System of Classification:

Basic concept, DSM, ICD

Unit 1, Topic 2, Psychopathology I

Dr. Lavina Singh

 Topics Covered

Statistical Classification of Diseases

Why are classification systems required?
Major systems of Classification
ICD and ICD-10
Mental Health Code Set
DSM and DSM-5
Categorizations in DSM-5
Similarities between ICD-10 and DSM-5
Differences between ICD-10 and DSM-5
Like in any other science classification is important in the field of
psychology as well, to understand, define and separate different
categories of dysfunctional behavior.
Understanding the nature, the causes and treatments of any mental
disorders should begin with classification.
classification is also important because at the primary level
psychologists like any other professionals required a naming system
or a common vocabulary to talk about their field so that there is some
kind of systematization and organization otherwise there will be a lot
of confusion.
For example : one psychologists will be referring schizophrenia as
depression another will be referring to same symptoms as mania.
Statistical Classification of Diseases

It is a method of grouping items

scientifically according to purpose and
codifying them with numerical
identification according to certain
principles.
Purpose of Classification

Communication
Control
Comprehension
Distinction
Prognosis/prediction
Why are classification systems required ?

Classification systems are required due to the reasons mentioned below:

They help in distinguishing one psychiatric diagnosis from another so that the
clinicians can provide the most effective treatment.
Classification systems also provide a common language among the healthcare
professionals.
They also help in exploring the still unknown causes of various mental disorders.
History of Classification

William Cullen-----1772: Grouped mental disorders together apart

from delirium. According to him mental disorders were part of
broad term neuroses which he used to denote diseases which
affect the nervous system.
19th century----many French writers published classifications
Phillipe Pinel: Treatise on Insanity (published in English in 1806):
divided mental disorders into mania with delirium, mania without
delirium, melancholia, dementia and idiocy.
Jean Etienne Esquirol (1845) : added new category ‘monomania’
characterized by partial insanity.
Karl Ludwig Kahlbaum: formulated two requirements for
research on nosology: total clinical picture, its entire course
Emil Kraeplin: 1883, developed the first modern classification
system for abnormal behaviour. His categories formed the
foundation for the Diagnostic and Statistical Manual of Mental
Disorders (DSM)
Approaches to classification

Categorical Approach

Dimensional Approach

Prototypical Approach
Categorical Approach

Kraepelin---first psychiatrist to classify psychological disorders

from a biological or medical point of view.
One set of causative factors which do not overlap with other
disorders. One defining criteria which everybody in category or in
the group should meet. After a category has been defined an
object is either a member of the category or it is not.
It assumes that distinctions among members of different
categories are qualitative.
Dimensional Approach

This approach describes the objects of classification in terms of

continuous dimensions.
Variety of cognitions, moods and behaviours with which the
patient presents have been noted and quantify them on a scale.
Eg: on a scale of 1 to 10 rate your anxiety
Prototypical Approach

It identifies some essential characteristics of a disorder and it also

allows for certain non-essential variations that do not necessarily
change the classification.
With this approach classifying the disorder by different possible
features or properties any candidate must meet (but not all) of
them to fall in that category.
 Major systems of Classification

International Classification of Diseases 10th edition [ICD-10] by WHO

Diagnostic and Statistical Manual of Mental Disorders 5th edition [DSM-5] by

APA

Chinese Classification of Mental Disorders [CCMD]

Latin American Guide for Psychiatric Diagnosis

The Research Domain Criteria [RDoC] by NIMMH

International Classification of
Diseases (ICD)
The first international classification edition , known as the
International list of Causes of Death, was adopted by the International
Statistical Institute in 1893.
The ICD has been revised and published in a series of editions to
reflect advances in health and medical science over time.
WHO was entrusted with the ICD at its creation in 1948 and published
the 6th version , ICD-6 that incorporated morbidity i.e., the number of
people affected by a particular disease.
ICD is revised in every 10 years.
ICD-10 was endorsed in May 1990 by the forty-third World Health
Assembly.
Key Facts

The ICD is the global health information standard for mortality and
morbidity statistics.
ICD is increasingly used in clinical care and research to define diseases
and study disease patterns, as well as manage health care, monitor
outcomes and allocate resources.
More than 100 co untries use the system to report mortality data, a
primary indicator of health status. This system helps to monitor death
and disease rates worldwide and measure progress towards the
Millennium Development Goals.
About 70% of the world’s health expenditures (USD $ 3.5 billion) are
allocated using ICD for reimbursement and resource allocation
The ICD defines the universe of diseases, disorders, injuries and other
related health conditions. These entities are listed in a comprehensive
way so that everything is covered. It organizes information into
standard groupings of diseases, which allows for:
easy storage, retrieval and analysis of health information for
evidenced-based decision-making;
sharing and comparing health information between hospitals, regions,
settings and countries
data comparisons in the same location across different time periods.
ICD has been classified into 43 languages so we can see how widely it is
used and the WHO nomenclature requires that all the countries that are
members of the WHO to use the most current version of the classification
system that is ICD 10.
ICD allows the counting of deaths as well as diseases, injuries, symptoms,
reasons for encounter, factors that influence health status, and external
causes of disease.

Versions of ICD
ICD-6 :- it was published in 1949, was the first to be shaped to become
suitable for morbidity. Accordingly, the name changed from
International List of Causes of death to International Statistical
Classification of Diseases.
ICD-7 :- The International Conference for the seventh revision of ICD
was held in Paris under the auspices of WHO expert committee on
Health Statistics , this revision was limited to essential changes and
amendments of errors and inconsistencies.
ICD-8 :- The 8th revision conference convened by WHO met in Geneva, from 6
to 12 July 1965. the revision was more radical than the seventh but left
unchanged the basic structure of the classification and the general philosophy of
classifying diseases.

ICD-9 :- The International Conference for the Ninth Revision of the ICD ,
injuries, and causes of death convened by WHO met in Geneva from 30
September to 6 October 1975. In the discussions leading up to the conference, it
had originally been intended that there should be little change other than
updating of the classification. This was mainly because of the expense of
adapting data processing systems each time the classification was revised.

ICD-9-CM :- International Classification of Diseases, Clinical

Modification (ICD-9-CM) is an adaption created by the U.S. National
Center for Health Statistics(NCHS) and used in assigning diagnostic
and procedure codes associated with inpatient, outpatient, and physician
office utilization in the United States. The ICD-9-CM is based on the
ICD-9 but provides for additional morbidity detail. It is updated annually
on October 1.
ICD-10 :- Work on ICD-10 began in 1983, and the new revision was
endorsed by the Forty-third World Health Assembly in May 1990. The
latest version came into use in WHO Member States starting in 1994. The
classification system allows more than 155,000 different codes and
permits tracking of many new diagnoses and procedures, a significant
expansion on the 17,000 codes available in ICD-9.

ICD-10-CM :- Adoption of ICD-10-CM was slow in the United States.

Since 1979, the US had required ICD-9-CM
codes for Medicare and Medicaid claims, and most of the rest of the
American medical industry followed suit. On 1 January 1999 the ICD-10
(without clinical extensions) was adopted for reporting mortality, but
ICD-9-CM was still used for morbidity. Meanwhile, NCHS received
permission from the WHO to create a clinical modification of the ICD-10,
and has production of all these systems:
ICD-10-CM, for diagnosis codes, replaces volumes 1 and 2. Annual
updates are provided.
ICD-10-PCS, for procedure codes, replaces volume 3. Annual updates are
provided.
International Classification of Diseases
[ICD]

Represents International Statistical Classification of Diseases and Health Related

Problems.

It can be defined as a system of categories to which morbid entities are

assigned according to the established criteria.

It is used to translate the diagnoses of diseases and other health related problems
from words into alphanumerical code.
 What is ICD-10?

It is a diagnostic system given by the World Health Organization.

ICD-10 was introduced in 1993.

India adopted the same in the year 2000.

ICD-10 is available in 6 official languages – Arabic, Chinese,

English, French, Spanish, and Russian. Other than these languages
it is available in 36 other languages as well.
Contd…
 Contd…
ICD-10 has total 22 chapters.

Alphanumerical coding (A00-Z99) has been used in the 10th revision of

ICD.

ICD-10 has 3 volumes:

❑ Volume 1: Main classifications
❑ Volume 2: Instructions/ Guidance to users
❑ Volume 3: Alphabetical Index

Chapter ‘F’ [F00-F99] in the ICD-10 classifies psychiatric disorders as

Mental Health Code Set
 Diagnostic and Statistical
Manual of Mental Disorders
[DSM]
DSM is a diagnostic tool used by clinicians and psychiatrists to diagnose psychiatric
illnesses.
It was introduced in 1952.
Published by American Psychiatric Association (APA).
Covers all categories of mental health disorders in both adults as well as children.
It is non-theoretical and focuses mostly on describing symptoms as well as statistics
concerning which gender is most affected by the illness, the typical age of onset, the
effects of treatment and common treatment approaches.
Diagnostic and Statistical Manual of
Mental Disorders (DSM)
The Diagnostic and Statistical Manual of Mental Disorders (DSM)
was created in 1952 by the American Psychiatric Association so
that mental health professionals in the United States would have a
common language to use when diagnosing individuals with mental
disorders.
It covers all categories of mental health disorders for both adults
and children.
The DSM is utilized widely in the United States and in other
countries for psychiatric diagnosis, treatment and insurance
coverage purposes.
In the United States, the Diagnostic and Statistical Manual of
Mental Disorders (DSM) has been the official American
classification scheme since its beginning in 1952.
The DSM has undergone number of revision some disorders have
been removed other disorders have been added.
DSM-I:- The first DSM put forward by the APA in 1952 was
referred to as the DSM1 and the main feature of the DSM was that
it had emerged from the search in military medicine and DSM1
was mainly an effort to standardize the diagnostic procedures been
used by military personnel during the second World war .
It consisted of 106 mental disorders and was 130 pages long .
DSM was criticized for its reliability and validity.
The major limitation of the DSM was that the concept had not been
scientifically tested. Also, all of the disorders listed were considered
to be reactions to events occurring in an individual’s environment.
DSM-II:- The DSM-II was published in 1968 but still had criticism
over its validity and reliability.
Changes in the DSM-II included eleven major diagnostic categories,
with 185 total diagnoses for mental disorders.
Additionally, increased attention was given to children and
adolescents in the DSM-II.
DSM-III :- The DSM-III was published in 1980.
DSM-III introduced a multi act in which the individual would be
measured or classified on a variety of Axis so as to get a more
broad and comprehensive picture of his mental condition rather
than concentrating on single dimensions finally when the version
in the form of DSM 3 was published it was 494 pages long and had
265 diagnostic categories.
Dr. Robert L. Spitzer was appointed to lead the changes to the DSM
in 1974.
DSM-III-R :- The DSM III was revised and published as
DSM-III-R in 1987 with 297 diagnoses.
DSM-IV :- The DSM-IV was published in 1994.
This edition was more research based as far as criteria and
diagnoses are concerned. It consisted of 365 diagnoses.
DSM-IV-TR :- An updated version of DSM-IV , called the
DSM-IV-TR, was published in 2000 and contained minor text
revisions in the descriptions of each disorder.
The DSM-IV-TR described disorders using five different
dimensions. This multiaxial approach was intended to help
clinicians and psychiatrists make comprehensive evaluations of
a client's level of functioning because mental illnesses often
impact many different life areas.
Multi axial approach in DSM-IV-TR

Axis I: Clinical Syndromes

This axis described clinical symptoms that cause significant impairment. Disorders were
grouped into different categories such as mood disorders, anxiety disorders, or eating
disorders.
Axis II: Personality and Mental Retardation
This axis described long-term problems in functioning that were not considered discrete
Axis I disorders. Personality disorders cause significant problems in how a patient relates
to the world and include antisocial personality disorder and histrionic personality
disorder. Mental retardation is characterized by intellectual impairment and deficits in
other areas such as self-care and interpersonal skills.
Axis III: Medical Conditions
These included physical and medical conditions that influence
or worsen Axis 1 and Axis II disorders. Some examples include
HIV/AIDS and brain injuries.
Axis IV: Psychosocial and Environmental Problems
Any social or environmental problems that may impact Axis I or
Axis II disorders were accounted for in this axis. These include
such things as unemployment, relocation, divorce, or the death
of a loved one.
Axis V: Global Assessment of Functioning
This axis allowed the clinician to rate the client's overall level of
functioning. Based on this assessment, clinicians could better
understand how the other four axes interacted and the effect on
the individual's life.
DSM-V
The APA ( American Psychiatric Association) published DSM-V in
2013.
The DSM-5 contains a number of significant changes from the
earlier DSM-IV. The most immediately obvious change is the shift
from using Roman numerals to Arabic numbers.
Perhaps most notably, the DSM-5 eliminated the axis system,
instead listing categories of disorders along with a number of
different related disorders. Some examples of categories included in
the DSM-5 include anxiety disorders, bipolar and related disorders,
depressive disorders, feeding and eating
disorders, obsessive-compulsive and related disorders, and
personality disorders.
It was a joint effort between the American Psychiatric Association,
the National Institute of Mental Health, the World Health
Organization, and the World Psychiatric Association.
A few other changes in the DSM-5:

Asperger's disorder was removed and incorporated under the category of

autism spectrum disorders.
Disruptive mood dysregulation disorder was added, in part to decrease
over-diagnosis of childhood bipolar disorders.
Several diagnoses were officially added to the manual including binge eating
disorder, hoarding disorder, and premenstrual dysphonic disorder.

While the DSM is an important tool, only those who have received
specialized training and possess sufficient experience are qualified to
diagnose and treat mental illnesses.
Mental health professionals also use the DSM to classify patients for billing
purposes. Just as with other medical conditions, the government and many
insurance carriers require a specific diagnosis in order to approve payment for
treatment.
 What is DSM-5?
DSM-5 stands for Diagnostic and Statistical Manual for Mental Disorders
Fifth edition.

Published in 2013 by APA.

Divided in 22 chapters.

Identified with Hindu rather than Roman numerical.

Follows non-axial system of classification.

Contd…
 Contd…

Divided into 3 sections:

❑ Section 1: DSM 5 basics

❑ Section 2: Diagnostic criterion and codes
❑ Section 3: Emerging measures and models and an Appendix
 Categorization in DSM-5

Chapter 1: Neurodevelopmental Disorders

Examples: Autism Spectrum Disorder, Specific Learning Disorder, ADHD- Attention Deficit
Hyperactivity Disorder.

Chapter 2: Schizophrenic Spectrum Disorders and other Psychotic Disorders

Examples: Schizophrenia, Brief Psychotic Disorder

Chapter 3: Bipolar and other related disorders

Examples: Bipolar Disorder, Cyclothymic Disorder

Chapter 4: Depressive Disorders

Examples: Major Depressive Disorder, Persistent Depressive Disorder
 Categorization in DSM-5
Chapter 6: Obsessive and Compulsive disorders
Examples: Obsessive Compulsive Disorder, Body Dysmorphic Disorder, Hoarding Disorder.
Chapter 7: Trauma and Stress-related disorders
Examples: Post Traumatic Stress Disorder [PTSD], Acute Stress Disorder, Adjustment Disorder.
Chapter 8: Dissociative disorders
Examples: Dissociative Identity Disorder, Dissociative Amnesia.

Chapter 9: Somatic symptom disorders

Examples: Illness Anxiety Disorder, Functional Neurological Symptom Disorder.

Chapter 10: Feeding and Eating disorders

Examples: Bulimia Nervosa, Aneroxia Nervosa, Binge Eating Disorder.
 Categorization in DSM-5
Chapter 11: Elimination disorders
Examples: Enuresis [Bladder], Encopresis [Bowel].

Chapter 12: Sleep - wake disorders

Examples: Insomnia, Narcolepsy.

Chapter 13: Sexual Dysfunctions

Examples: Erectile dysfunction, Female Orgasmic Disorder, Pre- Mature Ejaculation.

Chapter 14: Gender Dysphoria

Examples: Gender Dysphoria.

Chapter 15: Disruptive, Impulse- control, conduct disorder

Examples: Kleptomania, Intermittent Explosive Disorder, Conduct Disorder.
 Categorization in DSM-5

Chapter 16: Substance-relate and addictive disorders

Examples: Substance-use disorder, Substance- induced disorder.

Chapter 17: Neurocognitive disorders

Examples: Mild neurocognitive disorder, Major neurocognitive disorder.

Chapter 18: Personality Disorders

Examples: Borderline Personality Disorder, Narcisstic Personality Disorder, Anti-Social Personality
Disorder.

Chapter 19: Paraphilic Disorders

Examples: Pedophillic Disorder, Fetishistic Disorder, Transvestic Disorder.
 Categorization in DSM-5

Chapter 20: Other Mental Disorders

Examples: Other specified mental disorders caused due to another medical condition.

Chapter 21: Medication - induced movement disorders and other adverse effects of
medicines
Examples: Tardive Dyskinesia, Medication induced postural tremor.

Chapter 22: Other conditions that may be a focus of clinical attention

Examples: Problems related to abuse, Neglect Occupational Problem.
Similarities between DSM-5 and ICD-10
Disease Classification
Both ICD and DSM provide ways to classify diseases.

Adherence to medical model

ICD and DSM are not based on empirical evidence but are consensus formulations approved by
medical experts for research purpose.

Harmonized Definitions
ICD and DSM are similar for several diagnoses.
Example: DSM-5 and ICD-10 criteria coincide in severe cases of Alcohol Use Disorder (AUD)
diagnoses, social pragmatic disorder, and its treatment.

Cross walking in coding

ICD and DSM coding systems allow cross walking between the older and the newer versions.
Differences between DSM-5 and ICD-10

Purpose of Classification
ICD-10: used for inpatient claims and classifies illnesses after diagnosis.
DSM-5: used for exclusively classifying the mental disorders.

Code criteria for Asperger’s Disorder

ICD-10: categorizes Asperger’s Disorder under Pervasive Developmental Disorder (F84.5)
DSM-5: Diagnosis for Asperger’s Disorder is included in the Autism Spectrum Disorder.

Approving Body
ICD-10: written by WHO and National Council of Health.
DSM-5: developed by APA.

Contd…
 Contd…

Distinction in Substance Abuse

ICD-10: broadly classifies substance usage, abuse, and dependence.
DSM-5: provides no explicit distinction between substance abuse and dependence.

Specificity of cross walked codes

ICD-10: consists of cross walked codes from ICD-9 that are comprehensive.
DSM-5: medical coding cross walks will not provide comprehensive coding notes
specifying code chronology.
 Differences between ICD and
DSM
ICD DSM
The ICD is produced by a global The DSM is produced by a single
health agency with a constitutional national professional association.
public health mission.
The DSM is approved by the
The ICD is approved by the World assembly of the American Psychiatric
Health Assembly, composed of the Association, a group much like APA's
health ministers of all 193 WHO Council of Representatives.
member countries.
the DSM generates a very substantial
The ICD is distributed as broadly as portion of the American Psychiatric
possible at a very low cost, with Association's revenue, not only from
substantial discounts to low-income sales of the book itself, but also from
countries, and available free on the related products and copyright
Internet permissions for books and scientific
articles
 ICD DSM
WHO's primary focus for the mental
The primary constituency of the DSM
and behavioral disorders classification
is U.S. psychiatrists.
is to help countries to reduce the
disease burden of mental disorders. With clinical significance criteria and
ICD's development is global, specificity in the description, it is
multidisciplinary and multilingual. considered to be far more accurate
Although it promptly assists in data
collection, It is considered to be less
accurate
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https://www.slideshare.net/sramragh/dsm-5-53215885

https://www.slideshare.net/ManjuPilania/icd-10-2-final

https://www.verywellmind.com/the-diagnostic-and-statistical-manual-dsm-2795758

Abnormal Psychology – Clinical Perspectives on Psychological Disorders Seventh

Edition by Susan Krauss Whitbourne and Richard P. Halgin
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