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DSM-IV as a Classification System
Systems of classification for psychiatric diagnosis have several purposes: to distinguish one psychiatric diagnosis from another, so that clinicians can offer the most effective treatment; to provide a common language among health care professionals; and to explore the causes of the many mental disorders that are still unknown (Kaplan, Sadock, 1998, p. 287, from client's essay request).
Diagnosis is the foundation of all medical practices (Berrios, 1995). In recent years, the medical industry has experienced a revolution in medicine's ability to identify and treat the illnesses that burden humanity. The psychiatric industry, which specializes in treating mental illnesses, has been a key participant in this revolution, identifying new diagnostic measures and systems of classification for many psychiatric disorders.
As a result, modern psychiatrists rely on accurate and efficient diagnostic tools to help them identify the specific mental illnesses their patients suffer. Identifying these illnesses enables the psychiatrists to better determine what treatment their patients need. The American Psychiatric Association's Diagnostic and Statistical Manual (DSM), in its four editions, has become a key player in this process. DSM-IV, the latest edition, is based on years of research and the input of thousands of psychiatric experts in the United States and beyond.
DSM-IV has provided valuable insight for psychiatrists around the world by giving them access to a well-constructed, numerical index of mental illnesses grouped by categories and sub-categories. Each entry consists of a general description of the disorder followed by a listing of possible symptoms, which helps clinicians identify their patients' illnesses with a strong degree of accuracy and confidence. For this reason, DSM-IV has made great contributions to the delivery of health care.
This paper will describe how DSM-IV has met the general requirements of basic systems of classification for psychiatric diagnosis, helping psychiatrists provide the best possible health care for their patients and enabling treatment for diseases that were previously undiagnosed.
Brief Historical Review of Classification in Psychiatry
This sections aims to provide a brief overview of how the classification of psychiatric disorders has developed and to show how various factors have influenced classification, as a background to a discussion of how modern classification systems, particularly DSM-IV, contribute to health care.
The first recorded formal system of classification dates back to 4th century B.C. To the days of Hippocrates and his followers (Berrios, 1995). Before this, disorders were blamed on divine influence. Hippocrates and his followers did not believe that disorders were caused by divine influence and used the philosophical system developed by Empodocles, which instead attributed all matter to one of four elements -- earth, air, fire and water. Thus, they believed that physical and mental illnesses were caused by an imbalance of the four elements. From this assumption, they classified mental illness as an abnormality of the brain.
The Church Fathers (Augustine and Nemesius) in the post-Galenic era discovered the psychological functions of sensation, reason and memory in the anterior, middle and posterior ventricles of the brain (Berrios, 1996). Galen's belief that the animal spirits were in the rete mirabile (a vascular structure found in cow brains) continued to be repeated until early modern times even though Vesalius in the sixteenth century demonstrated that the human brain contained no such structure.
The Compendium Medicine of Gilbertus Anglicus (published in 1230) was the first book that contained the description of psychiatric disorders, including mania, melancholia, lethargy, epilepsy and demonic possession (Kroll, 1973). After that, many others followed. However, most of the classification systems focused on the spiritual and supernatural elements of disease until the seventeenth and eighteenth century, when people began to view disease as a physical and mental entity.
The twentieth century was the turning point for classification systems (Bynell, 1986). Sigmund Freud stressed the importance of psychological factors, using the unconscious and its psychological mechanisms to try to understand conscious structures. Freud's ideas were soon integrated into mainstream psychiatry and expanded upon.
His influence would dominate American psychiatry for decades, as evidenced in the Second Diagnostic and Statistical Manual
DSM II) until the St. Louis School re-emphasised biological psychiatry in the 1970s, with a classification based on that of Kraepelin, at a time when effective drug treatments were being developed for psychiatric disorders.
According to Goldman (1997, p. 53), "The development of the international classification of diseases
ICD) shows Kraepelin's influences. The English Psychiatrist Stengel (1959) compiled a report for WHO, which laid the foundation for the ICD 8 (1967). Until then, the ICD had only been accepted by five member states.
It was Stengel's brilliance that he based his classification not on aetiology, but on symptoms following Kraepelin's example. After being adopted into ICD 8, psychiatric classification was now based on symptoms which were reliably identifiable and on syndromes which are operationally refined. Both the subsequent ICD9 / ICD 10 and the DSM III/IV are based on this original 'blueprint'."
How DSM-IV Contributes to Health Care
Today, one of the major systems of classifying and diagnosing psychiatric problems is DMS-IV. According to Allne (1999, p. 162): "The DSM-IV is a descriptive nosology that has shaped psychiatric research and clinical practice by providing agreed-upon definitions of psychiatric disorders based on the current state of empirical data. Despite the critical importance of the DSM system of classification, this complex yet limited nosology will eventually be replaced by simpler, more incisive explanatory models of psychiatric illness that reflect the interplay of biological, psychological, environmental and social variables affecting the expression and treatment of psychiatric disorders."
It is important to note that DSM-IV serves as a reference and guide for psychiatrists, but cannot be used as an alternative to psychiatric help (American Psychiatric Press, 1997). DSM-IV has been carefully written and researched, but it cannot take the place of psychiatric training in the diagnosis and treatment of mental disorders and a doctor's educated judgment.
During a patient's visit, a psychiatrist begins his assessment of the patient's condition. Psychiatrists conduct a thorough general medical examination of each patient to assess his general health, taking note of previous physicians' comments. In addition, psychiatrists carefully question their patients about their past history and the symptoms of their disorder, the length of time they've experienced the symptoms, and their severity. Only after this thorough assessment will the psychiatrist turn to the DSM-IV for further guidance.
In order to facilitate health carte providers, DSM-IV is organized according to phenomenology, meaning that it is classified according to groups of similar symptoms that are commonly associated with a particular illness. These classifications aim to support the diagnostic process, providing psychiatrists with diagnostic guidelines.
DSM-IV has made many contributions to health care. As the number of psychiatric diagnoses has increased over the past few decades, researchers and psychiatrists have been able to share their knowledge of mental disorders with more accuracy. This has enabled psychiatrists to have access to more information, ultimately serving their patients better.
After a psychiatrist examines his patient and reviews sources from the DSM-IV, he is in a better position to make a diagnosis and recommend a treatment (Frances, 1990). However, it must be acknowledged that there are few perfect fits in the diagnosis of any medical condition, as symptoms tend to vary from person to person, both in type and severity. For this reason, psychiatrists know that they cannot rely solely on the DSM-IV; instead, they use it as a reference.
DSM-IV has become an invaluable classification system for psychiatric disorders over the years. It is now widely accepted in the United States as the common language of mental health clinicians and researchers for communicating on mental illnesses. Major textbooks of psychiatry make extensive reference to DSM-IV and have widely adopted its terminology and ideas. In addition, DSM-IV has been translated into many other languages.
In this light, it is apparent that DSM-IV has developed a common language among health care professionals around the world. This is very important in the United States and beyond, as it provides an important link for different cultures. To make it easier for psychiatrists to use DSM-IV to diagnose people from diverse cultural and ethnic settings, DSM-IV includes a section that covers culturally related features. This helps psychiatrists understand that how people from different cultural backgrounds will describe their psychiatric symptoms. It also provides guidance on how a patient's cultural and ethnic background will influence the patient. For example, in some cultures, depressive disorders are characterized more by physical symptoms than by emotions.
The clinical usefulness of the DSM-IV goes beyond just being a tool for making psychiatric diagnoses (American Psychiatric Press, 1994). Mental health professionals and physicians use it to communicate about mental health conditions.
When two psychiatrists discuss a diagnosis such as "major depressive disorder, single episode, severe with psychotic features," they both have the same conceptualization of different aspects of the illness. Without the DSM-IV, the two psychiatrists might have very different perceptions of the condition, which would generate confusion.
In addition, the DSM-IV enables mental health professionals to come to a common consensus on which symptoms…[continue]
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