FREE ESSAY ON ICD & THE DSM CLASSIFICATION SYSTEM.

ICD & THE DSM CLASSIFICATION SYSTEM.

Although at first sight the DSM-IV classification system appears to provide clinicians
with a useful framework of which to view their clients, on closer inspection however, the
picture is somewhat less satisfactory. Criticisms of the system range from Wakefield's
(1997) analysis that psychological presentation ranges from problems of living to harmful
dysfunction; through to Livesley, Schroeder & Jang's (1994) counter-argument that
evidence of discontinuity between different diagnoses and normality would support the
DSM's proposal of distinct diagnostic categories. Since these issues involved are quite
distinct, both these points of view are presented in relation to a cause and consequence
debate. Finally, conclusions are reflected in terms of the classification of the impulse
control disorders not else where specified (DSM-IV, 1996). Particularly, discussion is
given to the sub category of Kleptomania.
Criticisms of DSM -IV classification:
The four major criticisms of DSM -IV classification system are (1) that categories lack
independence, (2) the principles underlying them are diverse, (3) they are too
heterogeneous and (4) the reliability (consistency) and conceptual validity (correctness)
(Wakefield, 1997) of diagnosis is too low to be of any value. This leads to Wakefield's
(1997) argument that the diagnostic criteria of the DSM encompasses too many conditions
that do not adequately reflect a true indication of one psychological disorder. Wakefield
(1997) further argues that a pattern labelled 'harmful dysfunction' results in confusion
between boundaries along the continuum of disorder and non-disorder. Harmful dysfunction
results from a lack of consistency, clarification or identification of quite simply, what
should be diagnosed where. The harm in this case can result in negative evaluation of an
undesirable outcome that is placed within a specific diagnostic category. According to
the harmful dysfunction analysis, a disorder only exists where there is a clear and
identifiable internal mechanism resulting in harm to the individual. However it becomes
apparent that when using the DSM as a major diagnostic criteria in assessment, that many
clinicians in relying heavily upon criteria, over estimate the role of dysfunction in
their clients, therefore misinterpreting consequences and causes.
In relating this to classification of specific distress, Wakefield's (1997) analysis of
harmful dysfunction, implies that the DSM is formulated within a medical model that
suggests that psychological causation is involved in all DSM-IV and preceding
classification systems. In so much, common argument that all mental disorders must be
brain diseases is due to the fact that all mental states are regarded as brain states in
classification (Wakefield, 1997). A consequence is found through the harmful dysfunction
analysis that the application of medical approaches to both physical and mental disorder,
contrary to common suggestion (E.g.: the mind body dualism) are not necessarily true for
all instances of behaviour (Wakefield, 1997). Therefore, one must sharply distinguish
between the medical concept of a disorder from the representation of behavioural
consequence. According to Wakefield (1997) when a condition involves no significant harm
to the individual's overall well being or the well being of others, there is no disorder,
even if this obvious dysfunction is a naturally selected mechanism. This notion is
further discussed in relation to the overconclusivness of kleptomania in classification.
In exploring this debate as relating to the impulse control disorders not elsewhere
specified (ICD) - kleptomania, one can see the overlap of boundaries or in diagnostic
terms, classification of what acts of impulsivity are either a cause or consequence of
mental illness. Specifically, many authors (Dust, 1997; Bradford & Balmaceda, (1983),
1997; Keck, 1997; McElroy, 1992) have explored the commonality between what is described
as an impulse control disorder and what results in impulsivity as a consequence of
another diagnostic category. Such linkages include OCD, depression and anxiety. Table 1
summarises the overlap between kleptomania and other diagnostic criteria according the
literature exploring the overconclusivness of the DSM classification system. These
results indicate percentages of clients who present with Kleptomania yet held
differential diagnosis in both in and out patient settings.
Table 1:
Depression 13% (Dust, 1997
Mood Disorders 50% (Bradford & Balmaceda, (1983), 1997)
Bulimia 14.79% (Bradford & Balmaceda, (1983), 1997)
Dependence Disorders 4.7% (Leyjoyeux, 1997)
Mania 56% (Keck, 1997)
OCD 62% (McElroy, 1992)
Anxiety 23% (McElroy, 1992)
Kleptomania:
Debate over impulsion leading to compulsion has led to the notion according to many
authors such as McElroy, Hudson, Harrison, Kreck and Aizley (1992) that impulsion is an
indirect response to the need to reduce anxiety. This exemplifies that the diagnostic
criteria of ICD, does not represent individual criteria per se, but rather impulse
control is an inevitable consequence of the desire to reduce anxiety. Likening OCD to
kleptomania, McElroy et al., (1992) further argue that although not prevalent until
further diagnostic exploration is attempted, does the clinician gain an adequate insight
into how kleptomania is a result of the need to reduce anxiety. These authors argue that
in a total of 124 clinical samples, anxiety was a major predisposing factor within a
spectrum disorder pattern. In this kleptomania was an evident symptom in what is
described as the OCD-Impulse control spectrum; a spectrum that holds no distinct
classification, but rather is an encompassing spectrum of symptoms. 
Similarly, Fishbain (1987) in a study exploring the relationships between psychological
disorders and ICD depressive dispositions noted that depressive neurosis was a primary
factor in 42 % of all patients presenting to an outpatient treatment clinic. This led to
Fishbain (1987) exerting that perhaps within ICD, the primary diagnostic criteria of
'impulsion' is not a direct psychological construct, but rather a facilitator or
consequence of a much larger psychological continuum. The continuum described places
kleptomania as part of the psychosocial reaction model. In this model, kleptomania and
the ICD's in general are again placed in the spectrum of disorders that are
representative of a continuum approach to viewing mental illness. 
In applying findings to Wakefield's (1992) original analysis of the overconclusivness of
the DSM and the cause and consequence debate, distinction is not always evident in
classification. Goldman (1997), argues that kleptomania within the adolescent population
is indicative not of dysfunction, but rather is a response to a troublesome childhood.
Therefore, kleptomania becomes a response to an affective environment in the teen, and is
a demonstrative way of exhibiting dissatisfaction with lifestyle (Goldman, 1997). Harm
then, is not a direct indictor of pathology but rather kleptomania is a consequence of
the broader psychosocial spectrum. Moreover, Sarasalo (1996) further adds to this
argument by expanding through a psychosocial model of viewing kleptomania. Sarasalo
(1996) maintains that although the diagnostic criteria for kleptomania is defined
according the DSM as: recurrent failure to resist impulses to steal items even though the
items are not needed for personal use or monetary value (DSM-IV, 1997); low socialisation
of the individual can be a reinforcement of over stepping social boundaries. This indeed
is plausible when one considers the commodity of kleptomania that includes depression and
anxiety, as well as prognosis that begins in early childhood and adolescents. If this is
the case, etiology of kleptomania becomes a social rather than psychological dysfunction.
As the ICD -10 indicates that kleptomania is a response to a maladaptive environment,
classification should therefore focus not what is the psychological underpinnings of
kleptomania, but rather what is socially constructing it.
In summary, reports of discussed authors in relation to the criticism of the DSM
classification system argue that:
 Diagnostic criteria is too broad, therefore comorbidity is high
 Comorbidity and differential diagnosis indicates that when treating kleptomania
it should be regarded as a secondary symptom of a major psychological or psychosocial
dysfunction.
Conclusions:
Contrary to the overconclusivness argument, Livesley et al., (1994) argue that in any
classification system there must be some overlap or common thread running through
sub-groups of a particular category. Therefore Livesley's et al., (1994) counter-argument
that evidence of discontinuity between different diagnoses and normality would support
the DSM's proposal of distinct diagnostic categories. According to these authors, there
may of course, be a wide range of attribute's within a category, but for the DSM to
exist, it is essential that each of the classification subtype's must be clearly defined
and applied only to that specific disorder. Livesley et al., (1994) therefore reject the
notion of a spectrum disorder and the overconclusiveness of the DSM. Further support for
the exactitude of the current DSM classification system is ascertained in a study by
Wittenborn (1981), describing individuals who shared a common diagnosis from one
diagnostic category to another. It was found that clients differed greatly from each
other in terms of symptom patterns that according to diagnosis had placed then in the
same Impulse control disorder category. More simply what Wittenborn (1981) proposes is
that overconclusivness is not a result of fault in DSM classification, but rather it is
an inevitable process, as many persons share common complaints but their precise
symptomolgy that places them within a distinct category is what separates them.
These authors contrary to many perspectives previously presented, argue that the presumed
fundamental distinctions between one diagnostic criteria to another, in general has
proven elusive for those committed to the current classification system. However,
justification for overconclusivness is that most people experience all of the symptoms
associated with each disorder in the DSM over some period of time. The difference between
the subcategories however, despite the levels of overlap in symptomology, is seen to lie
in the degree of persistence of the symptoms which in one subcategory (Wittenborn1981).
It is therefore clinical judgement and appropriate use of any classification system that
is used to determine the degree of severity, not what or how many categories can be
placed upon the one individual. Perhaps this leads one to conclude that although
overconclusivness is apparent in many diagnoses, it may be a question of who is
over-conclusive, the DSM or user.
In summary however, in terms of the overconclusiveness of DSM criteria for kleptomania,
as described by Wakefield (1992), it can be argued that the diagnostic criteria is too
broad, reflected through high levels comorbididity with other disorders described. Hence
comorbididity and differential diagnosis may include kleptomania and a secondary rather
than primary condition. Moreover, the elusiveness of clients who fit neatly into one or
another diagnostic category is perhaps most clearly illustrated in previously discussed
overlapping subcategories. Thus clients that are described as having, for example
Kleptomania with depressive tendencies may alternatively be Depressive with Kleptomaniac
tendencies, but such a construct is not described in the DSM-IV or any preceding systems.
Indeed this argument again leads to a question of primary or secondary diagnosis and
cause or consequence.
Nevertheless, it should be stated that there are many problems associated with the
current DSM-IV classification systems for ICD, specifically kleptomania. Therefore,
despite the DSM's attempts at repeated modifications to refine this category, the
ambiguity of ICD still remains. However despite this acknowledgement must be given by the
clinician that diagnosis at a more detailed level should be based upon a broader socio
culture model that utilises classification not as a primary means of diagnosis, but
rather as a system that highlights the possibilities in classification.
Bibliography
References
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diagnosis. Archives of General Psychiatry, 49, 1238-1254
Goldman, K. (1997) In McElroy, J.L, Hudson, K, Harrison, D.L., Kreck, A., and Aizley, A.
(1992). Impulse control disorder.. London: Oxford University Press. 
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