Current schemes ICD10 and DSMIV

The DSM-IV and ICD-10 committees worked closely together and strove to have names and criteria that are as close as possible. (15> However, there are some general differences.

'Picture-fitting' versus 'menu-driven' approaches

First, as in adulthood, ICD-10 has one set of 'clinical descriptions and diagnostic guidelines' and a separate set of 'diagnostic criteria for research'. The former comprises general descriptions of disorders requiring a qualitative matching of case characteristics with the scheme, a 'picture-fitting' approach. The latter comprises lists of symptoms with explicit criteria detailing the number and permutation required for diagnosis, a 'menu-driven' approach. DSM-IV has only the latter, 'menu-driven' approach. It has advantages in increased reliability, but is relatively cumbersome so that many clinicians do not bother to apply the criteria rigorously. Even for the simpler DSM-III criteria, Prendergast et a/.(l6) found that whilst trained researchers achieved k values of 0.83, 0.80, and 0.74 for attention-deficit disorder, conduct disorder, and emotional disorder, the comparable figures for American clinicians in regular practice were 0.30, 0.27, and 0.27.

A further disadvantage of the 'menu-driven' approach arises in cases where although the clinician believes a diagnosis is present because of the severity of symptoms, their number is insufficient to meet criteria. For example, consider the following youth: he repeatedly mugs old ladies, sets fires frequently, often argues, is often spiteful or vindictive, has unusually severe tantrums, and has no friends or job because of his behaviour. According to ICD-10 research diagnostic criteria (or DSM-IV criteria) he has no diagnosis, as he has two but not three symptoms of conduct disorder, and three but not four symptoms of oppositional-defiant disorder. However, according to ICD-10 'diagnostic guidelines' he easily meets the requirements for conduct disorder since 'any category, if marked, is sufficient'.

Multiple diagnoses

A second difference between ICD-10 and DSM IV is in multiple diagnoses. ICD-10 encourages the selection of one diagnosis that closest fits the picture, assuming that differences are due to a variation upon the typical theme. DSM-IV (and the closely linked ICD-10 research criteria) encourages selection of as many diagnoses as criteria are met. Problems arise with this approach when symptoms are common to two disorders, for example irritability contributes to affective disorders and to conduct disorders, so double coding is more likely. Because comorbidity is very common in clinical practice, multiple coding is frequent using a 'menu-driven' approach so that it begins to approach a dimensional system and to lose the advantages of categorization.

The pros and cons of each approach will vary according to whether extra information is conveyed by the second diagnosis. Where there is good evidence of the validity of common comorbid conditions, ICD-10 has combined categories. Thus, the external validating characteristics of 'depressive conduct disorder' are similar to those of pure conduct disorder, with no increase of affective disorders in individuals followed up to adulthood, nor in their relatives. Double coding would convey erroneous information about the depressive aspect. 'Hyperkinetic conduct disorder', on the other hand, is characterized by more severe neuropsychological deficits than occur in either condition alone, and by worse psychosocial outcome in adulthood. Double coding would not convey the poor prognosis.

Multiaxial framework

P>ICD-10 has a multiaxial framework for psychiatric disorders in childhood and adolescence (17) which will be described here. DSM-IV uses a somewhat different multiaxial framework which is applicable for disorders arising at all ages. It will not be described here except as a contrast to ICD-10, as it is discussed in Chapter., 1.11. Each axis except the last (psychosocial impairment) is coded independently of the apparent causal contribution to the psychiatric syndrome. This avoids tricky decisions about causality and allows conditions to be recognized and clinical needs addressed.

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