Are the diagnosis,
diagnosis, and classification
really necessary in psychiatry?
psychiatry?
Classification, nosology
in psychiatry
What is „normal”
normal” or „pathological”
pathological” human
behaviour
Can the „pathological”
pathological”, the diagnosis be just
a label or stigma? (social
(social deviancy model)
model)
- / see antipsychiatry/
antipsychiatry/
Sandor Fekete
Dept.of Psychiatry,
Psychiatry, University of Pecs
http://
psychiatry.pote.hu
http://psychiatry.pote.hu
The Fundamental Purpose of Diagnosis
and Classification
The purpose of diagnosis and classification is to
isolate a group of discrete disease entities,
entities, each of
which is characterized by a distinct pathophysiology
and/
and/or etiology.
etiology. Ideally,
Ideally, all diseases in medicine
would be defined in terms of etiology.
etiology. For most
illnesses,
illnesses, however,
however, we do not know or understand
exactly the specific etiology
For most diseases,
diseases, however,
however, our understanding
is at the level of pathophysiology rather than
etiology.
etiology.
Most of the disorders or diseases diagnosed in
psychiatry are syndromes:
syndromes: collections of symptoms
that tend to occur together.
Purposes of Diagnosis in Psychiatry
Diagnosis helps to simplify our thinking and
reduce the complexity of clinical
Psychiatric diagnoses facilitate communicacommunication between clinicians.
clinicians.
Diagnoses help to predict the outcome of the
disorder
Diagnoses are often used to decide on an
appropriate treatment.
treatment.
Diagnosis are used to assist in the search for
pathophysiology and etiology
symptoms,
symptoms, outcome,
outcome, family clustering are
different in these disorders/
disorders/syndroms also
the biological background,
background, specific
responses in treatment
Diagnosis,
Diagnosis, classification in
psychiatry
Psychiatry tries consistently and
comprehensively formalize the diagnostic
processes for the disorders within its domain.
domain.
This precision and structure are particularly
important in psychiatry because it lacks
recognized etiologies for many disorders and
lack specific laboratory diagnostic tests as
well.
well.
diagnosis relies largely on the
patient’
patient’s presenting symptoms and history.
history.
Without such structure,
structure, the diagnostic
process could become confused and fuzzy.
fuzzy.
Other Purposes of Diagnosis
Diagnoses are used to monitor treatment and to
make decisions about reimbursement
Diagnoses are used by attorneys in malpractice
suits and in other litigation.
litigation.
Diagnoses
are
used
by
health
care
epidemiologists to determine the incidence
and prevalence of various diseases
throughout the world.
world.
Diagnoses are used to make decisions about
insurance coverage.
coverage.
fMRI – Anterior Cingula
Cingular Cortex
(ACC)
DSM IV APA (1994) classifies
mental disorders
DSM IV APA (1994) classifies
mental disorders
The American Psychiatric Association
has formulated a manual that summarizes
all the diagnoses used in psychiatry,
psychiatry,
specfies the symptoms that must be
present to make a given diagnosis and
organizes these diagtnosis together into a
classification system - Diagn.
Diagn. And Statist
Manual for mental Disorders (DSM)
DSMDSM-IV is largely descriptive and
atheoretical
DSMDSM-IV makes use of a novel multiaxical
system for recording diagnoses
- (characterizing patients in multiple ways
- evaluating all aspects of patient’
patient’s health
and social background
The five axes on which information should
be recorded are as follows:
follows:
Paralelly - the ICD system
international,
international, WHO supported,
supported,
rather used in Europe - ICD10
Diagnostic criteria for Dysthymic Disorder
- not multiaxial system
- more formal diagnostic categories
- list certain categories prefered by one or
another national school.
school.
- More for statistical reasons
Depressed mood - for at least 2 years - the mild,
mild,
chronic depression,
depression, low mood,
mood, anhedonia
Presence of two (or more) of the following:
following:
(1) poor appetite or overeating
(2) insomnia or hypersomnia
(3) low energy or fatigue
(4) low selfself-esteem
(5) poor concentration or making decisions
(6) feeling of hopelessness
Symptomless periods less than two months
No major depressive,
depressive, no manic episode,
episode, not other psychotic
conditions
Distress or impairment in social,
social, occupational functioning
Axis I is for the major clinical syndromes.
syndromes.
Axis II is for specific developmental
disorders (for children and adolescents and,
and,
in some cases,
cases, for adults),
adults), and personality
disorders (for adults,
adults, and occasionally for
children and adolescents).
adolescents).
Axis III is for physical disorders or
conditions that the clinican considers
potentially relevant to understanding or
management of the patient.
patient.
Axis IV,
IV, may be used to record the degree of
severity of psychosocial stressors that the
clinician considers significant in precipititating or
exacerbating,
exacerbating, the patient’
patient’s disorder.
disorder.
Axis V may be used to record the clinican’
clinican’s
judgment regarding the highest level of adaptive
functioning demonstrated by the patient during
the past year.
year.
Axis I: Clinical Disorders and Other
Conditions That May Be a Focus of
Clinical Attention
- Disorders usually first diagnosed in infancy,
infancy,
childhood,
childhood, or adolescence
- Delirium,
Delirium, dementia,
dementia, and amnestic and other
cognitive disorders
- Mental disorders due to a general medical
condition
- SubstanceSubstance-related disorders
- Schizophrenia and other psychotic disorders
- Mood disorders
- Anxiety disorders
Axis I: Clinical Disorders and Other
Conditions That May Be a Focus of
Clinical Attention
- Somatoform disorders
- Factitious disorders
- Dissociative disorders
- Sexual and gender identity disorders
- Eating disorders
- Sleep disorders
- ImpulseImpulse-control disorders not elsewhere classified
- Adjustment disorders
- Other conditions that may be a focus of clinical
attention
Personality: a repertoire of coping devices or
defenses that allows us to maintain an equilibrium
between our internal drives and the world around
us
Personality traits: results of development that
has been influenced
by culture and society
by the childchild-rearing practices of the family
by genetically determined temperamental
factors
Personality disorders : the personality traits are
inflexible and madaptive,
madaptive, causing significant
impairment in social or occupational functioning
and/orsubjective
and/orsubjective distress
Axis IV: Psychosocial and
Environmental Problems
Problems with primary support group
Problems related to the social environment
Educational problems
Occupational problems
Housing problems
Economic problems
Problems with access to health care services
Problems related to interaction with the legal
system/
system/crime
Other psychosocial and environmental problems
Axis II: Personality Disorders and
Mental Retardation
Paranoid personality disorder
Schizoid personality disorder
Schizotypal personality disorder
Antisocial personality disorder
Borderline personality disorder
Histrionic personality disorder
Narcissistic personality disorder
A
B
Avoidant personality disorder
Dependent personality disorder
C
ObsessiveObsessive-compulsive personality disorder
Mental retardation
Pathological personality
structures
NEUROTIC: integrated identity
highhigh-level defensive operations
(repression)
maintained reality testing
BORDERLINE:
identity diffusion
primitive defensive operations
maintained reality testing
PSYCHOTIC:
diffusion or lack of integration of
identity primitive defensive
operations (depersonalization)
(denial) impaired reality testing
Advantages and Disadvantages of the
DSM 28III/IV
28III/IV Approach I.
DSM IV substantially improved the reliability
of diagnosis.
diagnosis. Reliability,
Reliability, a biometric concept,
concept, refers
to the ability of two observers to agree on what they
see.
see.
The DSM IV approach has clarified the
diagnostic process and facilitated history taking.
taking.
DSM IV also clarified and facilitated the
process of differenctial diagnosis.
diagnosis.
Advantages and Disadvantages of the
DSM IV Approach II.
Comparison of BNOBNO-10 and DSMDSM-IV
criteria
BNOBNO-10
DSMDSM-IV
DSM IV may sacrifice validity for reliability.
reliability. Whereas
reliability refers to the capacity of individuals to agree on
what they see,
see, validity refers to the capacirty to make
useful predictions.
predictions.
origin
European
North American
Main purpose
Statistics
Research,
Research, clinical
In particular,
particular, the validity of a medical diagnostic system
refers to its ability to predict prognosis and outcome,
outcome,
response to treatment,
treatment, and ultimately etiology.
etiology.
axis
NonNon-multiaxial
Multiaxial
Empirical basis
moderate
Strong
categories
Not very exact
Quite clear,
clear,
some categories
are arbitrary
The increased precision sometimes gives clinicans
and researchers a false sense of certainty about what
they are doing.
doing.
BPRS - Bief Psychiatrc Rating Scale