Learning Objectives
- Explain what it means to make a clinical diagnosis.
- Define syndrome.
- Clarify and exemplify what a classification system does.
- Identify the two most used classification systems.
- Outline the history of the DSM.
- Identify and explain the elements of a diagnosis.
- Outline the major disorder categories of the DSM-5-TR.
- Describe the ICD-11.
- Clarify why the DSM-5-TR and ICD-11 need to be harmonized.
Clinical Diagnosis and Classification Systems
Before starting any type of treatment, the client/patient must be clearly diagnosed with a mental disorder. Clinical diagnosis is the process of using assessment data to determine if the pattern of symptoms the person presents with is consistent with the diagnostic criteria for a specific mental disorder outlined in an established classification system such as the DSM-5-TR or ICD-11 (both will be described shortly). Any diagnosis should have clinical utility, meaning it aids the mental health professional in determining prognosis, the treatment plan, and possible outcomes of treatment (APA, 2022). Receiving a diagnosis does not necessarily mean the person requires treatment. This decision is made based upon how severe the symptoms are, level of distress caused by the symptoms, symptom salience such as expressing suicidal ideation, risks and benefits of treatment, disability, and other factors (APA, 2022). Likewise, a patient may not meet the full criteria for a diagnosis but demonstrate a clear need for treatment or care, nonetheless. As stated in the DSM, “The fact that some individuals do not show all symptoms indicative of a diagnosis should not be used to justify limiting their access to appropriate care” (APA, 2022).
Symptoms that cluster together regularly are called a syndrome. If they also follow the same, predictable course, we say that they are characteristic of a specific disorder. Classification systems provide mental health professionals with an agreed-upon list of disorders falling into distinct categories for which there are clear descriptions and criteria for making a diagnosis. Distinct is the keyword here. People suffering from delusions, hallucinations, disorganized thinking (speech), grossly disorganized or abnormal motor behavior, and/or negative symptoms are different from people presenting with a primary clinical deficit in cognitive functioning that is not developmental but acquired (i.e., they have shown a decline in cognitive functioning over time). The former suffers from a schizophrenia spectrum disorder while the latter suffers from a neurocognitive disorder (NCD). The latter can be further distinguished from neurodevelopmental disorders which manifest early in development and involve developmental deficits that cause impairments in social, personal, academic, or occupational functioning (APA, 2022). These three disorder groups or categories can be clearly distinguished from one another. Classification systems also permit the gathering of statistics to determine incidence and prevalence rates and conform to the requirements of insurance companies for the payment of claims.
The most widely used classification system in the United States is the Diagnostic and Statistical Manual of Mental Disorders (DSM) which is a “medical classification of disorders and as such serves as a historically determined cognitive schema imposed on clinical and scientific information to increase its comprehensibility and utility. The classification of disorders (the way in which disorders are grouped) provides a high-level organization for the manual” (APA, 2022, pg. 11). The DSM is currently in its 5th edition Text-Revision (DSM-5-TR) and is produced by the American Psychiatric Association (APA, 2022). Alternatively, the World Health Organization (WHO) publishes the International Statistical Classification of Diseases and Related Health Problems (ICD) currently in its 11th edition. We will begin by discussing the DSM and then move to the ICD.
The DSM Classification System
3.2.2.1.A brief history of the DSM. The DSM-5 was published in 2013 and took the place of the DSM IV-TR (TR means Text Revision; published in 2000). In March 2022, a Text-Revision was published for the DSM-5, making it the DSM-5-TR.
The history of the DSM goes back to 1952 when the American Psychiatric Association published the first edition of the DSM which was “…the first official manual of mental disorders to contain a glossary of descriptions of the diagnostic categories” (APA, 2022, p. 5). The DSM evolved through four major editions after World War II into a diagnostic classification system to be used by psychiatrists and physicians, but also other mental health professionals. The Herculean task of revising the DSM began in 1999 when the APA embarked upon an evaluation of the strengths and weaknesses of the DSM in coordination with the World Health Organization (WHO) Division of Mental Health, the World Psychiatric Association, and the National Institute of Mental Health (NIMH). This collaboration resulted in the publication of a monograph in 2002 called A Research Agenda for DSM-V. From 2003 to 2008, the APA, WHO, NIMH, the National Institute on Drug Abuse (NIDA), and the National Institute on Alcoholism and Alcohol Abuse (NIAAA) convened 13 international DSM-5 research planning conferences “to review the world literature in specific diagnostic areas to prepare for revisions in developing both DSM-5 and the International Classification of Disease, 11th Revision (ICD-11)” (APA, 2022, pg. 6).
After the naming of a DSM-5 Task Force Chair and Vice-Chair in 2006, task force members were selected and approved by 2007, and workgroup members were approved in 2008. An intensive 6-year process of “conducting literature reviews and secondary analyses, publishing research reports in scientific journals, developing draft diagnostic criteria, posting preliminary drafts on the DSM-5 website for public comment, presenting preliminary findings at professional meetings, performing field trials, and revisiting criteria and text” was undertaken (APA, 2022, pg. 7). The process involved physicians, psychologists, social workers, epidemiologists, neuroscientists, nurses, counselors, and statisticians, all who aided in the development and testing of DSM-5 while individuals with mental disorders, families of those with a mental disorder, consumer groups, lawyers, and advocacy groups provided feedback on the mental disorders contained in the book. Additionally, disorders with low clinical utility and weak validity were considered for deletion while “Conditions for Future Study” were placed in Section 3 and “contingent on the amount of empirical evidence generated on the proposed diagnosis, diagnostic reliability or validity, presence of clear clinical need, and potential benefit in advancing research” (APA, 2022, pg. 7).
3.2.2.2. The DSM-5 text revision process. In the spring 2019, APA started work on the Text-Revision for the DSM-5. This involved more than 200 experts who were asked to conduct literature reviews of the past 10 years and to review the text to identify any material that was out-of-date. Experts were divided into 20 disorder review groups, each with its own section editor. Four cross-cutting review groups to include Culture, Sex and Gender, Suicide, and Forensic, reviewed each chapter and focused on material involving their specific expertise. The text was also reviewed by an Ethnoracial Equity and Inclusion work group whose task was to “ensure appropriate attention to risk factors such as racism and discrimination and the use of nonstigmatizing language” (APA, 2022, pg. 11).
As such, the DSM-5-TR “is committed to the use of language that challenges the view that races are discrete and natural entities” (APA, 2022, pg. 18). Some of changes include:
- Use of racialized instead of racial to indicate the socially constructed nature of race
- Ethnoracial is used to denote U.S. Census categories such as Hispanic, African American, or White
- Latinx is used in place of Latino or Latina to promote gender-inclusive terminology
- The term Caucasian is omitted since it is “based on obsolete and erroneous views about the geographic origin of a prototypical pan-European ethnicity” (pg. 18)
- To avoid perpetuating social hierarchies, the terms minority and non-White are avoided since they describe social groups in relation to a racialized “majority”
- The terms cultural contexts and cultural backgrounds are preferred to culture which is only used to refer to a “heterogeneity of cultural views and practices within societies” (pg. 18)
- The inclusion of data on specific ethnoracial groups only when “existing research documented reliable estimates based on representative samples.” This led to limited inclusion of data on Native Americans since data from nonrepresentative samples may be misleading.
- The use of gender differences or “women and men” or “boys and girls” since much of the information on the expressions of mental disorders in women and men is based on self-identified gender.
- Inclusion of a new section for each diagnosis providing information about suicidal thoughts or behavior associated with that diagnosis.
3.2.2.3. Elements of a diagnosis. The DSM-5-TR states that the following make up the key elements of a diagnosis (APA, 2022):
- Diagnostic Criteria and Descriptors – Diagnostic criteria are the guidelines for making a diagnosis and should be informed by clinical judgment. When the full criteria are met, mental health professionals can add severity and course specifiers to indicate the patient’s current presentation. If the full criteria are not met, designators such as “other specified” or “unspecified” can be used. If applicable, an indication of severity (mild, moderate, severe, or extreme), descriptive features, and course (type of remission – partial or full – or recurrent) can be provided with the diagnosis. The final diagnosis is based on the clinical interview, text descriptions, criteria, and clinical judgment.
- Subtypes and Specifiers – Subtypes denote “mutually exclusive and jointly exhaustive phenomenological subgroupings within a diagnosis” (APA, 2022, pg. 22). For example, non-rapid eye movement (NREM) sleep arousal disorders can have either a sleepwalking or sleep terror type. Enuresis is nocturnal-only, diurnal-only, or both. Specifiers are not mutually exclusive or jointly exhaustive and so more than one specifier can be given. For instance, binge eating disorder has remission and severity specifiers. Somatic symptom disorder has a specifier for severity, if with predominant pain, and/or if persistent. Again, the fundamental distinction between subtypes and specifiers is that there can be only one subtype but multiple specifiers. As the DSM-5-TR says, “Specifiers and subtypes provide an opportunity to define a more homogeneous subgrouping of individuals with the disorder who share certain features… and to convey information that is relevant to the management of the individual’s disorder” (pg. 22).
- Principle Diagnosis – A principal diagnosis is used when more than one diagnosis is given for an individual. It is the reason for the admission in an inpatient setting or the basis for a visit resulting in ambulatory care medical services in outpatient settings. The principal diagnosis is generally the focus of attention or treatment.
- Provisional Diagnosis – If not enough information is available for a mental health professional to make a definitive diagnosis, but there is a strong presumption that the full criteria will be met with additional information or time, then the provisional specifier can be used.
3.2.2.4. DSM-5 disorder categories. The DSM-5 includes the following categories of disorders:
Table 3.1. DSM-5 Classification System of Mental Disorders
| Disorder Category |
Short Description |
Module |
| Neurodevelopmental disorders |
A group of conditions that arise in the developmental period and include intellectual disability, communication disorders, autism spectrum disorder, specific learning disorder, motor disorders, and ADHD |
Not covered |
| Schizophrenia Spectrum |
Disorders characterized by one or more of the following: delusions, hallucinations, disorganized thinking and speech, disorganized motor behavior, and negative symptoms |
12 |
| Bipolar and Related |
Characterized by mania or hypomania and possibly depressed mood; includes Bipolar I and II and cyclothymic disorder |
4 |
| Depressive |
Characterized by sad, empty, or irritable mood, as well as somatic and cognitive changes that affect functioning; includes major depressive, persistent depressive disorder, mood dysregulation disorder, and premenstrual dysphoric disorder |
4 |
| Anxiety |
Characterized by excessive fear and anxiety and related behavioral disturbances; Includes phobias, separation anxiety, panic disorder, generalized anxiety disorder, social anxiety disorder, agoraphobia |
7 |
| Obsessive-Compulsive |
Characterized by obsessions and compulsions and includes OCD, hoarding, body dysmorphic disorder, trichotillomania, and excoriation |
9 |
| Trauma- and Stressor- Related |
Characterized by exposure to a traumatic or stressful event; PTSD, acute stress disorder, adjustment disorders, and prolonged grief disorder |
5 |
| Dissociative |
Characterized by a disruption or discontinuity in memory, identity, emotion, perception, body representation, consciousness, motor control, or behavior; dissociative identity disorder, dissociative amnesia, and depersonalization/derealization disorder |
6 |
| Somatic Symptom |
Characterized by prominent somatic symptoms and/or illness anxiety associated with significant distress and impairment; includes illness anxiety disorder, somatic symptom disorder, and conversion disorder |
8 |
| Feeding and Eating |
Characterized by a persistent disturbance of eating or eating-related behavior to include bingeing and purging; Includes pica, rumination disorder, avoidant/restrictive food intake disorder, anorexia, bulimia, and binge-eating disorder |
10 |
| Elimination |
Characterized by the inappropriate elimination of urine or feces; usually first diagnosed in childhood or adolescence; Includes enuresis and encopresis |
Not covered |
| Sleep-Wake |
Characterized by sleep-wake complaints about the quality, timing, and amount of sleep; includes insomnia, sleep terrors, narcolepsy, sleep apnea, hypersomnolence disorder, restless leg syndrome, and circadian-rhythm sleep-wake disorders |
Not covered |
| Sexual Dysfunctions |
Characterized by sexual difficulties and include premature or delayed ejaculation, female orgasmic disorder, and erectile disorder (to name a few) |
Not covered |
| Gender Dysphoria |
Characterized by distress associated with the incongruity between one’s experienced or expressed gender and the gender assigned at birth |
Not covered |
| Disruptive, Impulse-Control, Conduct |
Characterized by problems in the self-control of emotions and behavior and involve the violation of the rights of others and cause the individual to violate societal norms; includes oppositional defiant disorder, antisocial personality disorder, kleptomania, intermittent explosive disorder, conduct disorder, and pyromania |
Not covered |
| Substance-Related and Addictive |
Characterized by the continued use of a substance despite significant problems related to its use |
11 |
| Neurocognitive |
Characterized by a decline in cognitive functioning over time and the NCD has not been present since birth or early in life; Includes delirium, major and mild neurocognitive disorder, and Alzheimer’s disease |
14 |
| Personality |
Characterized by a pattern of stable traits which are inflexible, pervasive, and leads to distress or impairment; Includes paranoid, schizoid, borderline, obsessive-compulsive, narcissistic, histrionic, dependent, schizotypal, antisocial, and avoidant personality disorder |
13 |
| Paraphilic |
Characterized by recurrent and intense sexual fantasies that can cause harm to the individual or others; includes exhibitionism, voyeurism, sexual sadism, sexual masochism, pedophilic, and fetishistic disorders |
Not covered |
The ICD-11
In 1893, the International Statistical Institute adopted the International List of Causes of Death which was the first international classification edition. The World Health Organization was entrusted with the development of the ICD in 1948 and published the 6th version (ICD-6). The ICD-11 went into effect January 1, 2022, though it was adopted in May 2019. The WHO states:
ICD serves a broad range of uses globally and provides critical knowledge on the extent, causes and consequences of human disease and death worldwide via data that is reported and coded with the ICD. Clinical terms coded with ICD are the main basis for health recording and statistics on disease in primary, secondary and tertiary care, as well as on cause of death certificates. These data and statistics support payment systems, service planning, administration of quality and safety, and health services research. Diagnostic guidance linked to categories of ICD also standardizes data collection and enables large scale research.
As a classification system, it “allows the systematic recording, analysis, interpretation and comparison of mortality and morbidity data collected in different countries or regions and at different times.” As well, it “ensures semantic interoperability and reusability of recorded data for the different use cases beyond mere health statistics, including decision support, resource allocation, reimbursement, guidelines and more.”
Source: www.who.int/classifications/icd/en/
The ICD lists many types of diseases and disorders to include Chapter 06: Mental, Behavioral, or Neurodevelopmental Disorders. The list of mental disorders is broken down as follows:
- Neurodevelopmental disorders
- Schizophrenia or other primary psychotic disorders
- Catatonia
- Mood disorders
- Anxiety or fear-related disorders
- Obsessive-compulsive or related disorders
- Disorders specifically associated with stress
- Dissociative disorders
- Feeding or eating disorders
- Elimination disorders
- Disorders of bodily distress or bodily experience
- Disorders due to substance use or addictive behaviours
- Impulse control disorders
- Disruptive behaviour or dissocial disorders
- Personality disorders and related traits
- Paraphilic disorders
- Factitious disorders
- Neurocognitive disorders
- Mental or behavioural disorders associated with pregnancy, childbirth or the puerperium
It should be noted that Sleep-Wake Disorders are listed in Chapter 07.
Harmonization of DSM-5-TR and ICD-11
According to the DSM-5-TR, there is an effort to harmonize the two classification systems: 1) for a more accurate collection of national health statistics and design of clinical trials aimed at developing new treatments, 2) to increase the ability to replicate scientific findings across national boundaries, and 3) to rectify the issue of DSM-IV and ICD-10 diagnoses not agreeing (APA, 2022, pg. 13). Complete harmonization of the DSM-5 diagnostic criteria with the ICD-11 disorder definitions has not occurred due to differences in timing. The DSM-5 developmental effort was several years ahead of the ICD-11 revision process. Despite this, some improvement in harmonization did occur as many ICD-11 working group members had participated in the development of the DSM-5 diagnostic criteria and all ICD-11 work groups were given instructions to review the DSM-5 criteria sets and make them as similar as possible (unless there was a legitimate reason not to). This has led to the ICD and DSM being closer than at any time since DSM-II and ICD-8 (APA, 2022).
Key Takeaways
You should have learned the following in this section:
- Clinical diagnosis is the process of using assessment data to determine if the pattern of symptoms the person presents with is consistent with the diagnostic criteria for a specific mental disorder outlined in an established classification system such as the DSM-5-TR or ICD-11.
- Classification systems provide mental health professionals with an agreed-upon list of disorders falling into distinct categories for which there are clear descriptions and criteria for making a diagnosis.
- Elements of a diagnosis in the DSM include the diagnostic criteria and descriptors, subtypes and specifiers, the principle diagnosis, and a provisional diagnosis.
Review Questions
- What is clinical diagnosis?
- What is a classification system and what are the two main ones used today?
- Outline the diagnostic categories used in the DSM-5-TR.
