Classification in psychiatry

Case history 3

From the age of 18 years, Emily has always manipulated situations so that other people sort things out for her. If they refuse to do this she becomes angry and tearful. From the age of 30, she has experienced panic attacks when in crowds or shops. When 45, she had an episode of depression and obsessional symptoms occurring and remitting at the same time. She had a further episode of depression when given steroids for treatment of COAD when 54.

a What psychiatric disorders do you think Emily has experienced?

Before the 1970s, it was thought that schizophrenia was more common in the US than the UK. However, when this was properly researched, it turned out that there was no real difference in prevalence. The reason for the previously observed difference was that psychiatrists in the two countries had different views about the nature of the condition: American psychiatrists were more likely to diagnose schizophrenia and British psychiatrists more likely to diagnose manic-depression.

The development of standardised methods of classifying psychiatric disorders has improved communication between clinicians and has made it possible to research the aetiology, management and prognosis of a particular diagnosis, thereby providing an empirical basis for clinical practice. As a result, diagnosis becomes a useful procedure rather than just a way of labelling people (Fig. 1).

Fig. 1 If a diagnosis is used to inform clinical practice, it becomes more than just a label.

Classification systems

There are two major classification systems used in psychiatry. The first is the International Classification of Disease, 10th version (ICD10), devised by the World Health Organization in 1993. The second classification system is the Diagnostic Systems Manual, currently in its 4th version (DSM IV), which has been produced by the American Psychiatric Association. The two systems are broadly similar and in this book we have mostly followed ICD10. Table 1 outlines the ICD10 classification of psychiatric disorders.

Table 1 Outline of ICD10 classification of psychiatric disorders

Organic	Organic disorders: includes dementia, delirium, other organic disorders
	Mental and behavioural disorders due to psychoactive substance use
Functional	Schizophrenia, schizotypal and delusional disorders
	Mood disorders: includes bipolar disorder, depressive illness, cyclothymia, dysthymia
	Neurotic, stress-related and somatoform disorders: includes anxiety disorders, obsessive-compulsive disorders, reactions to stress, dissociative and somatoform disorders
	Behavioural syndromes associated with physiological disturbances and physical factors: includes eating disorders, sleep disorders, sexual dysfunction
	Disorders of adult personality and behaviour: includes personality disorders, factitious disorders
	Mental retardation
	Disorders of psychological development
	Behavioural and emotional disorders with onset usually occurring in childhood and adolescence
	Unspecified mental disorder

DSM V is due in 2012 and ICD11 in 2014. The greatest change is likely to be the introduction of dimensional measures for some conditions, in contrast to the sole use until now of categorical diagnoses. In general medicine, blood pressure is a dimensional measure, hypertension a category. Metabolic syndrome is a categorical construct that is based on a number of dimensional measures, such as waist circumference, blood pressure and serum glucose and lipids. In psychiatry, there are scales that can be used, for example, to give dimensional measures of psychosis, mood, anxiety and traits of personality, and these can be used as an alternative or, perhaps more pragmatically, as an adjunct to categorical diagnosis.

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