Definition of psychiatric
disorder
History. Classification. Prevalence.
Comorbidity. Epidemiology.
Definition
DSM criteria of abnormal behavior: “A behavior
is considered as abnormal if it is statistically rare,
deviates from society's unwritten rules (norms), it is
counter-productive to the individual and affects
individual's mental well-being”
Statistically rare behavior
Statistically rare behavior
Statistically rare behavior
Deviates from the norm
Deviates from the norm
Deviates from the norm
It's counter-productive
It's counter productive
It's counter productive
Affects the mental well-being
Affects the mental well-being
Affects the mental well-being
Normal Abnormal Normal
Definition
DSM criteria of abnormal behavior: “A behavior
is considered as abnormal if it is statistically rare,
deviates from society's unwritten rules (norms), it is
counter-productive to the individual and affects
individual's mental well-being”
Neuroscience: “Mental disorders are a diverse group of
brain disorders that primarily affect emotion, higher
cognition and executive function”
Philosopher: “There is no such thing as mental illness
in any culture, and that there could not be, because the
very notion of mental illness is based on a fundamental
mistake or set of mistakes.”
Wikipedia: “Mental disorder or mental illness are terms
used to refer to a psychological or physiological pattern
that occurs in an individual and is usually associated with
distress or disability that is not expected as part of
normal development or culture”
Diagnostic Systems
Diagnostic and Statistical Manual of Mental
Disorders (DSM)
Publisher: American Psychiatric Association
Last Version: IV-TR
Covers only Mental Disorders
International Classification of Diseases (ICD)
Publisher: World Health Organization
Last Version: 10
Covers all medical diagnosis (chapter 5: mental disorders)
ICD-10
[International Statistical Classification of Diseases and Related
Health Problems]
International Classification System. Coding of all kind of diseases and
mental disorders.
22 Categories
Examples:
Certain infectious and parasitic diseases
Diseases of the blood and blood-forming organs and certain
disorders involving the immune mechanism
Endocrine, nutritional and metabolic diseases
Mental and behavioural disorders
Diseases of the nervous system
Diseases of the eye and adnexa
Diseases of the ear and mastoid process
DSM
Categorical classification system
Mood disorders
Factitious disorders
16 Main Categories: Impulse-control
Anxiety disorders
Disorders usually first diagnosed in infancy, disorders not
childhood, or adolescence
Somatoform disorders elsewhere classified
Delirium, dementia, and amnestic and other
Sleep Disorders
Adjustment disorders
cognitive disorders
Dissociative disorders
Mental disorders due to a general medical
Sexual and gender identity
condition not elsewhere classified disorder
Substance-related disorders
Eating disorders
Schizophrenia and other psychotic disorders
Personality disorders
Example: Major Depressive Episode.
5 or more of these symptoms / 2 weeks:
• Depressed mood most of the day
• Markedly diminished interest or pleasure in all
• Significant weight loss when not dieting or weight gain
• Insomnia or hypersomnia nearly every day
• Psychomotor agitation or retardation nearly every day
• Fatigue or loss of energy nearly every day
• Feelings of worthlessness or excessive or inappropriate guilt nearly every day
• Diminished ability to think or concentrate, or indecisiveness, nearly every day
• Recurrent thoughts of death
Diagnostic Systems
DSM
Example
Multi-axial system
− Axis I: Clinical, developmental and
learning disorders Axis I: Major
− Axis II: Personality disorders and Depressive Disorder
mental retardation
Axis II: None
− Axis III: Medical conditions and
physical disorders. Axis III: Cancer
− Axis IV: Psychosocial and Axis IV: His mother
environmental factors contributing to died 2 weeks ago
the disorder
Axis V: 80%
− Axis V: Global Assessment of
Functioning (on a scale from 100 to 0)
The Timeline...
DSM-V is expected.
Ideally it will include
International International Statistical experimental criterion
Classification of Classification of sets aiming at
Causes of Death Diseases, Injuries and incorporating new
adopted in Paris. Causes of Death (v.6). DSM-II. No DSM-IV. genetic and
Little mention of Contains a whole major Conservative neurobiological
Mental Disorders section for mental differences to Revision of findings
disorders. the DSM-I DSM-III
1893 1918 1948 1952 1968 1980 1994 2000 2011
Statistical Manual
First DSM. Focused
for the use of DSM-III. Use
on diagnosis. Brief DSM-IV-TR.
Institutions for the of field-tested
descriptions of each Text is
Insane. 22 criteria to
disorder. Influenced revised, but
categories, mainly achieve
from psychoanalytic the diagnostic
referred to the reliability. No
thinking criteria are
somatic causes of theories of
not
behavioral disorders aetiology
Criticism of DSM
Use of categories
DSM uses categories, but drugs do not respect the
boundaries of the disorders.
Many disorders are better conceptualized as
dimensional traits.
Normal Abnormal/Mental Disorder
Different levels of symptoms. More or less severe cases.
“Not Otherwise Specified” category is used very often!
Co-morbidity
A large fraction of patients qualifies for multiple
diagnoses.
Possible explanations:
Mental Disorders and
Neuroscience
Need for integration of Neuroscience into DSM-V
Arbitrary boundaries between mental and neurological disorders.
Overlapping practice patterns between neurology and psychiatry.
Use of neurological techniques in order to treat mental disorders (e.g. deep brain
stimulation)
Both treat higher brain functions (e.g. autism, Alzheimer's disease, ADHD)
Biological basis of many mental disorders (e.g. schizophrenia, bipolar disorder)
Need to build a new dimensional diagnostic system.
Ultimate goal: a diagnostic classification system for mental disorders based not only on
symptomatology but also on aetiology and pathophysiology of the disorders.
How can Neuroscience help?
Neurogenetics
Significant influence of genes
(twin studies/adoption studies etc)
Many studies tried to identify the
role of genetic factors in
development of disorders.
Interaction between multiple
genetic factors that cause a
common symptom in different
mental disorders (e.g. gene
catechol-O-methyltransferase =>
metabolism of neurotransmitters
like dopamine=> schizophrenia-
like symptoms)
New technologies will provide
How can Neuroscience help?
Neuroimaging
Anatomical abnormalities
(e.g. less gray matter in
schizophrenics)
Future diagnostic
classifications
Contribution to experimental
therapies
a. Localization of abnormal
activations
b. Direct therapy in these
brain regions
(e.g. Experimental treatment
of depression with stimulation
How can Neuroscience help?
Example: Phenylketonuria [1 in 15,000 births]
autosomal recessive genetic disorder →
deficiency in the PAH enzyme
Discovery of phenylketones in urine of some
mentally retarded individuals
Anatomical differences (brain size ~80% of normal)
1950: More specific reports
White matter abnormalities (spongy change)
Pallor of myelin staining
Demyelination
Demyalination is caused after the birth
More accurate detection of PKU
Dietary Therapy (low in phenylalanine)
Today: Animal Models
Prevalence of Mental Disorders in
Europe
Prevalence rates of mental disorders in 6 E.U. Countries:
Belgium, France, Germany, Italy, the Netherlands and
Spain
Lifetime Prevalence
Total Males Females
Any Mental Disorder 25,00% 21.8% 28.1%
Any Mood Disorder 14,00% 9.5% 18.2%
Any Anxiety Disorder 13.6% 9.5% 17.5%
Any Alcohol Disorder 5.2% 9.3% 1.4%
Total Males Females
Major Depression 12.8% 8.9% 16.5%
Dysthymia 4.1% 2.6% 5.6%
GAD 2.8% 2.0% 3.6%
Social Phobia 2.4% 1.9% 2.9%
Specific Phobia 7.7% 4.9% 10.3%
PTSD 1.9% 0.9% 2.9%
Agoraphobia 0.9% 0.6% 1.1%
Panic Disorder 2.1% 1.6% 2.5%
Alcohol Abuse 4.1% 7.4% 1.0%
Alcohol Dependence 1.1% 1.8% 0.4%
ESEMeD/MHEDEA 2000 Investigators
Prevalence of Mental Disorders in
Europe
Prevalence rates of mental disorders in 6 E.U. Countries:
Belgium, France, Germany, Italy, the Netherlands and
Spain
12-month Prevalence
Declining rates
with
Age age
Group
18-24 13.7%
25-34 11.2%
35-49 9.6%
50-64 9.8%
>65 5.8%
Higher rates for
unmarried/divorced
Marital Status
Married 8.7%
Previously married 10.9%
Never married 11.8%
ESEMeD/MHEDEA 2000 Investigators
Prevalence of Mental Disorders in
Europe
Prevalence rates of mental disorders in 6 E.U. Countries:
Belgium, France, Germany, Italy, the Netherlands and
Spain
12-month Prevalence
Higher rates for higher
education levels
Education Any Mental Disorder Any Alcohol Disorder
0-4 Years 8.9% 0.2%
5-8 Years 7.0% 0.5%
9-12 Years 9.1% 0.9%
>13 Years 9.0% 1.2%
Higher rates in urban areas
Urbanicity
Rural 8.6%
Mid-size urban 9.9%
Large Urban 10.5%
ESEMeD/MHEDEA 2000 Investigators
Prevalence of major psychiatric
disorders
Example: Depression
Depression ranks 5th across women
and 7th across men as a cause of
morbidity (World Bank, 1993)
WHO: in 2020 depression will be the
second most important cause of
disability.
The cultural background is likely to
determine whether depression will be
experienced and expressed in
psychological and emotional terms or
in physical terms.
Bhugra & Mastrogianni, 2004
Prevalence of major psychiatric
disorders
Example: Depression
WHO, 1996: 10.4% received a “current
depressive episode” diagnosis
Co-morbidity: Depression, Anxiety, Alcohol
Misuse or Dependence, Panic Disorder,
Obsessive-Compulsive Disorder
Differences in prevalence across
cultures/countries
i. Different levels of awareness and
recognition
ii. Popular perceptions about the role of
doctor in each country
iii. Different pathways to health system (i.e.
medical care must be paid in Nigeria)
iv. Social stigma
v. Methodological Issues (lack of appropriate
instruments)
Bhugra & Mastrogianni, 2004
Prevalence of major psychiatric
disorders
Example: Depression – Ethnic
Minorities
USA
No differences between African
Americans and White Americans
(when demographic, sociocultural
and socio-economic factors are
controlled)
Puerto Ricans: higher depression
rates
Asian Americans: lower prevalence
of depression
UK
In general, higher prevalence rates
of depression on minority groups
Bhugra & Mastrogianni, 2004
Prevalence of major psychiatric
disorders
Example: Depression – Diagnosis
Depression is under-recognized throughout the world. Primary care
physicians detect only 50% of the cases
UK
Asians: visit their practitioner more frequently, but is less likely to
have their psychological difficulties identified (complaints about
somatic symptoms)
Indian women: 17% recognition
USA
Physicians are less likely to detect depression among African
American and Hispanic patients
Australia
Asians: lower rate of diagnosis (similar rate of self-reported
symptoms)
Prevalence of major
psychiatric disorders
Example: Depression – Diagnosis
Summary
Two main categorical systems:
DSM (mental disorders)
ICD (diseases and mental disorders)
Need for integration of Neuroscience in the
future versions of these categorical systems
Diagnosis
Treatment
Future Studying
Prevalence & Epidemiology
450 million people suffer from mental disorders
Most common: mood disorders
More women than men
Development during youth
Urban Areas > Rural Areas
Different rates around the world
Social factors (culture, language, minorities etc)
