W3-Module3 Classifications of Mental Illnesses
W3-Module3 Classifications of Mental Illnesses
W3-Module3 Classifications of Mental Illnesses
1
[Classifications of Mental Illnesses]
Objectives:
1. To discuss how mental diseases are classified
a) Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition
(DSM-5)
b) International Statistical Classification of Diseases and Related Health
Problems, 10th revision (ICD-10)
At the end of this module, students are expected to:
1. To classify mental disorders using internationally accepted standards of
classification
2. To understand the importance of the classification systems of mental
illness
“Not until we are lost do we begin to understand ourselves” - Henry David
Thoreau
1. Communication
2. Comprehension
3. Control
Course Module
What are the characteristics of a good classification system?
1. It is reliable.
It limits the errors that lead to false positive or false negative diagnosis.
2. It is valid.
3. It is universal.
4. It is efficient.
Categorical
This originated from the work of Emil Kraepelin (1856-1926), one of the
first psychiatrists to classify mental illnesses from a biologic perspective. In
this approach, every diagnosis is assumed to have an underlying mechanism,
called a pathophysiologic cause. The categorical approach of classifying
illnesses works on the assumption that individuals can be categorized as
healthy or ill. For those who are ill, different illnesses can be further
classified according to it similarity in disease presentation or causative
factor.
Dimensional
The dimensional approach of classifying illnesses works on the assumption
that a person’s usual behavior is a cumulative end result of various aspects
that lead to a person’s behavior. Examples of these aspects include mood,
personality, emotional stability, gender identity, interpersonal trust,
introversion and ability to communicate with other people. Normal
standards for these aspects can be defined, and use as a basis for classifying
abnormal behaviors. This approach to disease classification is beneficial in
deciding on appropriate treatment strategies. Because this approach
considers the objective measures of psychological aspects of the disease,
psychological based therapies may be individualized depending on the
severity of the patient’s presentation.
[Abnormal Psychology]
3
[Classifications of Mental Illnesses]
Prototypal approach
A prototype is a designated entity that ideally fits the categorical description
of a certain disease classification. In this approach of disease classification, a
prototype or a ‘model disease entity’ is used as a comparative standard by
which other diseases are compared with using a rating scale. For example, in
diagnosing major depressive disorder, a clinician will compare the disease
presentation of the patient to the narrative description of symptoms that
must be present in a patient with major depressive disorder. In this manner,
the clinician is able to match the patient’s presenting symptom, with that of
the disease prototype.
The Fifth edition of DSM was published last 2013, and is the most recently
updated manual (See Fig. 2). Its first edition was published in 1952.
However, the biggest paradigm shift in diagnosing mental disorders occurred
during the transition from DSM-II to DSM-III. DSM II used diagnostic
categorization, while DSM-III utilized the multi-axial diagnostic system.
Two major changes were introduced in DSM-III, which have been adapted by
subsequent editions:
Specific diagnostic criteria - includes specific symptoms of the disease
Extensive characteristic features of the disease such as essential
features, associated features and laboratory findings
Course Module
This diagnostic manual is continuously being revised to ensure diagnostic
reliability, validity, and efficiency with each new revision. In the subsequent
editions, DSM-IV and DSM-IV TR (text revision), approach to diagnosis still
used the multi-axial system.
Axis I contains all mental health illnesses (except those in Axis II).
Axis II contains personality disorders and mental retardation
Axis III contains non-psychiatric medical illnesses
Axis IV contains psychosocial and environmental problems
Axis V contains the Global Assessment of Functioning (GAF), which
is an objective measure of the patient’s psychosocial, occupational and
educational impairment.
DSM-V Chapters
Neurodevelopmental Disorders
This is a new chapter included in the Fifth edition of DSM. This includes
disorders that began during infancy, childhood or adolescence. Some
examples of diseases that are discussed here are autism and mental
retardation that is more appropriately known as intellectual disability and
intellectual development disorder subsequently. These disorders are not
exclusively seen in children because these conditions may persist across the
patient’s lifespan.
Course Module
depressive disorder. However, in depressive disorders, symptoms are not
temporary and it causes impairment of daily activities.
Anxiety Disorder
This is a group of disorders, which commonly involve feelings of anxiety and
fear. It is normal for people to be frightened or become anxious with an
appropriate stimulus. For example, it is normal to feel afraid after seeing a
horror movie. Some animals may also incite feelings of fear and anxiety such
as frogs, snakes and rodents. However, there is a pathologic expression of
fear and anxiety that causes impairment in daily activities. Usually people
with anxiety disorders have excessive feelings of fear and anxiety, even in the
absence of a stimulus. For example, when a person refuses to go out of the
house because of the fear of seeing a frog. These disorders have a wide range
of illnesses, which range from generalized anxiety disorder to phobias.
Fig. 5 Five year-old Omran Daqneesh, victim of August 2016 terrorist attacks
in Aleppo, Syria. (Anadolou Agency/Getty,2016)
[Abnormal Psychology]
7
[Classifications of Mental Illnesses]
Dissociative Disorders
Those who experience interrupted concept of reality, consciousness and
memory characterize patients with dissociative disorders. As the term
implies, patients suffering from this disorder become unfamiliar with his
identity and memory. The length of these disruptions has important
implications in diagnosis. Patients who experience temporary disruptions in
memory have a disorder called, dissociative amnesia. On the other hand,
those with a more permanent disease course have a disease entity referred
to as dissociative identity disorder. “Multiple personality disorder” is an old
term for patients with dissociative identity disorder.
Fig 6. Jeremy Gillitzer, a model who suffered from anorexia nervosa. (Jeremy
Gillitzer, 2014)
Course Module
Feeding and Eating Disorders
Those who are suffering from eating disorders usually have disturbances in
their perception of body shape and image (See Fig. 6). Examples of common
eating disorders are anorexia nervosa and bulimia. Both of these disorders
cause malnutrition if they remain unrecognized or untreated.
Elimination Disorders
Patients suffering from this disorder excrete fecal material or urine in an
abnormal manner. These disorders can be voluntary or involuntary. Two
most common disorders belonging to this category are encopresis and
enuresis. Encopresis is a condition wherein the patient defecates in places
other than the toilet. On the other hand, enuresis causes individuals to
urinate inappropriately.
Sleep-Wake Disorders
Sleeping disorders include a wide-variety of illnesses that manifest with
disturbances in sleep pattern or behavior. Aside from those with insomnia,
patients with sleep disorders also include those who have difficulty
maintaining normal sleep duration or those who are unable to sleep during
normal sleeping hours. Some of these disorders have a biological
explanation, while others largely depend on the individual’s psychological
status.
Sexual Dysfunctions
Patients suffering from sexual dysfunction are those with functional
abnormalities that are psychological in nature. As an example, those who
derive sexual gratification from unusual sources, such as seen in
exhibitionism or voyeurism. Patients with erectile dysfunction or premature
ejaculation also belong to this category.
Gender Dysphoria
Patients suffering from gender dysphoria are those who are not satisfied
with their gender identity. These individuals are uncomfortable of their
anatomical gender and they strongly believe that they should be otherwise.
As a result, patients usually dress up and act as the opposite gender. These
patients engage in “cross-dressing”, and some even opt for gender
reassignment surgery (See Fig.7 and Fig.8)
Course Module
disorder is now included in this category. In DSM-IV-TR, it used to be under
the category of impulse control disorder.
Neurocognitive disorders
Patients with these disorders suffer from disturbances in cognitive aspects of
thinking, usually involving memory. There are two major disorders that fall
under this category, namely dementia and delirium. Dementia is a cognitive
disorder that may be caused by biological illnesses such as Alzheimer’s
disease or stroke. Memory impairment is usually permanent for patients
with dementia. On the other hand, delirium is usually a temporary cognitive
disturbance caused by illnesses or chronic ingestion of illicit drugs and
alcohol.
Personality Disorders
People suffering for personality disorders have disturbances on how they
perceive oneself and other people. These disturbances cause significant
functional impairments that affect a person’s daily activities. A common
example of a personality disorder is antisocial personality disorder wherein
an individual lacks regard for moral and social norms, including the thoughts
and feelings of other people. People with antisocial personality disorder
commonly violate the law and commit crimes, without guilt or remorse for
what they have committed. This causes significant lifestyle impairment since
they cannot abide by rules and regulations. There are ten distinct types of
personality disorders that are grouped into clusters. Each cluster will be
discussed in a separate module towards the end of this course.
Paraphilic Disorders
Patient suffering from paraphilia usually generate unusual sources of sexual
arousal or interest that involves hurting, injuring, or forcing someone to do
an act against his will. Some examples of disorders under this category
include pedophilic disorder, sexual sadism disorder and exhibitionistic
disorder.
Other Disorders
These are mental disturbances that do not fit any of the other categories of
DSM-V.
[Abnormal Psychology]
11
[Classifications of Mental Illnesses]
Course Module
International Classification of Diseases (ICD)
International Classification of Diseases
The International Classification of Diseases is a broad diagnostic guideline for
all diseases, not limited to mental health disorders. Its tenth edition was
published in 1992 by the World Health Organization and is the most recent
edition. Mental and Behavioral disorders are a special subsection of the ICD.
Diseases are also classified into different categories in order to group
together illnesses with similar disease presentation, etiology and
management (See Fig. 12). Similar to DSM, disorders are also described
based on symptoms and duration of abnormality. Both DSM and ICD share a
similar criterion for all mental health illnesses in that the presence of a
disorder should cause significant impairment or distress. Also, medical
illnesses that may cause similar symptoms should have been ruled out.
To differentiate ICD and DSM, let us examine how both classification systems
described their criteria in diagnosing Generalized Anxiety Disorders.
Course Module
DSM-V Criteria for Generalized Anxiety Disorder
Notice the distinction how ICD and DSM described their criteria for
diagnosing generalized anxiety disorder. Both have specific clusters of
symptoms, which distinguish the behavior from normality (See Fig.11 and
Fig.12)
Glossary
categorical classification - one of the approaches in patient assessment,
wherein a patient is either a member of a category or not.
Course Module
metamphetamine - a prohibited drug derived from amphetamine
References
ABC Photo Archives. (n.d.). Bruce Jenner Trains For And Competes In The 1976
Montreal Summer Olympic Games [Photograph found in Disney ABC
Television Group]. In Getty Images. Retrieved from
http://www.gettyimages.com/license/479837454 (Originally
photographed 1976, June 4)
Anadolou Agency/ Getty Images. (2016). [Photograph found in Getty
Images]. In The Guardian News. Retrieved from
https://www.theguardian.com/commentisfree/2016/aug/20/omran
-picture-turning-point-syria-war-aleppo-david-nott (Originally
photographed 2016)
Butcher, J. N., Hooley, J. M., & Mineka, U. (2014). Abnormal psychology (16th
ed.). Upper Saddle River, New Jersey: Pearson.
Dalal, P. K., & Sivakumar, T. (2009). Moving towards ICD-11 and DSM-V:
Concept and evolution of psychiatric classification. Indian Journal of
Psychiatry, 51(4), 310–319. http://doi.org/10.4103/0019-
5545.58302
DSM-V. (2013, May 28). In PsychCentral. Retrieved from
http://pro.psychcentral.com/dsm-5-changes-feeding-eating-
disorders/004412.html#
Field, M., & Cartwright-Hatton, S. (2015). Essential abnormal & clinical
psychology (1st ed.). Thousand Oaks, California: SAGE Pulication.
Grunnitus Studios. (n.d.). [Photograph found in Photo Researchers, Inc]. In
Encyclopedia of Mental Disorders. Retrieved from
http://www.minddisorders.com/Br-Del/Catatonic-disorders.html
Jeremy Gillitizer. (2014). In New Health Advisor. Retrieved from
http://www.newhealthadvisor.com/Anorexia-Before-and-After.html
[Abnormal Psychology]
17
[Classifications of Mental Illnesses]
Kring, A. M., Johnson, S. L., Davidson, G. C., & Neale, J. M. (2012). Abnormal
psychology (12th ed.). Essex County, MA: John Wiley & Sons.
Leibovitz, A. (2015, July). Vanity Fair Cover [Photograph found in Vanity
Fair]. In Vanity Fair. Retrieved from
http://www.vanityfair.com/hollywood/2015/06/caitlyn-jenner-
bruce-cover-annie-leibovitz (Originally photographed 2015)
Osborne, R. E., Lafuze, J., & Perkins, D. V. (2016). Case analyses for abnormal
psychology: Learning to look beyond the symptoms. New York, NY:
Routledge.
PsychSearch. (2012). DSM books. Retrieved from
http://www.psychsearch.net/psychiatrys-bible-the-dsm-is-doing-
more-harm-than-good/
Puri, B. K., Hall, A. D., & Ho, R. (2014). Revision notes in psychiatry (3rd ed.).
Boca Raton, FL: Taylor & Francis.
Stern, T. A., Fava, M., Wilens, T. E., & Rosenbaum, J. F. (2016). Massachusetts
General Hospital Comprehensive Clinical Psychiatry (2nd ed.). St.
Louis,Missouri: Elsevier.
Course Module