Classification in Psychiatry and Psychiatric Rating Scales
Classification is the systematic arrangement of items in groups or categories according to established criteria. The classification of mental disorders consists of specific mental disorders that are grouped into various classes on the basis of some shared characteristics. Systems of classification for psychiatric diagnoses have several purposes: (1) to distinguish one psychiatric diagnosis from another, so that the clinicians can offer the most effective treatment; (2) to provide a common language among health care professionals; and (3) 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 (APA) in collaboration with other groups of mental health professionals and the International Classification of Diseases (ICD) developed by the World Health Organization (WHO). The ICD is the official classification system used in Europe and many other parts of the world, and the DSM is the official coding system used in the United States. The DSM describes manifestations of mental disorders in terms of its associated features; age, culture, and gender-related features; prevalence, incidence, and risks; course; complications; predisposing factors; familial pattern; and differential diagnosis. It is a multiaxial system that evaluates patients along several variables and contains five axes.
Psychiatric rating scales are a variety of questionnaires, interviews, checklists, outcome assessments, and other instruments that are available to inform psychiatric practice, research, and administration. They aid clinicians by helping them confirm their diagnoses and clarify their thinking in ambiguous situations. They can also provide a baseline for follow-up of the progress of an illness over time or in response to specific interventions. Without these scales, psychiatrists are left with only their clinical impressions, which does not allow for reliable comparison.
Students should study the questions and answers below for a useful review of these topics.
Helpful Hints
The student should be able to define the terms below, especially the diagnostic categories.
atheoretical
classification
clinical syndromes
competence
descriptive approach
diagnostic criteria
differential diagnosis
disability determination
DSM-IV-TR
ego dystonic
ego syntonic
familial pattern
Global Assessment of Functioning Scale
gross social norms
highest level of functioning
ICD-10
impairment
Emil Kraepelin
Likert scale
Mini-Mental State Examination
multiaxial system
partial and full remission
predictive validity
predisposing factors
prevalence
psychosocial and environmental stressors
reality testing
residual type
severity-of-stress rating
sex ratio
Social and Occupational Functioning Assessment Scale
Structured Clinical Interview for DSM
validity and reliability
Classification in Psychiatry
Questions
Directions
Each of the questions or incomplete statements below is followed by five suggested responses or completions. Select the one that is best in each case.
9.1. Axis II of the DSM-IV-TR includes which of the following disorders?
A. Occupational problem
B. Mental retardation
C. Neoplasms
D. Depressive disorder
E. Adjustment disorders
View Answer
9.1. The answer is B
Mental retardation is defined as deficits in cognitive abilities as well as in behaviors required for social and personal sufficiency, known as adaptive functioning. Recently, the field has replaced the term mental retardation with the more precise term of intellectual instability. This disorder is found in Axis II of the DSM-IV-TR. This axis also includes personality disorders, which are defined as enduring subjective experiences and behaviors that deviate from cultural standards, are rigidly pervasive, are stable through time and lead to unhappiness and impairment.
Occupational problem is included in Axis IV, which consists of psychosocial and environmental problems. Occupational problems often arise during stressful changes in work, namely, at initial entry into the workforce or when making job changes within the same organization to a higher position. Distress occurs particularly if these changes are not sought and no preparatory training has taken place, as well as during layoffs and at retirement. This is especially true if the retirement is mandatory and the person is not prepared for this event. Neoplasms are abnormal growths and dysplastic changes in tissue in animals and plants. Neoplasms are included in Axis III, which consists of physical disorders and general medical conditions that are present in addition to a mental disorder. The physical condition may be causative, the result of a mental disorder, or unrelated to the mental disorder. Major depressive disorder and adjustment disorders are both included in Axis I, which consists of clinical disorders and other conditions that may be the focus of clinical attention. Major depressive disorder is characterized by an all-encompassing low mood accompanied by low self-esteem and loss of interest or pleasure in normally enjoyable activities. It occurs without a history of a manic, mixed, or hypomanic episode and must last at least 2 weeks. Adjustment disorders are characterized by an emotional response to a stressful event. Typically, the stressor involves financial issues, a medical illness, or a relationship problem.
9.2. Which of the following about the multiaxial diagnostic classification is true?
A. It is required for proper use of DSM-IV-TR
B. Axis I precludes disorders diagnosed in infancy, childhood, or adolescence
C. Axis II consists of personality disorders only
D. Axis III lists only the physical disorders that are causative of the patient’s mental disorder
E. Axis IV stressors are evaluated based on the clinician’s assessment of the stress that an average person with similar sociocultural values and circumstances would experience from the psychosocial stressors.
View Answer
9.2. The answer is E
Axis IV codes the psychological and environmental problems that contribute significantly to the development or exacerbation of the current disorder. The evaluation of the stressors is based on the clinician’s assessment of the stress that an average person with similar values and circumstances would experience. This judgment is based on the amount of change that the stressor causes in the person’s life, the degree to which the event is desired and under the person’s control, and the number of stressors.
The DSM-IV-TR is a multiaxial system of evaluation in which different domains of information are described on five different axes. Proper use of the DSM-IV-TR does not require the use of the multiaxial format. The DSM-IV-TR also allows clinicians who do not wish to use the multiaxial format to list the diagnoses serially, with the principal diagnosis listed first. The purpose of multiaxial evaluation is to promote a comprehensive, biopsychosocial approach toward clinical assessment. Axis I consists of clinical disorders and other conditions that may be a focus of clinical attention. It includes disorders first diagnosed in infancy, childhood, or adolescence, excluding mental retardation and personality disorders, which are coded on Axis II. 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 of, the result of, or unrelated to the mental disorder.
9.3. A 16-year-old male high school student presents to a clinic because of episodes of diaphoresis and palpitations. These episodes typically last 5 minutes and occur without warning. The patient becomes quite scared during the episodes and begins to tremble. He is very embarrassed about his “mental disorder.” The DSM-IV-TR definition of a mental disorder includes all of the following except
A. deviant behaviors that are primarily between the individual and society
B. not merely expectable responses to particular events
C. significantly increased morbidity
D. significant disability
E. significant distress
View Answer
9.3. The answer is A
Mental disorders must be considered a manifestation of a behavioral, psychological, or biological dysfunction in the individual. Neither deviant behavior nor conflicts that are primarily between the individual and society are mental disorders unless the deviance or conflict is a symptom of a dysfunction in the individual. They are conceptualized as clinically significant behavioral or psychological syndromes or patterns that occur in an individual and that are associated with present distress or disability or with a significantly increased risk of suffering death, pain, disability, or an important loss of freedom. The syndromes must not be an expectable and culturally sanctioned response to a particular event.
9.4. The differentiation of in full remission from recovered requires consideration of which factor?
A. The characteristic course of the disorder
B. The length of time since the last period of disturbance
C. The total duration of the disturbance
D. All of the above
E. None of the above
View Answer
9.4. The answer is D (all)
In full remission means that there are no longer any symptoms or signs of the disorder present, but it is still clinically relevant to note the disorder. Recovered means that the disorder would no longer be noted. The differentiation of in full remission and recovered requires consideration of many factors, including the characteristic course of the disorder, the length of time since the last period of disturbance, and the total duration of the disturbance. However, the differentiation is not absolute. According to DSM-IV-TR, even when a patient is considered “recovered,” a history of the disorder may be noted if the physician believes the information is valuable to the case.
9.5. Dementia in Alzheimer’s disease may be characterized by each of the following terms except
A. mixed type
B. atypical type
C. acute onset
D. with late onset
E. with early onset
View Answer
9.5. The answer is C
Acute onset refers to vascular dementia, not dementia in Alzheimer’s disease, which has a progressive onset. The other four types—mixed, atypical, with late onset, and with early onset—all refer to dementia in Alzheimer’s disease.
9.6. “Not otherwise specified (NOS)” categories of DSM-IV-TR may be used when
A. the cause is uncertain
B. there is an atypical presentation
C. the symptoms are below the threshold for a specific disorder
D. the symptom pattern causes significant distress but has not been included in the DSM-IV-TR classification
E. all of the above
View Answer
9.6. The answer is E (all)
Each diagnosis has a “not otherwise specified” (NOS) category. According to DSM-IV-TR, an NOS diagnosis may be appropriate either when the symptoms are below the diagnostic threshold for one of the specific disorders or when there is an atypical or mixed presentation. It is similarly applicable if the symptom pattern has not been included in the DSM-IV-TR classification but it causes clinically significant distress or impairment of functioning or the cause is uncertain.
9.7. Which of the following is an appendix diagnosis in DSM-IV-TR?
A. Minor depressive disorder
B. Caffeine withdrawal
C. Premenstrual dysphoric disorder
D. Factitious disorder by proxy
E. All of the above
View Answer
9.7. The answer is E (all)
The DSM-IV-TR contains proposed criteria for 20 specific disorders that were not included in the official classification. They are instead included in an appendix so research can be conducted on their reliability, validity, and potential clinical utility (Table 9.1). Many of these disorders are currently captured by the classification under the “not otherwise specified” (NOS) designation. For example, depressive disorder NOS can be use for minor depressive disorder or premenstrual dysphoric disorder.
9.8. In DSM-IV-TR, the severity of all the following disorders are captured by the diagnostic code except
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