Multi-axial Classification of Child and Adolescent Psychiatric Disorders

Multi-axial Classification of Child and Adolescent Psychiatric Disorders: The ICD-10 Classification of Mental and Behavioral Disorders in Children and Adolescents

World Health Organization

New York: Cambridge University Press; 1996. 302 pp with index

ISBN 0-521-58133-8 (cloth)

For many decades, psychiatric epidemiology involving comparisons among countries has been handicapped by different classification systems. North Americans tend to use the Diagnostic and Statistical Manual of Mental Disorders, 4th edition, (DSM-IV) criteria, developed primarily by committees of the American Psychiatric Association, whereas western European countries use the International Classification of Diseases system, now in its 10th revision (ICD-10). This book is the ICD-10 equivalent of the big green DSM-IV manual that lists the multi-axial classification of psychiatric disorders, together with the brief description of signs and symptoms that make up the essence of the diagnoses.

The introduction, by the eminent child psychiatrist Michael Rutter, is first-rate. It indicates that there has been serious corroboration with DSM-IV. The similarities, including the use of a multi-axial description of each diagnosis and brief descriptions of signs and symptoms, are much more evident than any differences. As with DSM-IV, the diagnoses are based on clinical description and not on etiology, since precise causation in psychiatric disorders cannot be determined in most diagnostic categories.

As is often the case with British medical textbooks, the language is more succinct and the book is shorter than its North American counterpart.

A compare-and-contrast exercise does reveal some interesting, although relative minor, differences. Autism or pervasive development disorder and mental retardation are placed on axis II, instead of on axis I, in the ICD-10 system.

Under conduct disorders, always a problematic diagnostic category, there is an intriguing and possibly useful category called “conduct disorder confined to the family context.” In the section on affective disorders, the ICD-10 system does not include rapid cycling bipolar disorder.

The ICD-10 system has maintained a category of neurotic disorders, which are virtually identical to the personality disorders in DSM-IV. Among the neurotic disorders described by ICD-10 is “neurasthenia.” This concept, which feels outdated from a North American perspective, is related in a fairly modern way to postviral fatigue states and depression. “Neurasthenia” appears to have resurfaced in North America as chronic fatigue syndrome.

The section in ICD-10 on personality disorders suggests that these disorders can be diagnosed as early as 16 years of age, in contrast to the North American view that personality disorders begin only at age 18. The North American approach takes into account the flexibility of adolescent minds, which we hope will not settle into permanent personality structures prematurely. The use of the term “anankastic” for obsessive-compulsive disorders is another example of the way that traditional psychiatric phenomenology is maintained in the ICD-10.

Another example of a difference in terminology, which is illustrative of British brevity, is “clumsy child syndrome,” which is the same as “developmental coordination disorder,” described in DSM-IV.

In contrast with DSM-IV, ICD-10 does not set up lists of symptoms with the instruction that 3 or more must be present. There is usually a description of the general presentation of the problem. Instead of counting up symptoms, the clinician then forms personal impressions and makes his or her own judgements.

Axis V in ICD-10 refers to associated abnormal psychosocial situations. This is virtually the same as axis IV in DSM-IV, which refers to psychosocial and environmental problems. I found, however, that the ICD-10 axis V was more specific and clearer in describing the precise problems that children and families have. For instance, there is a specific category for lack of warmth in parent-child relationships, for scapegoating of a child, for disability in a sibling, for experiential privation and even for parental overprotection. Such clear categories allow family dysfunction to be introduced diagnostically in a clearer way.

The ICD-10 text on multi-axial classification of child and adolescent psychiatric disorders is a parallel but not identical effort to the DSM-IV currently in use in North America. Each system has something to teach the other. The continuing collaboration between the two evolving systems can only be of benefit. This book is not exactly a thriller to read, but for those interested in international collaboration in clarity of diagnostic categories, it is a very important sourcebook.