tag:theconversation.com,2011:/id/topics/icd-5630/articlesICD – The Conversation2019-11-27T11:01:09Ztag:theconversation.com,2011:article/1266422019-11-27T11:01:09Z2019-11-27T11:01:09ZWhy ageing should be classified as a disease<figure><img src="https://images.theconversation.com/files/302650/original/file-20191120-515-1k6wdii.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/nephew-touching-grandfathers-hand-sunlight-267900116">Brilliant Eye/Shutterstock</a></span></figcaption></figure><p>Since the time of the ancient Greeks, doctors and philosophers have argued whether ageing is a disease or a natural process. Many authors of the <a href="http://exhibits.hsl.virginia.edu/antiqua/humoral/">Hippocratic Corpus</a> argued that growing old invariably leads to frailty, disability and death, hence they saw ageing as a progressive and incurable disease. But the Roman physician Galen argued that while diseases are abnormal, ageing is universal, so ageing is a natural process rather than a disease. This dichotomy persists to this day and frames our conceptions of the problems of ageing and our proposed solutions. </p>
<p>Unlike Galen and Hippocrates, modern scientists understand how <a href="https://www.cell.com/abstract/S0092-8674(13)00645-4">some of the biological mechanisms that cause ageing work</a>. One of these, <a href="https://www.cell.com/cell/pdf/S0092-8674(19)31121-3.pdf">cellular senescence</a>, sheds important light on the ancient dichotomy. </p>
<p>When cells enter senescence (become old), they release a range of <a href="https://journals.plos.org/plosbiology/article?id=10.1371/journal.pbio.0060301">inflammatory factors and enzymes</a> that break down the tissue in which they reside. This lets immune cells reach the senescent cells and kill them. But if this process fails, senescent cells accumulate, changing the tissues in which they reside, causing many of the degenerative changes we perceive as ageing and age-related disease.</p>
<p>Cellular senescence is common across the tissues of the body and happens throughout life. When <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6115505/">senescent cells build up in the skin</a> causing wrinkles it is considered a “natural change”. Yet when <a href="https://www.sciencedirect.com/science/article/pii/S0531556510002238">senescent cells build up in the heart and blood vessels</a>, causing blood vessels to calcify, we call it “cardiovascular disease”. This is an error of logic and categorisation and not due to the intrinsic nature or complexity of pathology or disease.</p>
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<img alt="" src="https://images.theconversation.com/files/302663/original/file-20191120-515-15n7lgy.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/302663/original/file-20191120-515-15n7lgy.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=399&fit=crop&dpr=1 600w, https://images.theconversation.com/files/302663/original/file-20191120-515-15n7lgy.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=399&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/302663/original/file-20191120-515-15n7lgy.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=399&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/302663/original/file-20191120-515-15n7lgy.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=502&fit=crop&dpr=1 754w, https://images.theconversation.com/files/302663/original/file-20191120-515-15n7lgy.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=502&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/302663/original/file-20191120-515-15n7lgy.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=502&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Why are wrinkles considered natural?</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/very-nice-emotional-portrait-elderly-man-76859833">Laurin Rinder/Shutterstock</a></span>
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<h2>Haphazard coding</h2>
<p>Categories matter. So an international group of researchers we led and whose conclusions we support <a href="https://science.sciencemag.org/content/366/6465/576">suggested changes</a> to the <a href="https://www.who.int/classifications/icd/en/">World Health Organization’s International Classification of Disease (ICD)</a>. The ICD classification system began in the 19th century and is regularly updated. It provides the codes used to classify and report medical diagnoses and procedures. And it is central to understanding the causes of illness and death around the world.</p>
<p>The classification system is rooted in defining and grouping pathologies and diseases that, because of the “natural process” versus “disease” dichotomy, means that ageing changes are coded haphazardly – they are incomplete and inaccurate, and they overlap. </p>
<p>These new proposals intend to ensure the ICD has a complete list of pathologies and disorders related to ageing, and to make sure that the full spectrum and extent of degenerative changes are accounted for. This would mean that all ageing-related pathologies are included in disease or disorder classifications. This doesn’t currently take place. For example, a <a href="https://www.jamda.com/article/S1525-8610(16)30181-5/fulltext">code exists for age-related muscle wasting (sarcopenia)</a>, but there are no comprehensive codes covering the age-related wearing out of other organs.</p>
<p>As a result, an ageing “disease” classified and assessed for the level of severity in one organ can be unclassified in another. With a lack of classifications and staging, pathological ageing changes may not be logged. This means that treatment needs may be overlooked, such as atrophy, calcification and ageing in organs and tissues where these are not classified or assessed for severity. </p>
<p>Current treatments, including diet and exercise, could be effectively applied. And <a href="https://bmcmolcellbiol.biomedcentral.com/articles/10.1186/s12860-017-0147-7">there are</a> <a href="https://www.ncbi.nlm.nih.gov/pubmed/29997249">several</a> <a href="https://science.sciencemag.org/content/364/6441/636">drugs</a>, old and new, that could be used to prevent or reverse ageing. But, under the current ICD, opportunities to treat these problems might be missed. </p>
<p>This is a matter of particular concern at a time when the first drugs designed to target major mechanisms of ageing are entering <a href="https://clinicaltrials.gov/ct2/show/NCT04063124">clinical trials</a>. To deal with this, the group has proposed <a href="https://science.sciencemag.org/content/366/6465/576">classifications for ageing changes to cover all tissues, organs and glands</a> at the relevant level of detail. </p>
<p>A complete staging system similar to those used for tumours has also been proposed. The objective is to ensure that all pathology in ageing patients is recognised, recorded and treated, where possible. </p>
<p>The ICD is regularly updated and expanded to reflect progress in scientific and medical understanding, and the next edition is due to be published on January 1 2022. Given the importance of ageing in good health, we hope that the World Health Organization will accept the proposals and begin to classify the problems of ageing with a completeness that matches the scale of the problem.</p><img src="https://counter.theconversation.com/content/126642/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Richard Faragher serves on the Board of Directors of the American Federation for Aging Research and the Biogerontology Foundation. He is a member of the Scientific Advisory Board of the World Vision Fund.</span></em></p><p class="fine-print"><em><span>Stuart Calimport owns shares in GlaxoSmithKline plc and Syncona Limited.</span></em></p>Ageing is a disease and one that will increasingly be treatable.Richard Faragher, Professor of Biogerontology, University of BrightonStuart Calimport, Honorary Fellow, University of Liverpool, Imperial College LondonLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/631822016-07-29T02:18:02Z2016-07-29T02:18:02ZBeing transgender is not a mental illness, and the WHO should acknowledge this<figure><img src="https://images.theconversation.com/files/132434/original/image-20160729-12082-xdth3v.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The pathology lies in society discriminating against transgender people, not in transgender people themselves.</span> <span class="attribution"><a class="source" href="https://www.flickr.com/photos/taedc/17793410742/in/photolist-t7kT6Q-8pjv3k-cVJ9uj-saxCDw-f1y96p-cVJ9JG-9WPhBL-f1y9be-fndYDz-9Svn7g-cVJdh3-9SygtC-fndTux-9SyeCC-9SvogM-f1Nqh1-6S4uQR-9Svm5V-9Syi9C-f1Nqks-uDc4So-f3Gben-fntaYW-9WP8ZU-8pnAG9-9WLRpP-9WPFf5-cVJ9eC-fntcpG-f1y97x-vpHikj-cVJdLw-pvyekw-dWdb3z-f1y9ok-fndTh4-f1NqwW-oQfyYM-8hTY61-9Svrjc-dWizSU-f1Nqw9-fnt5YS-dWddUR-8nzner-9SvoWK-pvyf1u-avnGE5-8hTY6N-a2CRz6">Ted Eytan/Flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span></figcaption></figure><p>The World Health Organisation (WHO) has announced it may <a href="http://www.nytimes.com/2016/07/27/health/who-transgender-medical-disorder.html?_r=0">no longer classify</a> being transgender as a disorder in the revised version of its International Classification of Diseases (ICD), due for release in 2018. </p>
<p>The ICD is a diagnostic tool used across much of the world to diagnose health issues, including mental illness.</p>
<p>A study published this week in the <a href="http://www.thelancet.com/journals/lanpsy/article/PIIS2215-0366(16)30165-1/fulltext">Lancet medical journal</a> has lent support to this move. Echoing previous research, the study found poor mental health among transgender people is primarily the product of social stigma and violence. This counters the view that being transgender is itself pathological. </p>
<h2>History of diagnostic criteria</h2>
<p>Historically, it has been assumed that the sex we are assigned at birth determines our gender. Primarily on the basis of visual inspection of genitalia, people are considered male if they have a penis and female if they have a vagina. Respectively, people are expected to experience themselves as such. </p>
<p>For transgender people, these assumptive classifications are incorrect. Yet the belief that sex determines gender has remained, despite evidence to the contrary. </p>
<p>This is evident in the treatment of transgender people as disordered, as in the case of the ICD. This designation is a product of social values and norms, not of any evidence that transgender people are inherently disordered.</p>
<p>Calls to remove being transgender from the ICD reflect growing recognition of the rights of transgender people. In 2013, this was recognised in changes to the <a href="http://www.apa.org/monitor/2013/04/transgender.aspx">American Psychiatric Association’s fifth edition</a> of the Diagnostic and Statistical Manual (DSM). </p>
<p>The previous edition of the DSM included the diagnosis of gender identity disorder, which treated being transgender as a disorder. The DSM5 classifies being transgender under the diagnosis of gender dysphoria. The ICD’s proposed revised terms include gender incongruence or gender discordance. </p>
<p>Those involved in introducing new terminology to the DSM suggested the focus on dysphoria reflects the impact of social norms on transgender people, rather than being indicative of a disorder. As such, <a href="http://www.huffingtonpost.com/2013/06/04/gender-dysphoria-dsm-5_n_3385287.html">the diagnosis is limited</a> to the time in which the person is experiencing distress about their gender. </p>
<h2>Arguments for and against</h2>
<p>The DSM5 (and likely the ICD) retain mention of transgender people due to the apparent <a href="http://www.huffingtonpost.com/chase-strangio/gender-identity-disorder-dsm_b_2247081.html">necessity of a diagnosis</a> when accessing services covered by medical insurance or public health funds. Insurers, it is suggested, are unlikely to pay if there is not a diagnosed issue requiring treatment. </p>
<p>But the Standards of Care of the <a href="http://www.wpath.org/site_page.cfm?pk_association_webpage_menu=1351&pk_association_webpage=4655">World Professional Association for Transgender Health</a> recognise that some transgender people do not experience significant distress and should not need to do so in order to access services. </p>
<p>Transgender people have <a href="http://www.stp2012.info/old/en/news">long opposed diagnoses</a> being applied to their lives, even if to warrant access to services. Many have argued these pathologise transgender people’s lives, allow for gatekeeping of access to services and place unnecessary barriers to accessing them. </p>
<p>In terms of pathologisation, <a href="http://juliaserano.blogspot.com.au/2015/07/the-real-autogynephilia-deniers.html#more">it has been argued that</a> retaining diagnostic categories, even if not framed in terms of a disorder, may be used negatively by those opposing rights of transgender people. </p>
<p>In terms of gatekeeping, focusing on a particular description of what counts as transgender may encourage some to present a scripted account of their experiences in order to justify support. This could mean <a href="http://www.damienriggs.com/blog/wp-content/uploads/2013/09/Trans-Men-Disability.pdf">actual mental health issues</a> requiring attention are overlooked or minimised.</p>
<p>And in terms of barriers, services for transgender people are relatively limited in most countries – certainly so in Australia. Requiring a diagnosis means that before accessing specialist services such as endocrinologists or surgeons, transgender people must first attend appointments with mental health professionals. </p>
<p>Given the demand for mental health professionals, wait times can be long. <a href="http://tvo.org/article/current-affairs/shared-values/why-surgery-wait-times-put-transgender-people-at-risk-of-suicide">Research suggests</a> that people can be particularly vulnerable during the period between first disclosure of being transgender and accessing services. Long wait times extend this unnecessarily. </p>
<h2>Alternative approaches</h2>
<p>Some transgender people may certainly experience mental health concerns, as may any person. GP referral to a mental health professional currently provides a clear pathway to services. </p>
<p>Transgender people who do not require support for mental health, but who wish to access support for hormones or surgery, could be referred directly to specialists rather than via a mental health professional assessment. </p>
<p>This would require upskilling GPs so they are able to provide appropriate referral and initial support. Some transgender people may of course wish to access support from a mental health professional, but this would be at their discretion, not as a requirement for a diagnosis. </p>
<p>As when a person is pregnant, the pregnancy is not a diagnosis but a confirmation of fact, and services are provided accordingly. While the ICD <a href="http://www.icd10data.com/ICD10CM/Codes/Z00-Z99/Z30-Z39/Z34-">includes a code for professionals</a> who supervise a pregnancy, this is not <em>per se</em> a diagnosis. </p>
<p>A person who has received no care throughout their pregnancy can still walk into a hospital when in labour and receive services covered by health insurers or public funds. </p>
<p>Similarly, and as an <a href="http://www.icath.org">informed consent model</a> would advocate, transgender people are well versed in the facts of their lives and should be able to present for specialist services with a GP referral. </p>
<p>This would not prohibit transgender people also accessing mental health services. Treating mental health assessment (when needed) as separate from referrals for specialist services would help reduce gatekeeping and wait times. </p>
<p>Changes to the ICD, like the DSM, would be welcomed, as is research that continues to demonstrate the impact of social stigma. However, transgender people have long made these points, and we must acknowledge their rights to self-determination and timely access to services.</p><img src="https://counter.theconversation.com/content/63182/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Damien Riggs receives funding from the Australian Research Council. </span></em></p>Poor mental health in transgender people is primarily the product of social stigma and violence. This counters the view that being transgender is itself pathological.Damien Riggs, Associate Professor in Social Work, Australian Research Council Future Fellow, Flinders UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/145662014-01-02T19:44:55Z2014-01-02T19:44:55ZFeeling down: when does a mood become a disorder?<figure><img src="https://images.theconversation.com/files/37746/original/22nf5sb3-1386913892.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Clinical depression is distinguished severity, duration, persistence, and recurrence. </span> <span class="attribution"><span class="source">darcyadelaide/flickr</span></span></figcaption></figure><p>We’ve all felt sad, anxious or down at one time or another, but where does the normal experience of emotion end and the clinical picture of a mood or anxiety disorder begin?</p>
<p>Psychiatry has two widely used classificatory systems that provide definitions of “clinical” states of such emotions as differentiated from “normal” states – the World Health Organisation’s <a href="https://theconversation.com/two-visions-for-understanding-illness-dsm-and-the-international-classification-of-diseases-14167">International Classification of Diseases</a> and the American Psychiatric Association’s <a href="https://theconversation.com/explainer-what-is-the-dsm-14127">Diagnostic and Statistical Manual</a> (DSM). </p>
<p>The boundaries are not absolute and, in recent decades, the DSM in particular has been criticised for expanding the boundary of clinical states into essentially normal domains.</p>
<h2>Degrees of depression</h2>
<p>Clinical depression is distinguished in such diagnostic manuals by a number of parameters including severity, duration, persistence, and recurrence. </p>
<p>More severe depressive disorders are accompanied by the individual experiencing gravid depressive symptoms (such as suicidal preoccupations), by distinct impairment (such that it prevents them from going to work) and lasting more than two weeks.</p>
<p>Although severity is an important thing to consider in depression, we prefer to distinguish by depression type, not just severity. Depressive disorders can be divided into two types – melancholic and non-melancholic conditions. </p>
<p>The latter is a diverse group that could reflect the contribution of severe life events, such as being humiliated by a partner or a personality style that predisposes someone to depression. </p>
<p>Such personality styles include being an anxious worrier, sensitive to judgement by others, being a perfectionist, having intrinsically low self-esteem, being profoundly shy or having a low sense of self-worth since childhood. </p>
<p>In contrast, melancholic depression is better positioned as a disease, having rather specific clinical features, a strong genetic contribution, biological underpinnings and responding only partially to counselling or psychotherapy but well to antidepressant drugs. </p>
<p>During melancholic depressive states, the individual lacks energy, experiences little pleasure in life, is physically slowed down, and tends to feel much worse in the morning. </p>
<p>Extremely severe melancholic depression may even include psychosis, though importantly this is normally very responsive to appropriate medical treatment.</p>
<h2>Bipolar disorders</h2>
<p>The bipolar disorders are also better positioned as “diseases”. We now distinguish bipolar I (previously manic depressive illness) and bipolar II conditions – by the extremity of the highs. </p>
<p>While both bipolar I and bipolar II are characterised by swings from high to low moods, in bipolar I the highs (mania) are more extreme and can include psychosis or hospitalisation. </p>
<p>Highs (hypomania) in bipolar II are less extreme and will never include psychosis or a need for hospitalisation. While it’s normal for everyone to experience periods of happiness in their life, the highs experienced in bipolar are distinctly different. </p>
<p>The individual loses day-to-day anxieties, feels bulletproof or invulnerable, is excessively talkative, grandiose, creative, needs little sleep without feeling tired, is indiscreet, spends money on things that subsequently cause financial difficulty and may become sexually indiscreet or possibly aggressive.</p>
<h2>Anxiety disorders</h2>
<p>It’s normal for everyone to feel anxious in a variety of situations. Some people might feel anxious going to a party where they don’t know many people, for instance, or giving a speech. </p>
<p>The difference between normal anxiety and an anxiety disorder is when the anxiety is so persistent it stops you doing things you want to, or persists even when all logical reasons to be anxious are absent. </p>
<p>Generalised anxiety disorder, for instance, involves chronic worry without a definitive cause and social phobia involves a fear of talking to or being around others. </p>
<p>There are many different anxiety disorders, and it can be difficult to distinguish when normal anxiety starts to become a problem.</p>
<h2>Awareness and increase</h2>
<p>There are two possible reasons why there has been an increase in these conditions.</p>
<p>First, more people are willing to talk about their experiences, as the stigma of these conditions is slowly decreasing. And changes to criteria in diagnostic manuals have effectively classified some “normal” states as clinical conditions.</p>
<p>But being diagnosed with a mood or anxiety disorder can be a stressful experience itself. The reaction generally depends on how well the person relates to the diagnosis, whether or not the diagnosis was something anticipated and whether or not they expect a diagnosis and adequate treatment will improve their life. </p>
<p>The vast majority of conditions can be treated either psychiatrically or psychologically, but finding the right treatment, while ultimately rewarding, can also at times be frustrating.</p>
<p>It’s our opinion that Australia is ahead of many other western countries in having destigmatised mood disorders, and the stigma and negative consequences linked to seeking help has reduced considerably.</p>
<p>Unfortunately, this doesn’t mean that stigma is completely eradicated. Some employers may take advantage of knowing that an individual has a psychiatric condition. And the declaration of any condition can prevent people obtaining income protection, and even travel insurance.</p>
<p>But that shouldn’t stop people from seeking help when they feel their emotional health is at risk.</p><img src="https://counter.theconversation.com/content/14566/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Gordon Parker receives funding from the National Health and Medical Research Council and Department of Health and Ageing.</span></em></p><p class="fine-print"><em><span>Amelia Paterson does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>We’ve all felt sad, anxious or down at one time or another, but where does the normal experience of emotion end and the clinical picture of a mood or anxiety disorder begin? Psychiatry has two widely used…Gordon Parker, Scientia Professor , UNSW SydneyAmelia Paterson, Research Assistant, UNSW SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/141672013-05-22T20:42:29Z2013-05-22T20:42:29ZTwo visions for understanding illness: DSM and the International Classification of Diseases<figure><img src="https://images.theconversation.com/files/24244/original/n4ybcmmh-1369189681.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The DSM-5 is not the only system of classification of mental illness.</span> <span class="attribution"><span class="source">Image from shutterstock.com</span></span></figcaption></figure><p>The new Diagnostic and Statistical Manual (DSM-5) is the latest instalment in the long-running saga over the classification, nature and dimensions of mental illness. But it’s not the only system of classification of mental illness. </p>
<p>Since 1948, the World Health Organization has produced a section on mental diagnoses in its International Classification of Diseases (ICD). To understand why the DSM is such a controversial document, we need a sense of its historical relationship to the ICD.</p>
<h2>Initial harmony</h2>
<p>Between 1948 and 1965, the World Health Organisation produced three editions of the International Classification of Diseases. The release of ICD-6 in 1948 prompted the American Psychiatric Association (APA) to produce DSM-I in 1952. The American Psychiatric Association had lofty ambitions for its new manual.</p>
<p>Following the Second World War, the American Psychiatric Association was taken over by a group of young practitioners influenced by the Freudian model, with its emphasis upon neurotic illnesses. They met with some resistance from older psychiatrists, but their promise to extend psychiatry’s reach out of the mental hospitals and into society at large guaranteed them a 20-year dominance of the organisation. </p>
<p>Using ICD-6 as the foundation, they built their own classification system that served the interests of their profession. Between the ICD-6 and ICD-8, the World Health Organization’s classification was more or less harmonised with the DSM. And ICD-8 (1965) was very close to DSM-II (1968) in organisation, categories and description.</p>
<h2>DSM’s misstep</h2>
<p>To its detriment, however, DSM-II included homosexuality as a psychiatric condition. The gay liberation movement had emerged alongside the wider civil rights and women’s liberation movements, and forcefully challenged the APA’s pathologisation of homosexuality.</p>
<p>Following protests in the early 1970s, US psychiatrist and chair of DSM-III’s task force Robert Spitzer was given the task of defusing the situation. He redefined mental illness to exclude homosexuality from the DSM, replacing it with “sexual orientation disturbance”, which was supposedly experienced by those uncomfortable with their sexuality.</p>
<p>Although this was retrospectively celebrated as a milestone of psychiatric progressiveness, at the time many argued this decision was unscientific. How could something that had long been regarded as a disease be removed from a classificatory system as a result of political pressure?</p>
<h2>Change of direction</h2>
<p>Other criticisms were levelled against the APA on the back of this move. Insurance companies insisted they would only pay to treat “real” diseases, while an anti-psychiatry movement had become almost mainstream in many US universities. Something had to be done.</p>
<p>Spitzer was a long-term critic of post-war Freudian psychiatry and, along with a few like-minded colleagues, was deeply influenced by Emil Kraepelin, who had developed a method of descriptive psychiatry in the late 1890s. </p>
<p>Kraepelin’s system had no underlying theory of causation. Instead, he focused a detailed picture of the symptoms experienced by each of his patients. Collating these, he identified the twin-pillars of the psychoses: dementia praecox (later renamed schizophrenia) and manic depression (rebranded as bipolar).</p>
<p>Kraepelin’s method was not to many people’s liking in the early 1970s. But for Spitzer and his allies, it was a means to the end of transforming psychiatry. The psychobabble of the Freudian couch would be replaced by Kraepelin-style lists of symptoms that had to be observed before a categorical diagnosis could be made.</p>
<h2>A transformation</h2>
<p>The neo-Kraepelinians transformed the DSM to fit this model. DSM-III (1980) was, therefore, a radical departure from previous incarnations of the DSM and the ICD. The WHO responded by incorporating DSM-III’s innovations into ICD-10.</p>
<p>Nevertheless, there were significant differences between the two classifications. Nomenclature, diagnostic criteria and categories did not map one-to-one. What’s more, the DSM remained culture-bound and unable to cope with the complexities of gender and ethnicity in a multicultural world. </p>
<p>Harmonisation between the ICD and the DSM has remained an expressed goal of both the APA and the WHO. Currently, the APA is trumpeting the fact that ICD-11 will be very close to DSM-5. Whether this happens remains to be seen. And whether it is desirable is questionable.</p>
<h2>Divergent aims</h2>
<p>The DSM and the ICD serve similar but distinct purposes. While both can broadly be described as classifications that aid the collection and analysis of morbidity data, there has always been considerable scope to the ambitions of the DSM.</p>
<p>The ICD can be used for research while providing a tool for understanding patterns of mental illnesses. It may even contribute to diagnosis. But the DSM clearly wants to shape the wider practice of psychiatry.</p>
<p>There is no ICD equivalent of the DSM casebook, which shows how the DSM can be used in diagnosis and treatment. Neither is the ICD implicated in the jostling between pharmaceutical companies, the health insurance industry and the psychiatry profession, as each haggles with the other over the existence or the extension of particular illness categories. </p>
<p>Nor is the ICD a cash-cow for the WHO, unlike the DSM, which is a highly profitable enterprise. Indeed, the DSM is most certainly <em>not</em> disinterested.</p>
<h2>International impact</h2>
<p>For the majority of psychiatric practitioners outside of the United States, the DSM is one tool among many. Outside the US, it doesn’t possess the same power or authority. In Australia, for example, psychiatrists might be trained using the diagnostic criteria of the DSM to help them pass their exams, but in general they rely on clinical literature that is more detailed and, above all, relevant to their day-to-day practice. </p>
<p>Equally, the diagnoses of most clinicians, in the US and elsewhere, is coded using the ICD classification, which remains the principal means of statistically detailing the incidence of categories of mental illnesses.</p>
<p>The DSM-5 will probably be the most controversial book of 2013, provoking discussions about the reality, or otherwise, of particular diagnoses. But we shouldn’t get carried away with its influence over psychiatry worldwide. Outside of the US, psychiatrists are more concerned, on the one hand, with the wider clinical literature, and, on the other, using the ICD as a superior cross-cultural classification.</p><img src="https://counter.theconversation.com/content/14167/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>James Bradley does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>The new Diagnostic and Statistical Manual (DSM-5) is the latest instalment in the long-running saga over the classification, nature and dimensions of mental illness. But it’s not the only system of classification…James Bradley, Lecturer in History of Medicine/Life Science, The University of MelbourneLicensed as Creative Commons – attribution, no derivatives.