American and British Psychiatrists were shown the same video-taped clinical interviews and were asked to make Dx
• Compared with those in London, psychiatrists in new York diagnosed Schizophrenia twice as often, and Mania & Depression correspondingly less often

• London concept narrower
• NY concept includes: depression, mania, personality disorder, neurosis, schizophrenia

• Elements of disagreement

1. Inconsistency in Pt's 5%
2. Inadequate interviewing technique 33%
3. Inadequate use of diagnostic criteria 62%

(Ward et al 1962)

• Different questions were asked
• Different ways of interpreting information
• Different concept of individual symptom different concepts of diagnostic categories
• Unreliability resulting from inadequate interviewing technique can be reduced if psychiatrists are trained to use standard interview schedules

• Present State Examination (Wing et al, 1974)
• Schedule of Affective Disorder & Schizophrenia (Endicott & Spitzer, 1978)
• General Health Questionnaire (Goldberg)

Thinking, concentration, etc

• What has your concentration been like recently?
• Can you read an article in the paper or watch a TV prg right through?
• Do your thoughts drift off so that you don't take things in?
• Rate poor concentration

1. Only moderately form of symptom present during past month (eg. Can read a short article, can concentrate if tries hard) or intense less than 50% of the time
2. Symptoms clinically intense (cannot read or concentrate) more than 50% of the past month

DIAG: hierarchy

1. Organic
2. Schizophrenia + Affective disorder
3. Neurosis
4. Personality disorder

• To allocate a disorder to a diagnostic criteria
• Dx by aetiology - eg. Reactive psychosis, endogenous depression (many causes not known)
• Dx by symptomatology - eg. Neurotic depression, conduct disorder (most commonly used)
• Dx by course of illness - eg. Bipolar affective disorder, unipolar depression (long time needed)
• Most contemporary classifications of mental disorders are largely based on clinical symptoms

1. Abnormalities of subjective experience elicited by questioning
2. Abnormality of behaviour observed by the examined or described to the latter by others

Most begin by the separation of MR + personality disorders from mental illness

Then separation of organic from functional

1. Organic = demonstrable physical abnormality in the brain due to cerebral or systemic conditions (eg. Delirium, dementia)
2. Functional = no underlying physical diseases

Functional divided into

1. Neurotic = no loss of reality testing. Based on intrapsychic conflicts of life events that cause anxiety. Appears as symptom such as phobia, obsession, anxiety
2. Psychotic = loss of reality testing with delusions and hallucinations

Other categories

1. Developmental disorders (eg. Autism)
2. Alcoholism 7 drugs
3. Disorders specific to childhood and adolescence

• Derived from American Psychiatric Association
• With clear diagnostic criteria
• Definitions are mostly descriptive, theoretical statements are avoided, aetiology is included only when clearly demonstrable
• Multi-axial consisting all possible contributions who somebody who has mental illness

• Axis 1 = clinical disorders; other conditions that may be a focus of clinical attention
• Axis 2= personality disorders, MR
• Axis 3 = General medical conditions
• Axis 4 = psychosocial and environmental problems
• Axis 5 = global assessment of functioning

• Delirium, Dementia, Amnesic disorders
• Schizophrenia + other psychotic disorders
• Mood, anxiety, somatoform, dissociative, sexual, gender, eating, sleep, impulse-control, adjustment, other conditions that may be a focus of clinical focus

• Different clusters

Characteristic symptoms: 2 or more of the following, each present for a significant portion of time during a 1-month period (or less if successfully treated)

• Delusions
• Hallucinations
• Disorganised speech (eg. Frequent derailment or incoherence)
• Crossly disorganised or catatonic behaviour
• Negative symptoms - ie. Affective flattening, alogia, avolition

Social/ occupational dysfunction

• For a significant proportion of time since the onset of the disturbance one or more major areas of functioning such as work, interpersonal relationships, self-care markedly below level achieved prior to onset of illness

Duration: persist for at least 6m (must include at least 1 mth of symptoms - or less if successfully treated)

Criteria A (ie. active-phase symptoms) and may include periods of prodromal or residual symptoms

Etc

Exclude schizoaffective or mood disorder

Exclude Medical condition

Exclude Relationship to pervasive developmental disorder

• 65/M divorced street-sleeper
• 6w Hx of hearing voices discussing about him among themselves and reading his thoughts aloud
• Felt that people in the street looking at him
• Muttered to himself
• Odd logic
• Unkempt
• 21st episode of problem since onset 40 year
• In and out of mental hospital in these years
• Poor insight into illness and defaulted follow up every time after discharge
• U graduate, previous CEO of company
• Work performance deteriorated
• Company bankrupt (poor leadership)
• Wife and children left him
• Worked as clerk, non-skilled manual labour
• unemployed for 25 years
• Withdrawn and alone

(A)

• This Pt had symptoms for 6w (exceeds 1m period in criteria)
• Delusions: Pt thinks people talking about him, thoughts broadcasted
• Hallucinations - present
• Disorganised speech: odd logic, speech not comprehensible
• Negative symptoms: hair no combed, not washed, clothes torn (self-neglect)

Pt has 4 of category A symptoms

(B)

• Social-occupational: previous CEO to unemployed

(C)

• 40 years Hx therefore exceeds criteria for 6m)

Therefore this Pt satisfying criteria for schizophrenia

• Began in 1853 (International Classification of Causes of Death)
• Final revision in 1893

1. ICCD
2. International Statistical Classification of Disease, Injuries and Causes of Death: regular revisions, 10-yr. intervals
3. ICD (includes all diseases)

• Development of the classification of mental disorders in the 1948 (ICD 6th version)
• Section V: Mental, Psychoneurotic + Personality Disorder

• More comprehensive
• Related mental disorders assoc. with organic and psychical factors in other disease categories in ICD
• Eg. Psychosis associated with intracranial infection (292)
• Glossary of mental disorders: allowed diagnostic terms to be used in a uniform and consistent way

• Diagnostic Guidelines similar to DSM-IV diagnostic criteria
• Internationally accepted glossary of categories, description of the main features of each disorder
• A set of versions prepared for different purposes

Descriptions and guidelines are simply a set of symptoms and comments that have been agreed by a large number of advisors and consultants in many different countries, as a reasonable basis for 'reasonable"

• Axis 1 = clinical Dx
• Axis 2 = disability
• Axis 3 = environmental and circumstantial factors
• F0 - organic, incl. symptomatic, mental disorders
• F1 - mental and behavioural disorders due to psychoactive substance use
• F2 - schizophrenia, schizotypal

All the way to F9

• F = mental disorder
• 20 = schizophrenia
• 0 = sub-type (eg. Paranoid)
• 1 = course (eg. Episodic + progressive)

ICD-9 hysteria split into 5 categories in ICD-10

Based on ICD-8, ICD-9, DSM-III

1. Organic mental disorders
2. Psychotic conditions assoc. with physical illness
3. Toxic psychoses
4. Schizophrenia

Etc, up to

14. Child mental disorders

NEUROSIS (300)

• 9.1 Anxiety (300.0)
• 9.2 Hysteria (300.1)
• 9.3 Phobia (300.2)
• Etc