Short introduction to the history of DSM. Classification, prevalence, comorbidity, and epidemiology of the major mental disorders.

1. Definition of psychiatric disorder
History. Classification. Prevalence. Comorbidity. Epidemiology.

2. Definition
DSM criteria of abnormal behavior: “ behavior is considered as abnormal if it is
A
statistically rare, deviates from society's unwritten rules (norms), it is counter-productive
to theindividual and affectsindividual'smental well-being”

Statistically rare behavior 
Statistically rare behavior 
Statistically rare behavior

Deviates from the norm 
Deviates from the norm 
Deviates from the norm

It's counter-productive 
It's counter productive 
It's counter productive

Affects the mental well-being 
Affects the mental well-being 
Affects the mental well-being
Normal Abnormal Normal

3. Definition
DSM criteria of abnormal behavior: “ behavior is considered as abnormal if it is
A
statistically rare, deviates from society's unwritten rules (norms), it is counter-productive
to theindividual and affectsindividual'smental well-being”
Neuroscience: “ Mental disordersarea diversegroup of brain disordersthat primarily affect
emotion, higher cognition and executivefunction”
Philosopher: “There is no such thing as mental illness in any culture, and that there could
not be, because the very notion of mental illness is based on a fundamental mistake or set of
mistakes.”
Wikipedia: “ Mental disorder or mental illness are terms used to refer to a psychological or
physiological pattern that occurs in an individual and is usually associated with distress or
disability that isnot expected aspart of normal development or culture”

4. Diagnostic Systems
Diagnostic and Statistical Manual of Mental Disorders (DSM)
Publisher: American Psychiatric Association
Last Version: IV-TR
Covers only Mental Disorders
International Classification of Diseases (ICD)
Publisher: World Health Organization
Last Version: 10
Covers all medical diagnosis (chapter 5: mental disorders)

5. ICD-10
[International Statistical Classification of Diseases and Related Health Problems]
International Classification System. Coding of all kind of diseases and mental disorders.
22 Categories
Examples:

Certain infectious and parasitic diseases

Diseases of the blood and blood-forming organs and certain disorders involving the immune
mechanism

Endocrine, nutritional and metabolic diseases

Mental and behavioural disorders

Diseases of the nervous system

Diseases of the eye and adnexa

Diseases of the ear and mastoid process

6. DSM
Categorical classification system

Mood disorders

Factitious disorders
16 Main Categories: 
Impulse-control

Anxiety disorders

Disorders usually first diagnosed in infancy, disorders not
childhood, or adolescence

Somatoform disorders elsewhere classified

Delirium, dementia, and amnestic and other

Sleep Disorders 
Adjustment disorders
cognitive disorders 
Dissociative disorders

Mental disorders due to a general medical 
Sexual and gender identity
condition not elsewhere classified disorder

Substance-related disorders 
Eating disorders

Schizophrenia and other psychotic disorders 
Personality disorders
Example: Major Depressive Episode.
5 or more of these symptoms / 2 weeks:
• Depressed mood most of the day
• Markedly diminished interest or pleasure in all
• Significant weight loss when not dieting or weight gain
• Insomnia or hypersomnia nearly every day
• Psychomotor agitation or retardation nearly every day
• Fatigue or loss of energy nearly every day
• Feelings of worthlessness or excessive or inappropriate guilt nearly every day
• Diminished ability to think or concentrate, or indecisiveness, nearly every day
• Recurrent thoughts of death

7. Diagnostic Systems
DSM
Example

Multi-axial system
− Axis I: Clinical, developmental and learning disorders
− Axis II: Personality disorders and mental retardation Axis I: Major Depressive Disorder
− Axis III: Medical conditions and physical disorders. Axis II: None
− Axis IV: Psychosocial and environmental factors Axis III: Cancer
contributing to the disorder
Axis IV: His mother died 2 weeks
− Axis V: Global Assessment of Functioning (on a scale ago
from 100 to 0)
Axis V: 80%

8. The Timeline...
DSM-V is expected.
Ideally it will include
International International Statistical experimental criterion
Classification of Classification of sets aiming at
Causes of Death Diseases, Injuries and incorporating new
adopted in Paris. Causes of Death (v.6). DSM-II. No DSM-IV. genetic and
Little mention of Contains a whole major Conservative neurobiological
Mental Disorders section for mental differences to Revision of findings
disorders. the DSM-I DSM-III
1893 1918 1948 1952 1968 1980 1994 2000 2011
Statistical Manual
First DSM. Focused
for the use of DSM-III. Use
on diagnosis. Brief DSM-IV-TR.
Institutions for the of field-tested
descriptions of each Text is
Insane. 22 criteria to
disorder. Influenced revised, but
categories, mainly achieve
from psychoanalytic the diagnostic
referred to the reliability. No
thinking criteria are
somatic causes of theories of
not
behavioral disorders aetiology

9. Criticism of DSM
Use of categories

DSM uses categories, but drugs do not respect the boundaries of the disorders.

Many disorders are better conceptualized as dimensional traits.
Normal Abnormal/ Mental Disorder

Different levels of symptoms. More or less severe cases.

“Not Otherwise Specified”category is used very often!
Co-morbidity
Alarge fraction of patients qualifies for multiple diagnoses.
Possible explanations:
Shared genetic risk factors
Errors in splitting symptoms between different disorders

10. Mental Disorders and Neuroscience
Need for integration of Neuroscience into DSM-V

Arbitrary boundaries between mental and neurological disorders.

Overlapping practice patterns between neurology and psychiatry.

Use of neurological techniques in order to treat mental disorders (e.g. deep brain
stimulation)

Both treat higher brain functions (e.g. autism, Alzheimer's disease, ADHD)

Biological basis of many mental disorders (e.g. schizophrenia, bipolar disorder)

Need to build a new dimensional diagnostic system.

Ultimate goal: a diagnostic classification system for mental disorders based not only on
symptomatology but also on aetiology and pathophysiology of the disorders.

11. How can Neuroscience help?
Neurogenetics

Significant influence of genes (twin
studies/ adoption studies etc)
Many studies tried to identify the role of genetic
factors in development of disorders.

Interaction between multiple genetic factors that
cause a common symptom in different mental
disorders (e.g. gene catechol-O-methyltransferase
=> metabolism of neurotransmitters like
dopamine=> schizophrenia-like symptoms)

Newtechnologies will provide complete
information about the exact genetic factors

12. How can Neuroscience help?
Neuroimaging

Anatomical abnormalities
(e.g. less gray matter in schizophrenics)
Future diagnostic classifications

Contribution to experimental therapies
a. Localization of abnormal activations
b. Direct therapy in these brain regions
(e.g. Experimental treatment of depression
with stimulation of cingulate cortex)

13. How can Neuroscience help?
Example: Phenylketonuria [1 in 15,000 births]
autosomal recessive genetic disorder →deficiency in the PAH enzyme
Discovery of phenylketones in urine of some mentally retarded individuals

Anatomical differences (brain size ~80%of normal)

1950: More specific reports

White matter abnormalities (spongy change)

Pallor of myelin staining

Demyelination

Demyalination is caused after the birth

More accurate detection of PKU

Dietary Therapy (lowin phenylalanine)

Today: Animal Models

14. Prevalence of Mental Disorders in Europe
Prevalence rates of mental disorders in 6 E.U. Countries: Belgium, France, Germany, Italy, the
Netherlands and Spain
Lifetime Prevalence
Total Males Females
Any Mental Disorder 25,00% 21.8% 28.1%
Any Mood Disorder 14,00% 9.5% 18.2%
Any Anxiety Disorder 13.6% 9.5% 17.5%
Any Alcohol Disorder 5.2% 9.3% 1.4%
Total Males Females
Major Depression 12.8% 8.9% 16.5%
Dysthymia 4.1% 2.6% 5.6%
GAD 2.8% 2.0% 3.6%
Social Phobia 2.4% 1.9% 2.9%
Specific Phobia 7.7% 4.9% 10.3%
PTSD 1.9% 0.9% 2.9%
Agoraphobia 0.9% 0.6% 1.1%
Panic Disorder 2.1% 1.6% 2.5%
Alcohol Abuse 4.1% 7.4% 1.0%
Alcohol Dependence 1.1% 1.8% 0.4%
ESEMeD/MHEDEA 2000 Investigators

15. Prevalence of Mental Disorders in Europe
Prevalence rates of mental disorders in 6 E.U. Countries: Belgium, France, Germany, Italy, the
Netherlands and Spain
12-month Prevalence
Declining rates with age
Age Group
18-24 13.7%
25-34 11.2%
35-49 9.6%
50-64 9.8%
>65 5.8%
Higher rates for unmarried/ divorced
Marital Status
Married 8.7%
Previously married 10.9%
Never married 11.8%
ESEMeD/MHEDEA 2000 Investigators

16. Prevalence of Mental Disorders in Europe
Prevalence rates of mental disorders in 6 E.U. Countries: Belgium, France, Germany, Italy, the
Netherlands and Spain
12-month Prevalence
Higher rates for higher education levels
Education Any Mental Disorder Any Alcohol Disorder
0-4 Years 8.9% 0.2%
5-8 Years 7.0% 0.5%
9-12 Years 9.1% 0.9%
>13 Years 9.0% 1.2%
Higher rates in urban areas
Urbanicity
Rural 8.6%
Mid-size urban 9.9%
Large Urban 10.5%
ESEMeD/MHEDEA 2000 Investigators

17. Prevalence of major psychiatric disorders
Example: Depression

Depression ranks 5th across women and 7th across men
as a cause of morbidity (World Bank, 1993)

WHO: in 2020 depression will be the second most
important cause of disability.

The cultural background is likely to determine whether
depression will be experienced and expressed in
psychological and emotional terms or in physical terms.
Bhugra & Mastrogianni, 2004

18. Prevalence of major psychiatric disorders
Example: Depression

WHO, 1996: 10.4%received a “current depressive episode”
diagnosis

Co-morbidity: Depression, Anxiety, Alcohol Misuse or
Dependence, Panic Disorder, Obsessive-Compulsive Disorder

Differences in prevalence across cultures/ countries
i. Different levels of awareness and recognition
ii. Popular perceptions about the role of doctor in each country
iii. Different pathways to health system (i.e. medical care must be
paid in Nigeria)
iv. Social stigma
v. Methodological Issues (lack of appropriate instruments)
Bhugra & Mastrogianni, 2004

19. Prevalence of major psychiatric disorders
Example: Depression – Ethnic Minorities

USA

No differences between African Americans and
White Americans (when demographic, sociocultural
and socio-economic factors are controlled)

Puerto Ricans: higher depression rates

Asian Americans: lower prevalence of depression

UK

In general, higher prevalence rates of depression on
minority groups

African-Caribbean women: higher prevalence of
depression

Punjabis: more depressive ideas
Bhugra & Mastrogianni, 2004

20. Prevalence of major psychiatric disorders
Example: Depression – Diagnosis

Depression is under-recognized throughout the world. Primary care physicians detect only 50%of the
cases

UK

Asians: visit their practitioner more frequently, but is less likely to have their psychological difficulties
identified (complaints about somatic symptoms)

Indian women: 17%recognition

USA

Physicians are less likely to detect depression among African American and Hispanic patients

Australia

Asians: lower rate of diagnosis (similar rate of self-reported symptoms)

21. Prevalence of major psychiatric disorders
Example: Depression – Diagnosis

22. Summary
Two main categorical systems:

DSM (mental disorders)

ICD (diseases and mental disorders)
Need for integration of Neuroscience in the
future versions of these categorical systems

Diagnosis

Treatment

Future Studying
Prevalence & Epidemiology

450 million people suffer from mental disorders

Most common: mood disorders

More women than men

Development during youth

Urban Areas > Rural Areas

Different rates around the world

Social factors (culture, language, minorities etc)