How a Mental Illness is Determined and Classified
Many people often wonder how a doctor or a psychiatrist, and psychologist decide who has what mental illness and why. It is very tricky because many mental illnesses resemble each other. Sometimes it just does not seem to make any sense. There is a common amusement shared among university professors as they watch first year psychology students read about the different illnesses and then become convinced they have each and every mental illness they read about. Why is that?
Well, the first statement about mental illness that can be made is that a mental illness is an exaggeration of the behaviors everyone possesses. The difference between what is considered normal and what is considered abnormal or unhealthy is the degree of that behavior present. This becomes the bottom line for diagnosing mental illness. Every one of us will get down in the dumps from time to time, but not every one of us will be so down in the dumps that we cannot eat or sleep or do just about anything. We don’t spend our lives in bed staring up at the ceiling or thinking about death and committing suicide. When people get that far down in the dumps they are diagnosed with major depression, which is a serious mental illness. Having said that, even depression has different levels of severity from mild, to moderate and then severe. Sub-classifying a mental disorder according to its severity is done quite frequently and that is because different symptoms or severity of symptoms would be exhibited in these sub-divisions.
You may be thinking at this point, what is the big deal, do psychiatrists not have anything better to do with their time than stick labels on people? The answer is, these labels are often necessary to understand what is going on with the person in question and to provide the best possible treatment. For example, in the case of depression, major depression is treated with antidepressants to restore the chemical balance in the brain. Mild depression can be treated with a good self talk or talk with a friend, and often doesn’t last very long; and moderate depression may require therapy such as cognitive therapy to help the person get back on track. You would not want to avoid giving medication to someone who has major depression, because frankly all the other therapies would just not work when a person is that deeply depressed. Nor would you want to give unneeded medication to someone who really doesn’t need it and all they really require is a fresh outlook on life (mild depression). For people who have moderate depression they may need therapy to help them get focused and back on track. Therefore the doctor, psychiatrist, and counselor have to have a standard system to make these classifications.
Standardization is very important; otherwise there is chaos. Even with standardization, there is room for misdiagnosis--so imagine without it. The most common diagnostic tool for mental illness used in North America and different degrees around the world is the Diagnostic Statistical Manual, which was developed by the American Psychiatric Association. This manual is not only used by the medical community, it is used by government drug regulation agencies and policymakers; and pharmaceutical companies and the legal system also use it. Mental illness will not be accepted in court as a defense or as a claim for benefits from the government or an insurance company, etc., in a lawsuit, without a DSM diagnosis. Clinical studies, which require a certain type of person with a certain mental illness, will rely on the DSM classification to recruit their test subjects.
The DSM is the standard classification system for mental illness and through its history it has received much praise for its level of excellence and perhaps even more controversy for certain conditions listed as mental illness. For example, homosexuality was listed as a mental disorder in the DSM and was taken out in 1987 and no longer listed as a mental disorder.
The DSM was first published in 1952 and many disorders have been added since then, while others have been taken out. Some of the modern disorders are the same disorders but with new subtypes, and others are the same disorders now carrying an entirely new name. For example, what was once known as Manic Depressive Disorder is now called Bipolar Disorder. The manual came about as a compilation medical information and statistical data, and was based on a manual that was produced by the US army. There have been several revisions since 1952. The last version was the DSM IV published in 1994, with its revised edition the DSM IV-TR in 2000. Altogether there have been five revisions to date and the DSM V is in the works and expected to come out 2012.
International Statistical Classification of Diseases and Related Health Problems
The mental health section of the ICD is also another diagnostic tool that mental health professionals use, mostly in Europe. However, the DSM is most commonly used in North America. The DSM and ICD will try to synchronize coding systems but that is not always possible because the editions do not come out at the same time. Many psychiatrists across the world will use the ICD for clinical use and the DSM for research use.
History Behind the DSM
The need to collect and compile clinical statistical information first became important in the late 1880’s. In 1840, a single category on the US census was entitled, “idiocy/insanity”. By 1880 there were seven classifications included in the US census which were: mania, monomania, dipsomania, paresis, melancholia, dementia, and epilepsy . By 1917, the National Committee on Mental Hygiene along with the Committee on Statistics--now known the American Psychiatric Association--published a new hospital guide called the Statistical Manual for the Use of Institutions for the Insane. At this time there were 22 mental disorders classified. Standard Classified Nomenclature of Disease was also a classfication system used at the time as a subsection in the US Medical Guide. It was referred to as the “Standard”.
DSM – I (1952)
The need to recruit mentally stable soldiers during World War II brought the focus away from the medical community and onto the army. In 1943, the Medical 203 was created by a team of psychiatrists and Brigadier General William C. Menninger. There were major revisions from the old “Standard” to conform with more modern day thinking and the Medical 203 was widely used throughout the Armed Forces and The Veterans Association which used a variation of the Medical 203.
By 1949, the World Health Association published a section for mental disorders in the ICD making it the very first time an entire section of mental disorders was included.
By 1950, it was evident there was a clear need to develop a system that was standard rather than having so many classification systems to choose from. The DSM-I relied heavily upon the Medical 203 for its formulation, which was a statistical manual compiling the statistical data from the known medical sources of the time. This manual had 130 medical conditions.
DSM –II (1968)
This version was similar to the first one, and now had 182 conditions including Kreapelin’s System of Classification. The Manual was heavily influenced by the psychodynamic theory dominance of the times. The distinction between neurosis (worry and anxiety) and psychosis (out of touch with really, hallucinations and delusions) were clearly made.
The DSM II was widely controversial due to the signs of the times and the changing social values largely due to the work of Alfred Kinsey (doctor; researcher on human sexuality) and Evelyn Hooker (psychologist studying homosexuality). Their concerns focused on issue of homosexuality being categorized as a mental disorder. By the 7th printing the classification as a mental order was taken out. However, due to the strong influence of psychiatrist Robert Spitizer a new category called Gender Identity Disorder was included.
DSM – III (1980)
Again, the need to maintain standards for diagnostic classification between the European and North American medical community was the focus. Many debates went on as to how mental disorders should be classified and why. The heavy influence on psychodynamic theory was challenged. Some critics wanted to eliminate the term neurosis completely from the manual while others said that it would not be a qualified mental illness standard if psychological considerations rather than just biological-based illnesses were excluded. The classification Sexual Orientation Disturbance was changed for Ego-dystonic Homosexuality.
DSM – III-R (1987)
Categories were renamed and classified while others were deleted. The controversial Pre-menstrual Dysphoric Disorder and Masochistic Personality Disorder were deleted. The very controversial Sexual Identity Disorder was taken out, but its presence was still to be found in “Sexual Disorder not otherwise classified.” You can say that old habits are slow to die.
DSM –IV (1994)
A major difference in this version was the inclusion of a clinical significance requirement for at least half of their categories. The Illness must produce, “clinically significant distress or impairment in social, occupational, or other important areas of functioning”. As you see, homosexuals who are absolutely happy with their sexuality would not fall under this category of mental illness.
DSM – IV-TR (2000)
Has provided more clinical information on the existing mental conditions.
On Axis I you will find the major disorders. They are considered psychological, developmental and learning disorders, such as: Schizophrenia, Bipolar Disorder, depression, phobias, autism, and ADHD.
On Axis II you will have the personality disorders such as: Borderline Personality Disorder, Paranoid Personality Disorder, Schizoid Personality Disorder, Schizotypal Personality Disorder, Antisocial Personality Disorder, Narcissistic Personality Disorder, Histrionic Personality Disorder, Obsessive Compulsive Personality Disorder, and mental retardation.
On Axis III you will find brain injuries and other physical conditions, which can affect brain functioning.
On Axis IV you will find psychosocial and environment factors that contribute to a disorder
On Axis V you will find the Global Assessment of Functioning, or Global Assessment Scale for children under 18.