Classification of mental disorders
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The classification of mental disorders, also known as psychiatric nosology or psychiatric taxonomy, is central to the practice of
psychiatry Psychiatry is the medical specialty devoted to the diagnosis, treatment, and prevention of deleterious mental disorder, mental conditions. These include matters related to cognition, perceptions, Mood (psychology), mood, emotion, and behavior. ...
and other mental health professions. The two most widely used psychiatric classification systems are chapter V of the ''
International Classification of Diseases The International Classification of Diseases (ICD) is a globally used medical classification that is used in epidemiology, health management and clinical diagnosis. The ICD is maintained by the World Health Organization (WHO), which is the dir ...
'', 10th edition (
ICD-10 ICD-10 is the 10th revision of the International Classification of Diseases (ICD), a medical classification list by the World Health Organization (WHO). It contains codes for diseases, signs and symptoms, abnormal findings, complaints, social cir ...
), produced by the
World Health Organization The World Health Organization (WHO) is a list of specialized agencies of the United Nations, specialized agency of the United Nations which coordinates responses to international public health issues and emergencies. It is headquartered in Gen ...
(WHO); and the ''
Diagnostic and Statistical Manual of Mental Disorders The ''Diagnostic and Statistical Manual of Mental Disorders'' (''DSM''; latest edition: ''DSM-5-TR'', published in March 2022) is a publication by the American Psychiatric Association (APA) for the classification of mental disorders using a com ...
'', 5th edition (DSM-5), produced by the
American Psychiatric Association The American Psychiatric Association (APA) is the main professional organization of psychiatrists and trainee psychiatrists in the United States, and the largest psychiatric organization in the world. It has more than 39,200 members who are in ...
(APA). Both systems list disorders thought to be distinct types, and in recent revisions the two systems have deliberately converged their codes so that their manuals are often broadly comparable, though differences remain. Both classifications employ
operational definition An operational definition specifies concrete, replicable procedures designed to represent a construct. In the words of American psychologist S.S. Stevens (1935), "An operation is the performance which we execute in order to make known a concept." F ...
s. Other classification schemes, used more locally, include the '' Chinese Classification of Mental Disorders''. Manuals of limited use, by practitioners with alternative theoretical persuasions, include the '' Psychodynamic Diagnostic Manual''.


Definitions

In the scientific and academic literature on the definition or
categorization Classification is the activity of assigning objects to some pre-existing classes or categories. This is distinct from the task of establishing the classes themselves (for example through cluster analysis). Examples include diagnostic tests, identi ...
of mental disorders, one extreme argues that it is entirely a matter of value judgments (including of what is normal) while another proposes that it is or could be entirely objective and
scientific Science is a systematic discipline that builds and organises knowledge in the form of testable hypotheses and predictions about the universe. Modern science is typically divided into twoor threemajor branches: the natural sciences, which stu ...
(including by reference to statistical norms); other views argue that the concept refers to a "fuzzy
prototype A prototype is an early sample, model, or release of a product built to test a concept or process. It is a term used in a variety of contexts, including semantics, design, electronics, and Software prototyping, software programming. A prototype ...
" that can never be precisely defined, or that the definition will always involve a mixture of scientific facts (e.g. that a natural or
evolved Evolution is the change in the heritable Phenotypic trait, characteristics of biological populations over successive generations. It occurs when evolutionary processes such as natural selection and genetic drift act on genetic variation, re ...
function is not working properly) and value judgments (e.g. that it is harmful or undesired). Lay concepts of mental disorder vary considerably across different
cultures Culture ( ) is a concept that encompasses the social behavior, institutions, and Social norm, norms found in human societies, as well as the knowledge, beliefs, arts, laws, Social norm, customs, capabilities, Attitude (psychology), attitudes ...
and countries, and may refer to different sorts of individual and social problems. The WHO and national surveys report that there is no single consensus on the definition of mental disorder, and that the phrasing used depends on the social, cultural, economic and legal context in different contexts and in different societies. The WHO reports that there is intense debate about which conditions should be included under the concept of mental disorder; a broad definition can cover mental illness, intellectual disability, personality disorder and substance dependence, but inclusion varies by country and is reported to be a complex and debated issue. There may be a criterion that a condition should not be expected to occur as part of a person's usual culture or religion. However, despite the term "mental", there is not necessarily a clear distinction drawn between mental (dys)functioning and brain (dys)functioning, or indeed between the brain and the rest of the body.PDF
Most international clinical documents avoid the term "mental illness", preferring the term "mental disorder". However, some use "mental illness" as the main overarching term to encompass mental disorders. Some consumer/survivor movement organizations oppose use of the term "mental illness" on the grounds that it supports the dominance of a medical model. The term "serious mental impairment" (SMI) is sometimes used to refer to more severe and long-lasting disorders while "
mental health Mental health is often mistakenly equated with the absence of mental illness. However, mental health refers to a person's overall emotional, psychological, and social well-being. It influences how individuals think, feel, and behave, and how t ...
problems" may be used as a broader term, or to refer only to milder or more transient issues. Confusion often surrounds the ways and contexts in which these terms are used. Mental disorders are generally classified separately to
neurological disorders Neurological disorders represent a complex array of medical conditions that fundamentally disrupt the functioning of the nervous system. These Disorder of consciousness, disorders affect the brain, spinal cord, and nerve networks, presenting unique ...
,
learning disabilities Learning disability, learning disorder, or learning difficulty (British English) is a condition in the brain that causes difficulties comprehending or processing information and can be caused by several different factors. Given the "difficulty ...
or intellectual disabilities.


ICD-10

The
International Classification of Diseases The International Classification of Diseases (ICD) is a globally used medical classification that is used in epidemiology, health management and clinical diagnosis. The ICD is maintained by the World Health Organization (WHO), which is the dir ...
(ICD) is an international standard diagnostic classification for a wide variety of health conditions. The ICD-10 states that mental disorder is "not an exact term", although is generally used "...to imply the existence of a clinically recognisable set of symptoms or behaviours associated in most cases with distress and with interference with personal functions." Chapter V focuses on "mental and behavioural disorders" and consists of 10 main groups: * F0 – F9: Organic, including symptomatic, mental disorders * F10 – F-19: Mental and behavioural disorders due to use of psychoactive substances * F20 – F29: Schizophrenia, schizotypal and delusional disorders * F30 – F39: Mood ffectivedisorders * F40 – F49: Neurotic, stress-related and somatoform disorders * F50 – F59: Behavioural syndromes associated with physiological disturbances and physical factors * F60 – F69: Disorders of personality and behaviour in adult persons * F70 – F79: Mental retardation * F80 – F89: Disorders of psychological development * F90 – 98: Behavioural and emotional disorders with onset usually occurring in childhood and adolescence * In addition, a group of F99 "unspecified mental disorders". Within each group there are more specific subcategories. The WHO has revised ICD-10 to produce the latest version, ICD-11, adopted by the 72nd World Health Assembly in 2019 and came into effect on 1 January 2022.


DSM-IV

The DSM-IV was originally published in 1994 and listed more than 250 mental disorders. It was produced by the
American Psychiatric Association The American Psychiatric Association (APA) is the main professional organization of psychiatrists and trainee psychiatrists in the United States, and the largest psychiatric organization in the world. It has more than 39,200 members who are in ...
and it characterizes mental disorder as "a clinically significant behavioral or psychological syndrome or pattern that occurs in an individual,...is associated with present distress...or disability...or with a significantly increased risk of suffering" but that "...no definition adequately specifies precise boundaries for the concept of 'mental disorder'...different situations call for different definitions" (APA, 1994 and 2000). The DSM also states that "there is no assumption that each category of mental disorder is a completely discrete entity with absolute boundaries dividing it from other mental disorders or no mental disorders." The DSM-IV-TR (Text Revision, 2000) consisted of five axes (domains) on which disorder could be assessed. The five axes were: :Axis I: Clinical Disorders (all mental disorders except Personality Disorders and Mental Retardation) :Axis II: Personality Disorders and Mental Retardation :Axis III: General Medical Conditions (must be connected to a Mental Disorder) :Axis IV: Psychosocial and Environmental Problems (for example limited social support network) :Axis V: Global Assessment of Functioning (Psychological, social and job-related functions are evaluated on a continuum between mental health and extreme mental disorder) The axis classification system was removed in the
DSM-5 The ''Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition'' (DSM-5), is the 2013 update to the '' Diagnostic and Statistical Manual of Mental Disorders'', the taxonomic and diagnostic tool published by the American Psychiat ...
and is now mostly of historical significance. The main categories of disorder in the DSM are:


Other schemes

* The Chinese Society of Psychiatry's Chinese Classification of Mental Disorders (currently CCMD-3) * The Latin American Guide for Psychiatric Diagnosis (GLDP). * The
Research Domain Criteria The Research Domain Criteria (RDoC) project is an initiative of personalized medicine in psychiatry developed by US National Institute of Mental Health (NIMH). In contrast to the Diagnostic and Statistical Manual of Mental Disorders (DSM) maintai ...
(RDoC), a framework being developed by the National Institute of Mental Health *The
Hierarchical Taxonomy of Psychopathology A hierarchy (from Greek: , from , 'president of sacred rites') is an arrangement of items (objects, names, values, categories, etc.) that are represented as being "above", "below", or "at the same level as" one another. Hierarchy is an importan ...
(HiTOP), developed by the HiTOP consortium, a group of psychologists and psychiatrists who had a record of scientific contributions to classification of psychopathology.


Childhood diagnosis

Child and adolescent psychiatry sometimes uses specific manuals in addition to the DSM and ICD. The Diagnostic Classification of Mental Health and Developmental Disorders of Infancy and Early Childhood (DC:0-3) was first published in 1994 by Zero to Three to classify mental health and developmental disorders in the first four years of life. It has been published in 9 languages. The Research Diagnostic criteria-Preschool Age ( RDC-PA) was developed between 2000 and 2002 by a task force of independent investigators with the goal of developing clearly specified diagnostic criteria to facilitate research on psychopathology in this age group. The French Classification of Child and Adolescent Mental Disorders (CFTMEA), operational since 1983, is the classification of reference for French child psychiatrists.


Usage

The ICD and DSM classification schemes have achieved widespread acceptance in psychiatry. A survey of 205 psychiatrists, from 66 countries across all continents, found that ICD-10 was more frequently used and more valued in clinical practice and training, while the DSM-IV was more frequently used in clinical practice in the United States and Canada, and was more valued for research, with accessibility to either being limited, and usage by other mental health professionals, policy makers, patients and families less clear. . A
primary care Primary care is a model of health care that supports first-contact, accessible, continuous, comprehensive, and coordinated person-focused care. It aims to optimise population health and reduce disparities across the groups by ensuring equitable ...
(e.g. general or family physician) version of the mental disorder section of ICD-10 has been developed (ICD-10-PHC) which has also been used quite extensively internationally. A survey of journal articles indexed in various biomedical databases between 1980 and 2005 indicated that 15,743 referred to the DSM and 3,106 to the ICD. In
Japan Japan is an island country in East Asia. Located in the Pacific Ocean off the northeast coast of the Asia, Asian mainland, it is bordered on the west by the Sea of Japan and extends from the Sea of Okhotsk in the north to the East China Sea ...
, most university hospitals use either the ICD or DSM. ICD appears to be the somewhat more used for research or academic purposes, while both were used equally for clinical purposes. Other traditional psychiatric schemes may also be used.


Types of classification schemes


Categorical schemes

The classification schemes in common usage are based on separate (but may be overlapping) categories of disorder schemes sometimes termed "neo-Kraepelinian" (after the psychiatrist Kraepelin) which is intended to be atheoretical with regard to
etiology Etiology (; alternatively spelled aetiology or ætiology) is the study of causation or origination. The word is derived from the Greek word ''()'', meaning "giving a reason for" (). More completely, etiology is the study of the causes, origins ...
(causation). These classification schemes have achieved some widespread acceptance in psychiatry and other fields, and have generally been found to have improved
inter-rater reliability In statistics, inter-rater reliability (also called by various similar names, such as inter-rater agreement, inter-rater concordance, inter-observer reliability, inter-coder reliability, and so on) is the degree of agreement among independent obse ...
, although routine clinical usage is less clear. Questions of validity and
utility In economics, utility is a measure of a certain person's satisfaction from a certain state of the world. Over time, the term has been used with at least two meanings. * In a normative context, utility refers to a goal or objective that we wish ...
have been raised, both scientifically and in terms of social, economic and political factors—notably over the inclusion of certain controversial categories, the influence of the pharmaceutical industry, or the stigmatizing effect of being categorized or labelled.


Non-categorical schemes

Some approaches to classification do not use categories with single cut-offs separating the ill from the healthy or the abnormal from the normal (a practice sometimes termed "threshold psychiatry" or "
dichotomous A dichotomy () is a partition of a set, partition of a whole (or a set) into two parts (subsets). In other words, this couple of parts must be * jointly exhaustive: everything must belong to one part or the other, and * mutually exclusive: nothi ...
classification"). Classification may instead be based on broader underlying " spectra", where each spectrum links together a range of related categorical diagnoses and nonthreshold symptom patterns. Some approaches go further and propose continuously varying dimensions that are not grouped into spectra or categories; each individual simply has a profile of scores across different dimensions.
DSM-5 The ''Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition'' (DSM-5), is the 2013 update to the '' Diagnostic and Statistical Manual of Mental Disorders'', the taxonomic and diagnostic tool published by the American Psychiat ...
planning committees are currently seeking to establish a research basis for a hybrid dimensional classification of personality disorders. However, the problem with entirely dimensional classifications is they are said to be of limited practical value in clinical practice where yes/no decisions often need to be made, for example whether a person requires treatment, and moreover the rest of medicine is firmly committed to categories, which are assumed to reflect discrete disease entities. While the Psychodynamic Diagnostic Manual has an emphasis on dimensionality and the context of mental problems, it has been structured largely as an adjunct to the categories of the DSM. Moreover, dimensionality approach was criticized for its reliance on independent dimensions whereas all systems of behavioral regulations show strong inter-dependence, feedback and contingent relationships


Descriptive vs Somatic

Descriptive classifications are based almost exclusively on either descriptions of behavior as reported by various observers, such as parents, teachers, and medical personnel; or symptoms as reported by individuals themselves. As such, they are quite subjective, not amenable to verification by third parties, and not readily transferable across chronologic and/or cultural barriers. Somatic nosology, on the other hand, is based almost exclusively on the objective histologic and chemical abnormalities which are characteristic of various diseases and can be identified by appropriately trained pathologists. While not all pathologists will agree in all cases, the degree of uniformity allowed is orders of magnitude greater than that enabled by the constantly changing classification embraced by the DSM system. Some models, like Functional Ensemble of Temperament suggest to unify nosology of somatic, biologically based individual differences in healthy people (temperament) and their deviations in a form of mental disorders in one taxonomy.


Cultural differences

Classification schemes may not apply to all cultures. The DSM is based on predominantly American research studies and has been said to have a decidedly American outlook, meaning that differing disorders or concepts of illness from other cultures (including personalistic rather than naturalistic explanations) may be neglected or misrepresented, while Western cultural phenomena may be taken as universal.
Culture-bound syndromes In medicine and medical anthropology, a culture-bound syndrome, culture-specific syndrome, or folk illness is a combination of psychiatric and somatic symptoms that are considered to be a recognizable disease only within a specific society or c ...
are those hypothesized to be specific to certain cultures (typically taken to mean non-Western or non-mainstream cultures); while some are listed in an appendix of the DSM-IV they are not detailed and there remain open questions about the relationship between Western and non-Western diagnostic categories and sociocultural factors, which are addressed from different directions by, for example,
cross-cultural psychiatry Cross-cultural psychiatry (also known as ethnopsychiatry or transcultural psychiatry or cultural psychiatry) is a branch of psychiatry concerned with the cultural context of mental disorders and the challenges of addressing ethnic diversity in psy ...
or
anthropology Anthropology is the scientific study of humanity, concerned with human behavior, human biology, cultures, society, societies, and linguistics, in both the present and past, including archaic humans. Social anthropology studies patterns of behav ...
.


Historical development


Antiquity

In Ancient Greece,
Hippocrates Hippocrates of Kos (; ; ), also known as Hippocrates II, was a Greek physician and philosopher of the Classical Greece, classical period who is considered one of the most outstanding figures in the history of medicine. He is traditionally referr ...
and his followers are generally credited with the first classification system for mental illnesses, including
mania Mania, also known as manic syndrome, is a Psychiatry, psychiatric Abnormality (behavior), behavioral syndrome defined as a state of Abnormality (behavior), abnormally elevated arousal, affect (psychology), affect, and energy level. During a mani ...
,
melancholia Melancholia or melancholy (from ',Burton, Bk. I, p. 147 meaning black bile) is a concept found throughout ancient, medieval, and premodern medicine in Europe that describes a condition characterized by markedly depressed mood, bodily complain ...
,
paranoia Paranoia is an instinct or thought process that is believed to be heavily influenced by anxiety, suspicion, or fear, often to the point of delusion and irrationality. Paranoid thinking typically includes persecutory beliefs, or beliefs of co ...
,
phobias The English language, English suffixes -phobia, -phobic, -phobe (from Ancient Greek, Greek φόβος ''phobos'', "fear") occur in technical usage in psychiatry to construct words that describe irrational, abnormal, unwarranted, persistent, o ...
and Scythian disease (
transvestism Cross-dressing is the act of wearing clothes traditionally or stereotypically associated with a different gender. From as early as pre-modern history, cross-dressing has been practiced in order to disguise, comfort, entertain, and express onesel ...
). They held that they were due to different kinds of imbalance in four humors.


Middle ages to Renaissance

The Persian physicians 'Ali ibn al-'Abbas al-Majusi and Najib ad-Din Samarqandi elaborated upon Hippocrates' system of classification.
Avicenna Ibn Sina ( – 22 June 1037), commonly known in the West as Avicenna ( ), was a preeminent philosopher and physician of the Muslim world, flourishing during the Islamic Golden Age, serving in the courts of various Iranian peoples, Iranian ...
(980−1037 CE) in the ''Canon of Medicine'' listed a number of mental disorders, including "passive male homosexuality". Laws generally distinguished between "idiots" and "lunatics".
Thomas Sydenham Thomas Sydenham (; 10 September 1624 – 29 December 1689) was an England, English physician. He was the author of ''Observationes Medicae'' (1676) which became a standard textbook of medicine for two centuries so that he became known as 'The ...
(1624–1689), the "English Hippocrates", emphasized careful clinical observation and diagnosis and developed the concept of a
syndrome A syndrome is a set of medical signs and symptoms which are correlated with each other and often associated with a particular disease or disorder. The word derives from the Greek language, Greek σύνδρομον, meaning "concurrence". When a sy ...
, a group of associated symptoms having a common course, which would later influence psychiatric classification.


18th century

Evolution in the scientific concepts of
psychopathology Psychopathology is the study of mental illness. It includes the signs and symptoms of all mental disorders. The field includes Abnormal psychology, abnormal cognition, maladaptive behavior, and experiences which differ according to social norms ...
(literally referring to diseases of the mind) took hold in the late 18th and 19th centuries following the
Renaissance The Renaissance ( , ) is a Periodization, period of history and a European cultural movement covering the 15th and 16th centuries. It marked the transition from the Middle Ages to modernity and was characterized by an effort to revive and sur ...
and Enlightenment. Individual behaviors that had long been recognized came to be grouped into
syndromes A syndrome is a set of medical signs and symptoms which are correlated with each other and often associated with a particular disease or disorder. The word derives from the Greek σύνδρομον, meaning "concurrence". When a syndrome is paire ...
. Boissier de Sauvages developed an extremely extensive psychiatric classification in the mid-18th century, influenced by the medical
nosology Nosology () is the branch of medical science that deals with the classification of diseases. Fully classifying a medical condition requires knowing its cause (and that there is only one cause), the effects it has on the body, the symptoms th ...
of
Thomas Sydenham Thomas Sydenham (; 10 September 1624 – 29 December 1689) was an England, English physician. He was the author of ''Observationes Medicae'' (1676) which became a standard textbook of medicine for two centuries so that he became known as 'The ...
and the biological
taxonomy image:Hierarchical clustering diagram.png, 280px, Generalized scheme of taxonomy Taxonomy is a practice and science concerned with classification or categorization. Typically, there are two parts to it: the development of an underlying scheme o ...
of
Carl Linnaeus Carl Linnaeus (23 May 1707 – 10 January 1778), also known after ennoblement in 1761 as Carl von Linné,#Blunt, Blunt (2004), p. 171. was a Swedish biologist and physician who formalised binomial nomenclature, the modern system of naming o ...
. It was only part of his classification of 2400 medical diseases. These were divided into 10 "classes", one of which comprised the bulk of the mental diseases, divided into four "orders" and 23 "genera". One genus,
melancholia Melancholia or melancholy (from ',Burton, Bk. I, p. 147 meaning black bile) is a concept found throughout ancient, medieval, and premodern medicine in Europe that describes a condition characterized by markedly depressed mood, bodily complain ...
, was subdivided into 14 "species". William Cullen advanced an influential medical nosology which included four classes of neuroses: coma, adynamias, spasms, and vesanias. The vesanias included amentia, melancholia, mania, and oneirodynia. Towards the end of the 18th century and into the 19th, Pinel, influenced by Cullen's scheme, developed his own, again employing the terminology of genera and species. His simplified revision of this reduced all mental illnesses to four basic types. He argued that mental disorders are not separate entities but stem from a single disease that he called "mental alienation". Attempts were made to merge the ancient concept of
delirium Delirium (formerly acute confusional state, an ambiguous term that is now discouraged) is a specific state of acute confusion attributable to the direct physiological consequence of a medical condition, effects of a psychoactive substance, or ...
with that of insanity, the latter sometimes described as delirium without fever. On the other hand, Pinel had started a trend for diagnosing forms of insanity 'without delirium' (meaning hallucinations or delusions) – a concept of partial insanity. Attempts were made to distinguish this from total insanity by criteria such as intensity, content or generalization of delusions.


19th century

Pinel's successor, Esquirol, extended Pinel's categories to five. Both made a clear distinction between insanity (including mania and dementia) as opposed to
mental retardation Intellectual disability (ID), also known as general learning disability (in the United Kingdom), and formerly mental retardation (in the United States), Rosa's Law, Pub. L. 111-256124 Stat. 2643(2010).Archive is a generalized neurodevelopmental ...
(including idiocy and imbecility). Esquirol developed a concept of
monomania In 19th-century psychiatry, monomania (from Greek , "one", and , meaning "madness" or "frenzy") was a form of partial insanity conceived as single psychological obsession in an otherwise sound mind. Types Monomania may refer to: * Erotomania ( ...
—a periodic delusional fixation or undesirable disposition on one theme—that became a broad and common diagnosis and a part of popular culture for much of the 19th century. The diagnosis of "
moral insanity Moral insanity referred to a type of mental disorder consisting of abnormal emotions and behaviours in the apparent absence of intellectual impairments, delusions, or hallucinations. It was an accepted diagnosis in Europe and America through the s ...
" coined by James Prichard also became popular; those with the condition did not seem delusional or intellectually impaired but seemed to have disordered emotions or behavior. The botanical taxonomic approach was abandoned in the 19th century, in favor of an anatomical-clinical approach that became increasingly descriptive. There was a focus on identifying the particular psychological faculty involved in particular forms of insanity, including through
phrenology Phrenology is a pseudoscience that involves the measurement of bumps on the skull to predict mental traits. It is based on the concept that the Human brain, brain is the organ of the mind, and that certain brain areas have localized, specific ...
, although some argued for a more central "unitary" cause. French and German psychiatric nosology was in the ascendency. The term "psychiatry" ("Psychiatrie") was coined by German physician Johann Christian Reil in 1808, from the Greek "ψυχή" (''psychē'': "soul or mind") and "ιατρός" (''iatros'': "healer or doctor"). The term "alienation" took on a psychiatric meaning in France, later adopted into medical English. The terms
psychosis In psychopathology, psychosis is a condition in which a person is unable to distinguish, in their experience of life, between what is and is not real. Examples of psychotic symptoms are delusions, hallucinations, and disorganized or inco ...
and neurosis came into use, the former viewed psychologically and the latter neurologically. In the second half of the century, Karl Kahlbaum and Ewald Hecker developed a descriptive categorizion of
syndromes A syndrome is a set of medical signs and symptoms which are correlated with each other and often associated with a particular disease or disorder. The word derives from the Greek σύνδρομον, meaning "concurrence". When a syndrome is paire ...
, employing terms such as
dysthymia Dysthymia ( ), known as persistent depressive disorder (PDD) in the DSM-5-TR and dysthymic disorder in ICD-11, is a psychiatric condition marked by symptoms that are similar to those of major depressive disorder, but which persist for at leas ...
,
cyclothymia Cyclothymia (, ), also known as cyclothymic disorder, psychothemia / psychothymia, bipolar III, affective personality disorder and cyclothymic personality disorder, is a mental disorder, mental and Abnormal behaviour, behavioural Disease#Disorder ...
,
catatonia Catatonia is a complex syndrome most commonly seen in people with underlying mood disorders, such as major depressive disorder, or psychotic disorders, such as schizophrenia. People with catatonia exhibit abnormal movement and behaviors, wh ...
, paranoia and hebephrenia.
Wilhelm Griesinger Wilhelm Griesinger (29 July 1817 – 26 October 1868) was a German neurologist and psychiatrist born in Stuttgart. Life and career He studied under Johann Lukas Schönlein at the University of Zurich and physiologist François Magendie in Paris ...
(1817–1869) advanced a
unitary Unitary may refer to: Mathematics * Unitary divisor * Unitary element * Unitary group * Unitary matrix * Unitary morphism * Unitary operator * Unitary transformation * Unitary representation * Unitarity (physics) * ''E''-unitary inverse semigr ...
scheme based on a concept of brain pathology. French psychiatrists Jules Baillarger described "folie à double forme" and Jean-Pierre Falret described " la folie circulaire"—alternating mania and depression. The concept of adolescent insanity or developmental insanity was advanced by Scottish Asylum Superintendent and Lecturer in Mental Diseases Thomas Clouston in 1873, describing a psychotic condition which generally impacts those aged 18–24 years, particularly males, and in 30% of cases proceeded to "a secondary dementia". The concept of
hysteria Hysteria is a term used to mean ungovernable emotional excess and can refer to a temporary state of mind or emotion. In the nineteenth century, female hysteria was considered a diagnosable physical illness in women. It is assumed that the bas ...
(wandering womb) had long been used, perhaps since ancient Egyptian times, and was later adopted by Freud. Descriptions of a specific syndrome now known as
somatization disorder Somatic symptom disorder, also known as somatoform disorder or somatization disorder, is chronic somatization. One or more chronic physical symptoms coincide with excessive and maladaptive thoughts, emotions, and behaviors connected to those sym ...
were first developed by the French physician, Paul Briquet in 1859. An American physician, Beard, described " neurasthenia" in 1869. German neurologist Westphal, coined the term " obsessional neurosis" now termed obsessive-compulsive disorder, and
agoraphobia Agoraphobia is an anxiety disorder characterized by symptoms of anxiety in situations where the person perceives their environment to be unsafe with no way to escape. These situations can include public transit, shopping centers, crowds and q ...
. Alienists created a whole new series of diagnoses that highlighted single, impulsive behavior, such as
kleptomania Kleptomania is the inability to resist the urge to steal items, usually for reasons other than personal use or financial gain. First described in 1816, kleptomania is classified in psychiatry as an impulse-control disorder. Some of the main ch ...
, dipsomania,
pyromania Pyromania is an impulse-control disorder in which individuals repeatedly fail to resist impulses to deliberately start fires, to relieve some tension or for instant gratification. The term ''pyromania'' comes from the Greek word (''pyr'', 'f ...
, and nymphomania. The diagnosis of drapetomania was also developed in the Southern United States to explain the perceived irrationality of black slaves trying to escape what was thought to be a suitable role. The scientific study of
homosexuality Homosexuality is romantic attraction, sexual attraction, or Human sexual activity, sexual behavior between people of the same sex or gender. As a sexual orientation, homosexuality is "an enduring pattern of emotional, romantic, and/or sexu ...
began in the 19th century, informally viewed either as natural or as a disorder. Kraepelin included it as a disorder in his Compendium der Psychiatrie that he published in successive editions from 1883. In the late 19th century, Koch referred to "psychopathic inferiority" as a new term for moral insanity. In the 20th century the term became known as "psychopathy" or "sociopathy", related specifically to antisocial behavior. Related studies led to the DSM-III category of
antisocial personality disorder Antisocial personality disorder (ASPD) is a personality disorder defined by a chronic pattern of behavior that disregards the rights and well-being of others. People with ASPD often exhibit behavior that conflicts with social norms, leading to ...
.


20th century

Influenced by the approach of Kahlbaum and others, and developing his concepts in publications spanning the turn of the century, German psychiatrist
Emil Kraepelin Emil Wilhelm Georg Magnus Kraepelin (; ; 15 February 1856 – 7 October 1926) was a German psychiatrist. H. J. Eysenck's Encyclopedia of Psychology identifies him as the founder of modern scientific psychiatry, psychopharmacology and psychiatric ...
advanced a new system. He grouped together a number of existing diagnoses that appeared to all have a deteriorating course over time—such as
catatonia Catatonia is a complex syndrome most commonly seen in people with underlying mood disorders, such as major depressive disorder, or psychotic disorders, such as schizophrenia. People with catatonia exhibit abnormal movement and behaviors, wh ...
, hebephrenia and dementia paranoides—under another existing term " dementia praecox" (meaning "early
senility Dementia is a syndrome associated with many neurodegenerative diseases, characterized by a general decline in cognitive abilities that affects a person's ability to perform everyday activities. This typically involves problems with memory, ...
", later renamed schizophrenia). Another set of diagnoses that appeared to have a periodic course and better outcome were grouped together under the category of manic-depressive insanity (mood disorder). He also proposed a third category of psychosis, called paranoia, involving delusions but not the more general deficits and poor course attributed to dementia praecox. In all he proposed 15 categories, also including psychogenic neurosis, psychopathic personality, and syndromes of defective mental development (mental retardation). He eventually included homosexuality in the category of "mental conditions of constitutional origin". The neuroses were later split into anxiety disorders and other disorders. Freud wrote extensively on hysteria and also coined the term, "anxiety neurosis", which appeared in DSM-I and DSM-II. Checklist criteria for this led to studies that were to define
panic disorder Panic disorder is a mental disorder, specifically an anxiety disorder, characterized by reoccurring unexpected panic attacks. Panic attacks are sudden periods of intense fear that may include palpitations, sweating, shaking, shortness of breath ...
for DSM-III. Early 20th century schemes in
Europe Europe is a continent located entirely in the Northern Hemisphere and mostly in the Eastern Hemisphere. It is bordered by the Arctic Ocean to the north, the Atlantic Ocean to the west, the Mediterranean Sea to the south, and Asia to the east ...
and the
United States The United States of America (USA), also known as the United States (U.S.) or America, is a country primarily located in North America. It is a federal republic of 50 U.S. state, states and a federal capital district, Washington, D.C. The 48 ...
reflected a brain disease (or degeneration) model that had emerged during the 19th century, as well as some ideas from Darwin's theory of
evolution Evolution is the change in the heritable Phenotypic trait, characteristics of biological populations over successive generations. It occurs when evolutionary processes such as natural selection and genetic drift act on genetic variation, re ...
and/or Freud's
psychoanalytic PsychoanalysisFrom Greek: and is a set of theories and techniques of research to discover unconscious processes and their influence on conscious thought, emotion and behaviour. Based on dream interpretation, psychoanalysis is also a talk the ...
theories. Psychoanalytic theory did not rest on classification of distinct disorders, but pursued analyses of unconscious conflicts and their manifestations within an individual's life. It dealt with neurosis, psychosis, and perversion. The concept of
borderline personality disorder Borderline personality disorder (BPD) is a personality disorder characterized by a pervasive, long-term pattern of significant interpersonal relationship instability, an acute fear of Abandonment (emotional), abandonment, and intense emotiona ...
and other personality disorder diagnoses were later formalized from such psychoanalytic theories, though such ego psychology-based lines of development diverged substantially from the paths taken elsewhere within psychoanalysis. The philosopher and psychiatrist
Karl Jaspers Karl Theodor Jaspers (; ; 23 February 1883 – 26 February 1969) was a German-Swiss psychiatrist and philosopher who had a strong influence on modern theology, psychiatry, and philosophy. His 1913 work ''General Psychopathology'' influenced many ...
made influential use of a "biographical method" and suggested ways to diagnose based on the form rather than content of beliefs or perceptions. In regard to classification in general he prophetically remarked that: "When we design a diagnostic schema, we can only do so if we forego something at the outset … and in the face of facts we have to draw the line where none exists... A classification therefore has only provisional value. It is a fiction which will discharge its function if it proves to be the most apt for the time". Adolph Meyer advanced a mixed biosocial scheme that emphasized the reactions and adaptations of the whole organism to life experiences. In 1945, William C. Menninger advanced a classification scheme for the US army, called Medical 203, synthesizing ideas of the time into five major groups. This system was adopted by the
Veterans Administration The United States Department of Veterans Affairs (VA) is a Cabinet-level executive branch department of the federal government charged with providing lifelong healthcare services to eligible military veterans at the 170 VA medical centers an ...
in the
United States The United States of America (USA), also known as the United States (U.S.) or America, is a country primarily located in North America. It is a federal republic of 50 U.S. state, states and a federal capital district, Washington, D.C. The 48 ...
and strongly influenced the DSM. The term stress, having emerged from
endocrinology Endocrinology (from ''endocrine system, endocrine'' + ''wikt:-logy#Suffix, -ology'') is a branch of biology and medicine dealing with the endocrine system, its diseases, and its specific secretions known as hormones. It is also concerned with the ...
work in the 1930s, was popularized with an increasingly broad biopsychosocial meaning, and was increasingly linked to mental disorders. The diagnosis of
post-traumatic stress disorder Post-traumatic stress disorder (PTSD) is a mental disorder that develops from experiencing a Psychological trauma, traumatic event, such as sexual assault, domestic violence, child abuse, warfare and its associated traumas, natural disaster ...
was later created. Mental disorders were first included in the sixth revision of the
International Classification of Diseases The International Classification of Diseases (ICD) is a globally used medical classification that is used in epidemiology, health management and clinical diagnosis. The ICD is maintained by the World Health Organization (WHO), which is the dir ...
(ICD-6) in 1949. Three years later, in 1952, the
American Psychiatric Association The American Psychiatric Association (APA) is the main professional organization of psychiatrists and trainee psychiatrists in the United States, and the largest psychiatric organization in the world. It has more than 39,200 members who are in ...
created its own classification system, DSM-I. The Feighner Criteria group described fourteen major psychiatric disorders for which careful research studies were available, including
homosexuality Homosexuality is romantic attraction, sexual attraction, or Human sexual activity, sexual behavior between people of the same sex or gender. As a sexual orientation, homosexuality is "an enduring pattern of emotional, romantic, and/or sexu ...
. These developed as the
Research Diagnostic Criteria The Research Diagnostic Criteria (RDC) are a collection of influential psychiatric diagnostic criteria published in late 1970s under auspices of Statistics Section NY Psychiatric Institute, authors were Spitzer, R L; Endicott J; Robins E. PMID 115 ...
, adopted and further developed by the DSM-III. The DSM and
ICD The International Classification of Diseases (ICD) is a globally used medical classification that is used in epidemiology, health management and clinical diagnostics, diagnosis. The ICD is maintained by the World Health Organization (WHO), which ...
developed, partly in sync, in the context of mainstream psychiatric research and theory. Debates continued and developed about the definition of mental illness, the medical model, categorical vs dimensional approaches, and whether and how to include suffering and impairment criteria. There is some attempt to construct novel schemes, for example from an attachment perspective where patterns of symptoms are construed as evidence of specific patterns of disrupted attachment, coupled with specific types of subsequent trauma.


21st century

The
ICD-11 The ICD-11 is the eleventh revision of the International Classification of Diseases (ICD). It replaces the ICD-10 as the global standard for recording health information and causes of death. The ICD is developed and annually updated by the World H ...
and
DSM-5 The ''Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition'' (DSM-5), is the 2013 update to the '' Diagnostic and Statistical Manual of Mental Disorders'', the taxonomic and diagnostic tool published by the American Psychiat ...
are being developed at the start of the 21st century. Any radical new developments in classification are said to be more likely to be introduced by the APA than by the WHO, mainly because the former only has to persuade its own
board of trustees A board of directors is a governing body that supervises the activities of a business, a nonprofit organization, or a government agency. The powers, duties, and responsibilities of a board of directors are determined by government regulatio ...
whereas the latter has to persuade the representatives of over 200 countries at a formal revision conference. In addition, while the DSM is a bestselling publication that makes huge profits for APA, the WHO incurs major expense in determining international consensus for revisions to the ICD. Although there is an ongoing attempt to reduce trivial or accidental differences between the DSM and ICD, it is thought that the APA and the WHO are likely to continue to produce new versions of their manuals and, in some respects, to compete with one another.Dalal PK, Sivakumar T. (2009
Moving towards ICD-11 and DSM-V: Concept and evolution of psychiatric classification.
Indian Journal of Psychiatry, Volume 51, Issue 4, Page 310-319.


Criticism

There is ongoing scientific doubt concerning the
construct validity Construct validity concerns how well a set of indicators represent or reflect a concept that is not directly measurable. ''Construct validation'' is the accumulation of evidence to support the interpretation of what a measure reflects.Polit DF Bec ...
and reliability of psychiatric diagnostic categories and criteria even though they have been increasingly standardized to improve inter-rater agreement in controlled research. In the United States, there have been calls and endorsements for a congressional hearing to explore the nature and extent of harm potentially caused by this "minimally investigated enterprise". Other specific criticisms of the current schemes include: attempts to demonstrate natural boundaries between related syndromes, or between a common syndrome and normality, have failed; inappropriateness of statistical (factor-analytic) arguments and lack of functionality considerations in the analysis of a structure of behavioral pathology; the disorders of current classification are probably surface phenomena that can have many different interacting causes, yet "the mere fact that a diagnostic concept is listed in an official nomenclature and provided with a precise operational definition tends to encourage us to assume that it is a "quasi-disease entity" that can be invoked to explain the patient's symptoms"; and that the diagnostic manuals have led to an unintended decline in careful evaluation of each individual person's experiences and social context. Psychodynamic schemes have traditionally given the latter phenomenological aspect more consideration, but in
psychoanalytic PsychoanalysisFrom Greek: and is a set of theories and techniques of research to discover unconscious processes and their influence on conscious thought, emotion and behaviour. Based on dream interpretation, psychoanalysis is also a talk the ...
terms that have been long criticized on numerous grounds. Some have argued that reliance on
operational definition An operational definition specifies concrete, replicable procedures designed to represent a construct. In the words of American psychologist S.S. Stevens (1935), "An operation is the performance which we execute in order to make known a concept." F ...
demands that intuitive concepts, such as depression, need to be operationally defined before they become amenable to scientific investigation. However,
John Stuart Mill John Stuart Mill (20 May 1806 – 7 May 1873) was an English philosopher, political economist, politician and civil servant. One of the most influential thinkers in the history of liberalism and social liberalism, he contributed widely to s ...
pointed out the dangers of believing that anything that could be given a name must refer to a thing and
Stephen Jay Gould Stephen Jay Gould ( ; September 10, 1941 – May 20, 2002) was an American Paleontology, paleontologist, Evolutionary biology, evolutionary biologist, and History of science, historian of science. He was one of the most influential and widely re ...
and others have criticized
psychologists A psychologist is a professional who practices psychology and studies mental states, perceptual, cognitive, emotional, and social processes and behavior. Their work often involves the experimentation, observation, and interpretation of how ...
for doing just that. One critic states that "Instead of replacing 'metaphysical' terms such as 'desire' and 'purpose', they used it to legitimize them by giving them operational definitions. Thus in psychology, as in economics, the initial, quite radical operationalist ideas eventually came to serve as little more than a 'reassurance fetish' (Koch 1992, 275) for mainstream methodological practice." According to Tadafumi Kato, since the era of Kraepelin, psychiatrists have been trying to differentiate mental disorders by using clinical interviews. Kato argues there has been little progress over the last century and that only modest improvements are possible in this way; he suggests that only neurobiological studies using modern technology could form the basis for a new classification. According to Heinz Katsching, expert committees have combined phenomenological criteria in variable ways into categories of mental disorders, repeatedly defined and redefined over the last half century. The diagnostic categories are termed "disorders" and yet, despite not being validated by biological criteria as most medical diseases are, are framed as medical diseases identified by medical diagnoses. He describes them as top-down classification systems similar to the botanic classifications of plants in the 17th and 18th centuries, when experts decided
a priori ('from the earlier') and ('from the later') are Latin phrases used in philosophy to distinguish types of knowledge, Justification (epistemology), justification, or argument by their reliance on experience. knowledge is independent from any ...
which visible aspects of plants were relevant. Katsching notes that while psychopathological phenomena are certainly observed and experienced, the conceptual basis of psychiatric diagnostic categories is questioned from various ideological perspectives. Psychiatrist Joel Paris argues that psychiatry is sometimes susceptible to diagnostic fads. Some have been based on theory (overdiagnosis of
schizophrenia Schizophrenia () is a mental disorder characterized variously by hallucinations (typically, Auditory hallucination#Schizophrenia, hearing voices), delusions, thought disorder, disorganized thinking and behavior, and Reduced affect display, f ...
), some based on
etiological Etiology (; alternatively spelled aetiology or ætiology) is the study of causation or origination. The word is derived from the Greek word ''()'', meaning "giving a reason for" (). More completely, etiology is the study of the causes, origin ...
(causation) concepts (overdiagnosis of
post-traumatic stress disorder Post-traumatic stress disorder (PTSD) is a mental disorder that develops from experiencing a Psychological trauma, traumatic event, such as sexual assault, domestic violence, child abuse, warfare and its associated traumas, natural disaster ...
), and some based on the development of treatments. Paris points out that psychiatrists like to diagnose conditions they can treat, and gives examples of what he sees as prescribing patterns paralleling diagnostic trends, for example an increase in bipolar diagnosis once
lithium Lithium (from , , ) is a chemical element; it has chemical symbol, symbol Li and atomic number 3. It is a soft, silvery-white alkali metal. Under standard temperature and pressure, standard conditions, it is the least dense metal and the ...
came into use, and similar scenarios with the use of
electroconvulsive therapy Electroconvulsive therapy (ECT) is a psychiatry, psychiatric treatment that causes a generalized seizure by passing electrical current through the brain. ECT is often used as an intervention for mental disorders when other treatments are inadequ ...
,
neuroleptics Antipsychotics, previously known as neuroleptics and major tranquilizers, are a class of psychotropic medication primarily used to manage psychosis (including delusions, hallucinations, paranoia or disordered thought), principally in schizoph ...
, tricyclic antidepressants, and
SSRI Selective serotonin reuptake inhibitors (SSRIs) are a class of drugs that are typically used as antidepressants in the treatment of major depressive disorder, anxiety disorders, and other psychological conditions. SSRIs primarily work by ...
s. He notes that there was a time when every patient seemed to have "latent schizophrenia" and another time when everything in psychiatry seemed to be " masked depression", and he fears that the boundaries of the bipolar spectrum concept, including in application to children, are similarly expanding. Allen Frances has suggested fad diagnostic trends regarding
autism Autism, also known as autism spectrum disorder (ASD), is a neurodevelopmental disorder characterized by differences or difficulties in social communication and interaction, a preference for predictability and routine, sensory processing d ...
and
Attention deficit hyperactivity disorder Attention deficit hyperactivity disorder (ADHD) is a neurodevelopmental disorder characterised by symptoms of inattention, hyperactivity, impulsivity, and emotional dysregulation that are excessive and pervasive, impairing in multiple con ...
. Since the 1980s, psychologist
Paula Caplan Paula Joan Caplan (July 7, 1947 – July 21, 2021) was an American psychologist, activist, writer, and artist. Biography Caplan was an associate at Harvard University's W. E. B. Du Bois Institute, DuBois Institute, director of the Voices of D ...
has had concerns about psychiatric diagnosis, and people being arbitrarily "slapped with a psychiatric label". Caplan says psychiatric diagnosis is unregulated, so doctors are not required to spend much time understanding patients situations or to seek another doctor's opinion. The criteria for allocating psychiatric labels are contained in the
Diagnostic and Statistical Manual of Mental Disorders The ''Diagnostic and Statistical Manual of Mental Disorders'' (''DSM''; latest edition: ''DSM-5-TR'', published in March 2022) is a publication by the American Psychiatric Association (APA) for the classification of mental disorders using a com ...
, which can "lead a therapist to focus on narrow checklists of symptoms, with little consideration for what is causing the patient's suffering". So, according to Caplan, getting a psychiatric diagnosis and label often hinders recovery. The DSM and ICD approach remains under attack both because of the implied causality model and because some researchers believe it better to aim at underlying brain differences which can precede symptoms by many years.


See also

*
Abnormal psychology Abnormal psychology is the branch of psychology that studies unusual patterns of behavior, emotion, and thought, which could possibly be understood as a mental disorder. Although many behaviors could be considered as abnormal, this branch of ps ...
*
Diagnosis Diagnosis (: diagnoses) is the identification of the nature and cause of a certain phenomenon. Diagnosis is used in a lot of different academic discipline, disciplines, with variations in the use of logic, analytics, and experience, to determine " ...
* Diagnostic classification and rating scales used in psychiatry *
Medical classification A medical classification is used to transform descriptions of medical diagnoses or procedures into standardized statistical code in a process known as clinical coding. Diagnosis classifications list diagnosis codes, which are used to track dise ...
**
DSM-IV codes This is a list of mental disorders as defined in the DSM-IV, the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders. Published by the American Psychiatry Association (APA), it was released in May 1994, superseding the DSM-I ...
** Structured Clinical Interview for DSM-IV ''(SCID)'' *
Nosology Nosology () is the branch of medical science that deals with the classification of diseases. Fully classifying a medical condition requires knowing its cause (and that there is only one cause), the effects it has on the body, the symptoms th ...
* Operationalism *
Psychopathology Psychopathology is the study of mental illness. It includes the signs and symptoms of all mental disorders. The field includes Abnormal psychology, abnormal cognition, maladaptive behavior, and experiences which differ according to social norms ...
*
Relational disorder According to Michael First of the DSM-5 working committee the focus of a relational disorder, in contrast to other DSM-IV disorders, "is on the relationship rather than on any one individual in the relationship".Michael B. First, MD. A Research Age ...
(proposed DSM-5 new diagnosis)


References


External links

* Dalal PK, Sivakumar T. (2009
Moving towards ICD-11 and DSM-V: Concept and evolution of psychiatric classification.
Indian Journal of Psychiatry, Volume 51, Issue 4, Page 310–319. * {{Psychiatry Classification of mental disorders Mental disorders