Diagnosis and Psychiatry: Examination of the Psychiatric

Patient.
Signs and symptoms in psychiatry.

INTRODUCTION

Goal of the Clinical Psychiatric interview . The goal of the initial diagnostic
clinical psychiatric interview is to collect specific, detailed information
about 15 topics. These topics constitute the psychiatric evaluation.
Acquiring the database of information for these 15 topics enables the
interviewer to make diagnoses compatible with the revised fourth
edition of Diagnostic and Statistical Manual of Mental Disorders (DSM-
IV) on five axes and to develop a treatment plan acceptable to the
patient:
I. Identifying data. The patient's name, sex, age, race, marital
status, and vital signs.
II. Chief complaint. The chief complaint in the patient's own words.
Alternatively, signs of disordered functioning observed by the interviewer.
III. Informants. A list of all informants, their reliability, and level of
cooperation; also previous hospital records, if available. Such informants
are essential in circumstances that prevent the patient from providing
adequate information. Choosing the right set of informants is more
important than having a great number of informants.
IV. Reason for admission or consultation. The referral source;
in case of hospitalization, statement of legal status—voluntary versus
involuntary—and the reason why hospitalization is the safest and least
restrictive environment for treatment.
V. History of present illness. Early manifestations and recent
exacerbations of all psychiatric disorders present (Axis I and II);
review of diagnoses and treatments given by other providers.
VI. Psychiatric disorders in remission. Psychiatric disorders
presently in remission, especially substance abuse disorders;
psychiatric disorders first diagnosed in childhood and adolescence and
their treatments.
VII. Medical history. All medical disorders past and present and
their treatments and childhood disorders that involve the central
nervous system (CNS). For females, pregnancy status—especially if on
psychotropics or expecting the use of psychotropics and precautions
against pregnancy and concomitant pharmacological treatment. On all
patients, but particularly in consult-liaison work, the medical history
includes the interrelation of medical and psychiatric conditions.
VIII. Social history and premorbid personality. Early developmental
history. Description of premorbid personality as baseline for patient's best
level of functioning. Impact of Axis I and II disorders on patient's life. The
patient's psychosocial and environmental conditions predisposing to,
precipitating, perpetuating, and protecting against psychiatric disorders.
Premorbid versus morbid functioning. Present support system.
IX. Family history. Psychiatric history of first-degree relatives,
including treatment response as a possible genetic predisposition for the
patient.
X. Mental status examination. Appearance, consciousness,
psychomotor functions, speech, thinking, affect, mood, suggestibility, and
thought content; cognitive functions, such as orientation, memory,
intelligence, and executive functions; insight and judgment.
XI. Diagnostic formulation. Summary of biological, psychological, and
social factors contributing to the patient's psychiatric disorder.
XII. Differential diagnosis. Discussion of diagnostic options based on
overlapping symptomatology.
 XIII. Multiaxial psychiatric diagnosis. Information on all five axes.
XIV. Assets and strengths. Inventory of patient's knowledge,
interests, aptitudes, education, and employment status to be used in the
treatment plan.
XV. Treatment plan and prognosis. Account of psychopharmacological,
psychological, and social treatment modalities planned, frequency of
visits, and list of providers; discharge criteria if inpatient.

Psychiatric interviewing is a special form of human communication. The

interviewer asks the patient to disclose complaints, share problems, and
reveal suffering. According to the difficulties that the patient experiences
with this request, the interviewer shifts the focus between disorder-
centered and patient-centered interviewing. Disorder-centered
interviewing is based on a descriptive, a the oretical model of psychiatric
disorders called the medical model, which is the official model supported
by the American Psychiatric Association (APA) and the World Health
Organization (WHO) codified in DSM-IV-TR (2000) and the International
Classification of Diseases (ICD-10). This framework views psychiatric
disorders as similar to medical disorders, using criteria for diagnosis as
identifiable clusters of occurrences from a restricted menu of symptoms,
signs, and behaviors that cause morbidity and mortality.

TO establish a psychiatric diagnosis based on this descriptive medical

model, the interviewer chooses proven, symptom-oriented, open-ended
questions with a relatively narrow scope followed up by closed-ended,
nonleading questions centering on the disorder. Prerequisites for this style
are the knowledge of the DSM-IV-TR criteria and the 15 topics to be
covered. This disorder-centered interview style works for most cooperative
patients, patients whose communication skills are not impaired by their
Axis I and II disorders or their defense mechanisms. Disorder-centered
interviewing is driven by the patient's help-seeking behavior. Proficiency
for disorder-centered interviewing can be acquired during the first few
years of training.
In contrast, patient-centered interviewing is based on the introspective
model, which emphasizes the individuality of the patient's experience. This
model attends to the intrapsychic battle of conflicts. It is sensitive to the
patient's educational, emotional, intellectual, and social background, the
personality, and the individual symptom constellations tracing their arrival
to individual circumstances and the individual's unique response
(cognitive-behavioral model). One example of the introspective model is
the psychodynamic model. Interviewing based on the psychodynamic
model uses nonstructured, open-ended questions with a broad scope,
encouraging free association. The psychodynamic model posits the
etiology of psychiatric symptoms as responses to often unconscious inter-
and intrapersonal conflicts. It explores and interprets behaviors and
sequences of answers. In this model, the interviewer strives to help the
patient overcome self-defeating intra- and interpersonal conflicts.
The disorder-centered and patient-centered interviewing styles do not
exclude each other. They are end points of a continuum. The interviewer's
mobility and flexibility in gliding between the two extremes determine the
efficiency, reliability, validity, and quality of data collection. The degree of
the patient's impairment determines to which extent the disorder-
centered interview has to be augmented by patient-centered strategies.
The psychiatric interview progresses over time, which can be arbitrarily
subdivided into five phases. These phases cover sequentially the 15 (I to
XV) topics of the psychiatric evaluation.

Phase 1: Warm-up and Chief Complaint (I to IV)

Phase 2: The Diagnostic Decision Loop (V)

Phase 3: History and Database (VI to X)

Phase 4: Diagnosing and Feedback (XI to XIV)

Phase 5: Treatment Plan and Prognosis (XV)

The five phases divide the psychiatric interview longitudinally. Cross-
sectionally, the interview consists of four components, which the
interviewer must continuously monitor and propel throughout. Rapport
focuses on the doctor-patient relationship; a good rapport is a prerequisite
for an effective interview. Rapport is established in the opening; with a
cooperative and insightful patient, there is often little problem in
establishing and maintaining a good rapport. However, in patients who are
uncooperative or show poor insight, establishing a workable rapport with
the patient becomes a central issue.
Technique refers to the approaches the interviewer uses to keep an
interview "on track." It includes skills to appropriately select questions to
arrive at a diagnosis. Good technique is necessary to therapeutically
engage and work with difficult patients.
Mental status assessment captures the patient's experiences,
symptoms, signs, behaviors, thought content, cognitive level of
functioning, insight, and judgment during the actual time of the inter view.
Formal testing of mental status may take place late in the interview;
however, in a patient with a significantly altered mental status—whether it
be a boisterous, irritable, and uninterruptible manic patient, a minimally
responsive depressed patient, or a paranoid patient—his or her mental
status plays a significant role in the interview.
Diagnosing pursues a progression in the diagnostic decision process
from chief complaint to final diagnosis.
Signs and symptoms in psychiatry.
Signs are objective; symptoms are subjective. Signs are the clinician's
observations, such as noting a patient's agitation; symptoms are
subjective experiences, such as a person's complaint of feeling
depressed. In psychiatry, signs and symptoms are not so clearly
demarcated as in other fields of medicine; they often overlap. Because of
this, disorders in psychiatry are often described as syndromes—a
constellation of signs and symptoms that together make up a
recognizable condition. Schizophrenia, for example, is more often viewed
as a syndrome than as a specific disorder. This concept is expressed in
the use of the terms schizophrenic spectrum or the group of
schizophrenias.

RELATIONSHIP OF PSYCHIATRIC SIGNS AND SYMPTOMS TO NORMALITY.

Normality and mental health are central issues in psychiatric theory and
practice but are difficult to define. For example, normality has been
defined as patterns of behavior or personality traits that are typical or that
conform to some standard of proper and acceptable ways of behaving and
being. The use of terms such as typical or acceptable, however, has been
criticized, because they are ambiguous, involve value judgments, and vary
from one culture to another. To overcome this objection, psychiatrist and
historian George Mora
devised a system to describe behavioral manifestations that are normal in
one context but not in another, depending on how the person is viewed by
the society. This paradigm, however, may give too much weight to peer
group observations and judgments.

The table:
Term Concept
Autonormal Person seen as normal by his or her own society
Autopathological Person seen as abnormal by his or her own society
Heteronormal Person seen as normal by members of another
society observing him or her
Heteropathological Person seen as unusual or pathological by mem-
bers of another society observing him or her

The text revision of the fourth edition of the Diagnostic and Statistical
Manual of Mental Disorders (DSM-IV) offers no definition of normality or
mental health, although a definition of mental disorder is presented.
According to DSM-IV-TR, a mental disorder is conceptualized as a
behavioral or psychological syndrome or pattern that is associated with
distress (e.g., a painful symptom) or disability (i.e., impairment in one or
more important areas of functioning). In addition, the syndrome or
pattern must not be merely an expected and culturally sanctioned
response to a particular event, such as the death of a loved one. DSM-IV
emphasizes that neither deviant behavior (e.g., political, religious, or
sexual) nor conflicts that are primarily between the individual and society
are mental disorders.
 Psychiatry has been criticized over the years by certain groups for its
portrayal of normality. The psychology of women, for example, has been
criticized as sexist, because it was formulated initially by men; similar
criticism comes from other groups who believe that the portrayal of their
psychological issues is biased by placing undue emphasis on
psychopathology rather than healthy attributes. A much discussed issue is
the change in psychiatry's view of homosexuality from abnormal to
normal that took place in the 1970s, an evolution shaped by cultural
norms, society's expectations
and values, professional biases, individual differences, and the political
climate of the time.

BASIC DEFINITIONS OF GENERAL PSYCHOPATHOLOGY

SYMPTOM
A manifestation of a pathologic condition. Symptom
must not only differ the patient from other individu-
als, but provoke the loss of adaptation. For example. the
memory which is better than others is not a symptom, but
poor memory causes the loss of adaptation, so it is a
symptom.
SYNDROME A group of signs and symptoms that occur together in a
recognisable pattern. Since the true pathogenesis of psychiatric
syndromes is not well known, the repetition of these symptoms in different
patients is a feature of great significance for diagnostic. Syndrome defines
the actual condition of the patient. It is not only a stage of nosologic
diagnosis. Syndrome is a base of psychopharmacological treatment (for
example a good effect of neuroleptics in all kinds of paranoid states or
antidepressants in all kinds of depression).
PRODUCTIVE AND NEGATIVE SYMPTOMS:
Productive symptoms (plus-symptoms) — new additional functions and
phenomena which are not known in healthy individuals, appearance of
some
surplus traits over a normal level of functioning.
These symptoms are reversible, they usually occur in patients with acute
disorders. The majority of psychopharmacological drugs are intended for
treatment of productive symptoms.
Negative symptoms (deficiency) — the loss of normal functions (for
example the loss of memory). Usually these symptoms are irreversible but
it is a mistake to value the negative symptoms through the acute phase of
the illness (for example, the loss of appetite is reversible if it is a symptom
of acute depression). Some negative symptoms can be corrected by
vicarious drugs, but they appears again after the withdrawal.

LEVELS
OF MENTAL
DISORDERS

It is customary to divide mental disorder into Severe (psychoses) and

mild (neuroses). There is no satisfactory way for distinction between these
two groups. Usually the following criteria are used.

Psychoses — severe mental disorders, so patients:

• construct a false environment which they can not
distinguish from the reality (hallucinations, delusions etc.);
• show absurd or even dangerous behaviour (aggression, suicide,
excitement etc.) which can not be interpreted as understandable
development of the personality; ;
 • have poor insight (no sense of illness)

Neuroses — mild mental disorders, so patients:

• apprehend the real environment and situation
, 'without significant mistakes;
• do not assume rash, dangerous or antisocial actions;
• realise that they are mentally ill, suffer, seek help (have good
insight)
Organic disorders include trauma, tumour, intoxication (i.e. alcohol),
epilepsy, degenerative diseases
(Alzheimer's disease. Pick's disease etc.), consequences of somatic
diseases (arteriosclerosis, endocrine pathology, etc.) and others. In
psychiatry we can not directly observe the condition of brain, so the
diagnosis is based on characteristic symptoms and syndromes: delirium,
paroxysmal disorders, impairment of memory and intelligence.
Organic disorders are irreversible excepting some acute states (i.e.
delirium and paroxysms).
Functional disorders include stress induced diseases (reactive
psychoses and neuroses), bipolar psychosis, schizophrenia and some
others. No evident impairment of brain can be revealed with special
instrumental methods. All the symptoms are reversible. The exception is
deep personality changes in schizophrenic patients which are irreversible
(so some scientists concern schizophrenia as partially organic disorder).
Psychiatric classification

In the chapter on nosology in the first edition of the Comprehensive

Textbook of Psychiatry (CTP), published in 1967, Henry Brill discussed the
purposes and principles of classification, reviewed criticisms of the
classification of mental disorders, and identified problems with applying
the diagnostic manual to clinical practice. These same issues remain
relevant today and are discussed in this chapter on classification as well.
At the time of the first edition of the CTP, the first edition of the Diagnostic
and Statistical Manual' of Mental Disorders (DSM-I) was the official
diagnostic manual, although the second edition of the Diagnostic and
Statistical Manual of Mental Disorders (DSM-II) was published 1 year later
in 1968. Brill, chairman of the American Psychiatric Association's (APA's)
Committee on Nomenclature and Statistics from 1960 through 1965,
delineated six advantages of the then current nomenclature: (1)
widespread use, thereby facilitating communication among professionals;
(2) clear definition and delineation of the disorders; (3) compatibility with
the International Classification of Diseases (ICD) diagnostic system; (4)
clear guidelines for compilation and reporting of patient diagnostic data;
(5) comprehensive collection of diagnostic terms in one source; and (6)
ease of use. During the 35 years after this chapter was published, the
APA's diagnostic manual has been revised four times and plans are under
way to revise the manual again within the next decade. Although some of
the issues regarding psychiatric classification have remained the same
since the first edition of the CTP, because the APA's DSM has grown in
stature, political forces have increasingly voiced opinions regarding
classification issues, and discussions about conceptual issues in
classification have raised new questions.
The present chapter is divided into nine sections. It begins with a general
description of the purposes of classification. Next, the chapter turns to the
fundamental issue underlying a classification of mental disorders—the
definition of mental disorder. This section includes a discussion of the
impact of the operationalization of mental disorder on the epidemiology of
psychiatric disorders and an examination of the core component of DSM
definition of mental disorder—"a behavioral, psychological, or biological
dysfunction in the individual." This section ends with a review of Jerome C.
Wakefield's critique of DSM's definition of mental disorder and a review of
his concept of disorder as harmful dysfunction. The subsequent three
sections present an overview of the history of psychiatric classification,
the history of official classifications during the past two centuries, and the
recent history of classifications since the 1970s. The text revision of the
fourth edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM IV) classification is then described, highlighting and summarizing the
features of disorders included in the current nomenclature. Following this
is a review of issues related to the use of DSM-IV, and a summary of some
recent commentaries and research on the use of DSM in clinical practice.
There are many reasons why mental health professionals should care
about the way in which mental disorder is defined. The definition of
mental disorder guides distinguishing pathology from what is normal.
Consequently, the definition of mental disorder can influence estimates of
the prevalence of psychiatric disorders in the community, which, in turn,
influences the allocation of public health expenditures. The definition of
mental disorder can impact which behavioral, cognitive, and emotional
perturbations are included in the classification, and the inclusion and
exclusion of specific disorders from the DSM have been the source of
criticism and controversy. Whether a problem is considered a disorder
influences medical insurance reimbursement, and definitions of mental
disorder have varied in mental health parity statutes in different states.
Determination of the presence of mental disorder has potential legal
implications in criminal cases and decisions regarding disability
determinations. Lack of conceptual clarity regarding the definition of
mental disorder can contribute to abuses of psychiatric diagnoses as a
means of controlling or stigmatizing socially undesirable behavior. Finally,
lack of clarity in the conceptualization of a fundamental, core issue such
as the definition of mental disorder reduces confidence in the profession
as an authority regarding diagnostic issues and controversies.
Although it may be reassuring that difficulty in defining disorder is not
limited to the mental health field, the question of what is a mental
disorder should be addressed to guide the development of the
classification. In contrast to most medical disorders, mental disorders are
manifested by a quantitative deviation in behavior, ideation, and emotion
from a normative concept. The debates over whether certain behaviors,
ways of thinking, or emotional states should or should not be included in
the DSM classification (i.e., should or should not be considered disorders)
are grounded in ambiguities in the definition of mental disorder.
The first DSM to offer a definition of mental disorder was the third edition
of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III), and
this definition has been only slightly been modified in the revised third
edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-
III) and the DSM-IV.
In DSM-IV-TR, mental disorder is defined as a clinically significant
behavioral or psychological syndrome or pattern that occurs in an
individual and that is associated with present distress (e.g., a painful
symptom) or disability (i.e., impairment in one or more important areas of
functioning) or
with a significantly increased risk of suffering, death, pain, disability, or
an important loss of freedom. In addition, this syndrome or pattern must
not be merely an expectable and culturally sanctioned response to a
particular event.
Impairment or Distress Criterion Considered
The high prevalence rates of DSM-III and DSM-III-R psychiatric disorders in
the NCS and the ECA study raised concern that the diagnostic criteria were
overly inclusive, or incorrectly applied in an overly broad manner, and that
they identified nondisordered individuals as disordered Spitzer and
Wakefield indicated that there were two Ways in which the DSM
diagnostic criteria, even when applied correctly, might nonetheless
identify nondisordered individuals as having a mental disorder. One
instance occurs when individuals experience
normal reactions to stressful environments, and the other occurs when
individuals experience mild symptoms of a disorder that are insufficiently
severe to be considered a disorder. Spitzer and Wakefield labeled this
false-positive problem with the DSM criteria.
To reduce the problem of potential overdiagnosis, in DSM-IV, the
threshold to diagnose psychiatric disorders was raised by explicitly
adding a clinical significance criterion to approximately one-half of the
criteria sets. Precedent for this was found in the DSM-III-R criteria for
social phobia, simple phobia, and obsessive compulsive disorder
(OCD)The wording of the DSM-IV-TR clinical significance criterion varies
somewhat from disorder to disorder,
althought the most common wording is "the symptoms cause clinically
significant distress or impairment in social, occupational, or other
important areas of functioning." The introduction to the DSM IV-TR
manual indicates that the purpose of this criterion is to "help establish
the threshold for the diagnosis of a disorder in those situations in which
the symptomatic presentation by itself (particularly in its milder forms) is
not inherently pathological." This criterion, how ever, only addresses one
of the two potential causes of false positives the labeling of mild,
subthreshold conditions as disorders.
The criterion does not address the issue of labeling normal reactions To
stressful events as disorders. One problem with DSM-IV clinical
significance criterion is the uncertainty in how to interpret and apply it.
A second problem with DSM-IV clinical significance criterion is that it is
often redundant with the symptom criteria. Functional impairment is
intrinsic to many disorders. For example, the symptom criterion for the
disorder selective mutism is "consistent failure to speak in specific social
situations (in which there is an expectation for speaking, e.g., at school)
despite speaking in other situations." It is unclear how an individual can
meet this criterion and not meet the additional clinical significance
criterion that "the disturbance interferes with educational or occupational
achievement or with social communication." Thus, the clinical
significance criterion is unnecessary.
A third problem with the addition of the clinical significance criterion to
the symptom criteria sets is that some individuals who have a mental
disorder cannot be diagnosed as having the disorder, because the clinical
significance criterion is not met. This can be considered the false-negative
problem with the clinical significance criterion. For example, a child with
frequent motor and vocal tics is not diagnosed with Tourette's syndrome
unless the distress or impairment criterion is also met. This alludes to the
cardinal problem of diagnosing a disorder in the absence of knowledge
about underlying dysfunction. (The issue of dysfunction and its importance
in defining disorder is described in greater detail in the following section.)
To say that one child with tics has a disorder, because classmates,
parents, or teachers are intolerant of the symptoms and are thus
responsible for the child's distress or impairment, whereas another child
with the same symptom expression does not have a disorder because of a
different response from others, indicates that the concept of mental
disorder cannot simply be based on the presence of impairment or
distress. Disorders in other areas of medicine are diagnosed without
explicit reference to concepts of distress and impairment, although one or
the other is usually present. However, for most medical disorders, a
biological abnormality or underlying dysfunction can be identified. By
virtue of laboratory tests, conditions such as cancer, liver disease, and
cardiac disease can be diagnosed in the absence of distress or impairment
(or even the manifestation of clinical symptoms). Until underlying
psychological and biological dysfunctions are identified, then the definition
of mental disorder involves drawing an arbitrary line to minimize
falsepositive and false-negative diagnoses.

DSM-IV CLASSIFICATION
DSM-IV was published in the midst of the criticism that it represented the
third version of the DSM published within 14 years. This contrasted with
the 16-year interval between DSM-I and DSM-n and the 12-year interval
between DSM-II and DSM-III. Mark Zimmerman argued that the publication
of three DSM editions within such a short interval could result in six
problems: (1) an insufficient amount of time between DSM editions to
allow the accumulation of replicated research necessary to justify a
change in diagnostic criteria, thereby impeding progress in the
development of a valid classifcation; (2) the expenditure of resources to
compare the new diagnostic criteria with the old and thus divert effort
toward discovering pathophysiological mechanisms; (3) difficulties in
interpreting and resolving discrepant research findings based on different
criteria sets; (4) an increased number of diagnostic errors because of the
lack of time to leam the nuances of frequently changing diagnostic
criteria; impeded communication among clinicians, because three
diagnostic manuals will be in widespread use; and (6) frustration from
patients who have their diagnoses changed when the diagnostic manual
changes. The leaders of the Task Force charged with the
development of DSM-IV acknowledged concerns about the brief interval
between DSM editions and indicated that DSM-IV was to be the most
empirically grounded psychiatric classification system. The three
components of the empirical process underpinning DSM-IV were
comprehensive literature reviews, reanalyses of existing data bases, and a
series of field trials comparing existing and proposed criteria sets.
Along with the proliferation of DSM versions/the 1980s and 1990s
witnessed a proliferation of comment on the overall revision process, as
well as specific decisions regarding behavior and cognitive patterns that
were or were not included as disorders in the DSMs.
DSM-IV-TR lists 365 disorders in 17 sections, plus some diagnostic criteria
proposed for further study included in the appendix. This is an increase
from the 285 disorders in 17 sections in DSM-III and the 292 disorders in
18 sections in DSM-III-R.
Groups of Conditions in DSM-IV

Disorders usually first diagnosed in infancy, childhood, or adole scence

Delirium, dementia, amnestic, and other cognitive disorders Mental
disorders due to a general medical condition

Substance-related disorders

Schizophrenia and other psychotic disorders

Mood disorders

Anxiety disorders

Somatoform disorders
Factitious disorders
Dissociative disorders
Sexual and gender identity disorders
Eating disorders
Sleep disorders
Impulse-control disorders not elsewhere classified
Adjustment disorders
Personality disorders
Other conditions that may be a focus of clinical attention

International psychiatric diagnosis

Diagnosis and classification in psychiatry are critical for the scientific

development of this discipline across the world and for psychiatry to be
able to fulfill its most important role—serving effectively the patient who
presents for care. International classification and diagnosis deal with
concepts central to health and healthcare in a global manner, an approach
increasingly compelling in the interdependent world in which humans live.
A classification of diseases may be defined as a system Of categories to
which morbid entities are assigned according to some established criteria.
There is not a single correct set of criteria for classifying diseases. There
are many possible choices, and all of them depend on the particular
purpose of a classification system and the particular interest of its various
stakeholders. For the anatomist, for example, the main criteria may be the
part of the body affected, whereas, for the pathologist, it may be the
disease process; for the
public health practitioner, it may be the etiology, and, for the clinician, it
may be the particular manifestations of the illness process requiring
attention. This fact points out the importance of paying attention to the
needs of the multiple stakeholders of the system. However, global
usability demands two sometimes conflicting requirements of the system:
First, it must allow for the development of a language that is common to
all those using the system, such that communication among all of them is
possible to a substantial degree of intelligibility and reliability, so that
fundamental aspects of the phenomena to be assessed can be understood
and compared across the world. Equally important is the fact that not all
users of the system have the same needs in terms of the factors that
define the phenomena under study. Diagnosis in fact defines the field of
medicine in general and psychiatry in particular by delineating the
informational base necessary for clinical care and health promotion at the
individual and public health levels. Consequently, diagnosis is also a
fundamental concept for professional training and scientific research.
Furthermore, it informs the conceptualization of what a case is and the
methodology for its assessment in epidemiology and public health. With
various degrees of systematization and explicitness, diagnostic schemas,
as consensual notions and formats for describing clinical conditions, have
emerged since the dawn of mankind. In every case, these notions have
been
embedded within their time and culture.
Building on conceptual contributions over the past two centuries in
various parts of the world, and having the 100-year-old International
Classification of Diseases (ICD) as general reference, the worldwide
emphasis for advancing psychiatric diagnosis during the past several
decades has been on the use of more systematic formulations of
psychopathology and of explicit diagnostic criteria and rules of
assignment. This has led to gains in interrater agreement
(diagnostic reliability) and universal communicability of diagnostic
statements. These developments, although propitious for advancements in
the field, do not ensure gains in diagnostic validity or usefulness of the
diagnostic enterprise. Additionally, when assessing patients in populations
different from the culture in which these universalistic systems have been
created, validation of such systems in the populations of interest is
essential.
This has led to more recent efforts to update diagnostic validity, clinically
and epidemiologically, through development to enhance existing
universalistic diagnostic systems by paying attention to local realities and
the uniqueness of the individual. The first type of these developments
involves adaptations of the international classification system to regional
or national clinical patterns and needs. The second corresponds to
idiographic or personalized formulations, such as that proposed by the
World Psychiatric Association (WPA) International Guidelines for Diagnostic
Assessment (IGDA).
Outline of ICD10 Work toward the preparation of ICD-10 started in 1979,
the same year in which ICD-9 was put into effect. Its developmental
process involved the participation of the eight Collaborating Centers for
the Classification of Diseases; specialty divisions (such as Mental Health)
at the headquarters and the regional offices of the WHO;
nongovernmental organizations, such as the WPA; and a miscellaneous
panel of interested groups and individuals, all working under the
coordination of the WHO Unit on the Development of Epidemiological and
Health Statistical Services.
First to be noted in ICD-10 is its expanded scope, as indicated by
 its title. International Statistical Classification of Diseases and Related
Health Problems. This expression continues the trend that, starting with
an original set of causes of death, added morbidity in its fifth revision and,
more recently, added problems such as disabilities and factors that
influence health status, recognizing that more information is needed to
deal effectively with the evolving and complex issues of health care and
health promotion.
ICD-10 uses an alphanumeric code composed of a letter followed by
several digits. That arrangement more than doubles the number of
available categories. Splitting, rather than lumping, of categories has
marked the progression of ICD revisions, which has increased the need for
categorical slots. The first four characters of the code are internationally
official. The 5th and 6th character fields are available for regional and
special purpose adaptations. This arrangement maintains international
communication while accommodating local diversity.
Another powerful and innovative concept is that ICD-10 is a family of
disease and health-related classifications. At the core of the family are the
21 main chapters coded at the official three-character and four-character
levels and the short tabulation lists of causes of death and morbidity.
Peripherally located are the following classifications: specialty-based
adaptations (e.g., for oncology), in which the chief difference from the core
classification lies in the further extension of the ICD codes; (2)
classifications for primary care and general medical practice,
characterized by the condensation of categories and emphasis on less
rigorous diagnostic terminology and more immediate therapeutic
usefulness; and (3) classifications of information outside the core ICD,
such as that corresponding to disabilities and medical procedures. Also
part of the family is the International Nomenclature of Diseases, which
encompasses a list of recommended names for all diseases as well as their
definitions. In contrast to the concept of nomenclature, a classification, in
the words of the ICD pioneer William Farr, "groups diseases that have
considerable affinity or that are liable to be confounded with each other,
and therefore is likely to facilitate the deduction of general principles."
Main forms of human illness and related conditions constitute the 21
chapters as the core of ICD-10. New chapters structure the enlarged lists
of disorders of the nervous system (Chapter VI), eye and adnexa (Chapter
VII), and ear and mastoid process (Chapter VIII). The expanded chapter on
neoplasms covers one full letter and shares another with blood disorders,
which encompasses immunological conditions, such as acquired immune
deficiency syndrome (AIDS). Also, the classification of neoplasms is
multiaxial (one axis denotes topography and another morphology, i.e.,
histolog
ical type, and tumor invasiveness and differentiation).

List of Core Chapters of ICD-10

1. Certain infections and parasitic diseases

2. Neoplasms
3. Diseases of the blood and blood-forming organs and
certain disorders involving the immune mechanism
4. Endocrine, nutritional, and metabolic diseases
5. Mental and behavioral disorders
6. Diseases of the nervous system
7. Diseases of the eye and adnexa
8. Diseases of the ear and mastoid process
9. Diseases of the circulatory system
10. Diseases of the respiratory system
11. Diseases of the digestive system
12. Diseases of the skin and subcutaneous tissue
13. Diseases of the musculoskeletal system and connective
tissue
14. Diseases of the genitourinary system
15. Pregnancy, childbirth, and the puerperium
16. Certain conditions originating in the perinatal period
17. Congenital malformations, deformations, and
chromosomal abnormalities
18. Symptoms, signs, and abnormal clinical and laboratory
findings not elsewhere classified.
19. Injury, poisoning, and certain other consequences of
external causes
20. External causes o morbidity and mortality
21. Factors influencing health status and contact with health
services