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Chapter 3 CLASSIFICATION OF MENTAL DISORDERS

This chapter gives a birds eye view of the mental disorders, and introduces a system of classification. In later parts of the DOP, specific symptoms and disorders will be described in detail. The purposes of classification, that is, the putting of apparently related items into boxes or categories are to simplify large amounts of complicated information, and improve communication. In Chapter 1, mention was made of the two main systems of classification of mental disorders: (DSM-IV and ICD-10). These systems arrange large lists of mental disorders under a number of major headings (17 in the case of DSM-IV and 9 in the case of ICD10). New editions of these systems are in preparation. DSM-V will come into effect in May 2013 (Aboraya, 2010). We will concentrate on the current systems, but some news about plans for DSM-5 will be mentioned at the end of the chapter for those who just cant get enough information. The established systems are descriptive (where internal medicine was in the 19th century). Francis (2009) says it would be wise for us all to accept that descriptive psychiatry is a tired old creature. In the future, we hope to make diagnoses using objective means such as genetics an neuroimaging. Others have emphasised the importance of a method of diagnosis based on etiology. For example, McHugh (2005) describes an etiological diagnostic system of 4 clusters: 1) brain disease, in which there is disruption of neural underpinnings (e.g., schizophrenia and melancholic depression), 2) vulnerability because of psychological make-up (e.g., sensitive individuals and the personality disorders), 3) the adoption of behaviour that has become a relatively fixed and warped way of life (e.g., alcoholism and anorexia nervosa), and 4) conditions provoked by events that thwart or threaten (situational anxiety and posttraumatic disorder). In spite of the limitations of the DSM-IV and ICD-10, these are the systems we use at the moment. They have acceptable reliability but do not guide treatment. In this chapter a simplified classification system is presented (Table). The mental disorders have been arranged under the following headings: psychotic, mood, nonpsychotic, personality and organic mental disorders. A related classification is substance use disorders. There has been debate as to whether substance use disorders are social or behavioural problems, or mental disorders. Currently they are included as mental disorders in DSM-IV and ICD-10. However, in many jurisdictions, services are provided by separate, specialized treatment teams.

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Psychotic Disorders Schizophrenia Delusional Disorder Mood Disorder Bipolar Disorder (mania and depression phases) Major Depressive Disorder Cyclothymia Dysthymia Non-Psychotic Disorders Anxiety Disorders Generalized Anxiety Disorder Panic Disorder Phobic Disorders Obsessive Compulsive Disorders Post-traumatic Stress Disorder Eating Disorders Somatoform Disorders Personality Disorders odd and eccentric anxious and fearful dramatic and emotional Organic Mental Disorders Dementia Substance Use Disorders Intoxication and psychosis Dependence Withdrawal Table. A simplified classification system

The current method of diagnosing and classifying mental disorders is difficult because the process largely depends on clinical impressions. When tests are used, it is usually to rule out conditions which are not mental disorders, for example, a brain scan may be performed to rule out the possibility of brain tumour. The main data the psychiatrist has is the appearance and behaviour of the patient and the words he or she uses to describe thoughts, feelings and other experiences. Other data comes from physical examination by which various medical conditions which may at first appear to be mental disorders, such as Huntingtons disease or multiple sclerosis, and from psychological tests of memory

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and concentration, which help to identify organic mental disorders such as Alzheimers disease or other forms of dementia.

Madness Madness was one of Shakespeares favourite words. The English Dictionary offers three meanings. They are all in current use and this can cause misunderstandings. One meaning is senseless folly as when the two young, unsuited, incompatible people have a wild love affair. Such undue enthusiasm appeared in the newspaper headline: US Mad About Harry Potter. Another meaning has to do with anger, as when the fathers of the young people mentioned above discover the affair, splutter, cancel credit cards and talk of rewriting wills etc. A bumper sticker that used the angry meaning: Cigarette companies the truth will make you mad! A recent newspaper headline used the word in describing a famous murder-suicide, which is believed to by the result of an angry outburst.

Illustration. Headlines in newspapers and magazines, dubbed Crown Prince Dipendra of Nepal, The Mad Crown Prince. He is shown here holding an assault rifle of the type he used to kill his mother, father, seven other royal relatives and himself. He wanted to marry a woman who was unacceptable to his parents. He was caught between two cultures and addicted to alcohol and illegal drugs. He had previously reported depression and had taken some antidepressant medication. He could have been called mad using a number of meanings of the word. His murder-suicide was senseless and imprudent, it almost certainly involved great anger and he may well have been mad (psychotic) due to the effects of illegal drugs. While there is some evidence that he Crown Prince Dipendra had suffered depression in the past, there is no evidence that he was depressed at the time of the deaths, or that he had ever suffered a psychotic disorder.

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The third meaning has to do with mental disorder. However, in this field, madness has never been clearly defined. It last appeared in medical books over a century ago. It had been used interchangeably with the words, delusion, delirium and mania. These words currently have separate and distinct meanings. Thus, madness has no precise meaning in either common English or medical lexicons.

Illustration. Title page of a medical treatise on madness, published in 1758.

For mental health professionals, mad is sometimes used as a slang (picturesque, unconventional) word, roughly interchangeable with the term psychotic.

Psychotic disorders The term psychotic is used to describe particular symptoms, disorders and individuals. It is a term with many nuances. Psychotic symptoms indicate a loss of contact with reality, for example, when the individual believes something which has no basis in reality (delusions) or hears a voices when no one has spoken (hallucinations).

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However, similar symptoms can occur in healthy people. For example, some healthy people regularly hear their name called just as they are falling to sleep. These are called hypnagogic hallucinations. By definition, these people do hallucinate, but in the absence of additional symptoms, they are not suffering a psychotic disorder and cannot be described as being psychotic.

Illustration. This was written by a young Christian man who developed schizophrenia and began to believe that Satan had taken control in heaven. He had not decided to change his religion, that is, he had not become a devil worshiper, and he was distressed by his new belief. Given this mans personal history and cultural group, this belief was a delusion. There is also the suggestion of thought slippage. This man despised Satan, and it is unlikely that he would wish to apply the words but beautiful to him/her. It is probable that when he thought of heaven, he thought about the attributes of God, and stayed on that line of thinking while writing about Satan.

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Illustration. This letter was written by a man with schizophrenia. He had once been a patient of, but had not been seen by the author, for more than a year. During most of that year he had been in a psychiatric hospital, under the care of Dr Jeff Self. The patient writes that his hallucinations (voices) are worse than being dead or tortured. For some years he had experienced visual hallucinations of attractive women. He writes about having sex with his visions which he can feel in his pillows. It is very difficult to classify the information that he is having sex with his visions. If it is not possible to have sex with visions, then this is a false belief and could be classified as a delusion. But, was this man having visual hallucinations of himself having sex with the attractive women who appeared in his earlier visions? Insufficient details are available about his experience for firm conclusions to be reached. This patient had difficulty with logical thought, so he was unable to describe things better, even when specifically asked.

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Psychotic disorders are those in which there are psychotic symptoms, plus significant impairment of the capacity to function in everyday life. It is possible to have a mental disorder, and a psychotic symptom, but not to have a greatly reduced capacity to function in everyday life. Thus, it is possible to have a psychotic symptom without having a fully developed psychotic disorder. Consider a person who has suffered an acute psychotic disorder, who with treatment has returned to work and normal life, but who still hears a voice a few of times a day. This person may have full insight, meaning that he or she knows this voice is an hallucination and recognises the need for ongoing treatment. Such an individual experiences occasional psychotic symptoms, but the full psychotic disorder is in remission, and he or she would not be described as being psychotic. Consider a person with anorexia nervosa who purposefully restricts food intake and exercises excessively because of a fear of being fat, who is emaciated to a dangerous degree, but who nevertheless believes she or he is overweight. By strict criteria, this person is experiencing something at least very similar to a delusion. Further, when such patients see themselves in a mirror, they frequently see themselves as fat, a phenomenon which suggests mistakes of perception. This condition is often disabling (some people with anorexia nervosa can perform rewarding work and maintain stable relationships). In spite of apparent delusions and mistakes of perception, and some reduction in the ability to conduct a social and working life, anorexia nervosa is not classified as a psychotic disorder, and patients suffering this condition are not described as psychotic. As there may be some confusion, let us briefly consider the most common psychoses, or psychotic disorders. These are schizophrenia and delusional disorder. Schizophrenia is the archetypal psychosis. The symptoms of this disorder include hallucinations, delusions, reduced ability to think logically (thought slippage), behavioural signs such as the holding of bizarre postures, the loss of the ability to experience emotional feelings and spontaneity, social withdrawal, and personal neglect. During acute episodes, hallucinations, delusions and thought slippage are the most prominent symptoms. With treatment or natural remission these symptoms are less prominent and the loss of spontaneity, social withdrawal and personal neglect become more noticeable. Delusional disorder, in contrast, only manifests (one or more) delusions. Usually the delusion is of a paranoid type, and the patient believes he or she is being watched and is in danger from spies, organised crime, etc.. The patient may be able to work and appear normal to others. As there is only one symptom and the patient appears to function reasonably well outside the home, some may question whether this is truly psychotic disorder. However, in most instances, the individuals life is severely damaged by this disorder. Suspiciousness or frank delusions result in conflict at work and the patient is usually finally placed on some form of pension. The social life is also severely impaired,

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the patient eventually withdrawing to live behind reinforced doors with an array of locks, in a state of constant fear and apprehension.

Mood disorders The Oxford English Dictionary defines mood as 1. a particular sate of mind or feeling, 2. a prevailing feeling, spirit or tone. Thus, feelings are the central issue, and under this heading one might expect to include fear, jealousy or love. However, by convention and from a clinical perspective, the mood disorders are persistent conditions in which the prominent feeling is sadness or elation. Bipolar disorder (once called manic-depressive psychosis) is the most dramatic form. This disorder is characterised by mood elevated (manic) phases and sad (depressed) phases. These phases may last for months or even become chronic. For a given patient, swings may predominantly occur in one direction, alternatively, about equal numbers of swings may occur in each direction. In the mood elevated phase the patient is often over confident, grandiose, irritable and disinhibited, with rapid thoughts, reduced need for sleep and abundant energy. In depressed phases the mood and energy are low, thinking is slowed and the ability to concentrate is reduced. Sleep is disrupted, the patient often waking in the early hours and unable to return to sleep. There is loss of interest in food, sexual or any other activity, and weight loss is a frequent feature. Episodes in either direction may fail to satisfy the criteria for psychosis, thus the term manic-depressive psychosis is being superseded. The patient in a manic phase is clearly acting out of character, and with mood elevation as a springboard, problems frequently arise as patients engage in risky behaviour such as unwise investments, fast driving, illadvised sexual liaisons or audacious activities. The patient in a depressive phase may also act out of character, becoming inactive and withdrawn. Delusions of guilt are uncommon. However, frequently, the patient thinks about death and regrettably, suicide is more common than among the healthy population. Repeated episodes of severe depression may occur without manic episodes, and this has been called major depressive disorder or unipolar depression. There are also less severe mood disorders. Cyclothymia is a disorder in which both depression and elevations occur, and may be considered a less severe type of bipolar disorder. Dysthymia is a disorder which may be considered a less severe type of major depressive disorder.

Non-psychotic disorders

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The non-psychotic disorders are, in general, what Freud referred to as the neuroses. This is a mixed bag of conditions. The symptoms of the psychotic disorders such as hallucinations and delusions are largely unknown to healthy individuals. However, the symptoms of the non-psychotic disorders are known to us all, at least to some degree. These include distressing anxiety, which is similar to worry and fear - in a mild form is familiar to everyone who has taken an exam or been out on a first date. Generalized anxiety disorder is characterised by continuous, unprovoked anxiety. Panic disorder is characterized by sudden attacks of extreme anxiety during which the patient may struggle to get enough air, feel the heart thumping as if to burst, and fear that he or she may collapse or die. The phobic disorders (or phobias) are characterized by episodes of anxiety which is out of proportion to the danger of a particular situation. In agoraphobia, anxiety is triggered by the thought of leaving the home, and this may worsen if the home is left. In special phobias, anxiety increases at the thought of meeting a feared, specific agent or circumstance (spiders or lifts, for example), and life may be disrupted by the steps taken to avoid those agents or circumstances. Obsessive-compulsive disorder is a curious condition. Obsessions are repetitive thoughts which make no sense. Patients accept that these are their own thoughts, but they are unable to stop them. For example, the patient may have the irrational and unwelcome thought that his or her hands are contaminated by dirt or germs, alternatively, the patient may be dogged by the irrational thought that he or she killed God. The patient is distressed by the loss of control and the silliness of his/her thought. Compulsions are repetitive actions or urges in which the patient engages. Sometimes the compulsions relate to obsessions, as when the thought is that the hands are dirty and so the hands must be washed. But the compulsion may be that the hands must be washed 10 times, when washing once would be enough. In other cases, compulsions may have no relationship with obsessions, as for example when the patient feels anxious or uncomfortable until something is performed correctly; it may be that when walking into a room, night or day, the light switch must be flicked a certain number of times. Post traumatic stress disorder (PTSD) is an anxiety disorder which follows exposure to a traumatic event, particularly protracted traumatic events such as involvement in war, but sometimes following briefer, severe stress, such as rape. The eating disorders are also categorised among the other disorders because they dont fit anywhere else any better. This is a puzzling group of conditions, the best known being anorexia nervosa and bulimia nervosa. In anorexia nervosa there is purposeful weight loss through restriction of eating, excessive exercise and sometimes purging and vomiting. In spite of emaciation and threat to life, there may be the conviction of being fat, which cannot be dispelled by the use of scales, mirrors or photographs. In bulimia nervosa there are episodes of binge eating and compensatory behaviour to prevent weight gain, such as purging and vomiting. Various other disorders may be placed among the other disorders, including adjustment disorders and somatoform disorders. The adjustment disorders are states of distress which

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are triggered by strong stressors such as sudden loss due to fire or betrayal. The somatoform disorders are conditions in which there are physical symptoms, such as pain, inability to walk, or belief that one has a disease, in the absence of organic findings.

Personality disorders Personality has been defined as the predictable response of the individual to the environment (other people and the world in general). If we know people well, we know what they will like and dislike how far we can rely on them in tough times, whether they spend or save their money, in short, we know their personality. Personality disorder is present when features of the personality (characteristic ways of responding to the environment) cause subjective distress to the individual or significant impairment in his/her social or occupational function. Impaired social or occupational function involves others, thus, personality disorder causes distress to the individual and/or to those associated with the individual. There are three groups of personality disorders, 1) an odd and eccentric group in which a prominent feature is the absence of close relationships, 2) an anxious and fearful group in which a prominent feature is self doubt, and 3) a dramatic, emotional and erratic group in which prominent features are stormy relationships and sudden excessive anger.

Organic mental disorders Organic mental disorder is another collection of disorders which do not fit together particularly well, and which does not easily fit in anywhere else. There are two main forms, 1) where the problem lies in the brain, such as Alzheimers disease, and 2) where the problem lies elsewhere in the body, such as when the tyroid gland is not releasing enough hormone, leading to a depressive disorder. We will focus only on the first category. The original thinking was that the organic mental disorders had a physical (brain abnormality) basis, which could be demonstrated by some special investigation such as X-ray. At this early stage it was thought that other serious mental disorders such as schizophrenia and bipolar disorder did not have a physical basis. We now know from genetic and advanced brain scanning studies that probably all mental disorders have a physical basis. Thus, the organic mental disorders can be considered to be those disorders, the organic basis of which can be easily demonstrated using current technology. In this way the organic mental disorders category depends on the sophistication of current technology (not a satisfactory state of affairs).

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Dementia is the best known organic mental disorder. Here, the prominent symptoms are in cognition (memory and intelligence). There may also be hallucinations, delusions and mood changes.

Substance use disorders Substance use may or may not be included among the mental disorders, depending on the training and affiliation of the particular experts involved and the arrangement of local services. Psychoactive substances such as alcohol are taken because they induce a desired state of mind. Substance use disorders may be defined in different ways, but essentially they relate to the taking of legal substances (particularly alcohol) in excessive amounts and the taking of any illegal substance. The terms used and their definitions change from one era to the next. Problems include the immediate effects of acute intoxication (including psychosis), and longer term effects of addiction, withdrawal states and physical damage (including brain damage). Acute intoxication with alcohol may result in aggression or dangerous driving. Symptoms of distorted reality, including visual hallucinations and distortion to time are the desired effects of those taking hallucinogens such as LSD. Drug induced psychotic disorders are not sought after, but are common with amphetamine use. They feature delusions and auditory hallucinations and may persist for days after the drug has been ceased. With frequent drug use, tolerance develops. This means that the body adjusts to the effect of the substance and greater quantities are needed to produce the same effect. When this adjustment has occurred, the body may need the substance to function roughly normally, and withdrawal symptoms (sweating, trembling, body pain) may occur when the drug is not taken. Withdrawal states, particularly with alcohol, may include disorientation (being unaware of the time and place), inability to concentrate and understand what is happening in the environment, and hallucinations (particularly seeing spiders, snakes and other scary creatures). The term addiction is now less commonly used, being replaced by the terms, physical and psychological dependence (however, this may be reversed in DSM-V). Psychological dependence has developed when continuous use of the substance is required for the user to feel psychologically comfortable, and lack of the substance leads to psychological distress. Physical dependence has occurred when a continuous use of the substance is necessary to prevent withdrawal symptoms. Physical damage to body and brain results from the toxic effect of the substances and/or nutritional neglect. Using alcohol as an example, the toxic effects lead to liver failure and the nutritional neglect (vitamin B deficiency) leads to irreversible brain failure (dementia).

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In addition, substance abuse leads to mood and sexual problems, destruction of the family, loss of employment and income, and legal problems. The police become involved because of violence or driving offences during the intoxication phase, or due to theft, prostitution or drug dealing, as the user needs to raise money to support the habit.

DSM-IV The current diagnostic systems are descriptive and also, categorical meaning there is a distinct from normality. While this appears to be the case with schizophrenia, anxiety disorders are continuous with normality, we all have some level of anxiety at times, thus some conditions or aspects of mental symptoms are dimensional (we all sit somewhere along that dimension). It is understood that with DSM-IV, and effort will be made to include both categorical and dimensional factors (Rutter, 2011). It is also understood various childhood disorders will be combined under the heading of autism spectrum disorders, and a new condition temper dysregulation disorder with dysphoria has been proposed, in an attempt to modify the use of the diagnosis of bipolar disorder in children. References Aboraya A. Scientific forum on the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-V) an invitation. Psychiatry 2010; 7:32-36. Frances A. Wither DSM-V? British Journal of Psychiatry2009; 195:391-392. McHugh P. Striving for coherence: psychiatrys efforts over classification. Journal of the American Medical Association 2005; 293:2526-2528. Rutter M. Child psychiatric diagnosis and classification: concepts, findings, challenges and potential. Journal of Child and Adolescent Psychiatry 2011. doi: 10.1111/j.14697610.2011.02367.x