Classification of Mental Disorders & Multi-Axial Assessment (DSM IV-TR & ICD 10)

Classification of Mental Disorders &

Multi-Axial Assessment

(DSM IV-TR & ICD 10)

Diagnosis involves accumulation, interpretation & categorization of data. The main aim of this is to enable the clinician to use the most effective treatments available for that condition and to allow them to make accurate assessment of prognosis.

The Importance of diagnosis:

• Allows inter-professional communication
• Allows us to select appropriate treatments for patients
• Allows assessment of prognosis
• Allows scientific research to be preformed

However psychiatric diagnoses have been criticized because:

• They provide little information about aetiology
• They can carry pejorative connotation (negative labeling)
• Patients don't always fall into neat categories. Some may have some but not all of the characteristic features of one or more different diagnostic categories (hence the terms schizoaffective & borderline personality)
• The uniqueness of an individual patient is lost when labels are applied; one cannot fully convey a patient's predicament with a single label
• Historically psychiatric diagnosis has low reliability & Validity (in general psychotic conditions have high reliability and neurotic  conditions low reliability)

Both current diagnosis in psychiatry are categorical and can be monothetic (i.e. all criteria must be present e.g. Hypochodriasis) or Polythetic (some must be present e.g. Borderline personality disorders).

The International Classification of Diseases (ICD-10) 1992

Mental disorders are described within chapter V (F) of the ICD 10. There are 10 categories within this chapter & each is further subdivided into further 10.

Categories are denoted by the letter F (for mental disorders chapter), followed by a number for the main group (e.g. F3 for Mood Disorders), followed by a further number for the category within the group (e.g. F32 for depressive episode). A fourth character (or third no) is used if it is necessary to subdivide further (e.g. F32.2 for severe depressive episode without psychotic symptoms)

In Schizophrenia, a fifth character is used to specify the course of the disorder (e.g. F20.01 for paranoid schizophrenia, episodic with progressive deficit).

Different versions of the ICD 10 are available & it is therefore flexible and acceptable to a variety of users for a variety of purposes:

1. Clinical descriptions & diagnostic guidelines: for general clinical, educational & service use.

2. Diagnostic criteria for research

3. Primary care version.

4. Multiaxial version.

Main categories in ICD-10

F0  Organic, including symptomatic, mental disorders (e.g. dementia)

F1 Mental & behavioral disorders due to psychoactive substance use

F2 Schizophrenia, schizotypal & delusional disorders

F3 Mood (affective) disorder

F4 Neurotic, stress related & somatoform disorders (anxiety disorders, OCD)

F5 Behavioral syndromes associated with physiological disturbance & physical factors (e.g. eating disorders, sexual dysfunction)

F6 Disorders of adult personality & behavior (personality disorders and gender identity sexual preference.

F7 Mental retardation

F8 Disorders of psychological development (language and speech disorders)

F9 Behavioral & emotional disorders with onset usually occurring in childhood or adolescence (e.g. conduct disorders and hyperactivity)

Diagnostic & Statistical Manual of mental disorder (DSM) IV-TR (revised):

Published by the American Psychiatric Association (APA), it is a multi-axial classification. An assessment on several axes, each of which refers to a different domain of information that may help the clinician plan treatment & predict outcome:

• Provide more information about the patient than does a single category
• Facilitate comprehensive & systemic evaluation
• Provide a format for organizing & communicating clinical information & for reflecting the complexity of clinical situations
• Promotes the application of the biopsychosocial model

However, multiaxial system increase the time involved in making the diagnosis, are therefore not easy to apply in everyday clinical practice. Axes IV & V offer rather crude measurement of dubious reliability & validity.

Axis I  Clinical Disorders (may be >1)

Axis II  Personality disorder, Mental retardation

Axis III  General Medical Condition (potentially relevant to the mental disorder)

Axis IV  Psychosocial & Environmental Problems (which may affect the diagnosis, treatment or prognosis of the mental disorder)

Axis V  Global Assessment of Functioning (GAF): Psychological, social & occupational functioning on a hypothetical continuum of mental health-illness, on a scale 0-100.

State whether GAF is for the current period, at discharge or admission. Exclude impairment due to physical or environmental limitations.

References:

1. Stevens L, Rodin I, Psychiatry: An illustrated colour text, Churchill Livingstone 2001

2. Steple D. Oxford Handbook of Psychiatry, Oxford University Press, 2006

3. World Health Organisation (WHO): ICD10 Classification of Mental and Behavioural Disorders (1992)

4. American Psychiatric Association. The Diagnostic and statistical Manual of Mental Disorders (DSM-IV).1994