DSM IV
CLASSIFICATION
SYSTEM
PRESENTED BYMrs.Shalini Chhabra, Sr.Lecturer
Department Of Psychology
DAV College For Girls, Yamunanagar
Classification is important in any science whether we are
studying plants, planets and people. With an agreed upon
classification system we can be confident that we are
communicating clearly. If someone says to you “ I saw a coolie
running down the street, you probably have an accurate idea of
what the coolie looked like- not from seeing it but rather from
your knowledge of classification.
In Psychopathology class involves
the description of various types of categories of maladaptive
behaviour. Classification is necessarily first step towards
introducing some order into our discussion of the nature,
causes and treatment of such behaviour. It enables
communication about particular cluster of behaviour in agreed
upon and meaningful way e.g. we can not conduct research on
background of causal factor in a given disorder unless with
more or less clear definition of behaviour under examination.
•FEATURES OF AN IDEAL CLASSIFICATION:-
Granting that all classification system are fundamentally
arbitrary, some of them are much better than other in
helping us organize and discuss our observations. We take a
classification system’s usefulness on its four main features
1.Reliability:- Reliability is the degree to which a test or
measuring device produces the same result each time it is
used to measure the same thing.In the case of classification
it is a measure of extent to which different observer can
agree that a behaviour “fits”a given diagnosis category.
2.Validity:- Validity refers to the extent to which a
measuring instrument actually measures what it claims to
measure. In the case of classification validity is determined
by whether the diagnostic category tells us something
important or basic about the disorder.
3.Classification system should be more or less permanent.
4.In the classification system, there should be the
4. In the classification system, there should be the
characteristics of homogeneity in one group of disorder and
characteristics of heterogeneity between two group of
disorder.
• NEED FOR CLASSIFICATION:1. Such systems provide a language with which all mental
health professional can communicate. It enables efficient
communications e.g. instead of telling all the symptoms of
depression, one is able to say only depression to name a
particular type of mental disorder.
2. In order to study the natural history of a particular
disorder and develop an effective treatment it is necessary
to define the characteristics of disorder and have an
understanding of how it is different from other similar
disorders to the extent that relationship between diagnosis
and treatment has been established for a particular
category. The proper diagnosis of a person’s condition can
indicate the most effective treatment.
3. The ultimate purpose of classification is to develop an
understanding of the causes of the various mental disorders.
Knowing the causes of the disorder usually leads to the
development of an effective treatment.
•DSM CLASSIFICATION OF MENTAL DISORDERS:History of classification goes back to Hippocrates who
classified the mental disorder on the basis of biles. According
to him there are three biles in the body. Red, yellow and black.
Biles are some enzymes in the body. Red bile is responsible for
aggression, yellow for peace and black for severe depression.
Official classification of mental disorders first came into the
United in 1840. This trend continued in the United States and
now a days the most widely used classification scheme in
mental disorders in U.S. is Diagnostic and Statistical Manual
of Mental Disorders (DSM). There also exists a world wide
classification system called ICD which is called a International
Classification of Diseases, which cover all disorders and
diseases. Both the Psychiatric Association (APA) and World
Health Organization (WHO) have worked closely over the
years to ensure compatibility between the classification
systems.
APA first published DSM I in 1952, DSM II in 1968,
DSM III in 1980, DSM III R in 1987 and DSM IV in 1994.
DSM IV
DSM IV is developed mainly for the purpose for treatment,
research and education. This diagnosis manual is constructed
and documented on the basis of systematic and explicit
process. More than any other nomenclature of mental
disorders, DSM IV is grounded in empirical evidence.
In DSM IV each of the mental disorders is
conceptualized as a clinically significant behavioural or
psychological syndrome or pattern that occurs in an individual
and that is associated with present distress or disability or
with a significantly increased risk of suffering death, pain,
disability or an important loss of freedom. In addition, this
syndrome a pattern must not be merely an expectable and
culturally sanctioned response to a particular event e.g. the
death of loved one. Whatever its original cause, it must
currently be considered a manifestation of a behavioural,
psychological or biological dysfunction in the individual.
Neither deviant behaviour (e.g. political, religious or sexual)
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 as described
above.
Multi-axial Assessment:A multi axial system involves an assessment on several axes,
each of which refers to a different domain of information
that may help the clinician plan treatment & predict outcome.
There are five axes included in the DSM IV multi axial
classification:Axis I : Clinical Disorders
Other Conditions that may be a focus of clinical
attention.
Axis II : Personality Disorders and
Mental Retardation
Axis III: General Medical Conditions
Axis IV : Psycho-social and Environmental Problems.
Axis V
: Global Assessment of Functioning
AXIS I:-Axis I is for reporting all the various disorders or
conditions in the classification except for the Personality
Disorders and Mental Retardation (which are reported on Axis
II). Also reported on Axis I are other conditions that may be
a focus of clinical attention.
When an individual has more than one Axis I disorder
all of these should be reported. The principal diagnosis or the
reason for visit should be indicated by listing it first. When an
individual has both an Axis I and an Axis II disorder, the
principal diagnosis or the reason for visit will be assumed to be
on Axis I unless the Axis II diagnosis is followed by the
qualifying phrase (Principal Diagnosis) or (Reason for Visit).
If no Axis I disorder is present, this should be coded
as V 71.09. If an Axis I diagnosis is deferred, pending the
gathering of additional informational, this should be coded as
799.9
AXIS I
Clinical Disorder
Other conditions that may be a focus of Clinical Attention
1. Disorders usually first diagnosed in Infancy Childhood or
Adolescence (excluding Mental Retardation, which is
diagnosed on Axis II)
2. Delirium (disordered state of mind), Dementia (incoherent
speech), Amnesic and other cognitive disorders
3. Mental Disorders due to a General Medical condition
4. Substance related disorders
5. Schizophrenia and other Psychotic Disorders
6. Mood disorders
7. Anxiety disorders
8. Somatoform disorders
9. Factitious disorders
10.Dissociative disorders
11. Sexual and Gender Identity disorders
12. Eating disorders
13. Sleep disorders
14. Impulse control disorders (not elsewhere classified)
15. Adjustment disorders
16. Other conditions that may be a focus of clinical attention
AXIS II: Axis II is for reporting Personality Disorders and
Mental Retardation. It may also be used for noting prominent
maladaptive personality features and defense mechanisms.
The listing of Personality Disorders and Mental Retardation on
a separate axis ensures that consideration will be given to the
possible presence of Personality Disorders and Mental
Retardation that might otherwise be overlooked when
attention is directed to the usually more florid Axis I
disorders.
If an individual has more than one Axis II diagnosis then all
are reported. When an individual has both Axis I and an
Axis II diagnosis and Axis II is the principal diagnosis or
the reason for the visit, then this is indicated by adding the
qualifying phrase,” (Principal Diagnosis” or “Reason for visit”
after the Axis II diagnosis). If no Axis II disorder is
present, then it is coded as V 71.09. If an Axis II diagnosis
is deferred, pending the gathering of additional information,
then it is coded as 799.9.
AXIS II
Personality Disorders
Mental Retardation
1. Paranoid Personality Disorder
2. Schizoid Personality Disorder
3. Schizotypal Personality Disorder
4. Anti social Personality Disorder
5. Border line Personality Disorder
6. Histrionic Personality Disorder
7. Narcissistic Personality Disorder
8. Avoidant Personality Disorder
9. Dependant Personality Disorder
10. Obsessive Compulsive Personality Disorder
11. Personality Disorder (not otherwise specified)
12. Mental Retardation
AXIS III: Axis III is for reporting current general medical
conditions that are potentially relevant to the understanding
or management of the individual mental disorder.
When an individual has more than one clinically relevant
Axis III diagnosis, all are reported. If no Axis III disorder is
present, then that is indicated by the notation “Axis III:
None”. If an Axis III diagnosis is deferred, pending the
gathering of additional information then this is indicated by
the notation “Axis III-deferred”.
AXIS III
General Medical Conditions (with 1CD-9-CM codes)
1. Infectious and Parasitic Diseases
2. Neoplasm (growth of tissues in any part of body or tumor)
3. Endocrine, Nutritional and Metabolic Diseases and Immunity
Disorders
4. Diseases of Blood and Blood forming organs
5. Diseases of nervous system and sense organs
6. Diseases of circulatory system
7. Diseases of respiratory system
8.Diseases of digestive system
9. Diseases of genitourinary system
10. Complications of pregnancy, child birth and puerperium
(fever due to child birth)
11. Diseases of the skin and subcutaneous tissue
12. Diseases of musculoskeletal system and connective tissue
13. Congenital Anomalies
14. Certain conditions originating in the Prenatal period
15. Symptoms, Signs and ill-defined conditions
16. Injury and Poisoning
AXIS IV: Axis IV is for reporting psycho-social and
environmental problems that may effect the diagnosis,
treatment and prognosis of mental disorders. A psychosocial
or environmental problem may be a negative life event, and
environmental difficulty or deficiency, a family related or
other interpersonal stress, an inadequacy of social support or
personal resources or problem relating to the context in which
a person’s difficulties have developed. So called positive
stressors, such as job promotion should be listed only if they
constitute or lead to problem e.g. when a person has difficulty
adapting to the new situation.
When an individual has multiple psychosocial or
environmental problems in general the clinician note only those
problems that have been present during the year preceding
the current evaluation.
AXIS IV
Psychosocial and Environmental Problems
1. Problems with primary support group
2. Problems related to the social environment
3. Educational Problems
4. Occupational Problems
5. Housing Problems
6. Economic Problems
7. Problems with access to health care services
8. Problems related to interaction with the legal system/ crime
9. Other psycho social and environmental problems
AXIS V: Axis V is reporting the clinician judgment of the
individual’s overall level of functioning. This information is
useful in planning treatment and measuring its impact and in
predicting outcome.
This reporting is done using the Global Assessment of
Functioning (GAF) scale. The GAF scale reading is done only
with respect to psychological, social and occupational
functioning. The rating is not done with respect impairment in
functioning due to the physical or environmental limitations. In
most instances, rating on the GAF scale is done for the
current period as it will help in determining the need for
treatment or care. In some settings, GAF rating is done both
at time of admission and at the time of discharge. In some
instances GAF scale may also be rated for other periods e.g.
the highest level of functioning for at least a few months
during the past year.
AXIS V
Consider psychological, social and occupational functioning on a
hypothetical continum of mental health-illness. Do not include
impairment in functioning due to physical or environmental
limitations.
Code
100
Superior functioning in a wide range of activities. Life’s
problems never seem to get out of hand, is sought by
others because of his or her many positive qualities.
91
No symptoms.
90
Absent or minimal symptoms. Good functioning in all
areas. Interested and involved in a wide range of
activities, socially effective, generally satisfied with
81
life, no more everyday problems or concerns.
80
If symptoms are present, they are transient and
expectable reactions to psychosocial stressors; no
more than slight impairment in social, occupational
71
or social functioning.
70
Some mild symptoms or some difficulties in social,
occupational or school functioning but generally
functioning pretty well, has some meaningful inter61
-personal relationship.
60
Moderate symptoms or moderate difficulties in
51
social, occupational or school functioning.
50
Serious symptoms or any serious impairment in
41
social, occupational or school functioning.
40
Some impairment in reality testing or communication
or major impairment in several areas, such as work
or school, family relations, judgments thinking or
31
mood.
30
Behaviour is considerably influenced by delusions or
hallucination or serious impairment in communication
or judgment or inability to function in almost all
21
areas.
20
Some danger of hurting self or others or occasionally
fails to maintain minimal personal hygiene or gross
11
impairment in communication.
10
Persistent danger of severely hurting self or others
or persistent inability to maintain minimal personal
hygiene or serious suicidal act with clear expectation
1
of death.
0
Inadequate information.
• Examples of DSM IV Multi-axial Evaluation
Axis I
296.23
Major Depressive Disorder, Single Episode,
Severe without Psychotic Features.
Axis II
305.00
Alcohol Abuse
301.6
Dependent Personality Disorder Frequent
use of Denial
Axis III
None
Axis IV
Threat of job loss
Axis V
GAF = 35 (current)
Evaluation of DSM IV:
1. There are changes in multi-axial system. The childhood and
developmental disorders which were on Axis II in DSM III-R
are shifted to Axis I in DSM IV.
2. In DSM III-R, Axis IV was for the assessment of severity
of psychological stressors. But in DSM IV it is now for the
assessment for psychosocial and environmental problems.
3. Axis V is same as in DSM III-R except the scale points
have been extended from 90 to 100.
4. Some criteria's of mental disorders have been modified
such as the criteria for mental retardation has been modified
by including the diagnosis of deficiency of skills.
5. Learning disorders have been introduced in place of
academic skill disorders in DSM-III-R.
6. Communication disorders introduced in place of speech
disorders in DSM-III-R.
7. Some new disorders have been introduced e.g. feeding
disorder, delirium, dementia due to multiple causes, catatonic
disorders due to general medical conditions etc. DSM-III-R
disorders deleted from DSM IV are over anxious disorder of
childhood, avoidant disorder of childhood, undifferentiated
attention deficit disorder, passive aggressive personality
disorders.
CRITICISM:
1. After so much improvement in DSM IV. Some psychologists
shall talk about and doubts regarding the reliability and
validity of DSM IV.
2. Some of the psychologists has pointed out that in DSM IV
no attention is given to the history and developmental problem
of the patient.
3. In DSM IV sometimes the clinicians has to use his
impressionistic clinical judgment regarding the client e.g. when
a clinician has to decide the severity of particular disorder he
has to depend on his own judgment.
4. Some of the criticism focus on the fact that with the DSM
classification it is easy to define them in broad category but it
is very difficult to go in minute details of particular disorder
such sub categories are not mentioned in DSM IV.
5. In DSM IV little importance has been attained to the cause
of mental disorders.
6. In DSM classification the clinician has to apply multi-axial
System on every patient. It is really very torturous,
cumbersome and time consuming.
7. When we apply DSM IV on a particular patient sometimes
the symptoms and the criteria do not fit exactly on the
patient e.g. if in a particular disorder there are four important
symptoms but a patient is showing or exhibiting only three out
of them then the doubt arises i.e. whether to put that
particular patient in that category or not.
8. In DSM IV there is no provision of putting two disorders
together e.g. in day to day life it has been observed that
anxiety and depression sometimes they occur together, but in
DSM IV there is no such category which is known by the name
of Mixed Anxiety Depression disorder but in reality such
conditions occur and then the clinician is in the state of
uncertainty.