Post on 30-Jul-2018
ClassificationClassification, , nosologynosologyinin psychiatrypsychiatry
SandorSandor FeketeFekete
Dept.ofDept.of PsychiatryPsychiatry, , UniversityUniversity ofof PecsPecs
httphttp://://psychiatry.pote.hupsychiatry.pote.hu
AreAre thethe diagnosisdiagnosis, , andand classificationclassificationreallyreally necessarynecessary inin psychiatrypsychiatry??
WhatWhat is is „„normalnormal”” oror „„pathologicalpathological”” humanhumanbehaviourbehaviour
CanCan thethe „„pathologicalpathological””, , thethe diagnosisdiagnosis be be justjusta a labellabel oror stigma? (stigma? (socialsocial deviancydeviancy modelmodel) ) -- / / seesee antipsychiatryantipsychiatry/ /
symptomssymptoms, , outcomeoutcome, , familyfamily clusteringclustering arearedifferentdifferent inin thesethese disordersdisorders//syndromssyndroms alsoalsothethe biologicalbiological backgroundbackground, , specificspecificresponsesresponses inin treatmenttreatment
The The FundamentalFundamental PurposePurpose ofof DiagnosisDiagnosisandand ClassificationClassification
The The purposepurpose ofof diagnosisdiagnosis andand classificationclassification is is totoisolateisolate a a groupgroup ofof discretediscrete diseasedisease entitiesentities, , eacheach ofofwhichwhich is is characterizedcharacterized byby a a distinctdistinct pathophysiologypathophysiologyandand//oror etiologyetiology. . IdeallyIdeally, , allall diseasesdiseases inin medicinemedicinewouldwould be be defineddefined inin termsterms ofof etiologyetiology. . ForFor most most illnessesillnesses, , howeverhowever, , wewe dodo notnot knowknow oror understandunderstandexactlyexactly thethe specificspecific etiologyetiology
ForFor most most diseasesdiseases, , howeverhowever, , ourour understandingunderstandingis is atat thethe levellevel ofof pathophysiologypathophysiology ratherrather thanthanetiologyetiology. .
Most Most ofof thethe disordersdisorders oror diseasesdiseases diagnoseddiagnosed ininpsychiatrypsychiatry areare syndromessyndromes: : collectionscollections ofof symptomssymptomsthatthat tendtend toto occuroccur togethertogether. .
DiagnosisDiagnosis, , classificationclassification ininpsychiatrypsychiatry
PsychiatryPsychiatry triestries consistentlyconsistently andandcomprehensivelycomprehensively formalizeformalize thethe diagnosticdiagnosticprocessesprocesses forfor thethe disordersdisorders withinwithin itsits domaindomain. .
ThisThis precisionprecision andand structurestructure areare particularlyparticularlyimportantimportant inin psychiatrypsychiatry becausebecause itit lackslacksrecognizedrecognized etiologiesetiologies forfor manymany disordersdisorders andandlacklack specificspecific laboratorylaboratory diagnosticdiagnostic teststests asaswellwell. .
diagnosisdiagnosis reliesrelies largelylargely onon thethepatientpatient’’ss presentingpresenting symptomssymptoms andand historyhistory..WithoutWithout suchsuch structurestructure, , thethe diagnosticdiagnosticprocessprocess couldcould becomebecome confusedconfused andand fuzzyfuzzy. .
PurposesPurposes ofof DiagnosisDiagnosis inin PsychiatryPsychiatry
DiagnosisDiagnosis helpshelps toto simplifysimplify ourour thinkingthinking andandreducereduce thethe complexitycomplexity ofof clinicalclinical
PsychiatricPsychiatric diagnosesdiagnoses facilitatefacilitate communicacommunica--tiontion betweenbetween cliniciansclinicians. .
DiagnosesDiagnoses helphelp toto predictpredict thethe outcomeoutcome ofof thethedisorderdisorder
DiagnosesDiagnoses areare oftenoften usedused toto decidedecide onon ananappropriateappropriate treatmenttreatment..
DiagnosisDiagnosis areare usedused toto assistassist inin thethe searchsearch forforpathophysiologypathophysiology andand etiologyetiology
OtherOther PurposesPurposes ofof DiagnosisDiagnosis
DiagnosesDiagnoses areare usedused toto monitor monitor treatmenttreatment andand totomakemake decisionsdecisions aboutabout reimbursementreimbursement
DiagnosesDiagnoses areare usedused byby attorneysattorneys inin malpracticemalpracticesuitssuits andand inin otherother litigationlitigation..
DiagnosesDiagnoses areare usedused byby healthhealth carecareepidemiologistsepidemiologists toto determinedetermine thethe incidenceincidenceandand prevalenceprevalence ofof variousvarious diseasesdiseasesthroughoutthroughout thethe worldworld..
DiagnosesDiagnoses areare usedused toto makemake decisionsdecisions aboutaboutinsuranceinsurance coveragecoverage..
fMRIfMRI –– AnteriorAnterior CingulCingulaarr CortexCortex(ACC)(ACC)
DSM IV APA (1994) DSM IV APA (1994) classifiesclassifiesmentalmental disordersdisorders
The The AmericanAmerican PsychiatricPsychiatric AssociationAssociationhas has formulatedformulated a a manualmanual thatthat summarizessummarizesallall thethe diagnosesdiagnoses usedused inin psychiatrypsychiatry, , specfiesspecfies thethe symptomssymptoms thatthat must be must be presentpresent toto makemake a a givengiven diagnosisdiagnosis andandorganizesorganizes thesethese diagtnosisdiagtnosis togethertogether intointo a a classificationclassification systemsystem -- DiagnDiagn. . AndAnd StatistStatistManualManual forfor mentalmental DisordersDisorders (DSM)(DSM)
DSM IV APA (1994) DSM IV APA (1994) classifiesclassifiesmentalmental disordersdisorders
DSMDSM--IV is IV is largelylargely descriptivedescriptive andandatheoreticalatheoreticalDSMDSM--IV IV makesmakes useuse ofof a a novelnovel multiaxicalmultiaxicalsystemsystem forfor recordingrecording diagnosesdiagnoses-- ((characterizingcharacterizing patientspatients inin multiplemultiple waysways-- evaluatingevaluating allall aspectsaspects ofof patientpatient’’ss healthhealth
andand socialsocial backgroundbackgroundThe The fivefive axesaxes onon whichwhich informationinformation shouldshouldbe be recordedrecorded areare asas followsfollows: :
ParalellyParalelly -- thethe ICD ICD systemsysteminternationalinternational, WHO , WHO supportedsupported, ,
ratherrather usedused inin EuropeEurope -- ICD10ICD10
-- notnot multiaxialmultiaxial systemsystem
-- more more formalformal diagnosticdiagnostic categoriescategories
-- listlist certaincertain categoriescategories preferedprefered byby oneone ororanotheranother nationalnational schoolschool. .
-- More More forfor statisticalstatistical reasonsreasons
DiagnosticDiagnostic criteriacriteria forfor DysthymicDysthymic DisorderDisorder
DepressedDepressed moodmood -- forfor atat leastleast 2 2 yearsyears -- thethe mildmild, , chronicchronic depressiondepression, , lowlow moodmood, , anhedoniaanhedoniaPresencePresence ofof twotwo ((oror more) more) ofof thethe followingfollowing::(1) (1) poorpoor appetiteappetite oror overeatingovereating(2) (2) insomniainsomnia oror hypersomniahypersomnia(3) (3) lowlow energyenergy oror fatiguefatigue(4) (4) lowlow selfself--esteemesteem(5) (5) poorpoor concentrationconcentration oror makingmaking decisionsdecisions(6) (6) feelingfeeling ofof hopelessnesshopelessness
SymptomlessSymptomless periodsperiods less less thanthan twotwo monthsmonthsNo major No major depressivedepressive, no , no manicmanic episodeepisode, , notnot otherother psychoticpsychotic
conditionsconditionsDistressDistress oror impairmentimpairment inin socialsocial, , occupationaloccupational functioningfunctioning
AxisAxis II is is forfor thethe major major clinicalclinical syndromessyndromes..
AxisAxis IIII is is forfor specificspecific developmentaldevelopmentaldisordersdisorders ((forfor childrenchildren andand adolescentsadolescents andand, , inin somesome casescases, , forfor adultsadults), ), andand personalitypersonalitydisordersdisorders ((forfor adultsadults, , andand occasionallyoccasionally forforchildrenchildren andand adolescentsadolescents). ).
AxisAxis IIIIII is is forfor physicalphysical disordersdisorders ororconditionsconditions thatthat thethe clinicanclinican considersconsiderspotentiallypotentially relevantrelevant toto understandingunderstanding orormanagementmanagement ofof thethe patientpatient..
AxisAxis IVIV, , maymay be be usedused toto recordrecord thethe degreedegree ofofseverityseverity ofof psychosocialpsychosocial stressorsstressors thatthat thetheclinicianclinician considersconsiders significantsignificant inin precipititatingprecipititating ororexacerbatingexacerbating, , thethe patientpatient’’ss disorderdisorder..
AxisAxis VV maymay be be usedused toto recordrecord thethe clinicanclinican’’ssjudgmentjudgment regardingregarding thethe highesthighest levellevel ofof adaptiveadaptivefunctioningfunctioning demonstrateddemonstrated byby thethe patientpatient duringduringthethe pastpast yearyear. .
AxisAxis I: I: ClinicalClinical DisordersDisorders andand OtherOtherConditionsConditions ThatThat MayMay Be a Be a FocusFocus ofof
ClinicalClinical AttentionAttention-- DisordersDisorders usuallyusually firstfirst diagnoseddiagnosed inin infancyinfancy, ,
childhoodchildhood, , oror adolescenceadolescence-- DeliriumDelirium, , dementiadementia, , andand amnesticamnestic andand otherother
cognitivecognitive disordersdisorders-- MentalMental disordersdisorders duedue toto a a generalgeneral medicalmedical
conditioncondition-- SubstanceSubstance--relatedrelated disordersdisorders-- SchizophreniaSchizophrenia andand otherother psychoticpsychotic disordersdisorders-- MoodMood disordersdisorders-- AnxietyAnxiety disordersdisorders
AxisAxis I: I: ClinicalClinical DisordersDisorders andand OtherOtherConditionsConditions ThatThat MayMay Be a Be a FocusFocus ofof
ClinicalClinical AttentionAttention
-- SomatoformSomatoform disordersdisorders-- FactitiousFactitious disordersdisorders-- DissociativeDissociative disordersdisorders-- SexualSexual andand gendergender identityidentity disordersdisorders-- EatingEating disordersdisorders-- SleepSleep disordersdisorders-- ImpulseImpulse--controlcontrol disordersdisorders notnot elsewhereelsewhere classifiedclassified-- AdjustmentAdjustment disordersdisorders-- OtherOther conditionsconditions thatthat maymay be a be a focusfocus ofof clinicalclinical
attentionattention
AxisAxis II: II: PersonalityPersonality DisordersDisorders andandMentalMental RetardationRetardation
ParanoidParanoid personalitypersonality disorderdisorderSchizoidSchizoid personalitypersonality disorderdisorder AASchizotypalSchizotypal personalitypersonality disorderdisorder
AntisocialAntisocial personalitypersonality disorderdisorderBorderlineBorderline personalitypersonality disorderdisorder BBHistrionicHistrionic personalitypersonality disorderdisorderNarcissisticNarcissistic personalitypersonality disorderdisorder
AvoidantAvoidant personalitypersonality disorderdisorderDependentDependent personalitypersonality disorderdisorder CCObsessiveObsessive--compulsivecompulsive personalitypersonality disorderdisorder
MentalMental retardationretardation
Personality:Personality: a repertoire of coping devices ora repertoire of coping devices ordefenses that defenses that allows allows us to us to maintain an equilibrium maintain an equilibrium between our internal drives and the world aroundbetween our internal drives and the world aroundusus
Personality traits:Personality traits: results of development thatresults of development thathas been influencedhas been influencedby culture and societyby culture and societyby the childby the child--rearing practices of the familyrearing practices of the familyby genetically determined temperamental by genetically determined temperamental
factorsfactorsPersonality disorders :Personality disorders : the the personality traits arepersonality traits are
inflexible and inflexible and madaptivemadaptive, causing significant , causing significant impairmentimpairment in social or occupational functioningin social or occupational functioningand/and/orsubjectiveorsubjective distressdistress
Pathological personality Pathological personality structuresstructures
NEUROTIC:NEUROTIC: integrated identityintegrated identityhighhigh--level defensive operations level defensive operations (repression) (repression) maintained reality testingmaintained reality testing
BORDERLINE:BORDERLINE: identity diffusionidentity diffusionprimitive defensive operations primitive defensive operations maintained reality testingmaintained reality testing
PSYCHOTIC:PSYCHOTIC: diffusion or lack of integration of diffusion or lack of integration of identityidentity primitive defensive primitive defensive operations (depersonalization) operations (depersonalization) (denial) (denial) impaired reality testingimpaired reality testing
AxisAxis IV: IV: PsychosocialPsychosocial andandEnvironmentalEnvironmental ProblemsProblems
ProblemsProblems withwith primaryprimary supportsupport groupgroupProblemsProblems relatedrelated toto thethe socialsocial environmentenvironmentEducationalEducational problemsproblemsOccupationalOccupational problemsproblemsHousingHousing problemsproblemsEconomicEconomic problemsproblemsProblemsProblems withwith accessaccess toto healthhealth carecare servicesservicesProblemsProblems relatedrelated toto interactioninteraction withwith thethe legallegal
systemsystem//crimecrimeOtherOther psychosocialpsychosocial andand environmentalenvironmental problemsproblems
AdvantagesAdvantages andand DisadvantagesDisadvantages ofof thetheDSM DSM 2828III/IV III/IV ApproachApproach I.I.
DSM IV DSM IV substantiallysubstantially improvedimproved thethe reliabilityreliabilityofof diagnosisdiagnosis. . ReliabilityReliability, a , a biometricbiometric conceptconcept, , refersreferstoto thethe abilityability ofof twotwo observersobservers toto agreeagree onon whatwhat theytheyseesee. .
The DSM IV The DSM IV approachapproach has has clarifiedclarified thethediagnosticdiagnostic processprocess andand facilitatedfacilitated historyhistory takingtaking. .
DSM IV DSM IV alsoalso clarifiedclarified andand facilitatedfacilitated thetheprocessprocess ofof differenctialdifferenctial diagnosisdiagnosis. .
AdvantagesAdvantages andand DisadvantagesDisadvantages ofof thetheDSM IV DSM IV ApproachApproach II.II.
DSM IV DSM IV maymay sacrificesacrifice validityvalidity forfor reliabilityreliability. . WhereasWhereasreliabilityreliability refersrefers toto thethe capacitycapacity ofof individualsindividuals toto agreeagree ononwhatwhat theythey seesee, , validityvalidity refersrefers toto thethe capacirtycapacirty toto makemakeusefuluseful predictionspredictions. .
InIn particularparticular, , thethe validityvalidity ofof a a medicalmedical diagnosticdiagnostic systemsystemrefersrefers toto itsits abilityability toto predictpredict prognosisprognosis andand outcomeoutcome, , responseresponse toto treatmenttreatment, , andand ultimatelyultimately etiologyetiology..
The The increasedincreased precisionprecision sometimessometimes givesgives clinicansclinicansandand researchersresearchers a a falsefalse sensesense ofof certaintycertainty aboutabout whatwhattheythey areare doingdoing. .
ComparisonComparison ofof BNOBNO--10 10 andand DSMDSM--IVIV
criteriacriteria BNOBNO--1010 DSMDSM--IVIV
originorigin EuropeanEuropean NorthNorth AmericanAmerican
MainMain purposepurpose StatisticsStatistics ResearchResearch, , clinicalclinical
axisaxis NonNon--multiaxialmultiaxial MultiaxialMultiaxial
EmpiricalEmpirical basisbasis moderatemoderate StrongStrong
categoriescategories NotNot veryvery exactexact QuiteQuite clearclear, , somesome categoriescategoriesareare arbitraryarbitrary