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Classification in Psychiatry
Classification in Psychiatry
Systems of classification for psychiatric diagnoses have several purposes: to distinguish one psychiatric diagnosis from another, so that clinicians can offer the most effective treatment; to provide a common language among health care professionals; and to explore the still unknown causes of many mental disorders. The two most important psychiatric classifications are the Diagnostic and Statistical Manual of Mental Disorders (DSM), developed by the American Psychiatric Association in collaboration with other groups of mental health professionals, and the International Classification of Diseases (ICD), developed by the World Health Organization.
DSM-IV-TR’s RELATION TO ICD-10
The text revision of the fourth edition of the DSM (DSM-IV-TR) was designed to correspond to the tenth revision of the International Statistical Classification of Diseases and Related Health Problems (ICD-10), developed in 1992. This was done to ensure uniform reporting of national and international health statistics. In addition, Medicare requires that billing codes for reimbursement follow ICD-10. ICD-10 is the official classification system used in Europe and many other parts of the world. All categories used in DSM-IV-TR are found in ICD-10, but not all ICD-10 categories are in DSM-IV-TR.
DSM-IV-TR
The DSM-IV-TR is the official psychiatric coding system used in the United States. Although some psychiatrists have been critical of the many versions of DSM that have appeared since 1952, DSM-IV-TR is the official U.S. nomenclature. All terminology used in this textbook conforms to DSM-IV-TR nomenclature. Table 5-1 lists DSM-IV-TR diagnostic categories and the corresponding DSM-IV-TR numerical codes.
Basic Features
Descriptive Approach.
The approach to DSM-IV-TR is atheoretical with regard to causes. Thus, DSM-IV-TR attempts to describe the manifestations of the mental disorders and only rarely attempts to account for how the disturbances come about. The definitions of the disorders usually consist of descriptions of clinical features.
Diagnostic Criteria.
Specified diagnostic criteria are provided for each specific mental disorder. These criteria include a list of features that must be present for the diagnosis to be made. Such criteria increase the reliability of the diagnostic process.
Systematic Description.
DSM-IV-TR also systematically describes each disorder in terms of its associated features: specific age-, culture-, and gender-related features; prevalence, incidence, and risk; course; complications; predisposing factors; familial pattern; and differential diagnosis. In some instances, when many specific disorders share common features, this information is included in the introduction to the entire section. Laboratory findings and associated physical examination signs and symptoms are described when relevant. DSM-IV-TR is not, and does not purport to be, a textbook: No mention is made of theories of causes, management, or treatment, and the controversial issues surrounding a particular diagnostic category are not discussed.
Multiaxial Evaluation
DSM-IV-TR is a multiaxial system that evaluates patients along several variables and contains five axes. Axis I and Axis II make up the entire classification of mental disorder: 17 major classifications (Table 5-1) and more than 300 specific disorders. In many instances, patients have a disorder on both axes. For example, a patient may have major depressive disorder noted on Axis I and obsessive-compulsive personality disorder on Axis II.
Axis I.
Axis I consists of clinical disorders and other conditions that may be a focus of clinical attention.
Axis II.
Axis II consists of personality disorders and mental retardation. The habitual use of a particular defense mechanism can be indicated on Axis II.
Axis III.
Axis III lists any physical disorder or general medical condition that is present in addition to the mental disorder. The physical condition may be causative (e.g., kidney failure causing delirium), the result of a mental disorder (e.g., alcohol gastritis secondary to alcohol dependence), or unrelated to the mental disorder. When a medical condition is causative or causally related to a mental disorder, a mental disorder due to a general condition is listed on Axis I, and the general medical condition is listed on both Axis I and Axis III. In DSM-IV-TR’s example—a case in which hypothyroidism is a direct cause of major depressive disorder—the designation on Axis I is mood disorder due to hypothyroidism with depressive features, and hypothyroidism is listed again on Axis III.
