Mental Illness

The concept of mental disorder like many other concepts in medicine and science, lack a consistent operational definition that covers all situation (DSM 1995). Therefore helping to guide decision regarding which condition lie on the boundary between normality and pathology, each of the mental disorders is conceptualized as a clinically significant behavior or psychological syndrome or pattern that occurs in an individual and that is associated with present distress (e.g. a painful symptom) or disability (i.e. impairment in one or more important areas of functioning) or with a significantly increased risk of suffering death, pain, disability, or an important loss of freedom. In addition this syndrome or pattern must not be merely an expectable and culturally sanctioned response to particular event, for example the death of the loved one. Whatever its original causes it must currently be considered a manifestation of behavioral, psychological or biological dysfunction in the individual. Neither deviant behavior (e.g. political, religious or sexual) nor conflicts that are primarily between the individual and society are mental disorders unless the deviance or conflict is a symptom of a dysfunction in the individual as described above.
[P XXX – XXXI Diagnostic and Statistical Manual of Mental Disorder 4th edition]
The Basic Features are:

1. Use of Clinical Judgments
DSM-IV is a classification of mental disorders that was developed for use in clinical, educational and research settings. The diagnostic categories, criteria and textual descriptions are meant to be employed by individuals with appropriate clinical training and experience in diagnosis. The specific diagnostic criteria included in DSM-IV are meant to serve guidelines to be informed by clinical judgment and are not meant to be used in a cookbook fashion. For example the exercise of clinical judgment may justify giving a certain diagnosis to an individual event though the clinical presentation fall just short of meeting the full criteria for the diagnosis as long as the symptoms that are present are persistent and severe. On the other hand lack of familiarity with DSM-IV or excessively flexible and idiosyncratic application of DSM-IV criteria or conventions substantially reduces its utility as a common language for communication.

Here the limitation of the statistical system is highlighted where the clinical thinking and the experience of treating clinician takes the final call than the classification system. This is absolutely appropriate as the tool of classification that the clinician has made this can never become bigger than the man as the man made computer intelligence can never replace the dynamic human mind
[XXXii Diagnostic and Statistical Manual of Mental Disorder 4th edition]

2. Multi-axial Evaluation:
Labeling a patient with a diagnosis is not enough. This degrades the individual to just another case and does not direct attention to the whole individual. Recently there has been an upsurge of interest in multi-axial system for achieving a more complete diagnosis. The pattern adopted by DSM-IV. In this system an individual patient is diagnosed on 5 axes.

Axis I to report all the disorders or conditions in the classification.
(Personality Disorders and Mental Retardation are not included.)
For Examples
Ø Disorders usually first diagnosed in infancy, childhood, or adolescence.
Ø Delirium, Dementia and Amnestic and other cognitive disorder.
Ø Substance related disorders.
Ø Schizophrenia and other psychotic disorders.
Ø Mood Disorders.
Ø Anxiety Disorders.
Ø Somatoform disorders.
Ø Factitious disorders.

Axis II For reporting personality disorders and mental retardation. The habitual use of particular defense mechanism can be indicated on Axis II.
For examples:
Ø Paranoid personality disorder.
Ø Schizoid personality disorder.
Ø Antisocial personality disorder.
Ø Borderline personality disorder.
Ø Histrionic personality disorder.
Ø Narcissistic personality disorder.
Ø Avoidant personality disorder.
Ø Dependent personality disorder.
Ø Mental retardation.

Axis III For reporting current general medical conditions those are potentially relevant to understanding or management of the individual’s mental disorder.
General medical conditions can be related to mental disorders in a variety of ways. In some cases it is clear that the general medical condition is directly etiological to the development or worsening of mental symptoms. When mental disorder due to a general medical condition should be diagnosed on Axis I and general medical condition should be recorded on both Axis I and Axis III. For example when hypothyroidism is a direct cause of depressive symptoms, the designation on Axis 1 is Mood Disorder due to Hypothyroidism and hypothyroidism is listed again on Axis III.
There are other situations in which general medical conditions are recorded on Axis III because of their importance to the overall understanding with mental disorder. An Axis I disorder may be psychological reaction to an Axis III general medical condition (e.g. Adjustment Disorder with depressed mood as a reaction to diagnosis of carcinoma of breast).

Axis IV This axis is used to code psychological and environmental problems that contribute significantly to the development or exacerbation of the current disorder. The evaluation of stressors is based on the clinician’s assessment of the stress that an average person with similar socio-cultural values and circumstance would experience from psychosocial stressors.
Ø Psychosocial and Environmental Problems.
Ø Problems with primary support group.
Ø Problems related to the social problems.
Ø Educational problems.
Ø Occupational problems.
Ø Housing problems.
Ø Economic problems.
Ø Problems with access to health care services.
Ø Problems related to interaction with the legal system.

Axis V For reporting Global Assessment of Functioning (GAF) current and in past one year. Consider psychological, social and occupational functioning. It is rated on scale e.g. 100 for superior functioning, 91 for no symptoms, 90 for minimal symptoms e.g. mild anxiety before exam, 80 if symptoms are present e.g. difficulty in concentrating after family argument, 10 for persistent danger of severely hurting self or others.

Non-axial Format
Clinicians who do not wish to use the multiaxial format may simply list the appropriate diagnoses. Those choosing this option should follow the general rule of recording as many coexisting mental disorders, general medical conditions and other factor as relevant to the care and treatment of individual. The principal diagnosis or the reason for visit should be listed first.
The use of Multi-axial system facilitate comprehensive and systematic evaluation with attention to various mental disorders and general medical conditions, psychosocial and environmental problems and level of functioning that might be overlooked if the focus were on assessing a single presenting problem. A Multi-axial system provide a convenient format for organizing and communicating clinical information for capturing the complexity of clinical situations and for describing the heterogeneity of individuals presenting with same diagnosis. In addition the multi-axial system promotes the application of bio-psycho-social model in clinical, educational and research setting.

The utility and credibility of the systematic recording with proper scientific analysis and synthesis, focusing of clinical presentation of the individual, as an evolving phenomenon can be helpful in arriving at a specific individual, disease and remedial diagnosis, essential for planning proper therapeutic management, evaluation of prognosis and restoration of health.