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Title: DSM IV


1
DSM IV CLASSIFICATION
SYSTEM PRESENTED BY-

Mrs.Shalini Chhabra, Sr.Lecturer

Department Of Psychology

DAV College For Girls,
Yamunanagar
2
  • Classification is important in any science
    whether we are studying plants, planets and
    people. With an agreed upon classification system
    we can be confident that we are communicating
    clearly. If someone says to you I saw a coolie
    running down the street, you probably have an
    accurate idea of what the coolie looked like- not
    from seeing it but rather from your knowledge of
    classification.
  • In
    Psychopathology class involves the description of
    various types of categories of maladaptive
    behaviour. Classification is necessarily first
    step towards introducing some order into our
    discussion of the nature, causes and treatment of
    such behaviour. It enables communication about
    particular cluster of behaviour in agreed upon
    and meaningful way e.g. we can not conduct
    research on background of causal factor in a
    given disorder unless with more or less clear
    definition of behaviour under examination.
  • FEATURES OF AN IDEAL CLASSIFICATION-

3
  • Granting that all classification system are
    fundamentally arbitrary, some of them are much
    better than other in helping us organize and
    discuss our observations. We take a
    classification systems usefulness on its four
    main features
  • Reliability- Reliability is the degree to which
    a test or measuring device produces the same
    result each time it is used to measure the same
    thing.In the case of classification it is a
    measure of extent to which different observer can
    agree that a behaviour fitsa given diagnosis
    category.
  • Validity- Validity refers to the extent to which
    a measuring instrument actually measures what it
    claims to measure. In the case of classification
    validity is determined by whether the diagnostic
    category tells us something important or basic
    about the disorder.
  • 3.Classification system should be more or less
    permanent.
  • 4.In the classification system, there should be
    the

4
  • 4. In the classification system, there should
    be the
  • characteristics of homogeneity in one group of
    disorder and characteristics of heterogeneity
    between two group of disorder.
  • NEED FOR CLASSIFICATION-
  • Such systems provide a language with which all
    mental health professional can communicate. It
    enables efficient communications e.g. instead of
    telling all the symptoms of depression, one is
    able to say only depression to name a particular
    type of mental disorder.
  • In order to study the natural history of a
    particular disorder and develop an effective
    treatment it is necessary to define the
    characteristics of disorder and have an
    understanding of how it is different from other
    similar disorders to the extent that relationship
    between diagnosis and treatment has been
    established for a particular category. The proper
    diagnosis of a persons condition can

5
  • indicate the most effective treatment.
  • 3. The ultimate purpose of classification is to
    develop an understanding of the causes of the
    various mental disorders. Knowing the causes of
    the disorder usually leads to the development of
    an effective treatment.
  • DSM CLASSIFICATION OF MENTAL DISORDERS-
  • History of classification goes back to
    Hippocrates who classified the mental disorder on
    the basis of biles. According to him there are
    three biles in the body. Red, yellow and black.
    Biles are some enzymes in the body. Red bile is
    responsible for aggression, yellow for peace and
    black for severe depression. Official
    classification of mental disorders first came
    into the United in 1840. This trend continued in
    the United States and now a days the most widely
    used classification scheme in mental disorders in
    U.S. is Diagnostic and Statistical Manual of
    Mental Disorders (DSM). There also exists a world
    wide classification system called ICD which is
    called a International

6
Classification of Diseases, which cover all
disorders and diseases. Both the Psychiatric
Association (APA) and World Health Organization
(WHO) have worked closely over the years to
ensure compatibility between the classification
systems. APA first published DSM I in
1952, DSM II in 1968, DSM III in 1980, DSM III R
in 1987 and DSM IV in 1994.
DSM IV DSM IV is developed
mainly for the purpose for treatment, research
and education. This diagnosis manual is
constructed and documented on the basis of
systematic and explicit process. More than any
other nomenclature of mental disorders, DSM IV is
grounded in empirical evidence. In DSM
IV each of the mental disorders is conceptualized
as a clinically significant behavioural or
psychological syndrome or pattern that occurs in
an individual
7
and that is associated with present distress or
disability or with a significantly increased risk
of suffering death, pain, disability or an
important loss of freedom. In addition, this
syndrome a pattern must not be merely an
expectable and culturally sanctioned response to
a particular event e.g. the death of loved one.
Whatever its original cause, it must currently be
considered a manifestation of a behavioural,
psychological or biological dysfunction in the
individual. Neither deviant behaviour (e.g.
political, religious or sexual) nor conflicts
that are primarily between the individual and
society are mental disorders unless the deviance
or conflict is a symptom of a dysfunction in the
individual as described above. Multi-axial
Assessment- A multi axial system involves an
assessment on several axes, each of which refers
to a different domain of information that may
help the clinician plan treatment predict
outcome.
8
There are five axes included in the DSM IV multi
axial classification- Axis I Clinical
Disorders Other Conditions that may
be a focus of clinical
attention. Axis II Personality Disorders and
Mental Retardation Axis III General
Medical Conditions Axis IV Psycho-social and
Environmental Problems. Axis V Global
Assessment of Functioning AXIS I-Axis I is for
reporting all the various disorders or conditions
in the classification except for the Personality
Disorders and Mental Retardation (which are
reported on Axis II). Also reported on Axis I are
other conditions that may be
9
a focus of clinical attention. When
an individual has more than one Axis I disorder
all of these should be reported. The principal
diagnosis or the reason for visit should be
indicated by listing it first. When an individual
has both an Axis I and an Axis II disorder, the
principal diagnosis or the reason for visit will
be assumed to be on Axis I unless the Axis II
diagnosis is followed by the qualifying phrase
(Principal Diagnosis) or (Reason for Visit).
If no Axis I disorder is present, this
should be coded as V 71.09. If an Axis I
diagnosis is deferred, pending the gathering of
additional informational, this should be coded as
799.9 AXIS
I Clinical
Disorder Other conditions that may be a focus of
Clinical Attention
10
  1. Disorders usually first diagnosed in Infancy
    Childhood or Adolescence (excluding Mental
    Retardation, which is diagnosed on Axis II)
  2. Delirium (disordered state of mind), Dementia
    (incoherent speech), Amnesic and other cognitive
    disorders
  3. Mental Disorders due to a General Medical
    condition
  4. Substance related disorders
  5. Schizophrenia and other Psychotic Disorders
  6. Mood disorders
  7. Anxiety disorders
  8. Somatoform disorders
  9. Factitious disorders
  10. Dissociative disorders

11
11. Sexual and Gender Identity disorders 12.
Eating disorders 13. Sleep disorders 14. Impulse
control disorders (not elsewhere classified) 15.
Adjustment disorders 16. Other conditions that
may be a focus of clinical attention AXIS II
Axis II is for reporting Personality Disorders
and Mental Retardation. It may also be used for
noting prominent maladaptive personality features
and defense mechanisms. The listing of
Personality Disorders and Mental Retardation on a
separate axis ensures that consideration will be
given to the possible presence of Personality
Disorders and Mental Retardation that might
otherwise be overlooked when attention is
directed to the usually more florid Axis I
disorders.
12
  • If an individual has more than one Axis II
    diagnosis then all are reported. When an
    individual has both Axis I and an Axis II
    diagnosis and Axis II is the principal diagnosis
    or the reason for the visit, then this is
    indicated by adding the qualifying phrase,
    (Principal Diagnosis or Reason for visit after
    the Axis II diagnosis). If no Axis II disorder is
    present, then it is coded as V 71.09. If an Axis
    II diagnosis is deferred, pending the gathering
    of additional information, then it is coded as
    799.9.
  • AXIS II
  • Personality Disorders
  • Mental Retardation
  • Paranoid Personality Disorder
  • Schizoid Personality Disorder
  • Schizotypal Personality Disorder

13
4. Anti social Personality Disorder 5. Border
line Personality Disorder 6. Histrionic
Personality Disorder 7. Narcissistic Personality
Disorder 8. Avoidant Personality Disorder 9.
Dependant Personality Disorder 10. Obsessive
Compulsive Personality Disorder 11. Personality
Disorder (not otherwise specified) 12. Mental
Retardation AXIS III Axis III is for reporting
current general medical conditions that are
potentially relevant to the understanding or
management of the individual mental disorder.
When an individual has more than one
clinically relevant
14
  • Axis III diagnosis, all are reported. If no Axis
    III disorder is present, then that is indicated
    by the notation Axis III None. If an Axis III
    diagnosis is deferred, pending the gathering of
    additional information then this is indicated by
    the notation Axis III-deferred.
  • AXIS III
  • General Medical Conditions (with 1CD-9-CM codes)
  • Infectious and Parasitic Diseases
  • Neoplasm (growth of tissues in any part of body
    or tumor)
  • Endocrine, Nutritional and Metabolic Diseases and
    Immunity Disorders
  • Diseases of Blood and Blood forming organs
  • Diseases of nervous system and sense organs
  • Diseases of circulatory system

15
7. Diseases of respiratory system 8.Diseases of
digestive system 9. Diseases of genitourinary
system 10. Complications of pregnancy, child
birth and puerperium (fever due to child
birth) 11. Diseases of the skin and subcutaneous
tissue 12. Diseases of musculoskeletal system and
connective tissue 13. Congenital Anomalies 14.
Certain conditions originating in the Prenatal
period 15. Symptoms, Signs and ill-defined
conditions 16. Injury and Poisoning AXIS IV Axis
IV is for reporting psycho-social and
environmental problems that may effect the
diagnosis,
16
treatment and prognosis of mental disorders. A
psychosocial or environmental problem may be a
negative life event, and environmental difficulty
or deficiency, a family related or other
interpersonal stress, an inadequacy of social
support or personal resources or problem relating
to the context in which a persons difficulties
have developed. So called positive stressors,
such as job promotion should be listed only if
they constitute or lead to problem e.g. when a
person has difficulty adapting to the new
situation. When an
individual has multiple psychosocial or
environmental problems in general the clinician
note only those problems that have been present
during the year preceding the current
evaluation.
AXIS IV Psychosocial and
Environmental Problems
17
  • Problems with primary support group
  • Problems related to the social environment
  • Educational Problems
  • Occupational Problems
  • Housing Problems
  • Economic Problems
  • Problems with access to health care services
  • Problems related to interaction with the legal
    system/ crime
  • Other psycho social and environmental problems
  • AXIS V Axis V is reporting the clinician
    judgment of the individuals overall level of
    functioning. This information is useful in
    planning treatment and measuring its impact and
    in predicting outcome.

18
This reporting is done using the Global
Assessment of Functioning (GAF) scale. The GAF
scale reading is done only with respect to
psychological, social and occupational
functioning. The rating is not done with respect
impairment in functioning due to the physical or
environmental limitations. In most instances,
rating on the GAF scale is done for the current
period as it will help in determining the need
for treatment or care. In some settings, GAF
rating is done both at time of admission and at
the time of discharge. In some instances GAF
scale may also be rated for other periods e.g.
the highest level of functioning for at least a
few months during the past year.
AXIS V Consider
psychological, social and occupational
functioning on a hypothetical continum of mental
health-illness. Do not include impairment in
functioning due to physical or environmental
limitations.
19
  • Code
  • Superior functioning in a wide range of
    activities. Lifes
  • problems never seem to get out of
    hand, is sought by
  • others because of his or her many
    positive qualities.
  • No symptoms.
  • Absent or minimal symptoms. Good
    functioning in all
  • areas. Interested and involved in a
    wide range of
  • activities, socially effective,
    generally satisfied with
  • life, no more everyday problems or
    concerns.
  • If symptoms are present, they are
    transient and

20
  • expectable reactions to
    psychosocial stressors no
  • more than slight impairment in
    social, occupational
  • or social functioning.
  • Some mild symptoms or some difficulties
    in social,
  • occupational or school functioning
    but generally
  • functioning pretty well, has some
    meaningful inter-
  • -personal relationship.
  • Moderate symptoms or moderate
    difficulties in
  • 51 social, occupational or school
    functioning.

21
  • Serious symptoms or any serious
    impairment in
  • social, occupational or school
    functioning.
  • Some impairment in reality testing or
    communication
  • or major impairment in several
    areas, such as work
  • or school, family relations,
    judgments thinking or
  • mood.
  • Behaviour is considerably influenced
    by delusions or
  • hallucination or serious
    impairment in communication
  • or judgment or inability to
    function in almost all
  • 21 areas.

22
  • Some danger of hurting self or others
    or occasionally
  • fails to maintain minimal personal
    hygiene or gross
  • impairment in communication.
  • Persistent danger of severely hurting
    self or others
  • or persistent inability to maintain
    minimal personal
  • hygiene or serious suicidal act
    with clear expectation
  • 1 of death.
  • 0 Inadequate information.
  • Examples of DSM IV Multi-axial Evaluation

23
Axis I 296.23 Major Depressive Disorder,
Single Episode,
Severe without Psychotic Features.
305.00 Alcohol Abuse Axis II 301.6
Dependent Personality Disorder Frequent
use of Denial Axis III
None Axis IV Threat of
job loss Axis V GAF 35
(current) Evaluation of DSM IV 1. There are
changes in multi-axial system. The childhood and
developmental disorders which were on Axis II in
DSM III-R are shifted to Axis I in DSM IV.
24
2. In DSM III-R, Axis IV was for the assessment
of severity of psychological stressors. But in
DSM IV it is now for the assessment for
psychosocial and environmental problems. 3. Axis
V is same as in DSM III-R except the scale points
have been extended from 90 to 100. 4. Some
criteria's of mental disorders have been modified
such as the criteria for mental retardation has
been modified by including the diagnosis of
deficiency of skills. 5. Learning disorders have
been introduced in place of academic skill
disorders in DSM-III-R. 6. Communication
disorders introduced in place of speech disorders
in DSM-III-R. 7. Some new disorders have been
introduced e.g. feeding disorder, delirium,
dementia due to multiple causes, catatonic
25
disorders due to general medical conditions etc.
DSM-III-R disorders deleted from DSM IV are over
anxious disorder of childhood, avoidant disorder
of childhood, undifferentiated attention deficit
disorder, passive aggressive personality
disorders. CRITICISM 1. After so much
improvement in DSM IV. Some psychologists shall
talk about and doubts regarding the reliability
and validity of DSM IV. 2. Some of the
psychologists has pointed out that in DSM IV no
attention is given to the history and
developmental problem of the patient. 3. In DSM
IV sometimes the clinicians has to use his
impressionistic clinical judgment regarding the
client e.g. when a clinician has to decide the
severity of particular disorder he has to depend
on his own judgment.
26
4. Some of the criticism focus on the fact that
with the DSM classification it is easy to define
them in broad category but it is very difficult
to go in minute details of particular disorder
such sub categories are not mentioned in DSM
IV. 5. In DSM IV little importance has been
attained to the cause of mental disorders. 6. In
DSM classification the clinician has to apply
multi-axial System on every patient. It is really
very torturous, cumbersome and time
consuming. 7. When we apply DSM IV on a
particular patient sometimes the symptoms and the
criteria do not fit exactly on the patient e.g.
if in a particular disorder there are four
important symptoms but a patient is showing or
exhibiting only three out of them then the doubt
arises i.e. whether to put that particular
patient in that category or not.
27
8. In DSM IV there is no provision of putting two
disorders together e.g. in day to day life it has
been observed that anxiety and depression
sometimes they occur together, but in DSM IV
there is no such category which is known by the
name of Mixed Anxiety Depression disorder but in
reality such conditions occur and then the
clinician is in the state of uncertainty.
28
THANK
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