Classification

In our daily lives we come across a lot of information in the form of objects,
elements, concepts, living beings etc. It is amazing that we can deal with so much
information. We do so by putting information into classes or categories based on
our observations of shared characteristics, for example, all four-legged creatures
are categorized as animals. Classification can be defined as making generalizations
based on our observations. Classification is a necessary step for making sense of
information in all formal fields of knowledge, such as sciences, literature etc. Just
like other fields of knowledge, abnormal psychology also makes use of
classification to deal with information about the various disorders, their causes and
treatments.

Carson, Butcher, and Mineka (2007) have defined classification in abnormal

psychology as an attempt to delineate meaningful sub varieties of maladaptive
behavior. While diagnosis is assigning an individual to a category of a disorder
(e.g., phobia, depression etc.) based on symptoms, classification is assigning all the
possible categories to a system that will form the basis for diagnosis.

Need for classification in abnormal psychology (Carson, Butcher, & Mineka,

2007)
It differentiates among various types or categories of maladaptive behavior;
It brings order to the nature, causes, and treatment of such behavior;
It helps in meaningful communication about behavior (normal and abnormal);
It provides the basis for epidemiological data such as incidence and prevalence
of various disorders.
It provides basis for the formal diagnosis which is especially required by the socio-
legal system, e.g., insurance claims, court of law;
It also helps in identification of new type of disorders which require new treatment
techniques.
Methods of Classification:
1) Classical Categorical, 2) Dimensional and 3) Prototypical

Classical Categorical Approach: originated in the work of Emil Kraepelin (1856-

1926) and the biological tradition in the study of psychopathology. According to
Butcher, Mineka, Hooley, and Dwivedi (2016), classical approach assumes the
following:
a) All human behavior can be divided into the categories of healthy and disordered;
b) Disorders are divided into discreet and non-overlapping classes;
c) Only one set of causal factors per disorder exist;
d) There is only one set of defining criteria for each disorder, which must be met
for making a formal diagnosis.

Criticism: Psychological disorders are complex because psychological and social

factors interact with the biological factors to produce a disorder; hence the mental
health field has not adopted a classical categorical model (Frances & Widiger,
1986).

Dimensional Approach: as opposed to the classical categorical approach, the

dimensional approach assumes that:

a) A person’s behavior is defined in terms of different strengths along several

dimensions, for example, emotional stability, mood, aggression etc. which can be
rated on a Likert type of scale. Thus, a person’s behavior can be defined on a scale
of 0 to 10, as mildly anxious (2), moderately depressed (5), and mildly aggressive
(2);

b) Same dimensions are to be used for defining behavior of everyone;

c) Difference in behavior would be based on the ratings on the established

dimensions that may range from low to high.
Criticism: theorists have not reached a consensus on the number of dimensions that
can be used to define human behavior as some agree on one dimension while
others identify more than thirty-three dimensions (Millon, 1991).

Prototypical Approach: It combines both categorical and dimensional approaches.

A prototype is a conceptual entity depicting an idealized combination of
characteristics that more or less regularly occur together in a less than perfect or
standard way at the level of actual observation (Butcher, Mineka, Hooley, &
Dwivedi, 2016). According to this approach, certain essential characteristics are
required to classify an entity, however, there are some nonessential characteristics
also that do not change the classification.

Criticism: the categories of disorders are not clearly defined as some symptoms are
shared by more than disorder. However, it has become the most favored approach
as it is user friendly and enlists many different features of the disorder, out of
which not all but some are required for the formal diagnosis.

How did we reach to the present system of classification?

Kring, Johnson, Davison, and Neale (2012) have enlisted the following efforts at
classification:
1882, UK: Statistical Committee of the Royal Medico-Psychological Association
produced a classification system. Revised several times but was never adopted by
its members.
1889, Paris: Congress of Mental Science adopted a single classification- but was
never widely used.
1886, USA: Association of Medical Superintendents of American Institutions for
the Insane (a forerunner of American Psychiatric Association, APA) adopted a
revised British system.
1913, USA: APA accepted a new classification and incorporated some of
Kraepelin’s ideas but it lacked in consistency.
Development of WHO and DSM Systems
1939, WHO: added mental disorders to the International list of Causes of Death
(ICD)
1948, WHO: International Statistical Classification of Diseases, Injuries, and
Causes of Death included classification of abnormal behavior
1952, APA: Diagnostic and Statistical Manual (DSM)
1968, APA: DSM-II, reliability was very low
1969, WHO: a new classification system
1980, APA: DSM-III
1987, APA: DSM-III-R (R stands for Revision)
1994, APA: DSM-IV
2000, APA: DSM-IV-TR (TR stands for Text Revision)
2013, APA: DSM-5

General Criticisms of Classification

Classification leads to loss of information: classifying a person as depressed or
anxious results in loss of information about that person, reducing his/her
uniqueness. However, it is important to know whether the information lost is
relevant (Kring et al., 2012).

Labeling: once labeled, an individual start identifying him/herself with the negative
connotations associated with the label. It also leads to stigma as mental disorders
are viewed negatively by the society (Wahl & Harrman, 1989).

According to Kring et al (2012) some specific criticisms of diagnosis by DSM are:

Discrete Entity vs. Continuum (Categorical vs. Dimensional classification): The
debate of discrete versus continuum has not been resolved and despite criticism of
categorical approach, DSM represents a categorical that is a yes-no approach to
classification.

Reliability: the extent to which a classification system or a test produces the same
scientific observation each time it is applied. Reliability of DSM-I and II was not
accepted. Though, later DSMs improved on the account of reliability however, it
still remains questionable.

Validity: the extent to which a classification system measures what it is supposed

to measure. The diagnoses of DSM are referred to as constructs because they are
inferred not proven, entities. Construct validity is determined by evaluating the
extent to which accurate statements and predictions can be made about a category
once it has been formed. So DSM describes the constructs and not facts.

Nevertheless, classification systems like DSM helps us in understanding the

various disorders, differences among them, their causes and to plan treatment.

According to Barlow and Durand (2005) DSM-III in 1980 was a landmark in the
history of nosology (classification):

It departed radically from its predecessors, and three changes stood out:
First, an atheoretical approach to diagnosis was attempted that used the precise
description of the disorder rather than theories of causal factors.
Second, specific, and detailed criteria for disorders helped to study their reliability
and validity.
Third, it introduced a “multiaxial system” that allowed clinicians to have a detailed
information about their patients through rating them on five different dimensions,
or axes. The details of multiaxial system are given below:

Axis I: the disorder itself, such as, schizophrenia or mood disorder

Axis II: More enduring (chronic) disorders of personality
Axis III: Physical disorders and conditions
Axis IV: Amount of psychosocial stress reported by the patient and rated by the
clinician in a dimensional fashion
Axis V: Current level of adaptive functioning

A revision of DSM-III called DSM-III-R was published in 1987, with further

improvement in reliability and validity.
Problems with DSM-III and III-R
Some of the diagnostic categories had low reliability.
Some criteria were whimsically rather than empirically established, e.g., one of the
criteria for panic was four panics in a 4-week period. A figure reached through an
approximation rather than research.
Despite shortcomings, DSM-III and III-R had a substantial impact, was more
popular and more clinicians used it than the ICD system.
ICD-10 was published in 1993 and to increase compatibility between DSM and
ICD-10 work on DSM-IV and ICD-10 was started simultaneously.

DSM-IV (1994) and DSM-IV-TR (2000)

According to Barlow and Durand (2005):
Scientific data was used to make changes in the diagnostic system;
Reanalysis of large set of data was done to increase its utility for DSM-IV
Independent field trials examined the reliability and validity of alternative sets of
definitions or criteria, and, in some cases, the possibility of creating a new
diagnosis (Widiger et al., 1998)
The distinction between organically and psychologically based disorders was
eliminated.
The “multiaxial system” remains with some changes in the five axes. These
changes are following:

Axis I: Pervasive Developmental Disorders (PDD), Learning Disorders (LD),

motor skills disorders, and communication disorders, previously coded on Axis II
are now coded on Axis I
Axis II: Personality disorders and mental retardation
Axis III: General medical conditions
Axis IV: Psychosocial and environmental problems (instead of psychosocial stress
in DSM-III & III-R)
Axis V: Current level of functioning using the GAF; Global Assessment of
Functioning (rating scale of 0-100) in life areas (social and occupational
relationships and use of leisure time)
Importance of Multiaxial system
Usually people consult a clinician for Axis I disorder
Axis II disorder may exist prior to Axis I disorder
Presence of Axis II along with Axis I condition indicates difficulty in treatment
Axes III, IV, and V indicate the factors other than the symptoms that should be
considered in an assessment to understand the overall life situation, i.e.,
Axis III indicates medical condition believed to be relevant to the present disorder
Axis IV indicates a proximal and a contributory cause
Axis V indicates how much the person needs treatment based on GAF ratings

Other positive points of DSM-IV and DSM-IV-TR are:

Extensive description of diagnostic categories:
For each disorder there is a description of essential features, associated features
(lab findings and physical examinations), research literature about age of onset,
course, prevalence and sex ratio, familial pattern, and differential diagnosis.
Social and Cultural Considerations
“Cultural formulation guidelines” is a plan for integrating important social and
cultural influences on diagnosis (Mezzich et al., 1999), e.g.,
What is the primary social and cultural group of a patient (e.g., Chinese, Hispanic,
etc.)?
Have the immigrants mastered the language of their new country?
Does the patient use terms and descriptions from his or her “old” country to
describe the disorder?
These cultural considerations must not be overlooked in making diagnosis and
planning treatment, but yet, there is no research supporting the utility of these
cultural formulation guidelines (Alarcon et al., 2002).

Overall, the reliability of DSM has improved due to:

Increased explicitness of the DSM criteria;
Use of standardized, reliably scored interviews for collecting the information
needed for a diagnosis.
 According to (Davison, Neale, and Kring, 2004), following problems remain in
DSM-IV and DSM-IV-TR.

Criticisms of DSM-IV-TR
Though DSM-IV-TR is an improvement over the previous editions of the DSM,
however, it has been some limitations also:
Clinicians must determine the clinical significance of the criteria
The DSM-IV-TR uses subjective terms, such as, clinically significant, and markedly
in its instructions to clinicians for making a diagnosis. It requires clinicians to
determine the clinical significance of the enlisted symptoms and criteria. The clinician
must judge as to what constitutes a clinically significant abnormal behavior, however,
such a decision can be subjective. For example, in the enlisted diagnostic criteria for
schizophrenia, the list of symptoms in Criterion A include clinically significant
disorganized speech or behavior. Similarly, in Criterion B, dysfunction must be
markedly below the person’s previous level of functioning, without clear definition of
the term markedly (Caplan, 1995). It becomes even more complicated and subjective
when the clinician must rely on the patient’s self-report of previous level of
functioning to determine if the current level of functioning is markedly below the
previous one. Further, diagnoses of some disorders such as adjustment disorders, is
completely dependent on the clinician’s subjective decision. The diagnosis of an
adjustment disorder is based on the client’s response (which is excessive than the
normal response) to the identifiable stressors. Now, what may be excessive for one
clinician may not be excessive for another. Thus, it is likely, that the same client may
get a diagnosis of an adjustment disorder from one clinician and no such diagnosis
from another clinician. Thus, despite the improved reliability and validity of the
diagnostic criteria, the DSM-IV-TR still leaves a lot to the clinicians’ subjectivity in
making a diagnosis.

Disorders are defined as categories and not as continua

DSM-IV-TR is a categorical classification system, i.e., either a person has a disorder
or does not have a disorder, with nothing in between. However, disorders exist on a
continuum as continuous gradations. Thus, a disorder exists in different degrees in
different patients. For example, two persons, A and B are diagnosed with
schizophrenia, while person A is able to maintain the global adaptive functioning
(personal, social, and occupational), person B suffers from delusions, hallucinations,
avolition (lack of will), anhedonia (inability to experience pleasure) and is confined to
his room, refusing to maintain personal hygiene, interpersonal relationships and an
occupation. While both may have been hospitalized for a given time, however, after
their discharge, person A recovers and is able to achieve the previous level of
functioning, but person B still shows several symptoms and is unable to live
independently. Clearly, there is a difference in the degree of schizophrenia in persons
A and B and they should have different prognoses, course, and treatment plans but the
DSM-IV-TR clubs them together under the diagnostic category of schizophrenia.

Heterogeneity in diagnostic categories

Heterogeneity is found in the group of patients diagnosed with the same disorder
because DSM-IV-TR requires the patients to have some and not all the enlisted
symptoms for the diagnosis. For example, for the diagnosis of schizophrenia, out of
total five symptoms, only two are required for its diagnosis. Thus, among a group of
patients with schizophrenia, while some may suffer from hallucinations and delusions,
others may have negative symptoms and hallucinations, whereas still others may have
disorganized speech and delusions. While heterogeneity may not be a problem by
itself, but it is possible that heterogeneous groups may represent different types of the
disorder and may have a different course, prognosis and etiology and thus may require
different line of treatment (Messias & Kirkpatrick, 2001). Possibly, then DSM-IV-TR
may be obstructing the path to research about new disorders (Malik & Beutler, 2002).

All the symptoms of a disorder have an equal weightage

Each symptom in the enlisted criteria may not have equal importance but is given an
equal weightage (Malik & Beutler, 2002). For example, in major depressive disorder,
significant weight loss/gain or decreased/increased appetite and suicidal ideation, both
are enlisted symptoms, but clearly suicidal ideation is much more important to be
noted.
Arbitrariness in the number and duration of diagnostic criteria
A specific number of symptoms for a specific duration must be present to fulfill the
criteria for diagnosis of a disorder. The specified number of symptoms has no
scientific basis and is arbitrarily chosen. For example, why five and not four
symptoms are required for the diagnosis of major depressive disorder. Suppose a
patient report four and not five symptoms but has significant distress and is in clear
need of clinical assistance. Since, he does not meet the criteria for five symptoms,
should the clinician not diagnose and treat him? Similarly, the duration of symptoms
is 2 weeks (14 days) for the major depressive disorder. In such a case, while the
patient does not get the diagnosis till day 13 will suddenly get it just the next day (day
14). So, the patient’s diagnostic status changes significantly within 24 hours (Sullivan,
Bulik, & Kendler, 1998).

Restrictive criteria for some disorders

A nonspecific diagnosis labelled as ‘not otherwise specified’ (NOS) is given to the
patients who do not meet the necessary criteria for a given disorder but are
significantly distressed. Some of the disorders in DSM-IV-TR, like eating disorders
have such restricted criteria that many patients do not meet the necessary criteria and
hence remain undiagnosed despite distress and impairment (Sloan, Mizes, & Epstein,
2005). These patients are given the diagnosis of eating disorders (NOS) which not
only hinders their assessment and treatment but also research work in the field of
eating disorders.

Unnecessary classification of some mental health issues and medical disorders as

mental disorders
The number of disorders has steadily increased in DSM editions published since 1952
till date. DSM-IV-TR has classified more than 300 disorders. This inflation is not the
result of discovery of new disorders but due to the issues of payment (Eriksen &
Kress, 2005). Nowadays, many patients get reimbursement either from health
insurance companies, their employers or government agencies. To get the
reimbursement benefits, the patient must have a disorder classified in DSM. Thus,
some disorders which may not be valid from the scientific perspective are classified
just to ensure the payment from the various agencies. Besides an increased number of
mental disorders, DSM has also begun to include medical disorders which are not
mental disorders (Eriksen & Kress, 2005) such as, sleep apnea. It is a breathing
related sleep disorder partly caused by an obstructed breathing passage. Some
psychiatrists pushed for it to be included in the DSM, as insurance benefits cannot be
availed for a psychiatric treatment of a disorder which is not included in DSM (Houts,
2002). Besides the financial benefits, some medical conditions were included in the
DSM as these could be treated effectively with psychological treatment (Deckersbach
et al., 2006). For example, irritable bowel syndrome (IBS) which is a gastrointestinal
disorder with symptoms like stomach cramps, diarrhea, and bloating can be treated
successfully with psychological treatment (Blanchard et al., 2006).

Social factors are not recognized explicitly

In DSM-IV-TR, the diagnostic categories are based on the intraindividual (within the
individual) conflicts rather than the conflict between individual and society. However,
social factors such as, immigration; discrimination based on skin color, caste, religion,
socioeconomic status; loss of job; failure in an exam may lead to depression (Caplan,
1995).

High level of comorbidity raises questions about validity of diagnostic criteria

Comorbidity is found in at least fifty percent of the diagnosed cases (Kessler et al.,
2005). Comorbidity raises doubts about the mutual exclusivity of the diagnostic
categories. For example, most people (50% approx.) diagnosed with clinical
depression are also diagnosed with anxiety disorder (Kessler et al., 2003). Such a high
level of comorbidity implies that the two disorders may represent different forms of
the same underlying condition. This makes the validity of the diagnostic categories
doubtful.

Commonalities across diagnostic categories are ignored

Commonalities are found across the diagnostic categories either because of
comorbidity or because some disorders may share some of the symptoms. Disorders
sharing some common symptoms can be classified under an umbrella term rather than
as separate disorders with separately enlisted criteria. For example, internalizing and
externalizing disorders have emotional and behavioral problems as the common
underlying factor. Internalizing disorders are characterized by the over controlled and
externalizing disorders are characterized by the under controlled emotions and
behaviors. However, DSM-IV-TR has not given a categorization of these disorders
based exclusively on emotions and behaviors and has left it for the clinicians to find
commonalities among these disorders by themselves.

Despite several shortcomings, DSM-IV-TR remained the most widely used

classification system for more than two decades and provided the firm basis for the
new edition, the DSM-5.

DSM-5
To address the limitations in the DSM-IV-TR, latest empirically collected scientific
and clinical evidence was integrated to construct the DSM-5 with an aim to provide
the best possible care to patients and to provide improved utility for clinicians and
researchers.

APA, Division of Mental Health of WHO, World Psychiatric Association, and the
National Institute of Mental Health (NIMH) coordinated to begin the revision of
DSM-IV-TR in 1999 which stemmed into a publication, ‘A Research Agenda for
DSM-V’ in 2002. For the next five years (2003-2008), 13 international DSM-5
research planning conferences were held by the APA, WHO, NIMH, the National
Institute on Drug Abuse (NIDA), and the National Institute on Alcoholism and
Alcohol Abuse (NIAAA) “to review the world literature in specific diagnostic areas to
prepare for revisions in developing both DSM-5 and the International Classification
of Disease, 11th Revision (ICD-11)” (APA, 2013). This work was taken forward at a
massive level for “conducting literature reviews and secondary analyses, publishing
research reports in scientific journals, developing draft diagnostic criteria, posting
preliminary drafts on the DSM-5 Web site for public comment, presenting
preliminary findings at professional meetings, performing field trials, and revisiting
criteria and text” (APA, 2013). Finally, in 2013 these Herculean efforts resulted in the
much-awaited finished product, the ‘DSM-5’.
The DSM-5 has enlisted the following key elements of a diagnosis (APA, 2013):
1) Diagnostic Criteria and Descriptors – Diagnostic criteria are the standard
procedures for making a diagnosis. If the patient’s presenting complaint meets the full
criteria, severity and course specifiers can be added to indicate the patient’s current
condition. Diagnosis can be noted as “other specified” or “unspecified” if the full
criteria are not met. Indices of severity (mild, moderate, severe, or extreme),
descriptive features, and course (type of remission – partial or full – or recurrent) can
be provided with the diagnosis wherever applicable. The clinical interview, text
descriptions, criteria, and clinical judgment form the bases for the final diagnosis.

2) Subtypes and Specifiers – as the different individuals can manifest the same
disorder in different ways so the DSM uses subtypes and specifiers to better
characterize an individual’s disorder. Subtypes denote “mutually exclusive and jointly
exhaustive phenomenological subgroupings within a diagnosis” (APA, 2013). For
example, Enuresis is nocturnal only, diurnal only, or both. On the other hand,
specifiers are neither mutually exclusive nor jointly exhaustive hence, more than one
specifier can be given. For instance, major depressive disorder has a wide range of
specifiers that can be used to characterize the severity, course, or symptom clusters.
The subtypes and specifiers can be distinguished by their number, while there can be
multiple specifiers, there can be only one subtype.

3) Principal Diagnosis – in case of more than one diagnosis (comorbid disorders) a

principal diagnosis is used. The reason for the in or out-patient hood is the principal
diagnosis which is also the main focus of treatment.

4) Provisional Diagnosis – when a clinician is unable to make a definitive diagnosis

due to lack of enough information, however, at the same time, he/she can strongly
presume that the full criteria will be met with more information and/time, a
provisional specifier can be used.

From DSM-IV-TR to DSM-5: The Incorporated Changes

According to Regier, Kuhl, and Kupfer (2013), several changes were made from
DSM-IV-TR to DSM-5:
Cultural and Social Factors
The importance of cultural and social context for clinical care and research
applications was recognized by the DSM leadership. As the strong link between social
environment and epigenetic mechanisms (non-genetic influences on genes that change
the phenotypic expression of a gene), heritability, risk and resiliency factors became
more evident, the diagnostic criteria for not all but many disorders are now
accompanied by referenced findings for such factors. Additionally, cultural references
are presented for the symptom expressions with an acknowledgement that a given
symptom may be expressed more in a particular culture (e.g., European, Asian, or
African etc.), and cultural syndromes are also provided.

DSM-5 Classification
The outdated and inaccurate descriptive approach of DSM-IV for classification was
replaced by a new organizational structure for the DSM-5 in which disorders are
categorized into clusters based on shared physiological pathology, genetics, disease
risk, neuroscientific and clinical findings (Table A).
Table A. DSM-5 diagnostic chapters
Neurodevelopmental disorders
Schizophrenia spectrum and other psychotic disorders
Bipolar and related disorders
Depressive disorders
Anxiety disorders
Obsessive-compulsive and related disorders
Trauma- and stressor-related disorders
Dissociative disorders
Somatic symptom and related disorders
Feeding and eating disorders
Elimination disorders
Sleep-wake disorders
Sexual dysfunctions
Gender dysphoria
Disruptive, impulse-control, and conduct disorders
Substance-related and addictive disorders
Neurocognitive disorders
Personality disorders
Paraphilic disorders
Other mental disorders

The relative strength of relationships between disorder groups is reflected in

the linear structure of this organization whereas the internal organization of
disorder groups represents the developmental perspective. For example, the
first four chapters of the DSM-5 are Neurodevelopmental disorders,
Schizophrenia spectrum and other psychotic disorders, Bipolar and related
disorders, and Depressive disorders. Such an organization is consistent with
the findings of largest genome research study of mental disorders (Smoller,
Craddock, & Zöllner, 2013)

Integration of Dimensions
Despite the statement in the DSM-IV that “there is no assumption that each category
of mental disorder is a completely discrete entity with absolute boundaries dividing it
from other mental disorders” (APA, 1994), its strict categorical boundaries present the
psychiatric disorders as unitary, discrete phenomena. On the hand, the DSM-5
includes dimensional aspects of diagnosis along with categories. Although, diagnosis
is still largely categorical (based on “yes or no” decision), a gradient of a disorder is
provided by using specifiers, subtypes, severity ratings, and cross-cutting symptom
assessments. For example, the new “with anxious distress” specifier, applied to
depressive disorders and bipolar and related disorders may describe a particular
variant of mood disorder that causes impairment and/or distress and requires
treatment, although it includes symptoms that are not a part of the criteria for most
mood disorders (e.g., difficulty concentrating because of worry). Importantly, those
symptoms which were likely to be masked under a residual diagnosis of “not
otherwise specified” in the DSM-IV can now provide clinically useful information for
treatment planning. Further, DSM-5 promotes more specific treatment by providing
the severity (mild, moderate, severe) specifiers (Baumeister, 2012). In fact, to provide
dimensionality to the diagnoses, the DSM -5 has expanded the numbers of specifiers
and subtypes.
In DSM-5, some of the disorders existing as separate diagnostic categories in the
DSM-IV were combined to form spectra disorders. Autism Spectrum Disorder (ASD)
is the most prominent example. The autism disorder, Asperger’s disorder, child
disintegrative disorder, and pervasive developmental disorder NOS as separate
diagnostic categories in DSM-IV had very poor reliability data and failed to validate
their continued separation (Lord, Petkova, Hus, et al., 2012). Hence, the DSM-5 has
unified these under an umbrella term, ASD. However, to account for the ASD
variations, specifiers are provided, such as, presence or absence of intellectual
impairment, structural language impairment, co-occurring medical conditions, or loss
of established skills.

Finally, the DSM-5 encourages dimensional approach to further clinical and research
experience. Dimensional assessment must be done at a multilevel. The first level is
cross-cutting quantitative measures that can be applied across disorders which enables
the clinicians and researchers to examine the symptoms’ domains relevant to most
disorders, such as anxiety, mood, sleep, and cognitions. The second level involves the
diagnosis of a specific disorder which is achieved by a more in-depth assessment of
the particular symptom domain endorsed in the first level assessment. Finally, the
third level provides the level of severity for the diagnosis endorsed by the second
level of assessment. For example, if the first level endorses mood as the particular
symptom domain, then at the second level, the Patient-Reported Outcomes
Measurement Information System (PROMIS) Emotional Distress – Depression –
Short Form can be used. If the score indicates at the possible presence of major
depressive disorder, then after a clinical interview for assessing the presence of
diagnostic criteria, a diagnosis for depression may be given. Then at the third level,
The Nine-Item Patient Health Questionnaire can be administered to establish baseline
severity. For monitoring course and treatment response, severity level can be assessed
at regular intervals.

Revisions to Diagnostic Criteria

For most disorders no sweeping changes were made in the diagnostic criteria.
Nevertheless, some changes were made which are described below:
Combining and splitting DSM-IV disorders
As mentioned above, while some disorders were combined under a spectrum, such as
ASD, some were split into independent disorders such as DSM-IV’s reactive
attachment disorder which included the subtypes “emotionally withdrawn/inhibited”
and “indiscriminately social/disinhibited”. Though these subtypes shared etiology
(i.e., lack of a consistent, emotionally supportive caregiving environment), while the
reactive attachment subtype (reactive attachment disorder) is more similar to
internalizing disorders, like major depressive disorder, the social disinhibition subtype
is more similar to externalizing disorders, including ADHD. Further, the two subtypes
also demonstrate disparities in course and treatment response; thus, the DSM-5 now
includes each of the two subtypes as a separate full disorder (Zeanah & Gleason,
2010).

New disorders
The DSM-5 has included some new disorders, several of which existed in the DSM-
IV’s chapter on “conditions for further study”. The inclusion of new disorders was
based on an extensive and stringent review of existing evidence from neuroscience,
clinical need, and public health significance. Some of these new disorders are
hoarding disorder, disruptive mood dysregulation disorder (DMDD), binge eating
disorder, premenstrual dysphoric disorder, restless legs syndrome, and REM sleep
behaviour disorder (Regier et al., 2013).

Removal from DSM-IV

In the DSM-IV, those individuals were excluded from the diagnosis of major
depressive disorder who reported symptoms of major depressive disorder but were
also experiencing bereavement within the past 2 months. It was done to prevent
labelling with a mental disorder, of people experiencing normal grief reactions for
losing a loved one. However, such an exclusion also increased the risk of denying
diagnosis and treatment of bereaved individuals who were also experiencing major
depressive episode. Thus, DSM-5 lifted the bereavement exclusion and replaced it
with a detailed description of the difference between symptoms that characterize
normal grief and those that indicate a clinical disorder to (Zisook, Corruble, & Duan,
et al., 2012).
Changes in naming conventions
Some of the prevalent nomenclatures were deemed as pejorative by the advocacy
groups and thus most appropriate terms were evaluated to replace the objectionable
one. For example, several draft changes resulted in approval of the term “intellectual
disability in place of “mental retardation.” The term “substance use disorder” has
replaced the “substance abuse and substance dependence.” Also, the DSM-5 uses
“other specified” and “unspecified” categories in lieu of the “not otherwise specified”
categories in the DSM-IV (Regier et al., 2013).

Evaluation
The advantages and limitations of the DSM-5 can be determined after it has been used
for some time. Updated information about prevalence and comorbidities of the
various disorders like anxiety disorders, schizophrenia, major depressive disorder,
substance use disorders, etc. can be obtained from the worldwide epidemiological
studies. Currently, assessment materials based on DSM-5 are required for use in
primary care settings. Lastly, for the purpose of revisions, evidence should be
documented in the DSM-5 electronic archives.

The ICD-10
The ICD-10 was endorsed in May 1990 by the 43rd World Health Assembly. The
WHO states:
“ICD is the foundation for the identification of health trends and statistics globally,
and the international standard for reporting diseases and health conditions. It is the
diagnostic classification standard for all clinical and research purposes. ICD defines
the universe of diseases, disorders, injuries and other related health conditions, listed
in a comprehensive, hierarchical fashion that allows for: easy storage, retrieval and
analysis of health information for evidence-based decision-making; sharing and
comparing health information between hospitals, regions, settings, and countries; and
data comparisons in the same location across different time periods”
(http://www.who.int/classifications/icd/en/).

The ICD includes a Chapter V: Mental and Behavioral Disorders in which following
disorders are enlisted:
 • Organic, including symptomatic, mental disorders
• Mental and behavioral disorders due to psychoactive substance use
• Schizophrenia, schizotypal and delusional disorders
• Mood (affective) disorders
• Neurotic, stress-related and somatoform disorders
• Behavioral syndromes associated with physiological disturbances and physical
factors
• Disorders of adult personality and behavior
• Mental retardation
• Disorders of psychological development
• Behavioral and emotional disorders with onset usually occurring in childhood
and adolescence
• Unspecified mental disorder

Harmonization of DSM-5 and ICD-11

One of the aims of DSM-5 has been to bring consonance between the two
classification systems, i.e., DSM-5 and ICD-11 to ensure an accurate collection of
national health statistics and design of clinical trials. This would increase the ability to
replicate scientific findings across national boundaries and to rectify the lack of
agreement between the DSM-IV and ICD-10 diagnoses (APA, 2013). The continuous
collaboration of WHO and DSM workgroups will make it possible to have a more
compatible international statistical classification of mental disorders and will take the
field of clinical psychology closer to a truly unified nosology and a diagnostic
approach. Such collaborations will not only help the psychiatrists worldwide to better
care for individuals with mental disorders but would also lead to a more synergistic
international research approach to find the etiological factors and intervention for
these mental disorders.

The judicious use of the two widely used classification systems, the DSM and ICD by
the experienced professionals can be immensely helpful in understanding and dealing
with psychological disorders and for propagation of knowledge in the field of
psychopathology.