CRITICAL EVALUATION OF DIAGNOSTIC SYSTEM

International Classification of Diseases (ICD) by World Health Organization and Diagnostic and
Statistical Manual (DSM) by American Psychological Association are the two methods used in
classification of mental disorders. In order to reduce duality and confusion in the classification
of mental disorders both ICD and DSM work in mutual understanding even with their
differences. Both classification systems use common codes even though the specificity of
definition varies for each disorder. Both ICD and DSM classification allow code crosswalking
from older format to present one by revising it once in 10 years, in order to be updated with
the new scientific investigations and findings. This is a process where old code set isn’t entirely
replaced but rather expanded to broaden the documentation.

Brief history of ICD and DSM:

The first classification edition, known as the International List of Causes of Death, was adopted
by the International Statistical Institute in 1893. Mental disorders were first included in the
sixth revision of the ICD-6 in 1949. In 1957 Professor Stengel was invited by the WHO to review
the situation concerning psychiatric classifications. In 1980, WHO, in collaboration with the
Alcohol, Drug Abuse and Mental Health Administration (ADAMHA), undertook an even more
ambitious project aiming to further improve diagnostic tools, the classification of mental illness
and about factors relevant to its occurrence, course and outcome. At present we are in ICD-10
and ICD- 11 is in process.

The American Psychiatric Association first published a predecessor of DSM in 1844, as a

statistical classification of institutionalized mental patients. It was designed to improve
communication about the types of patients cared for in these hospitals. This forerunner of DSM
also was used as a component of the full U.S census. In 1952, the APA created its own
classification system, DSM-1. At present we are in DSM-5 edition.

Some of the differences that we can note in ICD and DSM are as follows:

 ICD is the WHO’s official classification recognized internationally.

 DSM is a classification provided by APA. Although it is officially used in the USA, DSM is
used by many countries worldwide.

 ICD includes 155,000 codes for all the various kinds of disorders and mental disorder is
the part of ICD dealing from code number F00-F99.
 DSM deals specifically with Mental disorders.

1
  Special attention is given to primary care as well as low and middle-income countries.
 DSM is beneficial for high-income countries to assist in the secondary psychiatric care.

 ICD is published in 43 languages.

 DSM is published in one language.

 ICD classification of mental health disorder has been produced in several versions for
different groups of users and for use in specific situations.
 Only one version of DSM is published.

Critical Analysis:
Classification system is necessary because it provides us with nomenclature (a naming system)
and enables us to structure information in a more helpful manner. Further it will help us to
understand in detail about each specific disorder and its symptoms, etiology, intensity,
duration, comorbidity, treatment and for further research in specific disorders. At a broader
level classification of mental disorders has social (in schools, NGO etc.,) legal and political
implications (policy making). On the other hand this classification system has negative
implications like loss of information and labeling or stigma. Let us examine critically as to what
extent the two important classification system of psychiatric disorders that is Diagnostic
Statistical Manual (DSM-5) and International Classification of Disorders (ICD-10) is useful.

1. As DSM-5 is restricted only to Mental health disorders it provides elaborate details

about each disorder. It gives clear idea about each specific disorder by providing clear
cut diagnostic features, associated features supporting diagnosis, subtypes/specifiers,
prevalence, development and course, risk and prognostic factors, diagnostic measure,
functional consequences, culture-related diagnostic issues, gender related diagnostic
issues, differential diagnosis and comorbidity. On the other hand ICD-10 contains
classification of all most all disorders and provides brief specific information about each
disorder. Elaborate descriptions given in DSM-5 gives clear understanding about each
specific disorder and avoids confusion.
2. The coding system in DSM and ICD are congruent. ICD-10 uses alphanumerical method
of classification.
For example: F20.10 where, F= identifies mental disorder chapter
2= section of schizophrenia and related disorders
0= schizophrenia
1= indicates type of schizophrenia= hebephrenia
0= indicates type of course= continuous

2
 In DSM before each disorder name, ICD-9-CM (Clinical Modification) codes are provided,
followed by ICD-10-CM codes in parentheses(brackets). Blank lines indicate that either
the ICD-9-CM or the ICD-10-CM code is not applicable. For some disorders, the code can
be indicated only according to the subtype or specifier. Following chapter titles and
disorder names, page numbers for the corresponding text or criteria are included in
parentheses.
For example:

Name of the disorder &

page number
ICD-9-CM &
ICD-10-CM
code is not
applicable

ICD-9-CM
code

ICD-10-CM code

This kind of codification makes it easy and less time consuming for the users. As there is
congruency between ICD-10 and DSM-5 it reduces our effort to learn two different
coding numbers and gives less scope for confusions.

3. DSM publishes only one version for varies fields such as research, education, teaching
psychiatric social workers, nursing and for clinical use. Whereas ICD-10 classification of
mental health disorder has been produced in several versions for different groups of
users and for use in specific situations. The decision to create different versions of the
classification introduced the need to consult and involve groups which have not worked
on psychiatric classification in the past, such a general practitioners. They are fully
compatible with each other relevant parts of the ICD. The publish of different versions
my sometimes leads to confusion and chaos but on the other hand it will be helpful for

3
 professionals working in various other set up other than clinical to know and guide
about mental illness.

4. ICD-10 uses Multiaxial system in order to classify mental disorders. Multiaxial

classification allows simultaneous assessment of different aspect of the patient’s illness.
Planning for care has to take into account not only the clinical psychiatric syndrome but
also the intellectual level of the patient, the social circumstances in which the patient
lives and any other diseases or impairment from which he or she may suffer. For this
purpose ICD-10 uses six axes for childhood mental disorder classification , that is :
 Axis I Clinical psychiatric syndrome
 Axis II Specific disorders of psychological development
 Axis III Intellectual level
 Axis IV Medical conditions
 Axis V Associated abnormal psychosocial situations
 Axis VI Global assessment of disability.

For adults ICD-10 uses three axes:

 Axis I Clinical diagnosis

 Axis II Disabilities
 Axis III Contextual factors.

On the other hand DSM-5 has removed 5 axial system which was present in DSM-IV TR
and at present DSM-5 is single axial system. Information from the first four DSM axes
are still taken into consideration, but now they are no longer seen as separate axes
instead they are combined together (Axis1-primary diagnosis+ Axis2-personality
disorder/mental retardation+ Axis3- medical and/or neurological problem impacting the
individuals psychological concerns). The nine categories of environmental and
psychological stressors impacting the client’s psychological functioning (such as job loss,
romantic separation or death) are now taken into account through a broadened set of V
and Z codes that clinicians can use to indicate additional areas of concern that could be
impacting diagnosis and treatment, or that could require further clinical attention.

In mental health set up as we cannot precisely point out a single factor and say that it is
a cause for the particular disorder. In my opinion it is best to look at the disorder in
various point of view and give an integral medication which can be a combination of
psychiatric medicine+ therapies+ nutritional food + healthy life style+ good social
environment + healthy relationships etc., this combination will definitely lead to a better

4
prognosis and recovery. Therefore, in my opinion it is better to have multiaxial system
than single axial system.

Both World Health Organization and American Psychological Association’s works are
appreciable for providing a classification system and promoting more research in this
area of mental health. Both ICD and DSM has their own positive and negative aspects
and they differ from each other in many aspects, but it is impressing that both
organizations support and help each other to update and to keep consistency with each
other. Even though we feel that DSM as a separate classification system for only one
country that is USA is not required but according to me it is good have separate manuals
for each countries so that they could include some of the culture, language, ethnic, race,
believes, heritage, social and political specific diagnosis. But it is also necessary to have
something at international level like ICD to guide all the other nation specific manuals.

REFERENCE:

1. Butcher, J. N., Holley, J. M., Mineka, S.,& Dwivedi, C. B. (20018). Abnormal

Psychology (16th ed.). Chennai: Pearson India Education Services.
2. Sartorius, N . (2007). Understanding the ICD-10 Classification of Mental Disorders A
Pocket Reference (2nd ed.). Delhi: Rajkamal Electronic Press.
3. American Psychiatric Association. (2013). Diagnostic And Statistical Manual Of
Mental Disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.
4. World Health Organization. (2007). The ICD-10 Classification of Mental and
Behavioral Disorders (10th ed.). Delhi : A.I.T.B.S. Publishers & Distributors (Regd.).

5
6