Current Psychiatric Classifications, i.e.

, DSM-5& ICD-10
Formal Diagnostic classification of mental Disorders Today,
there are two major psychiatric classification systems in use: the
International Classification of Disease (ICD-10) system,
published by the World Health Organization, and the Diagnostic
and Statistical Manual of Mental Disorders (DSM), published by
the American Psychiatric Association.
1. The ICD-10 system is widely used in Europe and many
other countries, whereas the DSM system is the standard
guide for the United States.
2. Both systems are similar in many respects, such as in using
symptoms as the focus of classification and in dividing
problems into different facets.
(Butcher, Hooley, & Susan, 2014)
1. DSM-5 was designed to correspond to the 10th revision of
ICD (ICD-10), first developed in 1992. This was done to
ensure uniform reporting of national and international
health statistics.
2. In addition, Medicare requires that billing codes for
reimbursement follow ICD.
3. All categories used in DSM-5 are found in ICD-10, but not
all ICD-10 categories are in DSM-5.
4. On October 1, 2014 all US health care providers and
systems, as recommended by the Centers Disease Control
and Prevention's National Center for Health Statistics
(CDC-NCHS) and the Centers for Medicare and Medicaid
Services (CMS), were expected to use the ICD- 10 codes
for mental disorders, the DSM-5 codes no longer being
 required for coding purposes. That date was postponed to
October 1, 2015.
(Sadock & Kaplan, 2015)
Classifying mental illness: a brief history
From the Latin term “insania” for insanity to the use of “mania”
and "melancholia" in Greek to denote a chaotic frenzy and
depression, there has been a rich vocabulary used to discuss
mental illness since ancient times. But the first attempt to
classify such afflictions was by the Greek physician Hippocrates
in 400 BC, who believed that mental illness stemmed from
imbalances of a person's black bile, yellow bile, phlegm, and
blood. Different imbalances resulted in particular symptoms
which could be split into the following categories: Mania,
Melancholy, Phrenitis (brain inflamation), Insanity,
Disobedience, Paranoia, Panic, Epilepsy, and Hysteria.
Inspired by botanical taxonomy (the classification of plants), a
French physician called François Boissier de Sauvages de
Lacroix published a system of classifying illness in 1763. This
classification included mental illnesses, subdivided into four
categories: 1) Hallucinations, 2) Morositates, 3) Deliria, and 4)
Folies Anomales. Within these categories were some familiar
symptoms including induced vomiting, mania, amnesia,
hypersexuality, panic, and insomnia. Other symptoms, like "the
uncontrollable impulse to dance" and "non-aggressive delirium
with accompanying sadness caused by the devil" are a world
away from the Western psychiatric manuals we know today.
The 19th century saw more attempts to classify mental illness.
In Germany, Karl Kahlbaum published his 'Classification of
Psychiatric Diseases and Mental Disturbances' (1863), positing a
system which classified mental illnesses by their symptoms.
Rejecting the tradition of labelling a symptom as a particular
illness, he conceptualised psychiatric diagnoses as clusters of
symptoms: mania as a symptom of a disorder instead of a
disorder in itself. Kahlbaum employed many terms that we still
use today including Dysthymia, Cyclothymia, Catatonia,
Paranoia, and Hebephrenia. Inheriting Kahlbaum's ideas, Emil
Kraeplin, in the late 19th and early 20th century, proposed a
system in which a disorder was defined not only by the
symptoms that constitute it, but also by the patterns and course
in which it presents. Famously, he differentiated between
Psychotic Disorders and Affective Disorders, providing the
foundations for what we now refer to as Schizophrenia and
Bipolar Disorder.
Today, the two most widely established systems of psychiatric
classification are the Diagnostic and Statistical Manuel of
Mental Disorders (DSM) and the International Classification for
Diseases (ICD). Despite each being as widely used as the other,
the ICD and the DSM conceptualise and classify mental
disorders in different ways.
What is the Diagnostic and Statistical Manual of Mental
Disorders (DSM)?
The DSM is published by the American Psychiatric Association,
America's main professional organisation of psychiatrists. It is
the world's largest psychiatric organisation, with upwards of
38,500 members in over 100 countries. Given that the DSM only
includes Mental Disorders, it is used primarily by Psychiatrists
but also by other mental health professionals. The beginnings of
the DSM arose before the APA went by its current name, then
called the Committee on Statistics of the American Medico-
Psychological Association. In 1917, it published the 'Statistical
Manual for the Use of Institutions for the Insane' which outlines
the symptoms of 21 disorders. All the disorders were, bar two,
psychotic in nature.
Reformulated as the DSM, the first edition was released in 1952
and contained 128 categories. It differentiated between organic
brain syndromes and functional (physically undetectable)
disorders. Functional disorders were further divided into
Psychotic Disorders, Neurotic Disorders (distress without
psychosis), and Personality Disorders. Descriptions were short,
leaving it up to the diagnosing clinician's discretion to interpret
meaning, focusing on the cause of disorders rather than their
symptoms. In this way, the manual honoured the psychodynamic
tradition. Whilst the first DSM- seemed to be aimed at
diagnosing patients in psychiatric hospitals, the DSM-2 (1968)
was thought to have more relevance to outpatients. The sections
on Depressive Disorders, Anxiety Disorders, and Personality
Disorders were expanded in this edition, and disorders specific
to children and adolescents - as well as a miscellaneous category
- were introduced. The seventh printing of DSM-2 saw
homosexuality depathologised, reflecting a departure from
mental illness as being a deviation from accepted social values.
The DSM-3 marked a paradigm shift: a move away from vague
descriptions mostly concerned with a disorder's origin, instead
embracing the clinical specificity of diagnostic criteria. With the
DSM-3 (1980) came the introduction of the multi-axial system.
The multi-axial system meant that a patient would be diagnosed
through information concerning fives separate axes: (I) clinical
disorders such as Psychotic Disorders, Mood Disorders, or
Anxiety Disorders, (II) Personality Disorders and
Developmental Delays, (III) physiological medical disorders
that have relevance to the patient's psychiatric presentation in
terms of affecting functioning or mood, or impacting medication
choices, (IV) psychosocial stressors in the patient’s
environment, (V) assessment of the patient’s general ability to
function. The practice of adding "not otherwise specified" onto
the category name of disorder was first seen in this manual,
meant as a way to indicate when a patient met many of the
diagnostic criteria without this being sufficient to obtain the
particular diagnosis. DSM-3 was revised seven years after its
initial publication and the DSM-3-R was released, changing
diagnostic criteria to reflect the newest research. The
reformulation also did away with exclusion criteria, leaving
behind a hierarchical structure and simplifying the task of
diagnosis.
Published in 1994, the DSM-4 built upon the clinical research
generated for its predecessor, with most diagnoses being
grounded in at least some research. Using a symptom-based
method of classification meant the manual grew considerably in
length. Field trials for it recruited participants from a variety of
ethnic and cultural backgrounds, demonstrating a new-found
concern for cross-cultural validity. In the same vein, culture-
specific disorders were included. DSM-4 was revised in 2000,
with corrections made to factual errors and research updated to
reflect that which was most recently published.
The DSM-5, published in 2013, is the most up-to-date manual.
Like the DSM-4, it is based upon the work of expert study
groups and makes use of large sets of data. Notably, the multi-
axial system was abandoned; the axes I, II, and III were
amalgamated to form Psychiatric and Medical Diagnoses;
psychosocial considerations were incorporated into the
descriptions of the disorders; and Axis V, the assessment of
general functioning, was dropped due to "conceptual lack of
clarity"(APA, 2013). Changes in the DSM-5 include the
diagnosis of Autism Spectrum Disorder subsuming what were
previously separate disorders and the inclusion of gender
dysphoria. DSM-5 also seeks to order categories of disorders in
a way that reflects aetiological similarity. For example, Trauma-
and Stressor-Related Disorders fall next to Dissociative
Disorders, acknowledging that all Dissociative Disorders but
one are necessarily traumagenic. Anxiety Disorders precede
Obsessive-Compulsive and Related Disorders, reflecting current
research which posits their similarity but also meaningful
distinction. The DSM-5 is a polythetic system in that lists of
symptoms are given and diagnostic labels are assigned to
patients based upon whether the specified symptoms - or
sometimes number of symptoms - are met.
What is the International Classification for Diseases (ICD)?
The other dominant diagnostic manual is the ICD. Born from the
'International List of Causes of Death', adopted in 1893 by the
International Statistical Institute, the ICD is used to compile
morbidity and mortality statistics. The 'International List of
Causes of Death' was revised five times since initial publication,
with the sixth version being rebranded as the ICD in 1948. The
ICD is created by the World Health Organisation (WHO), an
agency of the United Nations that is concerned with worldwide
public health. Translated into 43 languages, the ICD is used in
over 100 countries. Whilst the DSM is concerned only with
psychiatric disorders, the ICD includes all health disorders so is
utilised by a variety of medical professionals.
The ICD-6 was different to its predecessors in that it chronicled
not just mortality, but also morbidity. It included a chapter titled
Mental, Psychoneurotic, and Personality Disorders which
included three sections: Psychoses, Psychoneurotic Disorders,
and Disorders of Character, Behavior, and Intelligence. Across
these sections were 26 categories, each containing multiple
diagnoses. For example, within the Psychoses section was
Schizophrenic disorders (dementia praecox), which contained
the subcategories Simple type, Hebephrenic type, Catatonic
type, Paranoid type, Acute schizophrenic reaction, Latent
Schizophrenia, Schizo-Affective Psychosis, and
Other/Unspecified. These subcategories contained the diagnoses
themselves; the Simple type category contained Schizophrenia
and Dementia, in both simple and primary forms. There were no
descriptions accompany the diagnoses, just identifying numbers.
Apart from amendments of errors, no changes were made from
the ICD-6 to the ICD-7. In 1968, the ICD-8 came into effect.
The ICD-8 retained the psychoses section of ICD-7 but grouped
Neuroses, Personality Disorders, and other Nonpsychotic mental
disorders together, moving what was known as Mental
Retardation to its own section. The WHO published a glossary
of terms in 1974, designed to elucidate a greater understanding
of diagnostic categories given that the ICD-8 still lacked
descriptions. "It has become increasingly obvious that many key
psychiatric terms are acquiring different meanings in different
countries", reads the glossary, highlighting the need for
standardisation. The glossary took a descriptive, symptom-based
approach, and the ICD-9 (1979) incorporated much of it. The
ICD-9-CM was created by the U.S. National Centre for Health
Statistics, based on the ICD-9 but with additional morbidity
details. CM stands for Clinical Modification, and this adaptation
was created specifically for use in the American healthcare
system.
Since 1994, the ICD-10 has been in use, and is perhaps the most
radical change between versions of the manual yet. Like the
previous version, it has a clinically modified version for use in
America. The ICD-10 departs from the traditional division
between neurosis and psychosis that the ICD-9 recognised.
Instead, disorders are arranged in groups by likeness. For
example, Cyclothymia is no longer under the category of
Personality and Behavioural Disorders, it is now in Mood
(Affective) Disorders, reflecting our current understanding of
the disorder. In the ICD-10, the WHO attribute the greater detail
relating to Behavioural Syndromes and Mental Disorders
Associated with Physiological Dysfunction and Hormonal
Changes to the increasing use of liaison psychiatry. Mental and
Behavioural Disorders relating to substance use are rearranged,
now detailing both the substance used and what characterises the
coexisting syndrome. Schizophrenia, Schizotypal, and
Delusional Disorders have been expanded to include
Undifferentiated Schizophrenia, Post-Schizophrenic Depression,
and Schizotypal Disorder. A new subcategory of Disorders of
Adult Personality and Behaviour is in the ICD-10; it concerns
exaggeration or total fabrication of symptoms, either
psychological or physical. Developmental Disorders, such as
Autism, are classified as Pervasive Developmental Disorders in
the ICD-10 whereas the previous manual saw them labelled as
Psychoses.
The ICD-11 is set to come into effect in 2022. There are many
changes to the latest update, available online, with additional
diagnostic codes offering a greater level of specificity. Being
transgender will no longer be considered a mental disorder: a
change that reflects a contemporary understanding of gender
identity. Gaming Disorder will now be a diagnosable condition,
with the NHS already commencing specialised treatment for it,
as will Attention-Deficit Hyperactivity Disorder (ADHD). What
used to be known as "Enduring Personality Change After
Catastrophic Event" is going to be reformulated as Complex
Post-Traumatic Stress Disorder (CPTSD), and a Prolonged Grief
Disorder will be added. Perhaps the biggest shakeup is with
regards to Personality Disorders; someone will be diagnosed
with a primary personality dysfunction, with a signifier of
severity, along with any additional traits. The ICD-11 does not
provide operational criteria for disorders, but rather descriptions.