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THE DSM AND ICD
     PSYCHIATRIC
CLASSIFICATION SYSTEMS
FACILITATES CHARACTERIZATION,
COMMUNICATION AND RESEARCH
COMPLEXITY OF PHENOMENA ARE
REDUCED
TWO VIEWS:
    DIMENSIONALIZERS – DIMENSIONS OF
    FUNCTIONING,DIFFERENT
    PSYCHIATRIC D/O
    CATEGORIZERS – SPECIFIC GROUPS
    OF SYMPTOMS – REFLECT
    PSYCHIATRIC SYNDROMES
IMPORTANCE OF CLASSIFICATION FOR
     PSYCHIATRIC DIAGNOSIS
 DISTINGUISH BET DIFF PSYCHIATRIC
 DIAGNOSIS
 COMMON LANGUAGE AMONGST HEALTH
 PROFESSIONALS ENSURES
 RELIABILITY,COMMUNICATION AND
 STATISTICAL REPORTING
 EFFECTIVE TREATMENT
 STANDARD FRAME OF REFERENCE
 TEACHING-INTERNATIONAL REFERENCE
 SYSTEMS
IMPORTANCE OF CLASSIFICATION
            CONT.

PUBLIC ACESS – IMPROVES COMMUNICATION

IMPROVES RELIABILITY OF PSYCHIATRIC
DIAGNOSIS IN RESEARCH SETTINGS

UNDERSTANDING OF CAUSES AND
PROCESSES OF MENTAL DISORDERS
TWO MOST ACCEPTED PSYCHIATRIC
       CLASSIFICATIONS

DIAGNOSTIC AND STATISTICAL
MANUAL OF MENTAL DISORDERS
(DSM IV TR)

INTERNATIONAL CLASSIFICATION OF
DISEASES (ICD 10)

CLINICAL DESCRIPTIONS BASED ON
PHENOMENOLOGICAL APPROACHES
DSM

CATEGORICAL CLASSIFICATION

DIVIDES MENTAL DISORDERS

CRITERIA SETS – DEFINING FEATURES
HISTORY AND BACKGROUND
FIRST DSM – AMERICAN PSYCHIATRIC
ASSOCIATION COMMITTEE
DSM II – 1968
DSM III – 1980
REVISED DSM III – 1987
DSM III-R – 1987
DSM IV – 1994
DSM-IV-TR – 2000
HISTORY AND BACKGROUND
WHO – ICD-6
SECTION ON MENTAL DISORDERS
APA – VARIANT OF ICD-6
DSM-1 – FIRST OFFICIAL MANUAL OF
CLINICAL MENTAL DISORDERS
PSYCHOBIOLOGICAL VIEW
HISTORY AND BACKGROUND
DSM-II CORRELATED WITH ICD-8
DSM-III CORRELATED WITH 1CD-9
DSM-III
    –   EXPLICIT DIAGNOSTIC CRITERIA
    –   MULTI-AXIAL SYSTEM
    –   DESCRIPTIVE MEDICAL
        NOMENCLATURE
HISTORY AND BACKGROUND
DSM-III-R – EMPIRICAL RESEARCH

DSM-IV – SYSTEMATIC REVIEWS AND
FOCUSED FIELD TRIALS

GOAL – INCREASE PRACTICALITY AND
CLINICAL UTILITY

DSM IV-TR – NOS CATEGORY
DSM IV-TR
OFFICIAL CODING SYSTEM IN USA
ATHEORETICAL APPROACH TO CAUSES
DESCRIBES MANIFESTATIONS AND
DESCRIPTIONS OF CLINICAL FEATURES
OF MENTAL D/O
SPECIFIC DIAGNOSTIC CRITERIA
CRITERIA INCREASE RELIABILITY
DSM IV-TR
SYSTEMATIC DESCRIPTIONS:
   AGE
   CULTURE
   GENDER FEATURES
   PREVALENCE, INCIDENCE
   RISK , COURSE
   COMPLICATIONS
   PREDISPOSING FACTORS
   FAMILIAL PATTERNS
   DIFFERENTIAL DIAGNOSIS
   LAB FINDINGS
   PHYSICAL EXAMINATION SIGNS AND SYMPTOMS
DSM IV-TR

365 DISORDERS

17 SECTIONS

PROPOSED DIAGNOSTIC CRITERIA
DSM IV-TR ORGANIZATIONAL
           PLAN
16 MAJOR DIAGNOSTIC CLASSES
OTHER CONDITIONS THAT MAY BE FOCUS
OF CLINICAL ATTENTION
11 APPENDICES
         DIFFERENTIAL DX
         GLOSSARY
         CHANGES IN DSM-IV-TR
         CLASSIFICATION WITH ICD-10
         CULTURAL FORMULATION, ETC
AIMS OF DSM IV-TR
CLEAR DIAGNOSTIC CATEGORIES
DX, COMMUNICATION, STUDY AND TREAT
DIAGNOSTIC CRITERIA FOR RESEARCH
PURPOSES
RECORD KEEPING, DATA COLLECTION
REPORTING TO 3RD PARTIES – GOVN, PRIVATE
INSURERS
SUBTYPES
SPECIFIERS
INCREASED SPECIFICITY
AIMS OF DSM IV-TR

CLINICAL DECISIONS
        RX SETTING
        MODE OF RX
        DURATION OF RX
SEVERITY AND COURSE
      SPECIFIERS
MILD, MODERATE, SEVERE ONLY WHEN
FULL CRITERIA MET
INTENSITY OF S AND S
IMPAIRMENT IN OCCUPATIONAL AND
FUNCTIONAL IMPAIRMENT
MR
CONDUCT D/O
MANIC EPISODE
MAJOR DEPRESSIVE EPISODE
SEVERITY AND COURSE
        SPECIFIERS
PARTIAL REMISSION – FULL CRITERIA
PREVIOUSLY MET
FULL REMISSION – NO LONGER S AND S,
STILL CLINICALLY RELEVANT
PARTIAL AND FULL REMISSION FOR:
        MANIC EPISODE
        MAJOR DEPRESSIVE EPISODE
        SUBSTANCE DEPENDANCE
PRIOR HISTORY – USEFUL TO NOTE HX OF
CRITERIA PREVIOUSLY MET BUT NOW
RECOVERED
RECURRENCE
FULL CRITERIA NO LONGER MET

PARTIAL, FULL REMISSION,
RECOVERY

DO NOT MEET FULL THRESHOLD OF
D/O ACCORDING TO SPECIFIED
CRITERIA
NOS CATEGORIES
DIVERSITY OF CLINICAL
PRESENTATION
4 SITUATIONS:
– CRITERIA NOT MET FOR SPECIFIC D/O EG
  ATYPICAL, MIXED PICTURE
– DOES NOT CONFORM TO DSM IV
  CLASSIFICATION BUTCLINICAL
  SIGNIFICANT DISTRESS
– AETIOLOGY UNCERTAIN
– INSUFFICIENT DATA, INCONSISTENT
  INFORMATION
MULTIAXIAL ASSESSMENT

5 AXES
 – I – CLINICAL D/O, OTHER CONDITIONS
   FOCUS OF CLINICAL ATTENTION
 – II – PERSONALITY D/O
 – III – GMC
 – IV – PSYCHOSOCIAL, ENVIRONMENTAL
 – V – GAF
MULTIAXIAL ASSESSMENT
DIFFERENT DOMAINS OF
INFORMATION
PLAN RX AND PREDICT OUTCOME
ORGANIZING, COMMUNICATING
CLINICAL INFORMATION
CAPTURES COMPLEXITY OF CLINICAL
SITUATION
HETEROGENEITY OF PATIENT
BIOPSYCHOSOCIAL MODEL
AXIS I

PRINCIPAL DX

AXIS II CAN ALSO BE PRINCIPAL
DIAGNOSIS – MUST BE FOLLOWED BY
‘PRINCIPAL DX’ OR ‘REASON FOR VISIT’
AXIS II

PERSONALITY D/O
MR
MALADAPTIVE PERSONALITY
FEATURES
DEFENCE MECHANISMS
MORE THAN 1 DX
AXIS III
GMC RELEVANT TO MENTAL D/O
NO LINK BUT INCLUDED IF:
         OVERALL UNDERSTANDING OF PT
         AXIS I PSYCHOLOGICAL
         REACTION TO AXIS II
THOROUGHNESS OF EVALUATION
ENHANCES COMMUNICATION BETWEEN
HEALTH PROFESSIONALS
PROGNOSTIC AND RX IMPLICATION
AXIS IV
PYCHOSOCIAL AND ENVIRONMENTAL
PROBLEMS THAT AFFECT DX ,RX AND PX:
– PROBLEMS WITH PRIMARY SUPPORT
  GROUPS
– PROBLEMS RELATED TO SOCIAL
  ENVIRONMENT
– EDUCATIONAL PROBLEMS
– HOUSING PROBLEMS
– ECONOMIC PROBLEMS
– PROBLEMS WITH ACCESS TO HEALTH
  CARE SERVICES
AXIS IV
– PROBLEMS RELATED TO ACCESS TO
  HEALTH CARE SERVICES

– PROBLEMS RELATED TO INTERACTION
  WITH LEGAL SYSTEM/CRIME

– OTHER PSYCHOSOCIAL AND
  ENVIRONMENTAL PROBLEMS
AXIS V

GLOBAL ASSESSMENT OF FUNCTIONING
CLINICIANS JUDGEMENT – OVERALL
LEVEL OF FUNCTIONING
PLANNING RX
PREDICTING OUTCOME
GAF SCALE
GAF SCALE
TRACKS CLINICAL PROGRESS
SOCIAL,OCCUPATIONAL AND
PSYCHOLOGICAL FUNCTIONING
2 COMPONENTS – SYMPTOM SEVERITY
AND FUNCTIONING
REFLECTS WORSE OF 2
CURRENT PERIOD S/T ADMISSION,
DISCHARGE ETC
ADVANTAGES DSM IV-TR
WIDESPREAD USE – EASE OF
COMMUNICATION
CLEAR DEFINITION AND
DELINEATIONS
COMPATIBILITY WITH ICD10
REPORTING DIAGNOSTIC DATA
COLLECTION OF DIAGNOSTIC DATA
ADVANTAGES CONT
CATEGORICAL MODEL – VALID
THRESHOLDS FOR CASE
IDENTIFICATION WITH CLEAR
BOUNDARIES BETWEEN CLASSES

MULTIAXIAL EVALUATION PROMOTES
COMPREHENSIVE BIOPSYCHOSOCIAL
APPROACH
LIMITATIONS OF DSM IV-TR
FORENSIC SETTING
RISK OF INFORMATION MISUSED
INSUFFICIENT TO ESTABLISH MI,
COMPETENCY AND CRIMINAL
RESPONSIBILITY
NO IMPLICATIONS FOR DEGREE OF
CONTROL OVER BEHAVIOURS
ASSOCIATED WITH MI
FACILITATES LEGAL DECISIONS
CLINICAL JUDGEMENT

INDIVIDUALS WITH APPROPRIATE
CLINICAL TRAINING

CANNOT BE APPLIED MECHANICALLY
ETHNIC AND CULTURAL
      IMPLICATIONS
CHALLENGING IF PT AND CLINICIAN FROM
DIFFERENT BACKGROUNDS
INCORRECTLY DIAGNOSE
PSYCHOPATHOLOGY
INCORRECT PERSONALITY DIAGNOSTIC
CRITERIA ACROSS DIFFERENT CULTURAL
SETTINGS
ALLOWANCES MADE BY DSM
         DISCUSSES CULTURAL
         VARIATIONS
         CULTURE BOUND SYNDROMES
         CULTURAL FORMULATION
TREATMENT PLANNING


CLINICIAN REQUIRED TO OBTAIN
INFORMATION ABOVE THAT OF
DIAGNOSTIC CRITERIA
CATEGORICAL APPROACH
CATEGORIES OF MENTAL ILLNESS NOT
MUTUALLY EXCLUSIVE

INDIVIDUALS ARE HETEROGENOUS

NO CONSIDERATION OF PATIENTS
NARRATIVE HISTORY
LIMITATIONS OF DSMIV-TR
          CONT
NOT USEFUL FOR RESEARCH – HINDERS
INVESTIGATIONS INTO AET, PATHOPHYS,
GENETICS
NOT RELIABLE INTERCLINICIAN TOOL
PATIENTS NOT INCORPORATED IN RX
CHOICES
COMPLICATED-284 POTENTIAL DX
LESS VALIDITY- BEREAVEMENT
CONCEPTUAL INCONSISTENCY
LIMITATIONS OF DSM IV-TR
INCONSISTENCIES WITH REMISSION
STATUS
EXCUSION OF PSYCHODYNAMIC AND
PSYCHOSOCIAL PERSPECTIVES
UNCERTAINTY OF INTERPRETING
‘CLINICALLY SIGNIFICANT’ CRITERIA
MULTIAXIAL SYSTEM- TIME CONSUMING,
NOT USED
AXES IV, V- DUBIOUS RELIABILITY AND
VALIDITY
ICD 10
INTERNATIONAL CLASSIFICATION OF
DISEASES
CLASSIFICATION FOR EPIDEMIOLOGICAL
AND HEALTH MANAGEMENT PURPOSES
WHO
HISTORY AND BACKGROUND
1853 – INTERNATIONAL STATISTICAL
CONGRESS – W. FARR
REVISED OVER NEXT DECADES
1946 – WHO – INTERNATIONAL LIST OF
CAUSES IF MORBIDITY
1948 – 6TH REVISION
1975 – 9TH REVISION-BEGINNING OF ICD
9TH REVISION – DESCRIPTIONS OF
CATEGORIES OF CHAPTER V – MENTAL D/O
HX AND BACKGROUND

1989 – 10TH REVISION

ALPHANUMERICAL CODING SCHEME
OF 1 LETTER FOLLOWED BY 3
NUMBERS

INCREASE IN NUMBER OF
CATEGORIES, SEPARATE CHAPTERS
ICD 10
CHAPTER V – MENTAL D/O
CHAPTER VI – NEUROLOGICAL D/O
CHAPTER XIX – CLASSIFICATION OF
INJURIES – POISONING
CHAPTER XVIII – S AND S, ABN CLINICAL
AND LAB FINDINGS
CATEGORIES DENOTED BY LETTER
1ST NO – MAIN GROUP
2ND NO – CATEGORY WITHIN GROUP
4TH CHARACTER – FURTHER SUBDIVISION
F32.2 – SEVERE DEPRESSIVE EPISODE
WITHOUT PSYCHOTIC SYMPTOMS
ICD 10

SCZ – 5TH CHARACTER – SPECIFY
COURSE
F20.01 – PARANOID SCZ, EPISODIC
WITH PROGRESSIVE DEFICIT
DIFFERENT VERSIONS – FLEXIBILITY
AND ACCEPTIBILITY TO VARIOUS USERS
ICD 10
CLINICAL DESCRIPTIONS AND DIAGNOSTIC
GUIDELINES FOR GENERAL CLINICAL,
EDUCATIONAL AND SERVICE USE

DIAGNOSTIC CRITERIA FOR RESEARCH

PRIMARY CARE VERSION

MULTIAXIAL VERSION
CLINICAL DESCRIPTIONS…
EACH CATEGORY ACCOMPANIED BY
GLOSSARY OF BRIEF DEFINITIONS

FURTHER DEFINED SET OF CRITERIA

CRITERIA LESS PRECISE THAN DSM

ALLOWS CLINICIANS TO USE IN DAILY
PRACTICE
DIAGNOSTIC CRITERIA FOR RESEARCH


 TWO NB ANNEXES

 CULTURE SPECIFIC D/O


 PROVISIONAL CRITERIA FOR UNCERTAIN
 NOSOLOGICAL STATUS – BIPOLAR D/O II
MULTIAXIAL VERSION

ADULT PSYCHIATRY – 3 AXES

        CATEGORIZE CLINICAL SYNDROME

        LEVEL OF FUNCTIONAL CAPACITY/
        DISABILITY

        CATEGORIES OF IMPORTANCE IN
        THE UNDERSTANDING OF THE D/O
MULTIAXIAL VERSION

MENTAL D/O OF CHILDHOOD
6 AXES:
   CLINICAL PSYCHIATRIC SYNDROMES
   SPECIFIC D/O OF PSYCHOLOGIC DEVELOPMENT
   INTELLECTUAL LEVEL
   MEDICAL CONDITIONS
   ASSOCIATED ABNORMAL PSYCHOSOCIAL
   SITUATION
   GLOBAL ASSESSMENT OF PSYCHOSOCIAL
   DISABILITY
PRIMARY CARE VERSION

FEWER CATEGORIES
GENERAL PRACTITIONER, PRIMARY
HEALTH CARE STAFF,
PSYCHIATRISTS, OTHERS
2 CARDS
   WAY THAT CONDITION IS RECOGNIZED
   AND DIAGNOSED
   ADVICE ON MX
ADVANTAGES OF ICD 10

SIMPLICITY OF STRUCTURE AND USE
USED BY SPECIAL GROUPS, STILL
COMPATIBLE WITH ORIGINAL
CLASSIFICATION
COMPATIBILITY WITH NATIONAL AND
OTHER WIDELY USED CLASSIFICATIONS
DIFFERENCES KEPT TO MINIMUM
CONTINUITY OVER TIME
BASED ON INTERNATIONAL CONSENSUS
ADVANTAGES OF ICD 10

BASED ON INTERNATIONAL CONSENSUS
SEVERAL VERSIONS – ALL COMPATIBLE
WITH EACH OTHER
SEVERAL LANGUAGES
ADDITIONAL PUBLICATIONS FACILITATE ITS
USE
RESPONSIVE TO NEEDS OF PRACTICE
CATEGORIES FOR DIAGNOSIS
FREQUENTLY USED BUT NOSOLGY
UNCERTAIN
ADVANTAGES OF ICD 10

AVOIDS ‘SOCIAL FUNCTIONING’ AS
DIAGNOSTIC INDICATOR
RECENTLY INTRODUCED DX OF PUBLIC
HEALTH INTERES MILD COGNITIVE D/O
TERMINOLOGY EASY TO USE
SIGNIFICANT EXPANSION OF ACUTE
PSYCHOTIC D/O-DEVELOPING COUNTRIES
CATEGORICAL CLASSIFICATION
LIMITATIONS OF ICD 10

CATEGORICAL CLASSIFICATION-DISCRETE
ENTITY VIEW OF PSYCH D/O
LIMITATIONS OF CURRENT OPERATIONAL
      APPROACHES TO DIAGNOSIS
FOCUS ON EPISODE RATHER THAN LIFETIME
EXPERIENCE
HIERARCHIES LEAD TO LOSS OF INFO
BOUNDARIES BET CATEGORIES ARE
ARBITRARY
BOUNDARIES BET CATEGORIES REQUIRE
SUBSTANTIAL SUBJECTIVE JUDGEMENT
DIAGNOSTIC CATEGORIES ARE UNHELPFUL IN
DETERMINING SEVERITY
LIMITATIONS OF CURRENT OPERATIONAL
      APPROACHES TO DIAGNOSIS

 SUBCLINICAL CASES NOT ACCOMODATED
 FULLY
 NOS CATEGORIES HIGHLY HETEROGENOUS
 INCREASED GAPS BETWEEN RESEARCH
 FINDINGS AND DEFINITIONS OF CURRENT
 DIAGNOSTIC SYSTEMS – SACRIFICES VALIDITY
 FOR RELIABILITY
DIFFERENCES BETWEEN DSM AND ICD
         DSM IV-TR                       ICD10

PRODUCED BY APA                 WHO

ONE GROUP OF DISEASES, DIRECT   NUMBER OF CLASSIFICATIONS
INTEREST TO PARTICULAR          – EVEN CLASSIFICATION OF
PROFESSIONAL GROUP              REASON FOR CONTACT

NATIONAL DIAGNOSTIC             STATUTORY RESPONSIBILITY
CLASSIFICATION                  FOR RELIABLE REPORTING OF
                                DISEASES AND HEALTH
                                STATES TO THE WORLD
                                POPULATION

SINGLE SET OF OPERATIONAL       INTERRELATED VERSIONS
DIAGNOSTIC CRUTERIA FOR ALL     ADDRESSING DIFFERENT
USERS                           USERS IN SPECIFIC CONTEXTS
DIFFERENCES BETWEEN DSM AND ICD 10
          DSM IV-TR                    ICD10
 DEFINITIONAL DIFFERENCES-   DX OF HARMFUL USE FOCUSES
 SUBSTANCE D/O=FOCUS ON      ON DAMAGE TO USER’S
 NEGATIVE CONSEQUENCES       PHYSICAL AND MENTAL HEALTH

 ACUTE STRESS D/O-DX ONLY    WIDER RANGE OF RESPONSES-
 FOR SEVERE DISSOCIATIVE     MILD ANXIETY TO SEVERE
 REACTIONS                   DISSOCIATION

 DIFFERENCES IN DIAGNOSTIC   MINIMUM 3/12
 CRITERIA-DURATION,
 FREQUENCY ETC-DELUSIONAL
 D/O-3/12

 DIFFERENCES IN              HYPOCHONDRIASIS
 EXCLUSIONARY CRITEIA-
 HYPOCHONDRIASIS

 CONCEPTUAL DIFFERENCES OF   CONCEPTUAL DIFFERENCES OF
 DISORDERS                   DISORDERS
The dsmiv and_icd10_classification_systems_(background)
The dsmiv and_icd10_classification_systems_(background)
The dsmiv and_icd10_classification_systems_(background)
The dsmiv and_icd10_classification_systems_(background)
DSMV

CURRENTLY IN CONSULTATION,
PLANNING AND PREPARATION
DUE FOR PUBLICATION IN 2012/13
WORK GROUPS TO ADDRESSS MAJOR
GAPS
DEVELOPMENTAL ISSUES
REFINE PSYCHIATRIC ASSESSMENT
TECHNIQUE ACROSS
DEVELOPMENTAL STAGES
METHODS TO INTEGRATE
DEVELOPMENTAL ASSESSMENTS
INTO DIAGNOSTIC PROCESSING
DEFINING MENTAL ILLNESS
FACILITATING DIAGNOSTIC PROCESSES IN
NON-PSYCHIATRIC SETTINGS
APPLICABILITY OF CRITERIA ACROSS
DIFFERENT CULTURAL SETTINGS
VALIDATINGDIAGNOSTIC CRITERIA
INCREASING COMPATIBILITY BETWEEN
DSM V AND ICD 10
DIMENSIONAL APPROACH MORE SUPERIOR
PERSONALITY DISORDERS

DIMENSIONAL MODEL MAY BE SUPERIOR,
MORE RELIABLE, SPECIFIC AND CLINICALLY
INFORMATIVE
SHOULD THERE BE INDEPENDENCE AND
DISTINCTIVENESS BETWEEN AXIS I AND
AXIS II PERSONALITY D/O
BOTH FREQUENTLY CO-EXIST
AXIS II OFTEN A SIGNIFICANT
COMPLICATING FACTOR TO AXIS I
RELATIONAL PROBLEMS

PAINFUL PERSISTENT BEHAVIOURAL
PROBLEMS THAT SERIOUSLY AFFECT
JUDGEMENT
INCLUSION IN DSMV
PROPOSED CHANGES TO DSM IV-TR
            DX
  ELIMINATE ASPERGERS SYNDROME
  AS SEPARATE D/O
  MERGE UNDER AUTISM SPECTRUM D/
  O
  SEVERITY CAN BE RATED- SEVERE,
  MODERATE, MILD
PROPOSED NEW DSM V DX

COMPLEX POST TRAUMATIC STRESS D/O
DEPRESSIVE PERSONALITY D/O
NEGATIVISTIC ( PASSIVE-AGGRESSIVE ) PD
POST TRAUMATIC EMBITTERMENT D/O
RELATIONAL D/O
PD AND MR AS AXIS I D/O
SLUGGISH COGNITIVE TEMPERAMENT
REFERENCES

KAPLAN AND SADDOCK’S COMPREHENSIVE TEXTBOOK OF
PSYCHIATRY, 9TH EDITION 2009
KAPLAN AND SADDOCK’S SYNOPSIS OF PSYCHIATRY,10TH
EDITION
DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL
DISORDERS:DSM IV TR- APA 2000
A RESEARCH AGENDA FOR DSM V. KUPFER,D;
FIRST,M;REGIER,D
FIRST M.HARMONISATION OF ICD-11 AND DSM- V:
OPPORTUNITIES AND CHALLENGES.BJP 2009;195:382-390
JABLENSKY A.TOWARDS ICD-11 AND DSM-V:ISSUES BEYOND
HARMONISATION.BJP 2009;195:379-381
CRADDOCK,MICHAEL O.RETHINKING PSYCHOSIS.WORLD
PSYCHIATRY 2007;6(2):84-91
REFERENCES

DISTINGUISHING BETWEEN VALIDIDTY AND UTILITY
OF PSYCHIATRIC DIAGNOSIS. KWNDELL
R,JABLESKY A.AMJ 2003;160:4-12
CLINICAL UTILITY AS A CRITERION FOR REVISING
PSYCHIATRIC DIAGNOSIS. FIRST M,WILLIAMS
J,USTUN B, PEELE R. AMJ 2004;161;946-954
AMERICAN ASSOCIATION OF COMMUNITY
PSYCHIATRIST’S VIEWS ON GENERAL FEATURES
OF DSM-IV. BELL C,SOWERS W, THOMPSON K.
PSYCHIATRIC SERVICES,2008;59:687-689

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The dsmiv and_icd10_classification_systems_(background)

  • 1. THE DSM AND ICD PSYCHIATRIC CLASSIFICATION SYSTEMS
  • 2. FACILITATES CHARACTERIZATION, COMMUNICATION AND RESEARCH COMPLEXITY OF PHENOMENA ARE REDUCED TWO VIEWS: DIMENSIONALIZERS – DIMENSIONS OF FUNCTIONING,DIFFERENT PSYCHIATRIC D/O CATEGORIZERS – SPECIFIC GROUPS OF SYMPTOMS – REFLECT PSYCHIATRIC SYNDROMES
  • 3. IMPORTANCE OF CLASSIFICATION FOR PSYCHIATRIC DIAGNOSIS DISTINGUISH BET DIFF PSYCHIATRIC DIAGNOSIS COMMON LANGUAGE AMONGST HEALTH PROFESSIONALS ENSURES RELIABILITY,COMMUNICATION AND STATISTICAL REPORTING EFFECTIVE TREATMENT STANDARD FRAME OF REFERENCE TEACHING-INTERNATIONAL REFERENCE SYSTEMS
  • 4. IMPORTANCE OF CLASSIFICATION CONT. PUBLIC ACESS – IMPROVES COMMUNICATION IMPROVES RELIABILITY OF PSYCHIATRIC DIAGNOSIS IN RESEARCH SETTINGS UNDERSTANDING OF CAUSES AND PROCESSES OF MENTAL DISORDERS
  • 5. TWO MOST ACCEPTED PSYCHIATRIC CLASSIFICATIONS DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS (DSM IV TR) INTERNATIONAL CLASSIFICATION OF DISEASES (ICD 10) CLINICAL DESCRIPTIONS BASED ON PHENOMENOLOGICAL APPROACHES
  • 6. DSM CATEGORICAL CLASSIFICATION DIVIDES MENTAL DISORDERS CRITERIA SETS – DEFINING FEATURES
  • 7. HISTORY AND BACKGROUND FIRST DSM – AMERICAN PSYCHIATRIC ASSOCIATION COMMITTEE DSM II – 1968 DSM III – 1980 REVISED DSM III – 1987 DSM III-R – 1987 DSM IV – 1994 DSM-IV-TR – 2000
  • 8. HISTORY AND BACKGROUND WHO – ICD-6 SECTION ON MENTAL DISORDERS APA – VARIANT OF ICD-6 DSM-1 – FIRST OFFICIAL MANUAL OF CLINICAL MENTAL DISORDERS PSYCHOBIOLOGICAL VIEW
  • 9. HISTORY AND BACKGROUND DSM-II CORRELATED WITH ICD-8 DSM-III CORRELATED WITH 1CD-9 DSM-III – EXPLICIT DIAGNOSTIC CRITERIA – MULTI-AXIAL SYSTEM – DESCRIPTIVE MEDICAL NOMENCLATURE
  • 10. HISTORY AND BACKGROUND DSM-III-R – EMPIRICAL RESEARCH DSM-IV – SYSTEMATIC REVIEWS AND FOCUSED FIELD TRIALS GOAL – INCREASE PRACTICALITY AND CLINICAL UTILITY DSM IV-TR – NOS CATEGORY
  • 11. DSM IV-TR OFFICIAL CODING SYSTEM IN USA ATHEORETICAL APPROACH TO CAUSES DESCRIBES MANIFESTATIONS AND DESCRIPTIONS OF CLINICAL FEATURES OF MENTAL D/O SPECIFIC DIAGNOSTIC CRITERIA CRITERIA INCREASE RELIABILITY
  • 12. DSM IV-TR SYSTEMATIC DESCRIPTIONS: AGE CULTURE GENDER FEATURES PREVALENCE, INCIDENCE RISK , COURSE COMPLICATIONS PREDISPOSING FACTORS FAMILIAL PATTERNS DIFFERENTIAL DIAGNOSIS LAB FINDINGS PHYSICAL EXAMINATION SIGNS AND SYMPTOMS
  • 13. DSM IV-TR 365 DISORDERS 17 SECTIONS PROPOSED DIAGNOSTIC CRITERIA
  • 14. DSM IV-TR ORGANIZATIONAL PLAN 16 MAJOR DIAGNOSTIC CLASSES OTHER CONDITIONS THAT MAY BE FOCUS OF CLINICAL ATTENTION 11 APPENDICES DIFFERENTIAL DX GLOSSARY CHANGES IN DSM-IV-TR CLASSIFICATION WITH ICD-10 CULTURAL FORMULATION, ETC
  • 15. AIMS OF DSM IV-TR CLEAR DIAGNOSTIC CATEGORIES DX, COMMUNICATION, STUDY AND TREAT DIAGNOSTIC CRITERIA FOR RESEARCH PURPOSES RECORD KEEPING, DATA COLLECTION REPORTING TO 3RD PARTIES – GOVN, PRIVATE INSURERS SUBTYPES SPECIFIERS INCREASED SPECIFICITY
  • 16. AIMS OF DSM IV-TR CLINICAL DECISIONS RX SETTING MODE OF RX DURATION OF RX
  • 17. SEVERITY AND COURSE SPECIFIERS MILD, MODERATE, SEVERE ONLY WHEN FULL CRITERIA MET INTENSITY OF S AND S IMPAIRMENT IN OCCUPATIONAL AND FUNCTIONAL IMPAIRMENT MR CONDUCT D/O MANIC EPISODE MAJOR DEPRESSIVE EPISODE
  • 18. SEVERITY AND COURSE SPECIFIERS PARTIAL REMISSION – FULL CRITERIA PREVIOUSLY MET FULL REMISSION – NO LONGER S AND S, STILL CLINICALLY RELEVANT PARTIAL AND FULL REMISSION FOR: MANIC EPISODE MAJOR DEPRESSIVE EPISODE SUBSTANCE DEPENDANCE PRIOR HISTORY – USEFUL TO NOTE HX OF CRITERIA PREVIOUSLY MET BUT NOW RECOVERED
  • 19. RECURRENCE FULL CRITERIA NO LONGER MET PARTIAL, FULL REMISSION, RECOVERY DO NOT MEET FULL THRESHOLD OF D/O ACCORDING TO SPECIFIED CRITERIA
  • 20. NOS CATEGORIES DIVERSITY OF CLINICAL PRESENTATION 4 SITUATIONS: – CRITERIA NOT MET FOR SPECIFIC D/O EG ATYPICAL, MIXED PICTURE – DOES NOT CONFORM TO DSM IV CLASSIFICATION BUTCLINICAL SIGNIFICANT DISTRESS – AETIOLOGY UNCERTAIN – INSUFFICIENT DATA, INCONSISTENT INFORMATION
  • 21. MULTIAXIAL ASSESSMENT 5 AXES – I – CLINICAL D/O, OTHER CONDITIONS FOCUS OF CLINICAL ATTENTION – II – PERSONALITY D/O – III – GMC – IV – PSYCHOSOCIAL, ENVIRONMENTAL – V – GAF
  • 22. MULTIAXIAL ASSESSMENT DIFFERENT DOMAINS OF INFORMATION PLAN RX AND PREDICT OUTCOME ORGANIZING, COMMUNICATING CLINICAL INFORMATION CAPTURES COMPLEXITY OF CLINICAL SITUATION HETEROGENEITY OF PATIENT BIOPSYCHOSOCIAL MODEL
  • 23. AXIS I PRINCIPAL DX AXIS II CAN ALSO BE PRINCIPAL DIAGNOSIS – MUST BE FOLLOWED BY ‘PRINCIPAL DX’ OR ‘REASON FOR VISIT’
  • 24. AXIS II PERSONALITY D/O MR MALADAPTIVE PERSONALITY FEATURES DEFENCE MECHANISMS MORE THAN 1 DX
  • 25. AXIS III GMC RELEVANT TO MENTAL D/O NO LINK BUT INCLUDED IF: OVERALL UNDERSTANDING OF PT AXIS I PSYCHOLOGICAL REACTION TO AXIS II THOROUGHNESS OF EVALUATION ENHANCES COMMUNICATION BETWEEN HEALTH PROFESSIONALS PROGNOSTIC AND RX IMPLICATION
  • 26. AXIS IV PYCHOSOCIAL AND ENVIRONMENTAL PROBLEMS THAT AFFECT DX ,RX AND PX: – PROBLEMS WITH PRIMARY SUPPORT GROUPS – PROBLEMS RELATED TO SOCIAL ENVIRONMENT – EDUCATIONAL PROBLEMS – HOUSING PROBLEMS – ECONOMIC PROBLEMS – PROBLEMS WITH ACCESS TO HEALTH CARE SERVICES
  • 27. AXIS IV – PROBLEMS RELATED TO ACCESS TO HEALTH CARE SERVICES – PROBLEMS RELATED TO INTERACTION WITH LEGAL SYSTEM/CRIME – OTHER PSYCHOSOCIAL AND ENVIRONMENTAL PROBLEMS
  • 28. AXIS V GLOBAL ASSESSMENT OF FUNCTIONING CLINICIANS JUDGEMENT – OVERALL LEVEL OF FUNCTIONING PLANNING RX PREDICTING OUTCOME GAF SCALE
  • 29. GAF SCALE TRACKS CLINICAL PROGRESS SOCIAL,OCCUPATIONAL AND PSYCHOLOGICAL FUNCTIONING 2 COMPONENTS – SYMPTOM SEVERITY AND FUNCTIONING REFLECTS WORSE OF 2 CURRENT PERIOD S/T ADMISSION, DISCHARGE ETC
  • 30. ADVANTAGES DSM IV-TR WIDESPREAD USE – EASE OF COMMUNICATION CLEAR DEFINITION AND DELINEATIONS COMPATIBILITY WITH ICD10 REPORTING DIAGNOSTIC DATA COLLECTION OF DIAGNOSTIC DATA
  • 31. ADVANTAGES CONT CATEGORICAL MODEL – VALID THRESHOLDS FOR CASE IDENTIFICATION WITH CLEAR BOUNDARIES BETWEEN CLASSES MULTIAXIAL EVALUATION PROMOTES COMPREHENSIVE BIOPSYCHOSOCIAL APPROACH
  • 33. FORENSIC SETTING RISK OF INFORMATION MISUSED INSUFFICIENT TO ESTABLISH MI, COMPETENCY AND CRIMINAL RESPONSIBILITY NO IMPLICATIONS FOR DEGREE OF CONTROL OVER BEHAVIOURS ASSOCIATED WITH MI FACILITATES LEGAL DECISIONS
  • 34. CLINICAL JUDGEMENT INDIVIDUALS WITH APPROPRIATE CLINICAL TRAINING CANNOT BE APPLIED MECHANICALLY
  • 35. ETHNIC AND CULTURAL IMPLICATIONS CHALLENGING IF PT AND CLINICIAN FROM DIFFERENT BACKGROUNDS INCORRECTLY DIAGNOSE PSYCHOPATHOLOGY INCORRECT PERSONALITY DIAGNOSTIC CRITERIA ACROSS DIFFERENT CULTURAL SETTINGS ALLOWANCES MADE BY DSM DISCUSSES CULTURAL VARIATIONS CULTURE BOUND SYNDROMES CULTURAL FORMULATION
  • 36. TREATMENT PLANNING CLINICIAN REQUIRED TO OBTAIN INFORMATION ABOVE THAT OF DIAGNOSTIC CRITERIA
  • 37. CATEGORICAL APPROACH CATEGORIES OF MENTAL ILLNESS NOT MUTUALLY EXCLUSIVE INDIVIDUALS ARE HETEROGENOUS NO CONSIDERATION OF PATIENTS NARRATIVE HISTORY
  • 38. LIMITATIONS OF DSMIV-TR CONT NOT USEFUL FOR RESEARCH – HINDERS INVESTIGATIONS INTO AET, PATHOPHYS, GENETICS NOT RELIABLE INTERCLINICIAN TOOL PATIENTS NOT INCORPORATED IN RX CHOICES COMPLICATED-284 POTENTIAL DX LESS VALIDITY- BEREAVEMENT CONCEPTUAL INCONSISTENCY
  • 39. LIMITATIONS OF DSM IV-TR INCONSISTENCIES WITH REMISSION STATUS EXCUSION OF PSYCHODYNAMIC AND PSYCHOSOCIAL PERSPECTIVES UNCERTAINTY OF INTERPRETING ‘CLINICALLY SIGNIFICANT’ CRITERIA MULTIAXIAL SYSTEM- TIME CONSUMING, NOT USED AXES IV, V- DUBIOUS RELIABILITY AND VALIDITY
  • 40. ICD 10 INTERNATIONAL CLASSIFICATION OF DISEASES CLASSIFICATION FOR EPIDEMIOLOGICAL AND HEALTH MANAGEMENT PURPOSES WHO
  • 41. HISTORY AND BACKGROUND 1853 – INTERNATIONAL STATISTICAL CONGRESS – W. FARR REVISED OVER NEXT DECADES 1946 – WHO – INTERNATIONAL LIST OF CAUSES IF MORBIDITY 1948 – 6TH REVISION 1975 – 9TH REVISION-BEGINNING OF ICD 9TH REVISION – DESCRIPTIONS OF CATEGORIES OF CHAPTER V – MENTAL D/O
  • 42. HX AND BACKGROUND 1989 – 10TH REVISION ALPHANUMERICAL CODING SCHEME OF 1 LETTER FOLLOWED BY 3 NUMBERS INCREASE IN NUMBER OF CATEGORIES, SEPARATE CHAPTERS
  • 43. ICD 10 CHAPTER V – MENTAL D/O CHAPTER VI – NEUROLOGICAL D/O CHAPTER XIX – CLASSIFICATION OF INJURIES – POISONING CHAPTER XVIII – S AND S, ABN CLINICAL AND LAB FINDINGS CATEGORIES DENOTED BY LETTER 1ST NO – MAIN GROUP 2ND NO – CATEGORY WITHIN GROUP 4TH CHARACTER – FURTHER SUBDIVISION F32.2 – SEVERE DEPRESSIVE EPISODE WITHOUT PSYCHOTIC SYMPTOMS
  • 44. ICD 10 SCZ – 5TH CHARACTER – SPECIFY COURSE F20.01 – PARANOID SCZ, EPISODIC WITH PROGRESSIVE DEFICIT DIFFERENT VERSIONS – FLEXIBILITY AND ACCEPTIBILITY TO VARIOUS USERS
  • 45. ICD 10 CLINICAL DESCRIPTIONS AND DIAGNOSTIC GUIDELINES FOR GENERAL CLINICAL, EDUCATIONAL AND SERVICE USE DIAGNOSTIC CRITERIA FOR RESEARCH PRIMARY CARE VERSION MULTIAXIAL VERSION
  • 46. CLINICAL DESCRIPTIONS… EACH CATEGORY ACCOMPANIED BY GLOSSARY OF BRIEF DEFINITIONS FURTHER DEFINED SET OF CRITERIA CRITERIA LESS PRECISE THAN DSM ALLOWS CLINICIANS TO USE IN DAILY PRACTICE
  • 47. DIAGNOSTIC CRITERIA FOR RESEARCH TWO NB ANNEXES CULTURE SPECIFIC D/O PROVISIONAL CRITERIA FOR UNCERTAIN NOSOLOGICAL STATUS – BIPOLAR D/O II
  • 48. MULTIAXIAL VERSION ADULT PSYCHIATRY – 3 AXES CATEGORIZE CLINICAL SYNDROME LEVEL OF FUNCTIONAL CAPACITY/ DISABILITY CATEGORIES OF IMPORTANCE IN THE UNDERSTANDING OF THE D/O
  • 49. MULTIAXIAL VERSION MENTAL D/O OF CHILDHOOD 6 AXES: CLINICAL PSYCHIATRIC SYNDROMES SPECIFIC D/O OF PSYCHOLOGIC DEVELOPMENT INTELLECTUAL LEVEL MEDICAL CONDITIONS ASSOCIATED ABNORMAL PSYCHOSOCIAL SITUATION GLOBAL ASSESSMENT OF PSYCHOSOCIAL DISABILITY
  • 50. PRIMARY CARE VERSION FEWER CATEGORIES GENERAL PRACTITIONER, PRIMARY HEALTH CARE STAFF, PSYCHIATRISTS, OTHERS 2 CARDS WAY THAT CONDITION IS RECOGNIZED AND DIAGNOSED ADVICE ON MX
  • 51. ADVANTAGES OF ICD 10 SIMPLICITY OF STRUCTURE AND USE USED BY SPECIAL GROUPS, STILL COMPATIBLE WITH ORIGINAL CLASSIFICATION COMPATIBILITY WITH NATIONAL AND OTHER WIDELY USED CLASSIFICATIONS DIFFERENCES KEPT TO MINIMUM CONTINUITY OVER TIME BASED ON INTERNATIONAL CONSENSUS
  • 52. ADVANTAGES OF ICD 10 BASED ON INTERNATIONAL CONSENSUS SEVERAL VERSIONS – ALL COMPATIBLE WITH EACH OTHER SEVERAL LANGUAGES ADDITIONAL PUBLICATIONS FACILITATE ITS USE RESPONSIVE TO NEEDS OF PRACTICE CATEGORIES FOR DIAGNOSIS FREQUENTLY USED BUT NOSOLGY UNCERTAIN
  • 53. ADVANTAGES OF ICD 10 AVOIDS ‘SOCIAL FUNCTIONING’ AS DIAGNOSTIC INDICATOR RECENTLY INTRODUCED DX OF PUBLIC HEALTH INTERES MILD COGNITIVE D/O TERMINOLOGY EASY TO USE SIGNIFICANT EXPANSION OF ACUTE PSYCHOTIC D/O-DEVELOPING COUNTRIES CATEGORICAL CLASSIFICATION
  • 54. LIMITATIONS OF ICD 10 CATEGORICAL CLASSIFICATION-DISCRETE ENTITY VIEW OF PSYCH D/O
  • 55. LIMITATIONS OF CURRENT OPERATIONAL APPROACHES TO DIAGNOSIS FOCUS ON EPISODE RATHER THAN LIFETIME EXPERIENCE HIERARCHIES LEAD TO LOSS OF INFO BOUNDARIES BET CATEGORIES ARE ARBITRARY BOUNDARIES BET CATEGORIES REQUIRE SUBSTANTIAL SUBJECTIVE JUDGEMENT DIAGNOSTIC CATEGORIES ARE UNHELPFUL IN DETERMINING SEVERITY
  • 56. LIMITATIONS OF CURRENT OPERATIONAL APPROACHES TO DIAGNOSIS SUBCLINICAL CASES NOT ACCOMODATED FULLY NOS CATEGORIES HIGHLY HETEROGENOUS INCREASED GAPS BETWEEN RESEARCH FINDINGS AND DEFINITIONS OF CURRENT DIAGNOSTIC SYSTEMS – SACRIFICES VALIDITY FOR RELIABILITY
  • 57. DIFFERENCES BETWEEN DSM AND ICD DSM IV-TR ICD10 PRODUCED BY APA WHO ONE GROUP OF DISEASES, DIRECT NUMBER OF CLASSIFICATIONS INTEREST TO PARTICULAR – EVEN CLASSIFICATION OF PROFESSIONAL GROUP REASON FOR CONTACT NATIONAL DIAGNOSTIC STATUTORY RESPONSIBILITY CLASSIFICATION FOR RELIABLE REPORTING OF DISEASES AND HEALTH STATES TO THE WORLD POPULATION SINGLE SET OF OPERATIONAL INTERRELATED VERSIONS DIAGNOSTIC CRUTERIA FOR ALL ADDRESSING DIFFERENT USERS USERS IN SPECIFIC CONTEXTS
  • 58. DIFFERENCES BETWEEN DSM AND ICD 10 DSM IV-TR ICD10 DEFINITIONAL DIFFERENCES- DX OF HARMFUL USE FOCUSES SUBSTANCE D/O=FOCUS ON ON DAMAGE TO USER’S NEGATIVE CONSEQUENCES PHYSICAL AND MENTAL HEALTH ACUTE STRESS D/O-DX ONLY WIDER RANGE OF RESPONSES- FOR SEVERE DISSOCIATIVE MILD ANXIETY TO SEVERE REACTIONS DISSOCIATION DIFFERENCES IN DIAGNOSTIC MINIMUM 3/12 CRITERIA-DURATION, FREQUENCY ETC-DELUSIONAL D/O-3/12 DIFFERENCES IN HYPOCHONDRIASIS EXCLUSIONARY CRITEIA- HYPOCHONDRIASIS CONCEPTUAL DIFFERENCES OF CONCEPTUAL DIFFERENCES OF DISORDERS DISORDERS
  • 63. DSMV CURRENTLY IN CONSULTATION, PLANNING AND PREPARATION DUE FOR PUBLICATION IN 2012/13 WORK GROUPS TO ADDRESSS MAJOR GAPS
  • 64. DEVELOPMENTAL ISSUES REFINE PSYCHIATRIC ASSESSMENT TECHNIQUE ACROSS DEVELOPMENTAL STAGES METHODS TO INTEGRATE DEVELOPMENTAL ASSESSMENTS INTO DIAGNOSTIC PROCESSING
  • 65. DEFINING MENTAL ILLNESS FACILITATING DIAGNOSTIC PROCESSES IN NON-PSYCHIATRIC SETTINGS APPLICABILITY OF CRITERIA ACROSS DIFFERENT CULTURAL SETTINGS VALIDATINGDIAGNOSTIC CRITERIA INCREASING COMPATIBILITY BETWEEN DSM V AND ICD 10 DIMENSIONAL APPROACH MORE SUPERIOR
  • 66. PERSONALITY DISORDERS DIMENSIONAL MODEL MAY BE SUPERIOR, MORE RELIABLE, SPECIFIC AND CLINICALLY INFORMATIVE SHOULD THERE BE INDEPENDENCE AND DISTINCTIVENESS BETWEEN AXIS I AND AXIS II PERSONALITY D/O BOTH FREQUENTLY CO-EXIST AXIS II OFTEN A SIGNIFICANT COMPLICATING FACTOR TO AXIS I
  • 67. RELATIONAL PROBLEMS PAINFUL PERSISTENT BEHAVIOURAL PROBLEMS THAT SERIOUSLY AFFECT JUDGEMENT INCLUSION IN DSMV
  • 68. PROPOSED CHANGES TO DSM IV-TR DX ELIMINATE ASPERGERS SYNDROME AS SEPARATE D/O MERGE UNDER AUTISM SPECTRUM D/ O SEVERITY CAN BE RATED- SEVERE, MODERATE, MILD
  • 69. PROPOSED NEW DSM V DX COMPLEX POST TRAUMATIC STRESS D/O DEPRESSIVE PERSONALITY D/O NEGATIVISTIC ( PASSIVE-AGGRESSIVE ) PD POST TRAUMATIC EMBITTERMENT D/O RELATIONAL D/O PD AND MR AS AXIS I D/O SLUGGISH COGNITIVE TEMPERAMENT
  • 70. REFERENCES KAPLAN AND SADDOCK’S COMPREHENSIVE TEXTBOOK OF PSYCHIATRY, 9TH EDITION 2009 KAPLAN AND SADDOCK’S SYNOPSIS OF PSYCHIATRY,10TH EDITION DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS:DSM IV TR- APA 2000 A RESEARCH AGENDA FOR DSM V. KUPFER,D; FIRST,M;REGIER,D FIRST M.HARMONISATION OF ICD-11 AND DSM- V: OPPORTUNITIES AND CHALLENGES.BJP 2009;195:382-390 JABLENSKY A.TOWARDS ICD-11 AND DSM-V:ISSUES BEYOND HARMONISATION.BJP 2009;195:379-381 CRADDOCK,MICHAEL O.RETHINKING PSYCHOSIS.WORLD PSYCHIATRY 2007;6(2):84-91
  • 71. REFERENCES DISTINGUISHING BETWEEN VALIDIDTY AND UTILITY OF PSYCHIATRIC DIAGNOSIS. KWNDELL R,JABLESKY A.AMJ 2003;160:4-12 CLINICAL UTILITY AS A CRITERION FOR REVISING PSYCHIATRIC DIAGNOSIS. FIRST M,WILLIAMS J,USTUN B, PEELE R. AMJ 2004;161;946-954 AMERICAN ASSOCIATION OF COMMUNITY PSYCHIATRIST’S VIEWS ON GENERAL FEATURES OF DSM-IV. BELL C,SOWERS W, THOMPSON K. PSYCHIATRIC SERVICES,2008;59:687-689