A conceptual framework for the revision of the ICD‐10 classification of mental and behavioural disorders

Factors Associated with a Second Opioid Prescription Fill in Total Knee Arthroplasty

The World Health Organization (WHO) is currently revisiting the ICD. In the 10th version of the ICD, approved in 1990, hypochondriacal symptoms are described in the context of both the primary condition hypochondriacal disorder and as secondary symptoms within a range of other mental disorders. Expansion of the research base since 1990 makes a critical evaluation and revision of both the definition and classification of hypochondriacal disorder timely. This article addresses the considerations reviewed by members of the WHO ICD-11 Working Group on the Classification of Obsessive-Compulsive and Related Disorders in their proposal for the description and classification of hypochondriasis. The proposed revision emphasizes the phenomenological overlap with both anxiety disorders (e.g., fear, hypervigilance to bodily symptoms, and avoidance) and obsessive-compulsive and related disorders (e.g., preoccupation and repetitive behaviors) and the distinction from the somatoform disorders (presence of somatic symptom is not a critical characteristic). This revision aims to improve clinical utility by enabling better recognition and treatment of patients with hypochondriasis within the broad range of global health care settings.

The International Classification of Diseases (ICD) is in the process of being revised. Sexuality-related conditions have been identified as a key area for revision, with the aim of improving clinical utility. Proposed revisions will be field-tested to evaluate their cultural sensitivity, relevance, and appropriateness across developed and developing world contexts. Brazil, Lebanon, Mexico, and South Africa have been identified as potential field-testing sites. The purpose of this article is to describe a multistakeholder consultative approach to explore the feasibility of field studies in these countries. A broad spectrum of ∼30 stakeholders, including health and allied health professionals, legal and human rights advocates, and government sector and civil society representatives, were approached in each of these countries and invited to participate in 3-day workshops to develop potential field-testing protocols. Engagement with these stakeholders revealed challenges for initiating field-testing in these contexts, the most common being the limited access to sexual health treatment facilities for conducting clinic-based research. Potential protocols that accommodated local resources and infrastructure were developed. Secondary outcomes included the broadening of networks for professionals working in the area of human sexuality, mapping of services currently available for sexuality-related conditions locally, increased awareness and discussion about sexuality-related conditions, and the intersection with human and sexual rights.

Psychiatric classification: Current debate and future directions

To examine the conceptualizations held by psychiatrists and psychologists around the world of the relationships among mental disorders in order to inform decisions about the structure of the classification of mental and behavioral disorders in World Health Organization's International Classification of Diseases and Related Health Problems 11th Revision (ICD-11). 517 mental health professionals in 8 countries sorted 60 cards containing the names of mental disorders into groups of similar disorders, and then formed a hierarchical structure by aggregating and disaggregating these groupings. Distance matrices were created from the sorting data and used in cluster and correlation analyses. Clinicians' taxonomies were rational, interpretable, and extremely stable across countries, diagnostic system used, and profession. Clinicians' consensus classification structure was different from ICD-10 and the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders 4th Edition (DSM-IV), but in many respects consistent with ICD-11 proposals. The clinical utility of the ICD-11 may be improved by making its structure more compatible with the common conceptual organization of mental disorders observed across diverse global clinicians.

WPA contribution to the development of the chapter on mental disorders of the ICD-11

The current revisions of diagnostic classifications of mental and behavioural disorders attract diametrically opposed reactions from those who have to use the classifications. There are those who r...

ABSTRACT Background: The diagnosis of complex posttraumatic stress disorder (CPTSD) was included in the 11th revised edition of the International Classification of Diseases (ICD-11). CPTSD shares trauma-specific symptoms with its sibling disorder PTSD but is additionally characterized by disturbances of the individual’s self-organization (DSO). The clinical utility of the CPTSD diagnosis has yet to be thoroughly investigated. Objective: The current study aimed to examine the clinical utility of the CPTSD diagnosis, considering the upcoming implementation of ICD-11 in clinical practice. Method: International field studies, construct- and validity analyses leading up to the inclusion in ICD-11 are reviewed, and the diagnostic measures; International Trauma Questionnaire (ITQ) and International Trauma Interview (ITI) are presented. Also, the relationship between CPTSD and borderline personality disorder (BPD) is elaborated in an independent analysis, to clarify their differences in clinical relevance to treatment. Treatment implications for CPTSD are discussed with reference to existing guidelines and clinical needs. Results: The validation of ITQ and ITI contributes to the cementation of CPTSD in further clinical practice, providing qualified assessment of the construct, with intended informative value for both clinical communication and facilitation of treatment. CPTSD is found distinguishable from both PTSD and BPD in empirical studies, while the possibility of comorbid BPD/PTSD cases being better described as CPTSD is acknowledged. Practitioners need to employ well-established methods developed for PTSD, while considering additional DSO-symptoms in treatment of CPTSD. Conclusions: The inclusion of CPTSD in ICD-11 may potentially facilitate access to more tailored treatment interventions, as well as contribute to increased research focus on disorders specifically associated with stress. The clinical utility value of this additional diagnosis is expected to reveal itself further after ICD-11 is implemented in clinical practice in 2022 and onwards. Yet, CPTSD’s diagnostic inclusion gives future optimism to assessing and treating complex posttraumatic stress symptoms.

To explore the rationales of mental health professionals (mainly psychiatrists and psychologists) from 8 countries for removing specific diagnostic categories from mental disorders classification systems. As part of a larger study, 505 participants indicated which of 60 major disorders should be omitted from mental disorders classification systems and provided rationales. Rationale statements were analyzed using inductive content analysis. The majority of clinicians (60.4%) indicated that 1 or more disorders should be removed. The most common rationales were (a) problematic boundaries between normal and psychopathological conditions (45.9% of total removal recommendations), (b) problematic boundaries among mental disorders (25.4%), and (c) problematic boundaries between mental and physical disorders (24.0%). The categories most frequently recommended for deletion were gender identity disorder, sexual dysfunction, and paraphilias, usually because clinicians viewed these categories as being based on stigmatization of a way of being and behaving. A range of neurocognitive disorders were described as better conceptualized as nonpsychiatric medical conditions. Results were analyzed by country and country income level. Although gender identity disorder was the category most frequently recommended for removal overall, clinicians from Spain, India, and Mexico were most likely to do so and clinicians from Nigeria and Japan least likely, probably because of social and systemic factors that vary by country. Systematic differences in removal rationales by country income level may be related to the development, structure, and functioning of health systems. Implications for development and dissemination of the classification of mental and behavioral disorders in WHO's ICD-11 are discussed.

The beta draft of the chapter on mental and behavioural disorders of the eleventh revision of the International Classification of Diseases (ICD-11) is now available online at http://apps.who.int/classifications/icd11/browse/l-m/en. In addition to reading the contents, registered users can actively contribute to the development of the chapter by: a) commenting on the available materials and responding to the comments that have already been made; b) answering some questions about the quality of the materials; c) making proposals of changes or additions to the classification. The ICD-11 Clinical Descriptions and Diagnostic Guidelines for each disorder will finally contain the following elements: a definition, a set of inclusion and exclusion terms, a description of the essential (required) features, a characterization of the boundary of the disorder with normality (threshold for the diagnosis) and with other disorders (differential diagnosis), a series of coded qualifiers/subtypes, and a description of course features, associated clinical presentations, culture-related features, developmental presentations, and gender-related features (see(1)). At present, the beta draft includes the definitions of the various disorders (summary statements of about 100-125 words each), the inclusion and exclusion terms, and, in some cases, the definitions of qualifiers/subtypes. From the available materials, registered users are able to appreciate several features of the revised classification that have been already extensively discussed in the scientific literature (e.g.,(2–13)). Among them is the introduction of the grouping of disorders specifically associated with stress, including the new categories of complex post-traumatic stress disorder and prolonged grief disorder, and an extensively revised category of adjustment disorder. Acute stress reaction is now characterized as a non-disordered response and classified among “conditions associated with psychosocial circumstances” (see(6)). The definitions and subtyping of personality disorders and bodily distress disorder have also been extensively revised and simplified (see(2), (13)), and are being lively discussed on the beta draft platform. The grouping of impulse control disorders now includes also pathological gambling and compulsive sexual behaviour disorder (see(11)). A new name (“disorders of intellectual development”) and characterization is provided for those conditions that were subsumed under the heading “mental retardation” in the ICD-10 (see(10)). In the definition of schizophrenia, disturbances of self-experience are highlighted in addition to those of thinking, perception, cognition, volition and affect. The one month duration criterion is kept, and functional impairment is not mentioned as a mandatory criterion, contrary to the DSM-5. Qualifiers referring to the course of the disorder are introduced. Schizoaffective disorder is characterized cross-sectionally as a disorder in which the diagnostic requirements for schizophrenia and a mood episode are met within the same episode of illness, either simultaneously or within a few days, contrary to the longitudinal characterization of the DSM-5 (see(3)). In the grouping of mood disorders, the concept of mixed episode, characterized by either a mixture or a very rapid alternation of prominent manic and depressive symptoms on most days during a period of at least two weeks, is kept, contrary to the DSM-5 (see(4)). The categories of bipolar type II disorder and premenstrual dysphoric disorder are introduced (see(4)), and the definition provided for the latter is already being debated on the beta draft platform. In the grouping of feeding and eating disorders, subtypes of anorexia nervosa “with dangerously low body weight” and “with significantly low body weight” have been included, and the new category of avoidant-restrictive food intake disorder has been introduced (see(5)). Internet-based and clinic-based field studies of the new classification are now ongoing (see(1)). The former are being implemented through the Global Clinical Practice Network, currently including about 12,000 practitioners from all regions of the world. Psychiatrists can register to this network in any of nine languages at www.globalclinicalpractice.net. The possibility of an interaction between the ICD-11 and the Research Domain Criteria (RDoC) projects is also being considered. Indeed, the main objectives of the two projects (i.e., improving the clinical utility of psychiatric diagnoses for the former; exploring in an innovative way the etiopathogenetic underpinnings of psychopathology for the latter) can be regarded as complementary, and much can be done to reduce the current gap between the RDoC constructs and some clinical phenomena that psychiatrists encounter in their ordinary clinical practice, especially in the area of psychoses (see(14–26)).