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Chapter 3 Last modified 07 Feb 2006
CLASSIFICATION OF MENTAL DISORDERS
Aim and Introduction
The aim of this chapter is to take a bird’s eye view of the mental disorders, and introduce
a system of classification. In later parts of this download, specific symptoms and
disorders will be considered in more detail. The purpose of classification, that is, the
putting of apparently related items into boxes or categories, is to simplify matters and
assist us in our understanding of large amounts of complicated information. A system of
classification also assists in clear communication.
In Chapter 1, mention was made of the two main systems of classification of mental
disorders: The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition,
Text Revised, was published by the American Psychiatric Association, which is usually
referred to as the DSM-IV, and the International Classification of Diseases, Edition 10,
Classification of Mental and Behavioural Disorders, which was published by the World
Health Organisation, and is usually referred to as the ICD-10. These systems arrange
large lists of mental disorders under a number of major headings (17 in the case of DSM-
IV and 9 in the case of ICD-10).
In this chapter a simplified classification system is presented (Table 2). The mental
disorders have been arranged under the following headings: “psychotic”, “non-
psychotic”, “personality disorder” and “organic mental disorders”. A related
classification is “substance use disorders”. There has been debate as to whether substance
use disorders are social or behavioural problems, or mental disorders. Currently they are
included as mental disorders in DSM-IV and ICD-10, however in some jurisdictions,
services are provided by separate, specialized treatment teams.
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Psychotic Disorders
Schizophrenia
Delusional Disorder
Mood Disorder
Bipolar Disorder
(mania and depression phases)
Major Depressive Disorder
Cyclothymia
Dysthymia
Non-Psychotic Disorders
Anxiety Disorders
Generalized Anxiety Disorder
Panic Disorder
Phobic Disorders
Obsessive Compulsive Disorders
Post-traumatic Stress Disorder
Eating Disorders
Somatoform Disorders
Personality Disorders
odd and eccentric
anxious and fearful
dramatic and emotional
Organic Mental Disorders
Substance Use Disorders
Intoxication and psychosis
Dependence
Withdrawal
Table 2. A simplified classification system
The current method of diagnosing and then classifying mental disorders is difficult
because the process largely depends on clinical impressions rather than pathology reports.
There are few objective tests to assist in the diagnosis mental disorders. When tests are
used, it is usually to rule out conditions which are not mental disorders, for example, a
brain scan may be performed to rule out the possibility of brain tumour. At the moment,
the main data the psychiatrist has is the appearance and behaviour of the patient and the
words he or she uses to describe thoughts, feelings and other experiences. Other data
comes from physical examination by which various medical conditions which may at first
appear to be mental disorders, such as Huntington’s disease or multiple sclerosis, or from
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psychological tests of memory and concentration, which help to identify organic mental
disorders such as Alzheimer’s disease or other forms of dementia.
Madness
Taking an historical perspective we could first look at the old term, madness, one of
Shakespeare’s favourite words. The English Dictionary offers three meanings for the
word madness. They are all in current use and this can cause misunderstandings. One
meaning is senseless folly – as when the two young, unsuited, incompatible people have a
wild love affair. Such undue enthusiasm appeared in the newspaper headline: “US Mad
About Harry Potter”.
Another meaning has to do with anger, as when the fathers of the young people
mentioned above discover the affair, splutter, cancel credit cards and talk of rewriting
wills etc. A bumper sticker that used the angry meaning: “Cigarette companies – the truth
will make you mad!” A recent newspaper headline used the word in a famous murder-
suicide, which is believed to by the result of an angry outburst (Illustration 3.1).
Illustration 3.1. Headlines in newspapers and magazines around the world, dubbed Crown
Prince Dipendra of Nepal, “The Mad Crown Prince”. He is shown here holding an assault
weapon of the type he used to kill his mother, father, seven other royal relatives and
himself. He wanted to marry a woman who was unacceptable to his parents. He was
caught between two cultures and addicted to alcohol and illegal drugs. He had previously
reported depression and had taken some antidepressant medication. He could have been
called mad by a number of meanings of the word. His murder-suicide was senseless and
imprudent, it almost certainly involved great anger and he may well have been mad due
to the effects of illegal drugs.
While there is some evidence that he Crown Prince Dipendra had suffered depression in
the past, there is no evidence that he was still depressed at the time of the murder-suicide,
or that he had ever suffered a psychotic disorder.
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The third meaning has to do with mental disorder or insanity (Illustration 3.2). However,
in this respect, madness has never been clearly defined. While it is usually used to
identify severe mental disorder, such as psychosis, not being constrained by a proper
definition, it can also be used (usually to denigrate) to the lesser forms of mental disorder
and those suffering them.
Illustration 3.2. Title page of a medical treatise on madness, published in 1758.
The term madness last appeared in medical books over a century ago. It was used
interchangeably with the words, delusion, delirium and mania. These words currently
have separate and distinct meanings, but madness does not. Thus, madness has no precise
meaning in either common English or medical lexicons.
For mental health professionals, madness is a slang (picturesque, unconventional) word,
roughly interchangeable with the term psychotic.
Psychotic disorders
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The term psychotic is used to describe particular symptoms, disorders and individuals. It
is a term with many nuances and should be used with caution.
Psychotic symptoms indicate a “loss of contact with reality”, for example, when the
individual believes something which has no basis in reality (delusions) (Illustration 3.3)
or hears a voice when no one has spoken (hallucinations) (Illustration 3.4).
However, similar symptoms can occur in healthy people. For example, some healthy
people regularly hear their name called just as they are falling to sleep. These are called
hypnagogic hallucinations. By definition, these people do hallucinate, they hear their
name called when it is not called, but in the absence of additional symptoms, they are not
suffering a psychotic disorder and cannot be described as being psychotic.
Illustration 3.3. This was written by a young Christian man who developed schizophrenia
and began to believe that Satan had taken control in heaven. He had not decided to
change his religion, that is, he had not become a devil worshiper, and he was distressed
by his new belief. Given this man’s personal history and cultural group, this belief was a
delusion.
There is also the suggestion of thought slippage. This man had despised Satan, and it is
unlikely that he would wish to apply the words “but beautiful” to that subject. It is
probable that when he thought of heaven, he thought about the attributes of God, and
stayed on that line of thinking while writing about Satan.
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Illustration 3.4. This letter was written by a man with schizophrenia. He had once been a
patient of, but had not been seen by the author, for more than a year. During most of that
year he had been in a psychiatric hospital and was under the care of Dr Jeff Self. The
patient writes that his hallucinations (voices) are worse than being dead or tortured.
For some years he had experienced visual hallucinations of attractive women. He writes
about having sex with his visions which he can “feel” in his pillows. It is very difficult to
classify the information that he is having sex with his visions. If it is not possible to have
sex with visions, then this is a false belief and could be classified as a delusion.
But, was this man having visual hallucinations of himself having sex with the attractive
women who appeared in his earlier visions? Insufficient details are available about his
experience for firm conclusions to be reached.
This patient has some difficulty with logical thought, so he might not have been able to
describe things better, even if he had been asked.
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Psychotic disorders are those in which there are psychotic symptoms, plus gross
impairment of the capacity to function in everyday life. It is possible to have a mental
disorder, and a psychotic symptom, but not to have a greatly reduced capacity to function
in everyday life. Thus, it is possible to have a psychotic symptom without having a fully
developed psychotic disorder.
Consider a person who has recently suffered an acute psychotic disorder, who with
treatment has returned to work and normal life, but who still hears a voice a few of times
a day. This person may have full insight, meaning that he or she knows that the voice he
or she is hearing is, in fact, an hallucination. Such an individual experiences occasional
psychotic symptoms, but the full psychotic disorder is in remission, and he or she would
not be described as being psychotic.
Consider a person with anorexia nervosa who purposefully restricts food intake and
exercises because of a fear of being fat, who is emaciated to a dangerous degree, but who
nevertheless believes she or he is overweight. By strict criteria, this person is
experiencing something very similar to a delusion. Further, when such patients see
themselves in a mirror, they frequently “see” themselves as fat, a phenomenon which
suggests mistakes of perception. Although the condition is often disabling, some people
with anorexia nervosa are able to perform rewarding work and maintain stable
relationships. However, in spite of apparent “delusions” and mistakes of perception, and
some reduction in the ability to conduct a normal social and working life, such a person is
not suffering a psychotic disorder, and would not described as psychotic.
As there may be some confusion, let us briefly consider the most common “psychoses”,
or psychotic mental disorders. These are schizophrenia and delusional disorder.
Schizophrenia is a term which frequently appears in the lay media. It is the archetypal
psychosis. The symptoms of this disorder include hallucinations, delusions, reduced
ability to think logically (thought slippage), behavioural signs such as the holding of
bizarre postures, the loss of the ability to experience emotional feelings and spontaneity,
social withdrawal, and personal neglect. During acute episodes the hallucinations,
delusions and thought slippage are the most prominent symptoms. With treatment or
natural remission these symptoms are less prominent and the loss of spontaneity, social
withdrawal and personal neglect become more noticeable.
Delusional disorder is a psychotic disorder in which the only symptom is one or more
delusions. Usually the delusion is of a paranoid type, and the patient believes he or she is
being watched and is in danger from spies, organised crime or aliens. The patient may be
able to work and may appear normal to others. As there is only one symptom and the
patient appears to function reasonably well outside the home, some may question whether
this is truly psychotic disorder. However, in most instances the life is severely damaged
by this disorder. Suspiciousness or frank delusions result in conflict at work and the
patient is usually finally placed on some form of pension. The social life is also severely
damaged, the patient eventually withdrawing to live behind reinforced doors with an
array of locks, in a state of constant fear and apprehension.
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Mood Disorders
The Oxford English Dictionary defines mood as “1. a particular sate of mind or feeling 2.
a prevailing feeling, spirit or tone”. Thus, feelings are the central issue, and under this
heading one might expect to include fear, jealousy or love. However, by convention and
from a clinical perspective, the mood disorders are the persistent conditions in which the
prominent felling is sadness or elation.
Bipolar disorder (once called manic-depressive psychosis) is the most dramatic form.
This disorder is characterised by mood elevated (manic) phases and sad (depressed)
phases. These phases may last for months or even become chronic (constant). For a given
patient, swings may predominantly occur in one direction, alternatively, about equal
numbers of swings may occur in each direction. In the mood elevated phase the patient is
often over confident, grandiose, irritable and disinhibited, with rapid thoughts, reduced
need for sleep and abundant energy.
In depressed phases the mood and energy are low, thinking is slowed and the ability to
concentrate is reduced. Sleep is disrupted, the patient often waking in the early hours and
unable to return to sleep. There is loss of interest in food, sexual or any other activity, and
weight loss is a frequent feature.
Episodes in either direction may fail to satisfy the criteria for psychosis, thus the term
manic-depressive psychosis is being superseded. The patient in a manic phase is clearly
acting out of character, and with mood elevation as a springboard, problems frequently
arise as patients engage in risky behaviour such as unwise investments, fast driving,
sexual liaisons or audacious activities.
The patient in a depressive phase may also act out of character, becoming inactive and
withdrawn. Delusions of guilt are uncommon. However, frequently, the patient thinks
about death and regrettably, suicide is not uncommon.
Repeated episodes of severe depression may occur without manic episodes, and this has
been called major depressive disorder or unipolar depression. There are also less severe
mood disorders. Cyclothymia is a disorder in which both depression and elevations occur,
and may be considered a less severe type of bipolar disorder, and dysthymia is a disorder
which may be considered a less severe type of major depressive disorder.
Non-psychotic disorders
The non-psychotic disorders are, in general, what Freud referred to as the “neuroses”.
This is a mixed bag of conditions. The symptoms of the psychotic disorders such as
hallucinations and delusions are largely unknown to healthy individuals. However, the
symptoms of the non-psychotic disorders are known to us all, at least to some degree.
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These include distressing anxiety, which is similar to worry and fear, which in a mild
form is familiar to everyone who has taken an exam or been out on a first date.
General anxiety disorder is characterised by continuous, unprovoked anxiety. Panic
disorder is characterized by sudden attacks of extreme anxiety during which the patient
may struggle to get enough air, feel the heart thumping as if to burst, and fear that he or
she may collapse or die. The phobic disorders (or phobias) are characterized by episodes
of anxiety which is out of proportion to the danger of a particular situation. In
agoraphobia, anxiety is triggered by the thought of leaving the home, and this may
worsen if the home is left. In specific phobias, anxiety increases at the thought of meeting
a feared, specific agent or circumstance (spiders or lifts, for example), and life may be
disrupted by the steps taken to avoid those agents or circumstances.
Obsessive-compulsive disorder is a curious condition. Obsessions are repetitive thoughts
which make no sense. Patients accept that these are their own thoughts, but they are
unable to stop them. For example, the patient may have the irrational and unwelcome
thought that his or her hands are contaminated by dirt or germs, alternatively, the patient
may be dogged by the irrational thought that he or she “killed God”. The patient is
distressed by the loss of control and by the silliness of his or her thought. Compulsions
are repetitive actions or urges in which the patient engages. Sometimes the compulsions
relate to obsessions, as when the thought is that the hands are dirty and so the hands must
be washed. But the compulsion may be that the hands must be washed 10 times, when
washing once would be enough. In other cases, compulsions may have no relationship
with obsessions, as for example when the patient feels anxious or uncomfortable until
something is performed “correctly” and that may be that when walking into a room, night
or day, the light switch must be flicked a certain number of times.
Post traumatic stress disorder (PTSD) is an anxiety disorder which follows exposure to a
traumatic event, particularly protracted traumatic events such as sustained involvement in
war, but sometimes following briefer, severe stress, such as rape.
The eating disorders are also categorised among the “other disorders” because they don’t
fit anywhere else any better. This is a puzzling group of conditions, the best known being
anorexia nervosa and bulimia nervosa. In anorexia nervosa there is purposeful weight
loss through restriction of eating, excessive exercise and sometimes purging and
vomiting. In spite of emaciation and threat to life there may be the conviction of being
fat, which cannot be dispelled by the use of scales, mirrors or photographs. In bulimia
nervosa there are episodes of binge eating and compensatory behaviour to prevent weight
gain, such as purging and vomiting.
Various other disorders may be placed under this heading, including adjustment disorders
and somatoform disorders. The adjustment disorders are states of distress which are
triggered by strong stressors such as sudden loss due to fire or betrayal. The somatoform
disorders are conditions in which there are physical symptoms, such as pain, inability to
walk, or belief that one has a disease, in the absence of organic findings.
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Personality disorders
Personality has been defined as the predictable response of the individual to other people
and the world in general. If we know people well, we know what they will like and
dislike, how far we can rely on them in tough times, whether they spend or save their
money, in short, we know their personality.
Personality disorder is present when features of the personality (characteristic ways of
responding to the environment) cause subjective distress to the individual or significant
impairment in his/her social or occupational function. Impaired social or occupational
function involves others, thus, personality disorder causes distress to the individual
and/or to those associated with the individual.
There are three groups of personality disorders, 1) an odd and eccentric group in which a
prominent feature is the absence of close relationships, 2) an anxious and fearful group in
which a prominent feature is self doubt, and 3) a dramatic, emotional and erratic group in
which prominent features are stormy relationships and sudden excessive anger.
Organic mental disorders
Organic mental disorders is another collection of different disorders which do not fit
together particularly well, and which does not easily fit in anywhere neatly. There are two
main forms, 1) where the problem lies in the brain, such as Alzheimer’s disease, and 2)
where the problem lies elsewhere in the body, such as when the tyroid gland is not
releasing enough hormone, and a depressive disorder develops. We will focus only on the
first category.
The original thinking was that the organic mental disorders had a physical (brain
abnormality) basis which could be demonstrated by some special investigation such as an
X-ray. At this early stage it was thought that other serious mental disorders such as
schizophrenia and bipolar disorder did not have a physical basis. We now know from
genetic and advanced brain scanning studies that probably all mental disorders have a
physical basis.
Thus, the organic mental disorders can be considered to be those disorders, the organic
basis of which can be easily demonstrated using current technology. In this way the
organic mental disorders category depends on the sophistication or power of current
technology. Alternatively, organic mental disorders may be considered as those mental
disorders in which the pathology is at a cellular level, that is, there is actual damage to
cells, whereas the non-organic mental disorders are those at which the pathology is at a
sub-cellular level, that is, where the problem is with the molecules or chemicals which
the cells release.
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Dementia is the best known organic mental disorder. Here, the prominent symptoms are
in cognition (memory and intelligence). There may also be hallucinations, delusions and
mood changes.
Substance Use Disorders
Substance use may or may not be included among the mental disorders, depending on the
particular expert and the arrangement of local services. Psychoactive substances such as
alcohol are taken because they induce a pleasant state of mind. Substance use disorders
may be defined in different ways, but essentially they relate to the taking of legal
substances (particularly alcohol) in excessive amounts and the taking of any illegal
substance. The terms used and their definitions change from one era to the next.
There are the immediate effects of acute intoxication (including psychosis), and long
term effects of addiction, withdrawal states and physical damage (including brain
damage).
Acute intoxication with alcohol may result in aggression or dangerous driving. Psychotic
symptoms of distorted reality, with visual hallucinations and distortion to time are the
desired effects of the “hallucinogens” such as LSD. Drug induced psychotic disorders are
not sought after, but are common with amphetamine use. They feature delusions and
voices (auditory hallucinations) and may persist for days after the drug has been ceased.
With frequent drug use, tolerance develops. This means that the body adjusts to the effect
of the substance and greater quantities are needed to produce the same effect. When this
adjustment has occurred, the body may “need” the substance to function roughly
normally, and withdrawal symptoms (sweating, trembling, body pain) may occur when
the drug is not taken. Withdrawal states, particularly with alcohol, may include
disorientation (being unaware of he time and place), inability to concentrate and
understand what is happening in the environment, and hallucinations (particularly seeing
spider, snakes and other scary creatures).
The term addiction is now less commonly used, being replaced by the terms, physical and
psychological dependence. Psychological dependence has developed when continuous
use of the substance is required for the user to feel psychologically comfortable, and lack
of the substance leads to psychological distress. Physical dependence has occurred when
a continuous use of the substance is necessary to prevent withdrawal symptoms.
Physical damage to body and brain results from the toxic effect of the substances and/or
nutritional neglect. Using alcohol as an example, the toxic effects lead to liver failure and
the nutritional neglect (vitamin B deficiency) leads to irreversible brain failure
(dementia).
In addition, substance abuse leads to mood and sexual problems, destruction of the
family, loss of employment and income, and legal problems. The police become involved
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because of violence or driving offences during the intoxication phase, or due to theft,
prostitution or drug dealing, as the user needs to raise money to support the habit.
A Backward Glance
When you are dealing with large group of butterflies, motor car parts or mental disorders,
it helps to simplify matters if you put things in boxes or categories. This is more difficult
with mental disorders than butterflies, but even with butterflies there are different
systems you could use, such as wing span, colour, habitat, length of legs or those feeler
things that stick out of their heads.
At the moment, mental disorders can only be classified using our observations of the
patients appearance and behaviour, and what they tell us they are thinking, feeling and
experiencing. In the very near future, we should be able to use sophisticated medical
diagnostic machines. The electroencephalogram (EEG) which was developed over a
century ago and measures the electrical activity of the brain, has been quite helpful in the
management of epilepsy, but it has not been useful in psychiatric practice. Coaxial
tomography (CAT) and magnetic resonance imaging (MRI) are late twentieth century
discoveries which give us beautiful pictures of the brain. They pick up abnormalities such
as blood clots and tumours. When all the images from large groups of patients with
certain psychiatric disorders are added together, changes can be statistically
demonstrated. But statistical findings obtained from large groups of subjects are of little
use in individual cases. Thus, we wait for the next generation of diagnostic technology.
However, psychiatry is about being a human being. About mood, desire, thinking,
hearing, seeing, priorities, ambition and judgement. New technology will be able to
provide more information than currently available technology, but there will always be a
place for clinical assessment.
The classification system described above is about the best we can do at the moment. The
psychotic disorders (schizophrenia and delusional disorder) are marked by “breaks with
reality” that is, symptoms such as hallucinations and delusions.
The mood disorders, feature depression and elation, as well as associated symptoms such
as sleep and appetite problems. But, occasionally psychotic symptoms are also present.
The non-psychotic disorders are also an odd mix of conditions. Anxiety is a common
theme but generalized anxiety in which there is a fairly constant level of anxiety is very
different from PTSD, in which triggers may set off the reliving of past traumatic
experiences. In obsessive-compulsive disorder anxiety may flow as a consequence of
unwanted thoughts and may be reduced by the performance of apparently nonsensical
acts. For the sake of convenience, the eating disorders and somatoform disorders (in
which physical symptoms are present, but no physical basis can be identified) have also
been placed under the non-psychotic umbrella.
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Personality disorders are diagnosed when personality features cause subjective distress to
the individual or to those associated with the individual. Central features are low levels
personal and social effectiveness due to the failure to act autonomously and take
responsibility for actions, and impaired social tolerance and compassion.
The substance use disorders may be included as mental disorders. A wide range of
substances are abused, both legal and illegal. The signs and symptoms vary with the
particular substance and the history of use; disorders range from acute intoxication
through addiction, to psychosis and on to permanent brain and other organ damage.
