WPA contribution to the development of the chapter on mental disorders of the ICD-11: An update.

Abstract

The WPA is partnering with the World Health Organization (WHO) in the development of the chapter on mental disorders of the 11th edition of the International Classification of Diseases (ICD), whose publication is expected in the year 2015. WPA Member Societies participated in the WPA-WHO Global Survey on Psychiatrists' Attitudes Towards Mental Disorders Classification 1, which will guide the WHO in improving the clinical utility of the ICD classification of mental disorders. Almost 5,000 psychiatrists worldwide provided their feedback about their use of diagnostic systems in clinical practice, and the desirable characteristics of a classification of mental disorders. Participants expressed preference for a simpler system with 100 or fewer categories. Over two-thirds preferred flexible guidance to a strict criteria-based approach. Significant minorities of psychiatrists in Latin America and Asia reported problems with the cross-cultural applicability of existing classifications. Overall, ratings of ease of use and goodness of fit for specific ICD-10 categories were fairly high, but several categories were described as having poor utility in clinical practice. This is being an important focus for the ICD revision. Several WPA Member Societies and experts are being or will be involved in ICD-11 field trials and in the various translations/adaptations of the diagnostic system. The WPA is actively contributing to the process of harmonization between the ICD-11 and the DSM-5. The WPA Past-President, M. Maj, who chairs the ICD-11 Working Group on Mood and Anxiety Disorders, recently reported 2 about the expected convergences and divergences in the ICD-11 and DSM-5 approaches to the classification of mood disorders. Among the convergences, both systems are likely to include increased activation/energy as a defining symptom for mania, and to acknowledge that a manic/hypomanic syndrome emerging during antidepressant treatment, and persisting beyond the physiological effect of that treatment, qualifies for the diagnosis of manic/hypomanic episode. Furthermore, both systems are going to provide the clinician with the opportunity to acknowledge the occurrence of subsyndromal anxiety symptoms in a patient with a major depressive episode, by using a specifier (“with prominent anxiety symptoms” in ICD-11, “with anxious distress” in DSM-5). In ICD-11, bipolar II disorder is expected to be recognized as a distinct diagnostic entity, while in ICD-10 it is just mentioned among “other bipolar affective disorders”. Expected divergences between the ICD-11 and the DSM-5 will include a different characterization of mixed states and schizoaffective disorders. The ICD-10 bereavement exclusion in the diagnosis of depressive episode will be eliminated in the DSM-5, but two notes introduced in the text should attenuate the divergence from ICD-11, which is going to exclude from the diagnosis of depressive episode, in line with ICD-10, “normal bereavement reactions appropriate to the culture of the individual concerned”. The Chairman of the WPA Section on Schizophrenia, W. Gaebel, who chairs the ICD-11 Working Group on Psychotic Disorders, recently reported 3 about the expected convergences and divergences in the ICD-11 and DSM-5 approaches to the classification of psychotic disorders. Among the convergences, both systems are going to de-emphasize Schneider's first-rank symptoms in the diagnostic criteria for schizophrenia and to omit subtypes of the disorder. These subtypes are going to be replaced by six symptom specifiers (positive symptoms, negative symptoms, depressive symptoms, manic symptoms, psychomotor symptoms, cognitive impairment) in the ICD-11 and by corresponding dimensional assessments in the DSM-5. Among the divergences, the ICD-11 is expected to keep the one month duration criterion for the diagnosis of schizophrenia, and not to include functional impairment as a mandatory criterion. World Psychiatry is one of the main channels through which the international psychiatric community is being updated about the ICD-11 development. A Special Article authored by the ICD-11 International Advisory Group, summarizing the philosophy of the entire process, has been published in the journal 4, as well as the first report of the Working Group on Intellectual Disabilities 5 and a review of evidence and proposals for the ICD-11 classification of feeding and eating disorders 6. Several papers produced by the Working Group on Mood and Anxiety Disorders have been collected in a special supplement to the journal 7. Many relevant contributions have appeared in recent issues of the journal 8–27. All these articles are available on the WPA website (http://www.wpanet.org).