Classification of Psychiatric Disorders: Overview and Approach

The classification of psychiatric disorders is a pragmatic approach adopted to aid patient care,
communication among health professionals, and research. The ideal classification should be
based on the etiology of diseases. However, in psychiatry, the exact causes of many disorders
are unknown, making the classification based on symptom groupings or syndromes more
practical.

Syndromes vs. Diseases

 Syndrome: A collection of symptoms that occur together but may not always indicate
a specific disease. Syndromes do not necessarily have a single cause.
o Example: Korsakoff’s syndrome started with prominent symptoms like
confabulation (making up stories). Over time, other features like disorientation
and memory issues were added, and the syndrome was found to have a
neuropathological cause, turning it into a disease.

Early Classification

 Functional vs. Organic Disorders:

o Functional Disorders: Disorders like schizophrenia and manic depression,
where no obvious physical cause (organic damage) was initially found.
o Organic Disorders: Disorders resulting from brain damage, such as dementia
and delirium, which were later reclassified under more specific categories like
"cognitive disorders" (DSM-IV).

Organic Syndromes

Organic syndromes are disorders caused by brain damage and are classified into:

1. Acute Organic Syndromes: Rapid onset with altered consciousness.

o Types:
 Delirium: Dream-like state with hallucinations and illusions. Anxiety
and agitation are often present.
 Subacute Delirium: Lowered awareness, confusion, and occasional
hallucinations.
 Organic Stupor (Torpor): A severe reduction in responsiveness to
stimuli, often with post-recovery amnesia.
 Twilight State: Restricted consciousness dominated by specific ideas,
but the patient can still perform complex tasks.

Example: Delirium tremens in alcohol withdrawal, where the patient hallucinates and
cannot distinguish between reality and mental images.

2. Chronic Organic Syndromes: Progressive or long-lasting conditions, often

involving memory loss or cognitive decline.
o Types:
 Dementias: Generalized (e.g., Alzheimer's) or focal (e.g., frontal lobe
dementia, characterized by lack of drive, foresight, and empathy).
  Amnestic Disorders: Memory impairment without other cognitive
decline, as seen in Korsakoff’s syndrome.

Example: Frontal lobe dementia may show traits like a "happy-go-lucky" attitude or
rigid thinking patterns.

Examples of Psychiatric Syndromes and Classifications:

1. Mania: Elevated mood leads to symptoms like overactivity, pressured speech, and
flight of ideas, all coherent with the primary disorder of elevated mood.
2. Schizophrenia: Initially classified as functional, but modern research has identified
genetic and neurobiological abnormalities, hinting at an organic basis.

Key Points

 Primary vs. Secondary Symptoms:

o Primary Symptoms: Direct result of the disease process (e.g., hallucinations
in schizophrenia).
o Secondary Symptoms: Psychological responses or elaborations of the
primary symptoms (e.g., anxiety following hallucinations).
 Development of Syndromes: Psychiatric syndromes often begin with a prominent
symptom that eventually becomes part of a broader symptom complex as more
features are identified.

. Functional Syndromes

 Definition: Functional syndromes refer to disorders where no evident brain disease

can be detected using standard diagnostic tools, although it’s possible that more subtle
abnormalities exist at the cellular or neurochemical level.
 Historical Context:
o Mental illnesses were originally divided into two broad categories:
 Neuroses: Characterized by psychological distress, where reality
testing remains intact. Individuals have insight into their condition and
their overall personality is not severely affected.
 Psychoses: Involves a complete breakdown of reality testing and
insight. The individual has little to no awareness of their condition, and
their entire personality can be impacted.

2. Challenges with Definitions of Neuroses and Psychoses

 Blurring the Lines:

o Neurosis vs. Psychosis is not always clear-cut. There are cases where
individuals with neuroses may lack insight, while some with psychoses may
retain a degree of awareness and voluntarily seek treatment.
o Certain non-psychotic disorders like severe depression can cause personality
changes, while not all psychotic disorders necessarily result in dramatic
personality shifts.
 Key Thinkers:
 o Karl Jaspers (1962): Described neurosis as a defense mechanism, where
emotional or psychological conflicts are converted into physical symptoms
(e.g., in dissociative or conversion disorders).
o Kurt Schneider (1959): Differentiated normal human existence from
abnormal by stating that neuroses and personality disorders represent
quantitative variations (differences in degree), whereas severe disorders like
Obsessive-Compulsive Disorder (OCD) are qualitatively different from
normal functioning

3. Evolution of Neurosis and Psychosis in Psychiatric Classifications

 Traditional View:
o Neurotic Disorders: Considered mild mental illnesses where symptoms are
ego-syntonic (in harmony with the person's self-perception). Conditions like
anxiety, depression, or phobias were viewed under this umbrella.
o Psychotic Disorders: Severe mental health conditions where symptoms are
ego-dystonic (causing distress and being at odds with the self). Schizophrenia,
bipolar disorder with psychosis, and delusional disorders fall into this
category.
 Modern Shift:
o The DSM-IV (1994) eliminated the term ‘neurosis’, finding it imprecise and
insufficient to describe the complexity of anxiety and related disorders.
Instead, the term ‘anxiety disorders’ was introduced.
o The ICD-10 (1992), the World Health Organization's classification system,
maintained a broader approach and used terms like ‘neurotic, stress-related,
and somatoform disorders’ to capture these non-psychotic disorders.

4. Personality Disorders and Psychogenic Reactions

 Personality Disorders: Traditionally viewed as longstanding, inflexible patterns of

thinking, feeling, and behaving. They differ from neuroses in that personality
disorders often manifest as enduring traits, rather than temporary states of distress.
 Schneider’s Perspective:
o Neuroses as Reactions: Schneider proposed that neuroses are reactions of
abnormal personalities to stress or trauma. For instance, a person with an
anxious personality may develop an acute anxiety disorder when exposed to
severe stress.
 Psychogenic Reactions:
o Psychological reactions to life stressors or trauma that lead to psychiatric
conditions (e.g., acute anxiety, dissociative states). These reactions are seen
as exaggerated responses from individuals with pre-existing abnormal
personality traits.
o Psychogenic Psychoses: Certain personality traits (such as paranoia) may
develop into full-blown psychotic reactions under significant life stress.
 Classification: In modern classifications (e.g., ICD-10 and DSM-5), these are
categorized as acute and transient psychotic disorders or brief psychotic
disorders.
5. Modern Psychiatric Classifications: DSM and ICD

 Diagnostic and Statistical Manual of Mental Disorders (DSM):

o Published by the American Psychiatric Association, primarily used in the U.S.
o Focuses on operational definitions to ensure consistency across clinical
practice and research. Disorders are defined based on observable symptoms.
o Criticism: The DSM system is often criticized for being too rigid and
prescriptive, leading to diagnostic inflation (i.e., labeling normal behaviors as
mental illness).
 International Classification of Diseases (ICD):
o Developed by the World Health Organization and used globally.
o More clinically oriented, allowing greater flexibility in the application of
diagnostic categories based on the clinician’s judgment.
o Used in general healthcare systems, not just in psychiatry, covering all
diseases, including mental health disorders.
o ICD includes detailed criteria in research versions but remains more flexible in
clinical applications.

6. Key Differences between DSM and ICD

 DSM:
o Emphasizes clear, operational definitions for each disorder.
o More suitable for research due to its precise criteria but may lack flexibility in
real-world clinical practice.
 ICD:
o More clinician-friendly, adaptable to diverse healthcare settings.
o Promotes diagnostic judgment, making it ideal for use in non-specialized
healthcare contexts worldwide.

7. Evolution of DSM and ICD

 Timeline:
o DSM-I (1952): First edition, heavily influenced by psychoanalytic thinking.
o DSM-III (1980): Marked a major shift towards symptom-based, operational
criteria, abandoning psychoanalytic roots.
o DSM-5 (2013): Latest edition, introduced significant changes like spectrum
disorders (e.g., autism spectrum disorder) and dimensional approaches to
diagnosis.
o ICD-6 (1948): First edition to include mental health disorders.
o ICD-10 (1992): Adopted globally, remains the standard in many countries.
o ICD-11 (2019): Introduced significant updates, including reduced categories
for personality disorders, with a shift towards dimensional assessments (e.g.,
negative affectivity, dissociality).

8. DSM-5: Major Controversies

 Bereavement Exclusion:
o In previous versions, a person grieving a significant loss could not be
diagnosed with major depressive disorder within the first two months post-
 loss. DSM-5 removed this exclusion, sparking concerns that normal grief
could be pathologized.
 Addition of New Disorders:
o DSM-5 introduced 14 new disorders, such as:
 Hoarding Disorder: Previously categorized under OCD, now
recognized as a separate disorder.
 Binge Eating Disorder: Previously considered part of eating disorders
not otherwise specified (EDNOS), it now stands alone.
 Oppositional Defiant Disorder (ODD):
o Retained in DSM-5 but continues to face criticism for pathologizing childhood
behaviors that may be developmentally normal.

9. ICD-11: Key Changes

 Personality Disorders:
o Simplified classification, reducing distinct categories and focusing instead on
dimensional traits such as:
 Negative Affectivity: Emotional instability, frequent negative
emotions.
 Dissociality: Disregard for others' rights, lack of empathy.
 Disinhibition: Impulsivity, difficulty with self-control.
 Anankastia: Need for control, perfectionism, and rigidity.
 Detachment: Social and emotional withdrawal.
 Future of Classifications:
o Both DSM-5 and ICD-11 aim to move toward dimensional approaches to
better capture the nuances of mental health disorders, though the field remains
tied to categorical diagnoses for practical purposes.

10. Key Takeaways

 The distinction between functional syndromes (such as anxiety or depression) and

brain-based conditions remains a complex issue. Modern classifications like DSM-5
and ICD-11 aim to balance operational clarity with clinical flexibility.
 DSM-5 is research-oriented, providing detailed criteria for consistency, but faces
criticism for potentially over-pathologizing normal experiences. ICD-11, more widely
used globally, emphasizes flexibility and clinical judgment.
 Future classifications are likely to integrate more dimensional approaches, focusing
on traits and spectrum disorders rather than discrete categories, as psychiatric
research continues to evolve.

Interview Schedules in Epidemiological Studies: Detailed Notes

1. Diagnostic Interview Schedules (DIS)

 Purpose: DIS were developed to standardize psychiatric diagnoses in epidemiological

studies, particularly to meet the diagnostic criteria for ICD and DSM.
 Development:
o These schedules provide structured frameworks for assessing and diagnosing
mental disorders based on specific symptom criteria.
 o They include various versions tailored for clinical, research, and other
specialized purposes.

2. Structured Clinical Interview for DSM-5 (SCID-5)

 Origin: SCID-5 evolved from the SCID-IV, which was used for DSM-IV diagnoses.
 Versions of SCID-5:
o SCID-5-CV (Clinical Version): Designed for use in clinical settings, allowing
clinicians to make formal diagnoses.
o SCID-5-R (Research Version): Used for research purposes to ensure
consistency across studies.
o SCID-5-CT (Clinical Trials Version): Tailored for clinical trials to
standardize diagnostic criteria across subjects.
o SCID-5-PD (Personality Disorders Version): Focuses on diagnosing
personality disorders using the traditional categorical model.
o SCID-AMPD (Alternate Model for Personality Disorders): Allows for a
dimensional assessment of personality traits rather than relying on a
categorical diagnosis.
 Semi-Structured Format: SCID-5 allows flexibility in administration, where
interviewers can elaborate on responses and adjust the flow based on the interviewee's
answers.

3. Composite International Diagnostic Interview (CIDI)

 Development: The CIDI (Robins et al., 1989) evolved from the earlier Diagnostic
Interview Schedule (DIS), but it differs in several key aspects.
 Characteristics:
o Unlike SCID, the CIDI is fully standardized, not semi-structured. It is
designed to be administered by lay interviewers without requiring clinical
judgment.
o The interviewer strictly follows a prescribed set of questions and evaluates
symptoms like frequency, duration, and severity based on the respondent’s
answers.
o The interviewer’s role is limited to ensuring the respondent understands the
questions; no diagnostic interpretation is involved.
 Application:
o Suitable for large-scale epidemiological studies.
o Can be administered in computer format, allowing for self-administration
and automated data collection.
 Use in ICD: CIDI has been adapted to diagnose according to ICD-10 and later
evolved into the World Mental Health-CIDI (WHO WMH-CIDI), which evaluates
lifetime and 12-month prevalence of disorders.
o Does not assess personality disorders.
o Modular format allows for the evaluation of specific disorders, including
sections on functioning, service use, and family burden.
 Current Development: CIDI-5 is being developed to align with DSM-5 criteria.

4. Schedule for Clinical Assessment in Neuropsychiatry (SCAN)

 Evolution:
 o Developed in Europe from the older Present State Examination (PSE)
(Wing et al., 1974). SCAN (Wing et al., 1990) is a more comprehensive tool
used to assess and classify psychopathology in adults.
 Components of SCAN:
o Present State Examination (PSE-10): The latest version of the PSE, focusing
on current symptoms.
o SCAN Glossary: Defines symptoms and guides clinicians in symptom rating.
o Item Group Checklist (IGC): Allows direct rating of symptoms from case
notes.
o Clinical History Schedule (CHS): Captures detailed clinical histories and
additional diagnoses that PSE-10 might miss.
 Structure:
o Semi-Structured: SCAN includes probe questions to assess
psychopathological symptoms, which are then rated for severity. Interviewers
can use a more flexible interview style if needed to clarify or elaborate on
certain symptoms.
o A free-style interview can be conducted to ensure understanding of
symptoms, including using the patient’s own words for greater clarity.
 Diagnosis Process:
o SCAN generates diagnoses based on ICD-10 or DSM-IV criteria.
o It allows for a current diagnosis, lifetime diagnosis, or representative
episode diagnosis.
o Symptom ratings are entered into a computer algorithm, which then provides
a formal diagnosis.
 Use of Clinical Expertise:
o SCAN is conducted by mental health professionals (psychiatrists or clinical
psychologists) with clinical interviewing skills, approximating the 'gold
standard' for diagnosis.
o This makes SCAN more expensive compared to fully standardized interviews
(like CIDI) but adds depth and precision in diagnosis.
 Focus: SCAN focuses on clinical psychiatric disorders and pays little attention to
personality disorders.

5. Comparison of SCID, CIDI, and SCAN

 SCID:
o Semi-structured, used by clinicians with some flexibility in administration.
o Based on DSM criteria.
o Includes various versions for different uses (clinical, research, personality
disorders).
 CIDI:
o Fully standardized and can be administered by lay interviewers.
o Suitable for large-scale studies.
o No clinical judgment involved.
o Used for DSM and ICD diagnoses but excludes personality disorders.
 SCAN:
o Semi-structured, requires trained professionals.
o Diagnoses based on ICD and DSM criteria.
o Expensive but provides in-depth, high-quality clinical assessments.
6. Challenges with Standardized Interviews

 Advantages:
o Standardized interviews (like CIDI) allow for large-scale data collection
with consistent methodology, are cheaper, and do not require highly
specialized personnel.
o They ensure uniformity in diagnosis across studies, which is crucial in
epidemiological research.
 Disadvantages:
o The absence of clinical judgment in fully standardized interviews (like CIDI)
raises concerns about validity. Critics argue that some psychiatric disorder
prevalence rates may be overestimated without nuanced clinical interpretation.
 Semi-structured interviews (like SCID and SCAN), while more expensive, offer
greater depth and flexibility by incorporating clinical judgment, thereby improving
diagnostic accuracy.

7. Key Takeaways

 Interview schedules like SCID, CIDI, and SCAN are vital tools for standardizing
psychiatric diagnoses in both clinical and research settings.
 SCID offers flexibility and is tailored for clinical use, while CIDI provides a rigid,
standardized approach suitable for large-scale studies.
 SCAN, although resource-intensive, is seen as the 'gold standard' for in-depth clinical
diagnosis.
 Each schedule has strengths and weaknesses, particularly in the balance between cost-
effectiveness and the inclusion of clinical expertise.