Dr Kavita Ramanathan

CLINICAL PSYCHOLOGY EVOLUTION Psychopathology (pathos or suffering related to the psyche) has seen rapid evolution from the days where the demons and devils stole the show to an advanced, complex understanding of the human brain; what is normal and what is not. Why do I need this complex jargon filled classification? Worse, it changes before memorizing the old one! ‘Diagnosis’ (to know or to discern) is not only significant from point of view of treatment and prognosis, but also to enable a common language across the globe. It is central to medical instruction, research, inventions, and epidemiological studies. Medical coursework is exhaustive, and classification helps group complex diseases based on their similarity and separate them from those that are different. We are made by history. Earliest recordings in history link mental illnesses linked to being possessed by evil spirits and demons, requiring often drastic interventions like trephining, keeping patients in asylums and restraining the violent onesi. Hippocrates and Plato were among the first to reject these ideas and said that mental illness originated due to imbalances in the brain. It was not until the nineteenth century that systematic understanding and treatment of these patients was attempted. The two major contributions in this time were the ii • Psychodynamic theory by Sigmund Freud – mental illnesses was due to unresolved issues of the past and treat patients by having long dialogues with them. • Behaviourism theory by John B Watson - mental illness was due to cognitive behavioural conditioning and involved cognitive readapting. After the second World War, America felt the need for a more indepth formal classification system to help manage psychological problems in their War veterans. This paved the way for the Diagnostic and Statistical Manual for Mental Disorders by the American Psychiatric Association in the year 1952. It attempted to classify mental illness based on the antecedent socio-environmental causative factors. Today, genetics, childhood experiences, neurotransmitter imbalance, stress and many other factors are known to contribute to mental illnesses. Hence, due to ambiguity in the aetiology, DSM remained neutral towards aetiology in subsequent editions. How do I base my classification then? Due to unproven aetiologies, classification was increasingly based on symptomatology. Several symptoms often clustered together in individuals, giving us the syndromic approach to classify. WHO had included mental illnesses as a section in the International Classification of Diseases (ICD), which is widely used in Europe. So, which one do I follow? Several medical writing services provide scientific indexing that is difficult to comprehend. Chapter F of the ICD 10 iii classifies mental illnesses as below: - ICD CODE F00-F09 F10-F19 CATEGORY OF DISEASES Organic, including symptomatic mental disorders Mental and behavioural disorders due to psychoactive substance use EXPLANATION EXAMPLES Demonstrable aetiology – cerebral disease, brain injury etc Uncomplicated intoxication and harmful use to obvious psychotic disorders and dementia Dementia, delirium, amnesia, post-vascular event, postconcussion Alcohol, tobacco, stimulants, opioid, cannabinoids, cocaine, hallucinogens abuse F20-F29 Schizophrenia, schizotypal and delusional disorders F30-F39 Mood (affective) disorders F40-F48 Neurotic, stressrelated and somatoform disorders F50-F59 Behavioural syndromes associated with physiological disturbances and physical factors Disorders of adult personality and behaviour F60-F69 F70-F79 Mental retardation F80-F89 Disorders of psychological development Behavioural and emotional disorders with onset in childhood or adolescence F90-F99 Nonorganic psychosis (without insight) and associated with delusions &/or hallucinations Predominantly affecting the mood and hence activity level of patient Neurosis (with insight), mostly preceded by a stressor Affecting diet, sleep, sexual function with nonorganic causes Nonorganic behavioural disorders, impulse, habit, gender identity and sexual preferences Low IQ and delayed milestones Impairment of psychological milestones Adaptive disorders while growing Schizophrenia, acute psychosis, nonorganic delusional disorders Depression, Mania, Bipolar affective disorder Anxiety, phobia, obsessive-compulsive disorder , psychosomatic disorders Anorexia, bulimia, insomnia, night terrors, sexual dysfunction Personality types, Trans-sexual, transvestism, paedophilia severity and associated behavioural impairment Disorders of speech, language, scholastic skills, motor functions Hyperkinesis, conduct disorders, emotional disorder, tics, social dysfunction The DSM-5iv, released in 2013 with an update in 2017v, is followed in USA. The DSM-5 attempts to harmonise with the ICD-10 so as to not confuse researchers or hinder patient care. This classifies mental illnesses as below: • • • Neurodevelopmental disorders Schizophrenia spectrum and other psychotic disorders Bipolar and related disorders • • • • • • • • • • • • • • • • • • • Depressive disorders Anxiety disorders Obsessive-compulsive and related disorders Trauma and stressor related disorders Dissociative disorders Somatic symptom and related disorders Feeding and eating disorders Elimination disorders Sleep-wake disorders Sexual dysfunctions Gender dysphoria Disruptive, impulse-control and conduct disorders Substance-related and addictive disorders Neurocognitive disorders Personality disorders Paraphilic disorders Other mental disorders Medication-induced movement disorders and other adverse effects of medication Other conditions that may be a focus of clinical attention DSM-5 also has a chapter on ‘Emerging measures and Models’ which has several tools to help in patient care, understand the conditions in their cultural context and stimulate research. It highlights the need to have a dimensional approach, understanding the continuum in the symptomatology. The road ahead WHO has rolled out the ICD-11 transition and implementation guide in 2019 and ICD-11 is expected to come into effect in January 2022. It is available in a digitalized version and includes several health conditions and primary care along with diseases. It has a new classification and coding system, meant to make morbidity mortality studies easiervi. Current treatment includes pharmacotherapy and psychotherapy with institutional care. Mental health care is seeing a paradigm shift in management with increasing acceptance to non-Western systems of treatment and individualised care. Technology has opened newer ways of mental health management with gadgets and applications and FDA has established guidelines for digital psychiatry in the field of mental health care. i Alina Suris, Ryan Holliday, Carol North. The evolution of the classification of psychiatric disorders, concept paper Behavioural Sciences, 18 January 2016. ii Marc Jutras, BJMC, Vol. 59, no. 2, March 2017, pgs 86-88. Historical perspective on the theory, diagnosis and treatment of Mental illness iii The ICD-10 Classification of Mental and Behavioural disorders. Clinical descriptions and diagnostic guidelines. WHO 2015. iv Diagnostic and Statistical Manual of Mental Disorders Fifth edition. American Psychiatric Association 2013. v DSM-5 Update 2017. vi Icd.who.int