Essential Diagnostic Strategies

Presented by: John C. Simoneaux, Ph.D.

Professional Training Resources, Inc., publications and seminars are presented with the understanding that Professional Training Resources, Inc, does not render any legal or other specific professional services. The material contained in this booklet is intended to convey general information for educational purposes. Due to the rapidly changing nature of the law, information contained in publications may become outdated. Although professionals prepare these materials, nothing in this outline should be construed as legal or other advice on specific matters. As always, one should consult competent legal authorities on questions relating to the law and its application.

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MATERIALS PREPARED BY JOHN C. SIMONEAUX, PH.D. – Dr. Simoneaux is the owner of Professional Training Resources, Inc. and Consulting Psychologists of Central Louisiana. He is a psychologist practicing in the state of Louisiana. Dr. Simoneaux attended Nicholls State University, where he received his B.A. and M.A. degrees in Psychology, and Texas Tech University where he was awarded his Ph.D. After serving as the Program Director of the Adolescent and Children’s Service at Central Louisiana for several years he established a private practice with an emphasis on psychological assessments with forensic implications. His practice involves extensive work with the courts in the central Louisiana region and elsewhere over the past several years, completing numerous evaluations for children’s protective services, child custody, sanity, personal injury, and other forensic applications. Dr. Simoneaux routinely serves as a courtappointed expert witness, having frequently testified in many jurisdictions. He served as a Medical Expert for the Office of Hearings and Appeals (Social Security Administration).

This manual is intended for private use only. All rights are reserved by individual authors. Please do not reproduce any portion of this publication, without written permission of the author.

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Table of Contents: Page

DSM-5 The First 17 Pages

4

DSM-5: Use of the Manual – It’s not what you think it is

9

DSM-5 – Cautionary Statement Regarding Forensic Use

13

Grief in DSM-5 – Where is it?

15

Essential Elements of a Diagnostic Interview

17

Unstructured vs. Structured Interviews

19

ICD-10- International Statistical Classification of Diseases and Related Health Problems

20

Four Types of Diagnoses

41

The Meaning Behind the “Code”

42

Definitions of Illness and Disorder

43

Diagnoses and Pragmatism

45

Alternative Approaches

47

Should Disorders be Grouped Differently?

50

DSM-Controversies

53

Disorder or Not?

55

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DSM-5 – The First 17 Pages This first chapter (“Introduction”) comprises the first 17 pages of the softback edition published by the American Psychiatric Association. By the third paragraph, it appears that APA is acknowledging that efforts to improve the reliability of psychiatric diagnoses have not been successful – and admitting that this effort (i.e., DSM-5) may be only an incremental improvement. “The science of mental disorders continues to evolve”. It is recognized, however, that a rigid adherence to a categorical system does not accurately reflect what we see in our offices, clinics, and hospitals. It is noted that the scientific/clinical community must find ways to incorporate dimensional approaches to mental disorders – interesting in light of the 11th hour scrapping of proposed sweeping changes to personality disorders along those very lines. Nonetheless, it appears that the APA is trying hard, albeit awkwardly, to embrace the idea that “the boundaries between disorders are more porous than originally perceived. A very brief history (five sentences) is provided to describe previous editions, and a more extensive summary of the revision process is offered. A 28-member task force was developed in 2007 and work groups were formed, beginning in 2008 to set about proposing revisions over what was described as an “intensive” six-year period. Draft revisions were guided by the following four principles: 1. 2. 3. 4.

DSM-5 had to be useful for routine clinical practice Research evidence should guide any changes Continuity with previous editions should be maintained if possible No constraints should limit the degree of change proposed

New diagnoses and disorder subtypes and specifiers would be subject to stipulations involving reliability, clinical utility, and validity. It seems that a high priority was placed on eliminating the NOS categories, and one aim was to refine the definition of a “mental disorder”. Field trials were described as taking place in two major types of settings, large medical-academic sites (11 in North America) and in “routine clinical practices” (via recruitment of individual psychiatrists and other mental health clinicians – volunteers). In 2010, the APA developed its Web site to generate public and professional input into the development of the diagnostic manual. Drafts of changes were posted for a 2month comment period and more than 8,000 submissions were offered and reviewed initially. Revisions took place, and a second posting was published in 2011 – feedback was reviewed, and there was a third and final posting in 2012. More than 13,000 comments were received and reviewed and there were “thousands of organized petition signers for and against some proposed revisions . . .” Apparently, as the actual writing began, the members of 13 work groups collaborated with advisors and reviewers to draft the diagnostic criteria and the text. The text editor Professional Training Resources, Inc.

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reportedly worked in close collaboration with the work groups under the direction of the task force chairs. A “Scientific Review Committee (SRC)” was established to provide a peer-review process outside of the work groups and to ensure that the proposed changes could be supported by scientific evidence. All of this work was submitted to the APA Board of Trustees (the final authority) for consideration. Another committee was formed – the “Clinical and Public Health Committee” to consider other concerns relating to clinical utility, public health, etc. The APA Council on Psychiatry and Law reviewed disorders relevant to forensic environments and forensic experts advised work groups in pertinent areas. Many changes were subject to field trial testing, though there is an admission that “comprehensive testing of all proposed changes could not be accommodated by such testing because of time limitations and availability of resources.” Finally, recommendations from the task force were provided to the Board of Trustees and the APA Assembly’s Committee on DSM-5, made up of a “diverse group of assembly leaders”. An executive “summit committee” session was held, followed by a preliminary review by the full Board of Trustees, a vote, and approval for publication in December, 2012. Phew!!! The next section of the Introduction describes the new organizational structure of DSM5. In summary:     

The individual disorder definitions are the core of DSM-5 The classification of the disorders (the grouping) has never been thought of as significant It was thought that rethinking the organizational structure might improve clinical utility and stimulate new clinical perspectives and encourage research It is recognized that the criteria and their relationships may need to be modified as new evidence is gathered – Personality Disorders are in section II (diagnostic criteria) and Section III (Conditions for Further Study). DSM-5 had to be in harmony with ICD-11 (International Classification of Diseases – not yet published)

It is important to understand developmental and lifespan considerations that were used in an effort to improve usefulness. DSM-5 is organized by starting with diagnoses that are thought to reflect developmental processes that manifest early in life – those with an earlier onset are listed first. A similar approach is used within each chapter. The proposed organization of chapters after the neurodevelopmental disorders is based on groups of internalizing (that is, those with prominent anxiety, depressive, and somatic symptoms), externalizing (that is, those with prominent impulsive, disruptive conduct, and substance use symptoms), and other disorders. It is hoped that this will encourage further study of underlying pathophysiological processes that underlie Professional Training Resources, Inc.

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diagnostic comorbidity and symptom heterogeneity. Related to these recommendations were “scientific validators” that served to inform how the disorders would group together based on 11 indicators:           

Shared neural substrates Family traits Genetic risk factors Specific environmental risk factors Biomarkers Temperamental antecedents Abnormalities of emotional or cognitive processing Symptom similarity Course of illness High comorbidity Shared treatment response

It is hoped that this organizational structure will serve as a convenient transition to new diagnostic approaches, without disrupting current clinical practice. APA seems to recognize that alternative definitions for many disorders will be necessary, leading to a model focusing on dimensional, rather than categorical descriptions, but it was thought that such profound changes were premature and too disruptive. “Such a reformulation of research goals should also keep DSM-5 central to the development of dimensional approaches to diagnosis that will likely supplement or supersede current categorical approaches in coming years” (p. 13). The influence of cultural concerns and gender differences is discussed as well. It is noted that Section III contains tools for an extensive cultural assessment, and the Appendix contains a “Glossary of Cultural Concepts of Distress”. Three concempts are described that outline the recommended approach to culture-bound syndomes: 1. Cultural syndrome – A group of unchanging symptoms found in a specific cultural group. Community, or context – not recognized as an illness within the culture, but recognizable by an outside observer 2. Cultural idiom of distress – a way of talking about suffering among individuals within a group. This is not associated with specific symptoms or perceived causes, and may convey a wide range of discomfort 3. Cultural explanations or perceived cause – an explanatory model that provides a culturally determined etiology. It is noted that sex and gender differences are established for a number of mental disorders, and revisions include reviews of potential differences between men and women in illness expression. Sex differences are attributable to reproductive organs Professional Training Resources, Inc.

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and the individual’s genetic complement, while gender differences result from biological sex as well as the person’s self-representation. Gender can influence illness in several ways: 1. Exclusive determination of whether someone is at risk for a disorder (e.g., premenstrual dysphoric disorder). 2. Moderate the overall risk for the development of a disorder 3. Gender may influence the likelihood that particular symptoms are experienced DSM-5 includes information on gender at multiple levels. Gender-specific symptoms are added to diagnostic criteria. A gender-related specifier is provided to offer additional information on gender and diagnosis. Additionally, a section labeled “Gender-Related Diagnostic Issues” outlines other concerns that are pertinent. The APA was clear in it’s intent to do away with NOS designations, pointing out that they were being overused and they led to lack of specificity. Two options were proposed and ultimately implemented: 



Other Specified Disorder – Allows the clinician to describe the specific reason that person does not meet the criteria for any specific category within a diagnostic class. o Record the name of the category, followed by the specific reason – for example: “other specified depressive disorder, depressive episode with insufficient symptoms” Unspecified Disorder – Used when the clinician chooses to not specify the reason the criteria are not met. Example: “unspecified depressive disorder”

The Multiaxial System It’s gone. Separate notations for important psychosocial and contextual factors (IV) and disability (V) are to be outlined separately. Axis III has been combined with Axes I and II – clinicians should continue to list medical conditions that are important to the understanding of the person’s mental disorder(s). It was decided that ICD-9 CM V codes ICD-10 Z codes could be used to describe relevant psychosocial and environmental problems. GAF was dropped for several reasons with the WHODAS (World Health Organization Disability Assessment Schedule) suggested for further study. Finally, online enhancements are discussed. Only the most relevant clinical rating scales and measures are included in the print edition. Additional measures used in field trials are available online (www.psychiatry.org/dsm5), linked to the relevant disorders. The Cultural Formulation Interview, Cultural Formulation Interview – Informant Version, and other elements of the interview are available online at the same address. It is noted that PsychiatryOnline.org provides an online subscription service that enhances the Professional Training Resources, Inc.

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printed text. Also available are supportive references and additional information. DSM5 does not tell you this, but the annual fee for this service is presently $420.00 – information can be found at this address: http://www.appi.org/SearchCenter/Pages/SearchDetail.aspx?ItemId=POLIND

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DSM-5: Use of the Manual – It’s Not What You Think It Is The authors of DSM-5, in this section, seem to fall all over themselves reminding us of what DSM-5 is not, warning how it should not be used. However, the section starts by outlining that the design is to “provide a practical guide to using DSM-5”, especially for clinicians. It is noted that:       

Symptoms do not constitute comprehensive definitions of underlying disorders It is not sufficient to check off the symptoms to make a diagnosis This section does not recommend treatment options These diagnoses do not fully describe the range of mental disorders experienced by patients or seen by clinicians throughout the world DSM-5 does not capture the full range of psychopathology The definition of a mental disorder cannot capture all aspects of all disorders It is not possible to separate normal and pathological symptom expressions

With all of that said, the manual correctly underscores the fact that a careful clinical history is required for a complete case formulation, and that formulation should address the social, psychological, and biological factors that contributed to the mental disorder. Clinical training is necessary to recognize when the combination of factors adds up to a condition that exceeds “normal”, with the ultimate goal being the development of a comprehensive treatment plan informed by the patient’s cultural and social context. A long and wordy definition of a mental disorder is offered, that was reportedly developed for clinical, public health, and research purposes. It is noted that additional information is usually required beyond the diagnostic criteria to make legal judgments of criminal responsibility, eligibility for disability, and competency. In every case, however, the diagnosis should have clinical utility, helping to determine prognosis, to formulate a plan of treatment, and to predict treatment outcomes. Diagnosis is not equal to a need for treatment. Sometimes we see patients whose symptoms do not meet the full criteria for a specific disorder, but the person demonstrates a clear need for treatment or care. Three types of evidence are cited as being important in validating a diagnosis: 1. Antecedent variables a. Similar genetic markers b. Family traits c. Temperament d. Environmental exposure 2. Concurrent Validators Professional Training Resources, Inc.

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a. Similar neural substrates b. Biomarkers c. Emotional processing d. Cognitive processing e. Symptom similarity 3. Predictive Validators a. Similar clinical course b. Treatment response The most important standard for the DSM-5 disorder criteria is clinical utility. [Editorial note: This may be one of the more important statements in the entire manual]. The diagnosis should guide the clinical course and the treatment response of individuals grouped by a given set of diagnostic criteria. There is a chapter covering the relationship between a mental disorder and disability that outlines the decision to suggest the World Health Organization’s Disability Assessment Schedule (WHODAS) as useful standardized measure of disability in mental disorders. Since there are no clinically useful measurements of severity for mental disorders, it is often not possible to separate normal and pathological symptom expressions. A generic diagnostic criteria, requiring distress or disability is noted. This is very important, however, so I want to underscore and highlight this notation: “The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning” In what I consider to be a less important note, it is pointed out that the use of information from family members and other third-parties regarding the individual’s performance is recommended when necessary. In another “editorial” aside I must point out that, in my world, this kind of collateral information is often less useful because the clinician must wade through unintended bias (and sometimes outright lying) on the part of the collateral source. The “Elements of a Diagnosis” are outlined:     

Diagnostic criteria are guidelines for making diagnoses Subtypes and/or specifiers should be considered as appropriate Severity and course specifiers should be applied t0 describe current presentation (but only when full criteria are met) If full criteria are not met, consider “other specified” or “unspecified” designations Disorder severity should be applied (e.g., mild, moderate, severe, extreme). Severity specifiers rate the intensity, frequency, duration, symptom count, or

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 

other severity indicators and are indicated by the instruction “Specify current severity” in the criteria set. Disorder specific definitions are usually offered. Descriptive features (e.g., good to fair insight, in a controlled environment) should be offered. These are designed to convey additional information to inform treatment planning. Course specifiers should be reviewed (e.g., in partial remission, recurrent, etc.)

Subtypes and specifiers are coded in the fourth, fifth, or sixth digit, and provide for increased specificity: 



“Subtypes” – o mutually exclusive and jointly exhaustive subgroupings within a diagnosis o indicated by the instruction “Specify whether” in the criteria set. “Specifiers” – o Not necessarily mutually exclusive or jointly exhaustive o more than one specifier may be given. o They are indicated by the instruction “Specify” or “Specify if” in the criteria set. o Provide the ability to define a subgrouping of patients who share certain features, and to convey relevant information to patient management.

Sometimes subtypes and specifiers can be coded with a fifth digit, but often not since there is no analogue in the ICD system. A DSM-5 diagnosis usually is only applied to the individual’s current presentation previous diagnoses from which the person has recovered should be clearly noted. Course specifiers may help in this case. Not all disorders include course, severity, and/or descriptive features specifiers. A separate chapter in Section II is “Medication-Induced Movement Disorders and Other Conditions That May Be a Focus of Clinical Attention”. These conditions may be the reason the patient showed up in the first place, such as akathisia, tardive dyskinesia, and dystonia. In this section are descriptions of neuroleptic malignant syndrome (a lifethreatening condition) and antidepressant discontinuation syndrome (a commonly observed condition). The chapter just after this one describes other conditions that could be a focus of clinical attention such as relational problems, problems related to abuse and neglect, etc., (the “V-Codes). When there is more than one diagnosis for someone in an inpatient, the principal diagnosis is the condition established to be chiefly responsible for occasioning the admission of the individual. For someone in an outpatient setting, the principal diagnosis describes the condition that constitutes the reason for the visit that is chiefly Professional Training Resources, Inc.

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responsible for the services received during the visit. It is noted that it is sometimes difficult, and often arbitrary, to determine which diagnosis is “Principal”. The principal diagnosis is indicated by listing it first, with the remaining disorders listed in order of focus of attention and treatment. However, ICD coding rules require that the etiological medical condition be listed first – that would apply when the principal diagnosis or reason for visit is a mental disorder due to another medical condition (e.g., major neurocognitive disorder due to Alzheimer’s disease, psychotic disorder due to malignant lung neoplasm). If you are unsure about how to do this, then simply follow the principal diagnosis with a qualifying phrase such as “principal diagnosis” or “reason for visit”. Provisional This term is used when it is strongly presumed that the full criteria will eventually be met, but not enough information is available to make a firm diagnosis. Another use is for those situations in which differential diagnosis depends exclusively on the duration of the illness (i.e., schizophreniform disorder). Coding Every disorder has an identifying diagnostic and statistical code, and there are specific recording protocols for those codes established by WHO, the U.S. Centers for Medicare and Medicaid Services (CMS), and the Centers for Disease Control and Prevention’s National Center for Health Statistics. You will mess up the world if you do not follow these coding conventions. Presently, the official coding system is ICD-9-CM, but adoption of ICD-10-CM is scheduled for 10/1/14. ICD-10 codes are parenthetically shown in DSM-5, but should not be used until the official implementation. Assessment and Monitoring Tools Section II contains assessment tools, and descriptions of conditions for further study. These are included to highlight the “evolution and direction of scientific advances in these areas and to stimulate further research”. It is noted that the measures are provided to help in a comprehensive assessment. It is further suggested that the cultural formulation interview should be useful to assist in communication with an individual – it is included in this section. Diagnosis specific severity measures are provided to help establish a baseline for comparison with ratings on subsequent encounters.

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DSM-5 – Cautionary Statement Regarding Forensic Use As with previous editions of DSM, the American Psychiatric Association inserted caveats and warnings regarding the use of the diagnostic manual for matters relating to the courts. DSM-5 is no exception. It is recognized that the manual is often used as a reference for the court in “assessing the forensic consequences of mental disorders. The definition of a mental disorder that is included in DSM-5 was designed for clinicians, public health professionals, and researchers – not to meet the needs of the courts and attorneys. Of course, diagnoses and information used to generate diagnoses can help lawyers and legal decision makers to determine those factors that are necessary to make their determinations. The use of an established and widely accepted system of diagnosis adds to the value and reliability of determinations of the relevance of a mental illness in three ways: 1. Provides a compendium based on a review of the pertinent clinical and research literature and offers a possible understanding of the relevant characteristics of mental disorders 2. The literature related to diagnoses serve to prevent ungrounded speculation about mental disorders and about the functioning of a particular individual 3. Diagnostic information about the course of an illness may improve decision making when the legal issue concerns an individual’s mental functioning at a past or future point in time. The reader is informed, however, that the use of the diagnostic manual should be informed of the risks and implications of its use in forensic settings. There is a risk that diagnostic information might be misused or misunderstood since there is not an exact fit between questions that legal professionals may want answered, as compared to information that is relevant to a clinician. It is noted that a diagnosis of a mental illness does not at all imply that any legal criteria are met, such as competence, criminal responsibility, disability, etc.). Almost always, additional criteria would be necessary, along with specialized clinical/forensic skills, in order to make the proper legal recommendation. This could include information about the individual’s functional impairments and how those impairments affect the person’s specific abilities in question. These impairments often vary widely, even within a particular diagnostic. The assignment of a specific diagnosis does not imply a specific level of impairment or disability. The authors of DSM-5 say that it is “not advised” that nonclinical, nonmedical, or otherwise insufficiently trained individuals use DSM-5 to assess for the presence of a mental disorder. This clearly indicates that lawyers, attorneys, and/or other legal Professional Training Resources, Inc.

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personnel who are not specifically training regarding mental illness and diagnoses should not be using the manual. Further, those decision makers are cautioned that a diagnosis does not carry any implications about the causes of the mental disorder, or the degree to which the individual might have control over the behaviors that are associated with the disorder. It is noted that, even when a disorder does involve diminished capacity as a symptom, that fact by itself does not demonstrate that a specific person did or did not have voluntary control of his/her behavior at a specific time.

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Grief in DSM-5 – Where Is It? After considerable controversy while DSM-5 was under development, descriptions of grief are difficult to find in the text – and probably with good reason. While some proposed that was pathologize extended grief, and essentially decide how long “normal” grief should last, others wisely (in my opinion) suggested that grief is normative and adaptive. Any arbitrary determination about the “normal” course of grief would only be confusing and prejudicial, resulting in some believing that there are effectively “rules” for grieving and failing to follow those rules would mean that someone is ill or crazy. Instead of dealing with this problem directly and obviously, the authors of DSM-5 seem to have decided to underplay this concern, by leaving the description of “grief” to what is literally a footnote (written verbatim in two sections). However, the narrative included in this footnote is well-written, helpful, and instructive. I applaud the unnamed author. However, the information is not formatted in a way that is easily accessible – it is hidden. I decided, with this article, to bring it out from the shadows so it can be more useful to clinicians. The word “grief” is not referenced in the “Table of Contents” section, nor is it listed in the “Contents” at the beginning. There is a description, however, of “Persistent Complex Bereavement Disorder” in the section titled “Conditions for Further Study”, and “Bereavement” is referred to in a few places. It is briefly defined in the following way, under the heading of “Differential Diagnosis” in the “Separation Anxiety” description: Bereavement: Intense yearning or longing for the deceased, intense sorrow and emotional pain and preoccupation with the deceased or the circumstances of the death are expected responses occurring in bereavement, whereas fear of separation from other attachment figures is central in separation anxiety disorder. The above-mentioned footnote is found in three locations in DSM-5. Under the criteria for Bipolar I and for Bipolar II Disorder, as well as under the criteria for Major Depressive Disorders. Both of these notations are in the context of distinguishing grief from a major depressive episode (MDE). It is noted that it is useful to consider the difference between grief and depression, with the narrative going on to describe the differences in some detail. It would seem that this could have been more usefully illustrated in a tabular fashion, so I have taken the liberty below.

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Grief Predominant Affect

 Feelings of emptiness and loss

Course

 Increases in intensity over days or weeks  Occurs in waves  Waves are associated with thoughts or reminders of the deceased  May be accompanied by positive emotions and humor

Associated Features

Thought Content Self-Esteem

Cognitions

Major Depression  Persistent depressed mood  Inability to anticipate happiness or pleasure  More persistent  Not tied to specific thoughts or preoccupations

 Not typically associated with humor  Pervasive unhappiness and misery reported  Self-critical or pessimistic ruminations

 Preoccupation with thoughts and memories of the deceased  Generally preserved  Feelings of worthlessness and self-loathing are  Self-derogatory ideation common typically involves perceived failings vis-à-vis the deceased  Thoughts about death and  Thoughts are focused on dying are generally focused ending one’s own life on the deceased because of feeling worthless, undeserving  Possible focus on joining of life, or unable to cope the deceased with the pain of depression

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Essential Elements of A Diagnostic Interview: Sensitivity – Relates to the examiners ability to empathize with the child and to adjust his/her approach to the child’s developmental level. It also implies that the examiner is attentive to the child’s level of anxiety and attempt to carry out the evaluation process with the least amount of stress possible. Fluidity – The examiner should strive to maintain a natural and smooth flow in the child’s verbal and nonverbal communication. A sense of fluidity is created by facilitating smooth transitions from one topic to the next. By paying close attention to the child’s communications and emotional expression, the examiner can encourage a sense of cohesion and fluidity. Depth – The examiner should clarify and explore the main issues at hand, including their ramifications and meanings. Special attention is given to the child’s verbal and nonverbal manifestations of affect. Every time the child exhibits affect, the examiner should ask the child to verbalize what made him/her feel that particular way. When the child is narrating events that are filled with emotion by nature, but the child does not display the corresponding affect, the examiner should be aware of the discrepancy and try to draw out suppressed emotions. Coherence – As the examiner tries to connect and integrate the information gathered during the interview, he/she brings coherence to the process. Inexperienced interviewers often give the process a quality of discontinuity or fragmentation. When this happens one is left with the impression that the communication is unclear of disjointed, that certain areas were not explored adequately, or that certain topics were missed altogether. When coherence is not achieved, the child often feels irritated and misunderstood. Specificity – Refers to the understanding and identification of the presenting complaints and to the clarification of the context in which the symptoms appear. Because psychopathology and problems of adaptation do not go hand in hand, the examiner needs to clarify how psychopathology interferes with the patient’s adaptive capacity. Comprehensiveness – The examiner should strive to be thorough. Comprehensiveness is achieved by exploring all the possible ramifications of a given problem in the context of the child’s developmental history and his/her current family and school circumstances. Meaningfulness – The interview should make overall sense. This speaks to the quality of meaningfulness. By following through with a topic and sticking to it until full understanding is achieved, the examiner gains depths and breadth of meaning.

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Versatility – Versatility relates to the examiner’s skill in meeting and engaging diverse presentations of child and family dysfunctions. The diagnostic interview needs to be tailored to the child’s and family’s needs. In order to build a bridge of trust and create an atmosphere of understanding, the examiner needs to address the specific issues relating to the child’s and family’s presenting problems. A monotonous or ritualistic survey of symptoms will not achieve this goal. Efficiency – The examiner needs to keep up a diligent pace in the process of a diagnostic interview. He/She must be efficient with time, so there should be a flexible and clear plan in mind. The experienced examiner knows how to differentiate the essential from the unimportant and learns to obtain the fundamental data in the least possible time and to use the obstacles as vehicles to increase understanding of the child and the child’s circumstances.

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Unstructured vs. Structured Interviews: Unstructured Interviews: The interview is considered to be unstructured if the examiner does not follow a prefixed scheme to conduct the interview process. The examiner does not follow a prearranged path in the exploration of the relevant issues or in the manner in which he/she completes the mental status examination. This provides a great deal of flexibility. The examination can be tailored to the relevant issues or to the most salient aspects that emerge during the examination. The examiner should try to follow a coherent threat in the flow of emerging data and takes advantage of the child’s emotional abreactions to understand the nature of the child’s internal conflict and distress. In unstructured interviewing, the examiner emphasizes the process and the vicissitudes of affect, and tries to help the patient see connections between the content of the interview and troublesome emotional factors that the patient may be experiencing. The empathic and emotional processes are emphasized, and building rapport and establishing a solid therapeutic alliance are the major objectives. The patient’s ability to relate to the examiner is more important than the data and the thoroughness of the interview. This method does not usually cover all areas of a clinical interview in a consistent and systematic fashion and frequently leaves important areas unexplored. Significant room exists for subjective inferences regarding observations and diagnosis. Structured Interviews: The structured interview seeks consistent and systematic data gathering and high levels of reliability in the diagnostic process. In the most structured from of interview, the examiner uses a standardized set of questions and stays within the predetermined format of the examination, without deviating, until the interview is completed. Structured interviewing has a unique role in research, in epidemiological studies, and in developmental studies. In structured interviewing, the degree of the examiner’s inferences is decreased significantly. Examples of highly structured interviews include the Diagnostic Interview for Children and Adolescents (DICA) and the Diagnostic Interview Schedule for Children (DISC). Examples of semistructured interviews include the Schedule for Affective Disorders and Schizophrenia for School Age Children (K-SADS), the Child Assessment Schedule, and the Interview Schedule for Children. Structured interviews have a number of limitations that make them unsuitable in clinical practice. The protocols are rigid and time-consuming. When the protocols are given to children and their families, they are left with the impression that the examiner ism ore interested in completing the test instrument than in listening to their concerns.

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ICD – 10 -- International Statistical Classification of Diseases and Related Health Problems (10th Revision) General Description: The Tenth Revision of the International Statistical Classification of Diseases and Related Health Problems is the latest in a series that was formalized in 1893 as the Bertillon Classification or International List of Causes of Death. A complete review of the historical background to the classification is given in Volume 2. While the title has been amended to make clearer the content and purpose and to reflect the progressive extension of the scope of the classification beyond diseases and injuries, the familiar abbreviation "ICD" has been retained. In the updated classification, conditions have been grouped in a way that was felt to be most suitable for general epidemiological purposes and the evaluation of health care. Volume 1 - Tabular List The first volume, which runs well over 1,000 pages, contains the classification at the three- and fourcharacter levels, the classification of the morphology of neoplasms, special tabulation lists for mortality and morbidity, definitions, and the nomenclature regulations. The volume also reproduces the report of the International Conference for the Tenth Revision, which indicates the many complex considerations behind the revisions. Volume 2 - Instruction Manual The second volume consolidates notes on certification and classification formerly included in Volume 1, supplemented by a great deal of new background information, instructions, and guidelines for users of the tabular list. Historical information about the development of the classification, which dates back to 1893, is also included. Volume 3 - Alphabetical Index The final volume presents the detailed alphabetical index. Expanded introductory material is complemented by practical advice on how to make the best use of the index. To facilitate efficient coding, the index includes numerous diagnostic terms commonly used as synonyms for the terms officially accepted for use in the classification. General principles of ICD-10 ICD-10 is much larger than ICD-9. Numeric codes (001-999) were used in ICD-9, whereas an alphanumeric coding scheme, based on codes with a single letter followed by two numbers at the three-character level (A00-Z99), has been adopted in ICD-10. This has significantly enlarged the number of categories available for the classification. Further detail is then provided by means of decimal numeric subdivisions at the four-character level. The chapter that dealt with mental disorders in ICD-9 had only 30 three-character categories (290-319); Chapter V(F) of ICD-10 has 100 such categories. A proportion of these categories have been left unused for the time being, so as to allow the introduction of changes into the classification without the need to redesign the entire system. Professional Training Resources, Inc.

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ICD-10 as a whole is designed to be a central ("core") classification for a family of disease- and healthrelated classifications. Some members of the family of classifications are derived by using a fifth or even sixth character to specify more detail. In others, the categories are condensed to give broad groups suitable for use, for instance, in primary health care or general medical practice. There is a multiaxial presentation of Chapter V(F) of ICD-10 and a version for child psychiatric practice and research. The "family" also includes classifications that cover information not contained in the ICD, but having important medical or health implications, e.g. the classification of impairments, disabilities and handicaps, the classification of procedures in medicine, and the classification of reasons for encounter between patients and health workers.

F00-F09 Organic, including symptomatic, mental disorders F00-F09 Organic, including symptomatic, mental disorders F00

Dementia in Alzheimer's disease

F00.0 Dementia in Alzheimer's disease with early onset F00.1 Dementia in Alzheimer's disease with late onset F00.2 Dementia in Alzheimer's disease, atypical or mixed type F00.9 Dementia in Alzheimer's disease, unspecified F01

Vascular dementia

F01.0 Vascular dementia of acute onset F01.1 Multi-infarct dementia F01.2 Subcortical vascular dementia F01.3 Mixed cortical and subcortical vascular dementia F01.8 Other vascular dementia F01.9 Vascular dementia, unspecified F02

Dementia in other diseases classified elsewhere

F02.0 Dementia in Pick's disease F02.1 Dementia in Creutzfeldt-Jakob disease F02.2 Dementia in Huntington's disease F02.3 Dementia in Parkinson's disease F02.4 Dementia in human immunodeficiency virus [HIV] disease F02.8 Dementia in other specified diseases classified elsewhere Professional Training Resources, Inc.

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F03

Unspecified dementia

A fifth character may be added to specify dementia in F00-F03, as follows: .x0 Without additional symptoms .x1 Other symptoms, predominantly delusional .x2 Other symptoms, predominantly hallucinatory .x3 Other symptoms, predominantly depressive .x4 Other mixed symptoms F04

Organic amnesic syndrome, not induced by alcohol and other

psychoactive substances F05

Delirium, not induced by alcohol and other psychoactive substances

F05.0 Delirium, not superimposed on dementia, so described F05.1 Delirium, superimposed on dementia F05.8 Other delirium F05.9 Delirium, unspecified F06

Other mental disorders due to brain damage and dysfunction and to physical disease

F06.0 Organic hallucinosis F06.1 Organic catatonic disorder F06.2 Organic delusional [schizophrenia-like] disorder F06.3 Organic mood [affective] disorders .30 Organic manic disorder .31 Organic bipolar disorder .32 Organic depressive disorder .33 Organic mixed affective disorder F06.4 Organic anxiety disorder F06.5 Organic dissociative disorder F06.6 Organic emotionally labile [asthenic] disorder F06.7 Mild cognitive disorder F06.8 Other specified mental disorders due to brain damage and dysfunction and to physical disease Professional Training Resources, Inc.

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F06.9 Unspecified mental disorder due to brain damage and dysfunction and to physical disease F07

Personality and behavioural disorders due to brain disease, damage and dysfunction

F07.0 Organic personality disorder F07.1 Postencephalitic syndrome F07.2 Postconcussional syndrome F07.8 Other organic personality and behavioural disorder due to brain disease, damage and dysfunction F07.9 Unspecified organic personality and behavioural disorders due to brain disease, damage and dysfunction F09

Unspecified organic or symptomatic mental disorder

F10-F19 Mental and behavioural disorders due to psychoactive substance abuse Mental and behavioural disorders due to psychoactive substance use F10.- Mental and behavioural disorders due to use of alcohol F11.- Mental and behavioural disorders due to use of opioids F12.- Mental and behavioural disorders due to use of cannabinoids F13.- Mental and behavioural disorders due to use of sedatives or hypnotics F14.- Mental and behavioural disorders due to use of cocaine F15.- Mental and behavioural disorders due to use of other stimulants, including caffeine F16.- Mental and behavioural disorders due to use of hallucinogens F17.- Mental and behavioural disorders due to use of tobacco F18.- Mental and behavioural disorders due to use of volatile solvents F19.- Mental and behavioural disorders due to multiple drug use and use of other psychoactive substances Four- and five-character codes may be used to specify the clinical conditions, as follows: F1x.0 Acute intoxication .00

Uncomplicated

.01

With trauma or other bodily injury

.02

With other medical complications

.03

With delirium

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.04

With perceptual distortions

.05

With coma

.06

With convulsions

.07

Pathological intoxication

F1x.1 Harmful use F1x.2 Dependence syndrome .20

Currently abstinent

.21

Currently abstinent, but in a protected environment

.22 Currently on a clinically supervised maintenance or replacement regime [controlled dependence] .23

Currently abstinent, but receiving treatment with aversive or blocking drugs

.24

Currently using the substance [active dependence]

.25

Continuous use

.26

Episodic use [dipsomania]

F1x.3 Withdrawal state .30

Uncomplicated

.31

With convulsions

F1x.4 Withdrawal state with delirium .40 Without convulsions .41 With convulsions F1x.5 Psychotic disorder .50 Schizophrenia-like .51 Predominantly delusional .52 Predominantly hallucinatory .53 Predominantly polymorphic .54 Predominantly depressive symptoms .55 Predominantly manic symptoms .56 Mixed F1x.6 Amnesic syndrome Professional Training Resources, Inc.

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F1x.7 Residual and late-onset psychotic disorder .70 Flashbacks .71 Personality or behaviour disorder .72 Residual affective disorder .73 Dementia .74 Other persisting cognitive impairment .75 Late-onset psychotic disorder F1x.8 Other mental and behavioural disorders F1x.9 Unspecified mental and behavioural disorder

F20-F29 Schizophrenia, schizotypal and delusional disorders F20-F29 Schizophrenia, schizotypal and delusional disorders F20

Schizophrenia F20.0 Paranoid schizophrenia F20.1 Hebephrenic schizophrenia F20.2 Catatonic schizophrenia F20.3 Undifferentiated schizophrenia F20.4 Post-schizophrenic depression F20.5 Residual schizophrenia F20.6 Simple schizophrenia F20.8 Other schizophrenia F20.9 Schizophrenia, unspecified

A fifth character may be used to classify course: F20.x0

Continuous

F20.x1

Episodic with progressive deficit

F20.x2

Episodic with stable deficit

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F20.x3

Episodic remittent

F20.x4

Incomplete remission

F20.x5

Complete remission

F20.x8

Other

F20.x9

Course uncertain, period of observation too short

F21

Schizotypal disorder

F22

Persistent delusional disorders F22.0 Delusional disorder F22.8 Other persistent delusional disorders F22.9 Persistent delusional disorder, unspecified

F23

Acute and transient psychotic disorders F23.0 Acute polymorphic psychotic disorder without symptoms of schizophrenia F23.1 Acute polymorphic psychotic disorder with symptoms of schizophrenia F23.2 Acute schizophrenia-like psychotic disorder F23.3 Other acute predominantly delusional psychotic disorder F23.8 Other acute and transient psychotic disorders F23.9 Acute and transient psychotic disorder, unspecified

A fifth character may be used to identify the presence or absence of associated acute stress: F23.x0 Without associated acute stress F23.x1 With associated acute stress

F24

Induced delusional disorder

F25

Schizoaffective disorders F25.0 Schizoaffective disorder, manic type F25.1 Schizoaffective disorder, depressive type F25.2 Schizoaffective disorder, mixed type F25.8 Other schizoaffective disorders

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F25.9 Schizoaffective disorder, unspecified F28

Other nonorganic psychotic disorders

F29

Unspecified nonorganic psychosis

F30-F39 Mood (affective) disorders F30 Manic Episode F30.0 Hypomania F30.1 Mania without psychotic symptoms F30.2 Mania with psychotic symptoms F30.8 Other manic episodes F30.9 Manic episode, unspecified

F31 Bipolar affective disorder F31.0 Bipolar affective disorder, current episode hypomanic F31.1 Bipolar affective disorder, current episode manic without psychotic symptoms F31.2 Bipolar affective disorder, current episode manic with psychotic symptoms F31.3 Bipolar affective disorder, current episode mild or moderate depression .30 Without somatic syndrome .31 With somatic syndrome F31.4 Bipolar affective disorder, current episode severe depression without psychotic symptoms F31.5 Bipolar affective disorder, current episode severe depression with psychotic symptoms F31.6 Bipolar affective disorder, current episode mixed F31.7 Bipolar affective disorder, currently in remission F31.8 Other bipolar affective disorders F31.9 Bipolar affective disorder, unspecified

F32 Depressive episode F32.0 Mild depressive episode

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.00 Without somatic syndrome .01 With somatic syndrome F32.1 Moderate depressive episode .10 Without somatic syndrome .11 With somatic syndrome F32.2 Severe depressive episode without psychotic symptoms F32.3 Severe depressive episode with psychotic symptoms F32.8 Other depressive episodes F32.9 Depressive episode, unspecified

F33 Recurrent depressive disorder F33.0 Recurrent depressive disorder, current episode mild .00 Without somatic syndrome .01 With somatic syndrome F33.1 Recurrent depressive disorder, current episode moderate .10 Without somatic syndrome .11 With somatic syndrome F33.2 Recurrent depressive disorder, current episode severe without psychotic symptoms F33.3 Recurrent depressive disorder, current episode severe with psychotic symptoms F33.4 Recurrent depressive disorder, currently in remission F33.8 Other recurrent depressive disorders F33.9 Recurrent depressive disorder, unspecified

F34 Persistent mood [affective] disorders F34.0 Cyclothymia F34.1 Dysthymia F34.8 Other persistent mood [affective] disorders F34.9 Persistent mood [affective] disorder, unspecified

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F38 Other mood [affective] disorders F38.0 Other single mood [affective] disorders .00 Mixed affective episode F38.1 Other recurrent mood [affective] disorders .10 Recurrent brief depressive disorder F38.8 Other specified mood [affective] disorders

F39 Unspecified mood [affective] disorder

F40-F48 Neurotic, stress-related and somatoform disorders F40 Phobic anxiety disorders F40.0 Agoraphobia .00 Without panic disorder .01 With panic disorder F40.1 Social phobias F40.2 Specific (isolated) phobias F40.8 Other phobic anxiety disorders F40.9 Phobic anxiety disorder, unspecified

F41 Other anxiety disorders F41.0 Panic disorder [episodic paroxysmal anxiety] F41.1 Generalized anxiety disorder F41.2 Mixed anxiety and depressive disorder F41.3 Other mixed anxiety disorders F41.8 Other specified anxiety disorders F41.9 Anxiety disorder, unspecified

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F42 Obsessive-compulsive disorder F42.0 Predominantly obsessional thoughts or ruminations F42.1 Predominantly compulsive acts [obsessional rituals] F42.2 Mixed obsessional thoughts and acts F42.8 Other obsessive-compulsive disorders F42.9 Obsessive-compulsive disorder, unspecified

F43 Reaction to severe stress, and adjustment disorders F43.0 Acute stress reaction F43.1 Post-traumatic stress disorder F43.2 Adjustment disorders .20 Brief depressive reaction .21 Prolonged depressive reaction .22 Mixed anxiety and depressive reaction .23 With predominant disturbance of other emotions .24 With predominant disturbance of conduct .25 With mixed disturbance of emotions and conduct .28 With other specified predominant symptoms F43.8 Other reactions to severe stress F43.9 Reaction to severe stress, unspecified

F44 Dissociative [conversion] disorders F44.0 Dissociative amnesia F44.1 Dissociative fugue F44.2 Dissociative stupor F44.3 Trance and possession disorders F44.4 Dissociative motor disorders F44.5 Dissociative convulsions

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F44.6 Dissociative anaesthesia and sensory loss F44.7 Mixed dissociative [conversion] disorders F44.8 Other dissociative [conversion] disorders .80 Ganser's syndrome .81 Multiple personality disorder .82 Transient dissociative [conversion] disorders occurring in childhood and adolescence .88 Other specified dissociative [conversion] disorders F44.9 Dissociative [conversion] disorder, unspecified

F45 Somatoform disorders F45.0 Somatization disorder F45.1 Undifferentiated somatoform disorder F45.2 Hypochondriacal disorder F45.3 Somatoform autonomic dysfunction .30 Heart and cardiovascular system .31 Upper gastrointestinal tract .32 Lower gastrointestinal tract .33 Respiratory system .34 Genitourinary system .38 Other organ or system F45.4 Persistent somatoform pain disorder F45.8 Other somatoform disorders F45.9 Somatoform disorder, unspecified

F48 Other neurotic disorders F48.0 Neurasthenia F48.1 Depersonalization-derealization syndrome F48.8 Other specified neurotic disorders

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F48.9 Neurotic disorder, unspecified F50-F59 Behavioural syndromes associated with physiological disturbances and physical factors F60-F69 Disorders of adult personality and behaviour F70-F79 Mental retardation F80-F89 Disorders of psychological development F90-F98 Behavioural emotional disorders with onset usually occurring in childhood or adolescence

Behavioural syndromes associated with physiological disturbances and physical factors

F50 Eating disorders F50.0 Anorexia nervosa F50.1 Atypical anorexia nervosa F50.2 Bulimia nervosa F50.3 Atypical bulimia nervosa F50.4 Overeating associated with other psychological disturbances F50.5 Vomiting associated with other psychological disturbances F50.8 Other eating disorders F50.9 Eating disorder, unspecified

F51 Nonorganic sleep disorders F51.0 Nonorganic insomnia F51.1 Nonorganic hypersomnia F51.2 Nonorganic disorder of the sleep - wake schedule F51.3 Sleepwalking [somnambulism] F51.4 Sleep terrors [night terrors] F51.5 Nightmares F51.8 Other nonorganic sleep disorders Professional Training Resources, Inc.

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F51.9 Nonorganic sleep disorder, unspecified

F52 Sexual dysfunction, not caused by organic disorder or disease F52.0 Lack or loss of sexual desire F52.1 Sexual aversion and lack of sexual enjoyment .10 Sexual aversion .11 Lack of sexual enjoyment F52.2 Failure of genital response F52.3 Orgasmic dysfunction F52.4 Premature ejaculation F52.5 Nonorganic vaginismus F52.6 Nonorganic dyspareunia F52.7 Excessive sexual drive F52.8 Other sexual dysfunction, not caused by organic disorder or disease F52.9 Unspecified sexual dysfunction, not caused by organic disorder or disease

F53 Mental and behavioural disorders associated with the puerperium, not elsewhere classified F53.0 Mild mental and behavioural disorders associated with the puerperium, not elsewhere classified F53.1 Severe mental and behavioural disorders associated with the puerperium, not elsewhere classified F53.8 Other mental and behavioural disorders associated with the puerperium, not elsewhere classified F53.9 Puerperal mental disorder, unspecified

F54 Psychological and behavioural factors associated with disorders or diseases classified elsewhere F55 Abuse of non-dependence-producing substances F55.0 Antidepressants F55.1 Laxatives Professional Training Resources, Inc.

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F55.2 Analgesics F55.3 Antacids F55.4 Vitamins F55.5 Steroids or hormones F55.6 Specific herbal or folk remedies F55.8 Other substances that do not produce dependence F55.9 Unspecified

F59 Unspecified behavioural syndromes associated with physiological disturbances and physical factors

Disorders of adult personality and behaviour F60 Specific personality disorders F60.0 Paranoid personality disorder F60.1 Schizoid personality disorder F60.2 Dissocial personality disorder F60.3 Emotionally unstable personality disorder .30 Impulsive type .31 Borderline type F60.4 Histrionic personality disorder F60.5 Anankastic personality disorder F60.6 Anxious [avoidant] personality disorder F60.7 Dependent personality disorder F60.8 Other specific personality disorders F60.9 Personality disorder, unspecified

F61 Mixed and other personality disorders F61.01 Mixed personality disorders F61.11 Troublesome personality changes Professional Training Resources, Inc.

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F62 Enduring personality changes, not attributable to brain damage and disease F62.0 Enduring personality change after catastrophic experience F62.1 Enduring personality change after psychiatric illness F62.8 Other enduring personality changes F62.9 Enduring personality change, unspecified

F63 Habit and impulse disorders F63.0 Pathological gambling F63.1 Pathological fire-setting [pyromania] F63.2 Pathological stealing [kleptomania] F63.3 Trichotillomania F63.8 Other habit and impulse disorders F63.9 Habit and impulse disorder, unspecified

F64 Gender identity disorders F64.0 Transsexualism F64.1 Dual-role transvestism F64.2 Gender identity disorder of childhood F64.8 Other gender identity disorders F64.9 Gender identity disorder, unspecified

F65 Disorders of sexual preference F65.0 Fetishism F65.1 Fetishistic transvestism F65.2 Exhibitionism F65.3 Voyeurism F65.4 Paedophilia

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F65.5 Sadomasochism F65.6 Multiple disorders of sexual preference F65.8 Other disorders of sexual preference F65.9 Disorder of sexual preference, unspecified

F66 Psychological and behavioural disorders associated with sexual development and orientation F66.0 Sexual maturation disorder F66.1 Egodystonic sexual orientation F66.2 Sexual relationship disorder F66.8 Other psychosexual development disorders F66.9 Psychosexual development disorder, unspecified A fifth character may be used to indicate association with: .x0 Heterosexuality .x1 Homosexuality .x2 Bisexuality .x8 Other, including prepubertal

F68 Other disorders of adult personality and behaviour F68.0 Elaboration of physical symptoms for psychological reasons F68.1 Intentional production or feigning of symptoms or disabilities either physical or psychological [factitious disorder] F68.8 Other specified disorders of adult personality and behaviour

F69 Unspecified disorder of adult personality and behaviour

Mental retardation F70 Mild mental retardation F71 Moderate mental retardation F72 Severe mental retardation Professional Training Resources, Inc.

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F73 Profound mental retardation F78 Other mental retardation F79 Unspecified mental retardation

A fourth character may be used to specify the extent of associated behavioural impairment: F7x.0 No, or minimal, impairment of behaviour F7x.1 Significant impairment of behaviour requiring attention or treatment F7x.8 Other impairments of behaviour F7x.9 Without mention of impairment of behaviour

Disorders of psychological development F80 Specific developmental disorders of speech and language F80.0 Specific speech articulation disorder F80.1 Expressive language disorder F80.2 Receptive language disorder F80.3 Acquired aphasia with epilepsy [Landau-Kleffner syndrome] F80.8 Other developmental disorders of speech and language F80.9 Developmental disorder of speech and language, unspecified

F81 Specific developmental disorders of scholastic skills F81.0 Specific reading disorder F81.1 Specific spelling disorder F81.2 Specific disorder of arithmetical skills F81.3 Mixed disorder of scholastic skills F81.8 Other developmental disorders of scholastic skills F81.9 Developmental disorder of scholastic skills, unspecified

F82 Specific developmental disorder of motor function

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F83 Mixed specific developmental disorders

F84 Pervasive developmental disorders F84.0 Childhood autism F84.1 Atypical autism F84.2 Rett's syndrome F84.3 Other childhood disintegrative disorder F84.4 Overactive disorder associated with mental retardation and stereotyped movements F84.5 Asperger's syndrome F84.8 Other pervasive developmental disorders F84.9 Pervasive developmental disorder, unspecified

F88 Other disorders of psychological development F89 Unspecified disorder of psychological development , and associated problems.

Behavioural and emotional disorders with onset usually occurring in childhood and adolescence

F99 Unspecified mental disorder

F90 Hyperkinetic disorders F90.0 Disturbance of activity and attention F90.1 Hyperkinetic conduct disorder F90.8 Other hyperkinetic disorders F90.9 Hyperkinetic disorder, unspecified

F91 Conduct disorders Professional Training Resources, Inc.

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F91.0 Conduct disorder confined to the family context F91.1 Unsocialized conduct disorder F91.2 Socialized conduct disorder F91.3 Oppositional defiant disorder F91.8 Other conduct disorders F91.9 Conduct disorder, unspecified

F92 Mixed disorders of conduct and emotions F92.0 Depressive conduct disorder F92.8 Other mixed disorders of conduct and emotions F92.9 Mixed disorder of conduct and emotions, unspecified

F93 Emotional disorders with onset specific to childhood F93.0 Separation anxiety disorder of childhood F93.1 Phobic anxiety disorder of childhood F93.2 Social anxiety disorder of childhood F93.3 Sibling rivalry disorder F93.8 Other childhood emotional disorders F93.9 Childhood emotional disorder, unspecified

F94 Disorders of social functioning with onset specific to childhood and adolescence F94.0 Elective mutism F94.1 Reactive attachment disorder of childhood F94.2 Disinhibited attachment disorder of childhood F94.8 Other childhood disorders of social functioning F94.9 Childhood disorder of social functioning, unspecified

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F95 Tic disorders F95.0 Transient tic disorder F95.1 Chronic motor or vocal tic disorder F95.2 Combined vocal and multiple motor tic disorder [de la Tourette's syndrome] F95.8 Other tic disorders F95.9 Tic disorder, unspecified

F98 Other behavioural and emotional disorders with onset usually occurring in childhood and adolescence F98.0 Nonorganic enuresis F98.1 Nonorganic encopresis F98.2 Feeding disorder of infancy and childhood F98.3 Pica of infancy and childhood F98.4 Stereotyped movement disorders F98.5 Stuttering [stammering] F98.6 Cluttering F98.8 Other specified behavioural and emotional disorders with onset usually occurring in childhood and adolescence F98.9 Unspecified behavioural and emotional disorders with onset usually occurring in childhood and adolescence

F99 Mental disorder, not otherwise specified

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Four Types of Diagnoses: Wulff (1976) described four types of diagnoses: Symptom or Pseudoanatomical Diagnoses – Examples include fever, headache, or chronic diarrhea. These symptoms offer nothing to the clinician in terms of communicating information regarding treatment and prognosis.

Syndromes – Aggregated clusters of symptoms that probabilistically coexist. These are empirically derived diagnoses whose utility is ultimately defined by their predictive validity, especially in terms of practical therapeutic utility. Given the absence of a test to ensure the accuracy of syndromic psychiatric conditions, clinicians must recognize that these conditions may reflect more than one etiology or pathogenic mechanism. DSM-IV is full of syndromes that have not been validated. Even though the use of explicit categorical criteria to define a case may enhance reliability, it is impossible to determine at this time whether such an approach in fact enhances or limits diagnostic validity. One might seek to “test” all DSM diagnoses by their predictive validity – their ability to predict responses to therapeutic interventions and prospectively frame the probabilities of longer-term clinical outcomes.

Anatomical Diagnoses – These diagnoses became the norm for much of general medicine in the past. Such methods have been shown to have limited utility in psychiatry. Moreover, organ- or tissuePants getting smaller syndrome related diagnoses can have multiple etiologies (such as cirrhosis, cardiomyopathy, Alzheimer’s disease), a situation that can be likened to the nonspecificity of syndromes. Demonstrating that a condition is organic has little utility clinically unless there is a definable cause that can be treated; most often, clinicians are relegated to using treatments that were developed empirically for phenomenologically similar idiopathic psychiatric conditions. Ultimately, one must discern how brain function, psychological processes, and environmental influences interact to affect the expression of distress, disease, health, and illness. Etiological Diagnoses – Based on causes, not manifestations. Etiologically specific conditions cut across syndrome boundaries and often organ system boundaries. For example, infectious and inflammatory-immune diseases and diabetes present with a wide variety of symptoms, signs, or abnormal laboratory test results.

Wulff, H. R. (ed) (1976). Rational Diagnosis and Treatment. Oxford: Blackwell Scientific.

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The Meaning Behind the “Code” The diagnostic codes listed in the DSM-IV-TR were derived from the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM). This is the official coding system for reporting morbidity and mortality in the United States.

The codes range from 290.0 to 319.00 since they are actually derived from the specific “mental disorders” section of a much larger coding system that identifies all medical disorders. ICD-9-CM codes actually extent from 001 (Cholera) to 999 (Complications of Medical Care, Not Elsewhere Classified).

ICD-9 codes are required of clinicians working in the United States in order to get reimbursement from both government agencies, such as Medicare and Medicaid, as well as private insurers. The U.S. government plans to adopt ICD-10-CM in the fall of 2008 (probably October). Because the codes are updated yearly, the DSM-IV-TR codes have to be similarly updated. Thankfully, these changes are relatively infrequent. It anticipated that DSM-IV-CR (code revision) will be published to coincide with national adoption of ICD-10-CM.

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Definitions of Illness and Disorder: The World Health Organization (WHO) has always avoided defining disease, illness, or disorder in the successive revisions of the International Classification of Diseases, Injuries and Causes of Death (now called the International Statistical Classification of Diseases and Related Health Problems). The current ICD-10 Classification of Mental and Behavioral Disorders simply uses disorder to avoid the problems inherent in the use of the terms disease and illness. The WHO defines disorder as to imply the existence of a clinically recognizable set of symptoms or behavior associated in most cases with distress and with interference with personal functions.

The current edition of the Diagnostic and Statistical Manual of Mental Disorders, DSM-IV-TR provides a detailed definition of the term mental disorder. The definition is 146 words long and includes a clear statement that “neither deviant behavior 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,” but the definition fails to define or explain the crucial term dysfunction, except to say that it may be “behavioral, psychological, or biological” (p. xxxi).

It has been suggested that DSM-V should include a definition of mental disorder that can be used as a criterion for assessing potential candidates for inclusion in the classification, and deletions from it. The task force that produced DSM-IV asserted that there is no fundamental difference between mental illnesses or disorders and physical illnesses or disorders.

The most fundamental issue is whether the terms disease, illness, and disorder are biomedical terms or sociopolitical terms that involve value judgment. There are at least four types of definitions reflecting differing assumptions about the nature of disease or disorder:

Sociopolitical: A condition is regarded as a disease if it is agreed to be undesirable and if it seems on balance that physicians and their technologies are more likely to be able to deal with it effectively than are any of the potential alternatives, such as the criminal justice system (treating it as a crime), the church (treating it as a sin), or social work (treating it as a social problem). This approach is pragmatic and utilitarian. Whether the antisocial behavior of habitual delinquents is best regarded as criminal behavior or as a manifestation of antisocial personality disorder would be determined by the relative success of the criminal justice system versus psychiatry and clinical psychology in reducing the antisocial behavior. A given condition might be a mental disorder in one setting, but not in another, depending on the relative efficiency of medical and other approaches to the problem in those different settings.

Biomedical: The most widely quoted purely biomedical criterion of disease is the “biological disadvantage”. A disease is defined as “the sum of the abnormal phenomena displayed by a group of living organisms in association with a specified common characteristic or set of characteristics by which they differ from the norm for the species in such a way as to place them at a biological disadvantage. Professional Training Resources, Inc.

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Although many mental disorders are associated with a reduced life expectancy, and some are associated with a conspicuously reduced fertility, the biological disadvantage criterion has strange consequences when applied to mental disorders. Some milder conditions (phobias), as well as disorders with onset after the prime reproductive years, would fail to qualify as disorders, whereas other conditions that are not regarded as mental disorders, such as homosexuality, would fall under the definition of disorder.

Combined biomedical and sociopolitical: It has been argued that mental disorders are biological dysfunctions that are also harmful, implying that the concept of mental disorder necessarily involves both a scientific or biomedical criterion and an explicit value judgment or sociopolitical criterion. Originally it was determined that dysfunction should imply the failure of a biological mechanism to perform a natural function for which it has been designed by evolution. This has been shown to raise many problems. Too little is known about the evolution of most of the higher cerebral functions whose malfunctioning probably underlies many mental disorders. Mood states such as anxiety and depression may have evolved as biologically adaptive responses to danger or loss rather than being failures of evolutionarily designed functions. Several important cognitive abilities, like reading, have been acquired too recently to be plausibly regarded as natural functions designed by evolution.

Ostensive: It has been suggested that it is impossible to provide semantic or operational definitions of the concept of mental illness or disorder, only of individual disorders. Individual diseases are very heterogeneous because they have been identified at various stages over the last 400 years with defining characteristics of quite varied kinds. Some, like migraines, are still defined by their clinical syndromes. Others, such as mitral stenosis, by their morbid anatomy; tumors by their histopathology; most infections by the causative organism, porphyria by its biochemistry; Down syndrome by its chromosomal architecture, etc.

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Diagnoses and Pragmatism: Minimally, there are 3 parties involved in the practice of diagnosis: 1. 2. 3.

A specific patient to whom the diagnosis is applied A mental health professional who applies the diagnosis Society – others for whom the diagnosis has consequences

Diagnosis as a Solution to Social Problems:

Applying a diagnosis solves several social problems:   

  

When an individual causes problems to society, applying a diagnosis functions to justify intervention by mental health professionals For the individuals who were disturbed by the ill person, their social problems are solved when the disturbing person is either removed or changed. The more diagnoses we have at our disposal, the more options we have to bring relief to those who benefit from including disturbing behavior under the authority and sanction of mental health practitioners. Receiving a diagnosis often entitles a person to get social services that might otherwise not be available or that might not be paid for by a third party. Receiving a diagnosis may be personally comforting as it provides and “explanation”. Receiving a diagnosis may excuse a person from acts for which they might otherwise be held responsible or even punished.

Diagnosis as a Palliative for Professional Discomfort:  

Applying a diagnosis can bring relief to the practitioner who is otherwise confused by the behavior of the patient. Applying the diagnosis may dictate a prescribed course of action that the practitioner can follow.

Diagnosis as Organizer and Provider of Professional Identity:    

The practice of a diagnosis can make research easier to conduct and support. The most common research design (diagnostic category designs) almost guarantee publishable results – promoting highly publishable research also promotes the practice of diagnosis. Having diagnostic labels for sets of behaviors facilitates funding agencies’ calls for research proposals. Having more diagnostic labels provides researchers with professional identities and areas of expertise that may justify the reception of grants.

Diagnosis as a Marketing Tool:

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 

Diagnosis is a marketing strategy for the pharmaceutical manufacturers – having new diagnoses or new names for old diagnoses makes this marketing effort more successful. The diagnosis is marketed, and so, too, is a particular view about the nature of mental disorders.

Diagnosis as a Generator of Profits for the American Psychiatric Association: 

Some have alleged that the production of new revisions of the DSM may have become profitable in its own right – each addition of a new diagnostic label expands the practice of diagnosis, and each new edition of the manual guarantees a new round of sales of the DSM book.

There has arisen a small industry of DSM-related materials, including various workshops and continuing education seminars for professionals.

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Alternative Approaches: Ideal Types: A hypothetical construct denoting a configuration of characteristics which on the basis of theory and observations, are assumed to be interrelated. Ideal types are idealized descriptions that offer a particular perspective on a condition and impose conceptual clarity on cases that, by their nature, are fuzzy and imprecise. This assessment process does not require the clinician to assess diagnostic criteria and make a diagnostic decision based on the number of features present. Instead, an actual case is compared with ideal or prototypical cases. In the process, the relationship among clinical features is clarified and understood. Prototype: Organized around prototypical cases (the best examples of the concept), with less prototypical cases forming a continuum away from prototypical cases. This structure is especially pertinent to the classification of personality disorders, because clinicians seem to use prototypic categorization intuitively in everyday discussion, describing patients as exhibiting “typical borderline personality disorder” or “classic histrionic tdiagnoses. Prototypes establish gradients of category membership. This method would involve lists of features that define a concept or diagnosis. These lists are not orheganized, except in terms of the degree to which each feature is prototypical of the diagnosis. Westen and Shedler (2000) used a Q-factor analysis (a type of inverse factor analysis that explores the relationship among subjects, rather than descriptive items or traits as in standard factor analysis). Seven clusters were identified: 1. 2. 3. 4. 5. 6. 7.

Dysphoric Schizoid Antisocial Obsessional Paranoid Histrionic Narcissistic

Single vs. Separate Axes: The decision to place personality disorders on a separate axis in DSM-III was based on pragmatic considerations rather than any theoretical or empirical rationale. The development of a separate axis created the impression that there are fundamental differences between personality disorder and other mental disorders. This idea has encouraged discrimination toward those with personality disorder and has led to problems in funding treatment. It is used to refuse treatment and to justify a moralistic attitude toward those suffering from the condition. DSM revisers will need to consider whether the negative effects on patients of placing personality disorder on a separate axis outweigh the advantages derived from focusing Professional Training Resources, Inc.

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attention on personality disorder. Major qualitative differences between personality disorder and all other mental disorders are not apparent. Recent evidence suggests that personality disorder shares some vulnerability factors with a range of other mental disorders, such as mood, anxiety, and substance-related disorders. The assertion that the diagnosis of personality disorder is based on traits and attitudes that manifest themselves early in life and remain stable over time does not withstand close scrutiny. DSM criteria set include items that are similar to Axis I criteria. Some Axis I criteria are similar to traits. The two axes share dimensions, such as impulsivity, affective lability, anxiousness, and cognitive dysregulation.

There has been a tendency to think of Axis I disorders as largely biological/genetic, while Axis II disorders have been thought to be psychosocial in origin. The origins of mental disorders are actually much more complex. Most conditions arise from an interaction of an array of biological and environmental factors. Behavior genetic analyses of twin data show that the traits constituting personality disorder, like those of normal personality, have a substantial heritable component. Heritable traits such as neuroticism that are strongly associated with personality disorder also predispose to a range of Axis I disorders, including mood and anxiety disorders. A final reason for asserting that personality disorders should have their own axis is that they are more stable and enduring than clinical syndromes. This argument confuses the stability of personality disorder with the stability of personality traits. The evidence for the stability of personality traits does not apply to all aspects of personality. Many of the features of personality disorder also show considerable temporal instability, and even the presence of the diagnosis fluctuates over time. Any difference in temporal stability between personality disorder and other mental disorders applies only to episodic mental disorders and not to those that follow a chronic course. Dysthymic disorder, schizophrenia, and some cases of delusional disorder show levels of stability that do not differ appreciably from those of personality disorder. Higher Order Patterns – Multivariate statistical studies have identified a variety of higher-order factors that represent broad patterns of personality disorder. Four factors have been proposed: Emotional Dysregulation – Characterized by lower-order traits such as affective lability, anxiousness, negative temperament, eccentric perceptions, cognitive dysregulation, submissiveness, and self-harm. The construct resembles Borderline Personality Disorder but covers a wide range of behaviors. This factor is consistently identified and should be a central component of any classification of personality disorder.

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Dissocial Behavior – Defined by such traits as callousness, rejection, and conduct problems. Callousness and rejection are core features. This factor resembles psychopathy as described by Cleckley and Hare. Inhibitedness -- Characterized by avoidance of intimacy, restricted expression of inner experiences, and social avoidance. The essential feature is expressing any kind of feeling, and a reluctance to reveal information about the self. This patterns appears to represent the social withdrawal associated with Cluster A diagnoses and avoidant personality disorder.

Basic Dispositional Traits A set of more specific traits are necessary to represent clinically significant individual differences. Behavior genetic suggest that personality is inherited as a large number of genetic dimensions that predispose to specific or basic-level traits. In effect, the lowerorder traits should be defined to reflect specific genetic dimensions. Lower order studies show remarkable agreement on the basic traits of personality disorder. A preliminary list includes:

               

Affective lability Anxiousness Callousness Cognitive dysregulation Compulsivity Conduct problems Insecure attachment Intimacy avoidance Narcissism Oppositionality Rejection Restricted expression Social avoidance Stimulus seeking Submissiveness Suspiousne

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Should Disorders be Grouped Differently? Throughout history, proposals for etiologically-based diagnostic systems, ranging from phrenology to psychoanalysis, have alternated with proposals for description-based systems.  

    

Hippocrates believed that mental health depended on the balance of blood, phlegm, black bile, and yellow bile Parcelsus developed a classification system for mental disorders that was based on etiology: vesania (disorders caused by poison), lunacy (a periodic condition influenced by the phases of the moon), and insanity (diseases caused by heredity). In the 1800s, an attempt was made to classify mental illness according the presence of brain lesions Kraepelin hoped that there would be an etiologically based system to complement his descriptive one. DSM-I had only 3 superordinate categories DSM-II had 10 superordinate categories DSM-III increased the number of categories to 16. These diagnostic classes were subsequently used, with minor modifications, in DSM-III-R and DSM-IV.

In more recent versions of DSM, the guiding principle for the creation of the higherorder classes was descriptive and pragmatic, based on clinical utility and the facilitation of differential diagnosis rather than on an empirical foundation or theory about pathogenesis.

Organizational Questions Should DSM-V include a group of Obsessive-Compulsive Spectrum disorders? During the development of DSM-IV there was some consideration given to moving Body Dysmorphic Disorder (BDD) and hypochondriasis to the anxiety disorders section because of their apparent similarities with Obsessive Compulsive Disorder. The obsessive-compulsive spectrum concept is an example of how disorders might be reorganized on the basis of a presumably shared pathogenesis. Disorders are thought to have a “spectrum membership” on the basis of their similarities with OCD in a variety of domains. These similarities involve not only symptoms, but also sex ratio, age at onset, course, comorbidity, joint familial loading, treatment response, and presumed Professional Training Resources, Inc.

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etiology. The obsessive-compulsive spectrum shares similarities with some other proposed spectra, such as the schizophrenia spectrum and the affective spectrum.

Disorders commonly included in the spectrum are:    

Tourette’s Disorder BDD Hypochondriasis Impulse Control Disorders o Trichotillomania o Kleptomania

Should Somatoform Disorders be moved to different sections on DSM-V? According to DSM-IV-TR, the common feature of the Somatoform Disorders is the presence of physical symptoms that suggest a general medical condition. The grouping of these disorders in a single section is based on clinical utility rather than shared etiology. Even though the somatoform disorders seem quite similar in content (focus on the body) they are dissimilar in form and are likely to have distinct etiologies. It is sometimes difficult to differentiate hypochondriasis from the somatic obsessions of OCD. Some of the somatoform disorders appear heterogeneous. The relationship between somatization disorder and other psychiatric disorders is even less clear. Comorbidity studies suggest a relationship with conversion disorder, dissociative disorders, depressive disorders, panic disorder, substance-related disorders, and cluster B personality disorders. Family studies suggest a relationship with substance-related disorders and antisocial personality disorder.

Should delusional and nondelusional variants of disorders be combined? There have been discussions about whether delusional and nondelusional variants of disorders should be classified as a single disorder, spanning a spectrum of isight, or should they be classified as distinct disorders? One inconsistency is DSM-IV-TR’s statement that delusional OCD, unlike delusional BDD or hypochondriasis, may be classified as either delusional disorder or psychotic disorder not otherwise specified. Another inconsistency is that whereas BDD and OCD may be double coded with their delusional variant (such as, patients with delusional symptoms may receive both

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diagnoses). This reflects the possibility that their delusional and nondelusional forms constitute the same disorder, this is not noted as an option for hypochondriasis. OCD and hypochondriasis have a “poor insight” specifier, but BDD does not. This is the case even though BDD is more often characterized by poor insight than is OCD. The criteria for hypochondriasis further differentiate delusional and nondelusional forms of the disorder which specifies that the belief is “not of delusional intensity”. Some believe that future research will show that BDD, OCD, hypochondriasis, and anorexia nervosa are characterized by a spectrum of insight and that the subtype model – with and without psychotic features – used to classify mood disorders will prove more valid and clinically useful than the current schema. Should DSM-V include a section of stress-related disorders? While DSM-IV was being debated, there was an option offered to move PTSD from the anxiety disorders section into a newly created section of “stress-related disorders”. It was unclear, however, which disorders should be members of the new category. One proposal included PTSD and acute stress disorder – a second proposal also included adjustment disorder. A third, broader proposal included all three of these disorders plus pathological grief and uncomplicated bereavement. Yet another proposal was to create a new category called disorders of extreme stress not otherwise specified, a residual category for responses following trauma that do not meet criteria for acute stress disorder or PTSD. It was also proposed that PTSD be classified with the dissociative disorders. The rationale for proposing a “stress-related disorders” category is that it emphasizes stress as a common etiologic factor. Classifying stress-related disorders together would facilitate differential diagnosis and grouping PTSD, acute stress disorder, and adjustment disorder would make DSM more compatible to ICD-10. The major limitation of this proposal is that, although stress clearly plays an important role in the onset of these disorders, it is not their only cause. There are also significant genetic influences on symptom liability. Another drawback is that although some research suggests a special etiological connection between a traumatic event and PTSD, a stress is nonetheless nonspecific as a risk factor for psychiatric illness, playing an etiological role in many disorders, not just the proposed members of a stress-related category.

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DSM -- Controversies The organization and the structure of the DSM present precise and exacting criteria to be used to diagnose a mental disorder. The level of precision and specificity of criteria have persuaded many professionals to conclude (without critical evaluation) that the DSM identifies and describes clear and distinct disorders, in a manner both useful and beneficial to professionals and consumers. The DSM does have merit. When used correctly, it is very reliable, that is, one group of professionals using the DSM will often reach a similar diagnosis as another. Yet scientists and practitioners are concerned that these diagnoses, although reliable, are often wrong and may do more harm than good. There is considerable overlap among diagnostic categories in the DSM. A more desirable or less desirable diagnosis can be made depending on the evaluator. Even when agreeing upon diagnoses, many professionals question the usefulness of the diagnoses and conclusions reached using the DSM. In other words, the diagnosis is not much more than a label based on an arbitrary set of symptoms. Frequently, a DSM diagnosis does not indicate the best course of action or even what treatment is necessary. Unfortunately there does not appear to be any clearly useful relationship between the DSM diagnosis, treatment and its outcome. For all the apparent precision and reliability, the DSM diagnostic system minimizes one important fact. The DSM was not constructed scientifically but is based on a consensus building process that is highly political, partially democratic and even resistant to scientific evidence. The mere fact that any diagnostic system is reliable does not mean the system is valid, useful or beneficial. Another important scientific observation is that very similar symptoms and behaviors resulting in a specific DSM diagnosis, can have many entirely different causes. More importantly, each cause can require an entirely different treatment. Diagnosis using the DSM does not identify the necessary treatment. The differences between people and their social environments can have a dramatic influence on how symptoms are expressed. Individuals might express a problem arising from the same source, by manifesting very different symptoms and behaviors. Culture and ethnicity are powerful moderators that strongly influence how people behave and how symptoms are reported and even experienced. The diagnostic process employed by the DSM is nowhere near the quality and sophistication of the diagnostic process in medicine - and many physicians argue that the medical diagnostic process is not sufficiently reliable or valid. And while there are similar diagnostic processes in medicine, most medical diagnoses are at least based on objective findings and scientific methods. For example, diagnoses of various forms of cancer are based on the observation of distinct physical structures and variations in biochemistry. The diagnosis of pneumonia is based on the presence of a bacterial or viral agent with fairly distinct symptoms, histories and responsiveness to treatment. Hypertension is identified by numerical measures of blood pressure, within normal deviations. Only a few areas of medical diagnoses are based purely on the patient's subjective complaints or vague medical terms. The overall diagnostic process employed in the DSM is not much more sophisticated than those used to reach the most general diagnosis of headache, a stomach ache or inner ear problems. There are many forms of headaches, stomachaches and inner ear problems. There are many things that can cause a headache: for example, a tumor, tension, injury, disease, flu, allergies, a cold or bacterial infection. In mental health, no matter how rigid the application of the DSM diagnostic or how sophisticated the interview process, the emerging patterns may have many origins. There can be many sources and causes of a particular problem; one type of traumatic experience can result in many different responses. As a result, the outcomes and treatment approaches can vary with the individual's beliefs, values, attitudes, culture, ethnicity and resources.

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Mental health professionals can rarely make a diagnosis based on identifiable changes or deviations in the structure or functions of the human body. With the exception of injury, aging, disease or forms of poisoning, very few mental health problems are medically related. Depending on whom you ask, between 70 and 90% of all diagnoses are the result of social, psychological and cultural factors that influence our lives. In sharp contrast, the pharmaceutical companies, which support a great deal of research and medical training, generally promote the assumption that disorders are the result of defective biology or genetics. Some people are simply different. They are not necessarily defective if they have difficulty fitting into rigid societal roles. But even when problems are psychological, drug companies promote that disorders can still be treated safely and in a cost effective manner with drugs as an alternative or as an adjunct to psychotherapy. Other issues created by the use of DSM are subtler, but they are real and they are important. For one thing, some professionals are losing sight of the patient as human being. They are also losing sight of how diagnostic labels impact upon patient rights, and the risks associated with using health insurance. (These risks are outlined in the full article, web reference above). Needless to say, teenagers’ entire future and prospects for employment can be altered by a seemingly innocent diagnosis. Professionals are increasingly at risk of becoming involved in a diagnostic process that does little more than expose consumers to significant risk in order to generate an authorization for payment from a managed care company. Of greater concern is the growing pressure by managed care to treat the symptoms of a DSM diagnosis and not the patient. The lifestyle, values and processes that create or sustain a patient's distress are ignored. Instead, the management or reduction of DSM defined symptoms becomes the focus. In the world of managed mental health care there is a growing emphasis on quick diagnosis and treatment of symptoms, not causes. When managing the initial set of symptoms, underlying causes may be missed. For instance, a cyclical mood disorder, such as cyclothymia, can co-exist with another diagnosis, for example, obsessive compulsive disorder or rare hormonal conditions.

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Disorder or Not? The authors of the various DSMs have had some difficulty even defining the word “disorder”. Even with a much-improved definition of mental disorder, there would still be problems and limitations. Any attempt to come up with an adequate definition that appropriately covers every conceivable scenario is doomed to fail. The text of DSM-IV-TR states that “no definition adequately specifies precise boundaries for the concept of ‘mental disorder’” (p. xxx). Further, in ICD-10 there are no attempts to define disease or illness. Some argue that no such definition is necessary. Including a definition of mental disorder does carry some important advantages: 1.

2. 3. 4.

The definition can help in the creation of a conceptual framework for delineating the boundaries between mental disorders and healthy states – the definition provides guidance on how to construct diagnostic criteria sets for individual disorders so as to minimize overdiagnosis or the problem of “false positives. The resulting conceptual framework can be of assistance in making decisions concerning whether newly proposed syndromes represent psychiatric disorders or nondisorder problems of living. A definition of mental disorder can help explain why particular distinctions are made and why there are disputes about some conditions. The definition can help in distinguishing between mental disorders and other medical conditions.

Questions have been raised over the past several years regarding whether certain disorders that are considered mental disorders in DSM-IV-TR should be considered neurological conditions. For example, it was suggested that Tourette’s Disorder be moved in ICD-9-CM from the chapter titled “Mental Disorders” to the chapter titled “Diseases of the Nervous System and Sense Organs”. Although the primary reason was to increase reimbursement for treatment of the condition, the evidence supporting the claim included functional imaging studies that demonstrated central nervous system dysfunction. If many disorders are based on central nervous system dysfunction, are they mental disorders or neurological disorders? This could spell the end of psychiatry and psychology as separate disciplines. This begs the question of whether a serviceable distinction can be maintained between psychiatric and neurological disorders. The general organizational principle governing the placement of disorders in larger categories in ICD-10 is ad hoc, being based on both etiology (e.g., “Infectious and Parasitic Diseases” and “Neoplasms”) and physiology or anatomy (e.g., “Endocrine, Nutritional, and Metabolic Diseases and Immunity Disorders,” “Diseases of the Blood and Blood-Forming Organs,” and “Diseases of the Genitourinary System”). The distinctions do not help in making the distinction between neurological and mental disorders because both entail dysfunctions involving the central nervous system. Historically, disturbances with an established physiological etiology localized to the central nervous system have been considered neurological, whereas idiopathic or functional disturbances have been deemed psychiatric. Ignorance of brain pathology allowed many conditions to be considered psychiatric disorders, which later, as knowledge increased, became known as neurological disorders. Epilepsy is the most obvious example. Some mental disorders might not involve neurological dysfunctions. Some dysfunctions may not be dysfunctions in neurological “hardware” but may instead be dysfunctions in the processing of psychological meanings that form the “software” of the brain.

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It is often assumed that mental disorders are those with mental etiologies. However, the fact that a mental process caused a physical disorder does not mean that the resulting disorder was a mental disorder, because the resulting type of dysfunction was physical. If the psychological factor itself was independently specifiable as a mental disorder, it would be said that there are both a mental disorder and a physical disorder, and possibly that the physical disorder is secondary to the mental disorder. Probably the most meaningful distinction between mental and nonmental involves the domain of disorder functions, not the etiology. A mental disorder involves a dysfunction in a cognitive, motivational, behavioral, emotional, or other psychological mechanism. Psychological mechanisms are those that have some special involvement of representational meanings or consciousness. In many cases, whether a particular type of dysfunction is considered psychiatric or neurological reflects historical traditions regarding which specialty is primarily involved in its management. For example, aphasia secondary to a stroke is usually considered neurological because patients are usually cared for by a neurologist. Memory loss, loss of abstract reasoning, and personality change (i.e., dementia) is considered psychiatric because a psychiatrist is usually responsible for management. Ultimately, establishing the boundary between mental disorders and other general medical conditions is inherently less important than clarifying the boundary between disorder and nondisorder. The classification of a condition as mental or neurological does not need to have any implications for correct identification of the problem. However, confusion about the distinction between disorder and nondisorder can lead to false positives and/or false negatives in diagnosis and to less than optimal treatment decisions.

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