Global Clinical Practice Network Research Articles

COVID-19 vaccine attitudes among mental health professionals in the WHO’s global clinical practice network

Although COVID-19 vaccines have demonstrated efficacy, there is variability in health professionals’ attitudes towards these agents. Factors associated with mental health professionals’ attitudes towards COVID-19 vaccination are not well understood. We investigated these factors by administering a newly developed measure, the COVID-19 Vaccine Attitudes Questionnaire (C-VAQ), to members of the World Health Organization’s Global Clinical Practice Network (GCPN) of mental health professionals. 1,931 GCPN members representing all world regions participated between July 28 and September 7, 2021. Mental health professionals’ attitudes towards COVID-19 vaccination were assessed in one of five languages (Chinese, English, French, Japanese, Russian, or Spanish) using the C-VAQ. Internal consistency, factor structure, and predictive validity of the C-VAQ were examined, and a multiple-linear regression model was employed to assess C-VAQ score predictors, including sociodemographic variables (age, gender, WHO region, country income level, profession, and years of professional experience) as well as country mortality rate and the stringency of each country’s response to COVID-19. The C-VAQ demonstrated good internal consistency and external validity. Items loaded on to a single factor. Having received a COVID-19 vaccine, higher country mortality rate, and higher stringency index was significantly associated with more positive vaccine attitudes. Lower age, residing in a low-and-middle income country, and living in Asia were all was significantly associated with less positive vaccine attitudes. The C-VAQ scores were negatively correlated with the number of concerns about the COVID-19 vaccination. The C-VAQ was useful in demonstrating the extent to which additional work is needed to improve mental health professionals’ attitudes towards COVID-19 vaccines globally. Relatively poorer attitudes toward vaccination among some mental health clinicians around the world suggests the need for broad, multi-pronged interventions.

Mental health professionals' use of the ICD-11 classification of impulse control disorders and behavioral addictions: An international field study.

The ICD-11 chapter on mental, behavioral and neurodevelopmental disorders contains new controversial diagnoses including compulsive sexual behavior disorder (CSBD), intermittent explosive disorder (IED) and gaming disorder. Using a vignette-based methodology, this field study examined the ability of mental health professionals (MHPs) to apply the new ICD-11 diagnostic requirements for impulse control disorders, which include CSBD and IED, and disorders due to addictive behaviors, which include gaming disorder, compared to the previous ICD-10 guidelines. Across eleven comparisons, members of the WHO's Global Clinical Practice Network (N = 1,090) evaluated standardized case descriptions that were designed to test key differences between the diagnostic guidelines of ICD-11 and ICD-10. The ICD-11 outperformed the ICD-10 in the accuracy of diagnosing impulse control disorders and behavioral addictions inmost comparisons, while the ICD-10 was not superior in any. Thesuperiority of the ICD-11 was particularly clear where new diagnoses had been added to the classification system or major revisions had been made. However, the ICD-11 outperformed the ICD-10 only in a minority of comparisons in which mental health professionals were asked to evaluate cases with non-pathological high involvement in rewarding behaviors. Overall, the present study indicates that the ICD-11 diagnostic requirements represent an improvement over the ICD-10 guidelines. However, additional efforts, such as training programs for MHPs and possible refinements of diagnostic guidance, are needed to avoid over-diagnosis of people who are highly engaged in a repetitive and rewarding behavior but below the threshold for a disorder.

Longitudinal Impact of the COVID-19 Pandemic on Stress and Occupational Well-Being of Mental Health Professionals: An International Study.

Increased levels of occupational stress among health professionals during the COVID-19 pandemic have been documented. Few studies have examined the effects of the pandemic on mental health professionals despite the heightened demand for their services. A multilingual, longitudinal, global survey was conducted at 3 time points during the pandemic among members of the World Health Organization's Global Clinical Practice Network. A total of 786 Global Clinical Practice Network members from 86 countries responded to surveys assessing occupational distress, well-being, and posttraumatic stress symptoms. On average, respondents' well-being deteriorated across time while their posttraumatic stress symptoms showed a modest improvement. Linear growth models indicated that being female, being younger, providing face-to-face health services to patients with COVID-19, having been a target of COVID-related violence, and living in a low- or middle-income country or a country with a higher COVID-19 death rate conveyed greater risk for poor well-being and higher level of stress symptoms over time. Growth mixed modeling identified trajectories of occupational well-being and stress symptoms. Most mental health professions demonstrated no impact to well-being; maintained moderate, nonclinical levels of stress symptoms; or showed improvements after an initial period of difficulty. However, some participant groups exhibited deteriorating well-being approaching the clinical threshold (25.8%) and persistently high and clinically significant levels of posttraumatic stress symptoms (19.6%) over time. This study indicates that although most mental health professionals exhibited stable, positive well-being and low stress symptoms during the pandemic, a substantial minority of an already burdened global mental health workforce experienced persistently poor or deteriorating psychological status over the course of the pandemic.

Case-controlled field study of the ICD-11 clinical descriptions and diagnostic requirements for Bodily Distress Disorders

AimsMental disorders characterized by preoccupation with distressing bodily symptoms and associated functional impairment have been a target of major reconceptualization in the ICD-11, in which a single category of Bodily Distress Disorder (BDD) with different levels of severity replaces most of the Somatoform Disorders in ICD-10. This study compared the accuracy of clinicians' diagnosis of disorders of somatic symptoms using either the ICD-11 or ICD-10 diagnostic guidelines in an online study. MethodsClinically active members of the World Health Organization's Global Clinical Practice Network (N = 1065) participating in English, Spanish, or Japanese were randomly assigned to apply ICD-11 or ICD-10 diagnostic guidelines to one of nine pairs of standardized case vignettes. The accuracy of the clinicians' diagnoses as well as their ratings of the guidelines' clinical utility were assessed. ResultsOverall, clinicians were more accurate using ICD-11 compared to ICD-10 for every presentation of a vignette characterized primarily by bodily symptoms associated with distress and impairment. Clinicians who made a diagnosis of BDD using ICD-11 were generally correct in applying the severity specifiers for the condition. LimitationsThis sample may represent some self-selection bias and thus may not generalize to all clinicians. Additionally, diagnostic decisions with live patients may lead to different results. ConclusionsThe ICD-11 diagnostic guidelines for BDD represent an improvement over those for Somatoform Disorders in ICD-10 in regard to clinicians' diagnostic accuracy and perceived clinical utility.

An international survey examining the impact of the COVID-19 pandemic on telehealth use among mental health professionals

BackgroundCOVID-19 has profoundly affected the work of mental health professionals with many transitioning to telehealth to comply with public health measures. This large international study examined the impact of the pandemic on mental health clinicians’ telehealth use. MethodsThis survey study was conducted with mental health professionals, primarily psychiatrists and psychologists, registered with WHO's Global Clinical Practice Network (GCPN). 1206 clinicians from 100 countries completed the telehealth section of the online survey in one of six languages between June 4 and July 7, 2020. Participants were asked about their use, training (i.e., aspects of telehealth addressed), perceptions, and concerns. OutcomesSince the pandemic onset, 1092 (90.5%) clinicians reported to have started or increased their telehealth services. Telephone and videoconferencing were the most common modalities. 592 (49.1%) participants indicated that they had not received any training. Clinicians with no training or training that only addressed a single aspect of telehealth practice were more likely to perceive their services as somewhat ineffective than those with training that addressed two or more aspects. Most clinicians indicated positive perceptions of effectiveness and patient satisfaction. Quality of care compared to in-person services and technical issues were the most common concerns. Findings varied by WHO region, country income level, and profession. InterpretationFindings suggest a global practice change with providers perceiving telehealth as a viable option for mental health care. Increasing local training opportunities and efforts to address clinical and technological concerns is important for meeting ongoing demands.

A global field study of the international classification of diseases (ICD-11) mood disorders clinical descriptions and diagnostic guidelines

BackgroundWe report results of an internet-based field study evaluating the diagnostic guidelines for ICD-11 mood disorders. Accuracy of clinicians’ diagnostic judgments applying draft ICD-11 as compared to the ICD-10 guidelines to standardized case vignettes was assessed as well as perceived clinical utility. Methods1357 clinician members of the World Health Organization's Global Clinical Practice Network completed the study in English, Spanish, Japanese or Russian. Participants were randomly assigned to apply ICD-11 or ICD-10 guidelines to one of eleven pairs of case vignettes. ResultsClinicians using the ICD-11 and ICD-10 guidelines achieved similar levels of accuracy in diagnosing mood disorders depicted in vignettes. Those using the ICD-11 were more accurate in identifying depressive episode in recurrent depressive disorder. There were no statistically significant differences detected across classifications in the accuracy of identifying dysthymic or cyclothymic disorder. Circumscribed problems with the proposed ICD-11 guidelines were identified including difficulties differentiating bipolar type I from bipolar type II disorder and applying revised severity ratings to depressive episodes. Clinical utility of ICD-11 bipolar disorders was found to be significantly lower than for ICD-10 equivalent categories. LimitationsStandardized case vignettes were manipulated to evaluate specific changes. The degree of accuracy of clinicians’ diagnostic judgments may not reflect clinical decision-making with patients. ConclusionsAlignment of the ICD-11 with current research appears to have been achieved without sacrificing diagnostic accuracy or clinical utility though specific training may be necessary as ICD-11 is implemented worldwide. Areas in which the ICD-11 guidelines did not perform as intended resulted in further revisions.

The COVID-19 pandemic in Russia: Effects on clinicians and mental health services

Since COVID-19 was declared a pandemic by the World Health Organization in March 2020, it has had different infection rates across the world. Russia had one of the largest numbers of infected cases during 2020, but with a lower overall fatality rate. Nevertheless, as in other countries, clinical practice within the mental health care system has faced many stresses and challenges. This concerned the need to organize a treatment of COVID-19 in psychiatric hospitals, as well as a transformation of outpatient care, including psychotherapy, which has largely switched to a remote format. To better understand the effects of the pandemic on mental health professionals, a large-scale study has been implemented through the Global Clinical Practice Network, one of the largest professional communities, which includes 969 members from Russia. The study assessed how COVID-19 affected clinical practice and well-being of clinicians. The first of three surveys was launched in June 2020, in six languages including Russian. Over 2,500 global mental health professionals participated in the study, including 205 clinicians from Russia. Current work circumstances, work-related stressors, and use of telehealth were evaluated. In Russia, the data collection period was characterized by generally improvement in the overall pandemic situation. Results to be presented include the proportion of clinicians that continued working, what kinds of services they provided, their well-being strategies, telehealth modalities and areas in which they had particular concerns about assessment, treatment, or monitoring of patients with mental disorders using remote technologies.DisclosureNo significant relationships.

The impact of COVID-19 on clinical practice and well-being of global mental health professionals

Some of the most direct and brutal effects of the COVID-19 pandemic are experienced by health care professionals who are working in demanding environments while having to deal with their own fears of infection and mortality. To assess the impact of COVID-19 on the practice and well-being of global mental health professionals, we designed a three-part, longitudinal, internet-based study. Here we present data from part 1, implemented in June-July 2020 in six languages to members of WHO’s Global Clinical Practice Network composed of 15,500 mental health practitioners. The study assessed COVID-19’s impact on: work circumstances; occupational well-being; use and transition to telehealth; and expectations, needs and recommendations. 2,505 mental health professionals from 126 countries responded to the study (47% psychiatrists). 93.7% of respondents were currently practicing and 70.9% continued to see patients in person. The impact on clinical workload varied in terms of direction and extent depending on type of service provided and country of practice. Most participants had started or increased their use of telehealth services, and we identified a need for training to support telehealth use. Overall, clinicians scored high on well-being indices. However, a subset scored above the cutoff for low well-being and reported a significant number of post-traumatic symptoms. Five factors affected work-related stress: fear of infection, severe COVID-related events, life disruption, lack of adequate protection and role disruption. Data from this study will provide information relevant for the design, development, and integration of mental health services in the continuing pandemic, and in similar future scenarios.DisclosureNo significant relationships.

Letter to the Editor: EDUCATIONAL ACTIVITIES RELATED TO THE ICD-11 CHAPTER ON MENTAL DISORDERS.

Letter to the Editor: EDUCATIONAL ACTIVITIES RELATED TO THE ICD-11 CHAPTER ON MENTAL DISORDERS.

Patient descriptions of loss of control and eating episode size interact to influence expert diagnosis of ICD-11 binge-eating disorder.

BackgroundAlthough data suggest that the sense of “loss of control” (LOC) is the most salient aspect of binge eating, the definition of LOC varies widely across eating disorder assessments. The WHO ICD-11 diagnostic guidelines for binge eating do not require an objectively large amount of food, which makes accurate LOC diagnosis even more critical. However, it can be especially challenging to assess LOC in the context of elevated weight status and in the absence of compensatory behaviors. This ICD-11 field sub-study examined how descriptions of subjective experience during distressing eating episodes, in combination with different eating episode sizes, influence diagnoses of binge-eating disorder (BED).MethodMental health professionals with eating disorder expertise from WHO’s Global Clinical Practice Network (N = 192) participated in English, Japanese, and Spanish. Participants were asked to select the correct diagnosis for two randomly assigned case vignettes and to rate the clinical importance and ease of use of each BED diagnostic guideline.ResultsThe presence of LOC interacted with episode size to predict whether a correct diagnostic conclusion was reached. If the amount consumed during a typical distressing eating episode was only subjectively large compared to objectively large, clinicians were 23.1 times more likely to miss BED than to correctly diagnose it, and they were 9.7 times more likely to incorrectly diagnose something else than to correctly diagnose BED. In addition, clinicians were 10.8 times more likely to make a false positive diagnosis of BED when no LOC was described if the episode was objectively large. Descriptions of LOC that were reliably associated with correct diagnoses across episodes sizes included two that are similar to those already included in proposed ICD-11 guidelines and a third that is not. This third description of LOC focuses on giving up attempts to control eating because perceived overeating feels inevitable.ConclusionsResults highlight the importance of detailed clarification of the LOC construct in future guidelines. Explicitly distinguishing LOC from distressing and mindless overeating could help promote consistent and accurate diagnosis of BED versus another or no eating disorder.

Accuracy of diagnostic judgments using ICD-11 vs. ICD-10 diagnostic guidelines for obsessive-compulsive and related disorders

BackgroundWe report results of an internet-based field study evaluating the diagnostic guidelines for the newly introduced ICD-11 grouping of obsessive-compulsive and related disorders (OCRD). We examined accuracy of clinicians’ diagnostic judgments applying draft ICD-11 as compared to the ICD-10 diagnostic guidelines to standardized case vignettes. Methods1,717 mental health professionals who are members of the World Health Organization's Global Clinical Practice Network completed the study in Chinese, English, French, Japanese, Russian or Spanish. Participants were randomly assigned to apply ICD-11 or ICD-10 guidelines to one of nine pairs of case vignettes. ResultsParticipants using ICD-11 outperformed those using ICD-10 in correctly identifying newly introduced OCRD, although results were mixed for differentiating OCRD from disorders in other groupings largely due to clinicians having difficulty differentiating challenging presentations of OCD. Clinicians had difficulty applying a three-level insight qualifier, although the ‘poor to absent’ level assisted with differentiating OCRD from psychotic disorders. Brief training on the rationale for an OCRD grouping did not improve diagnostic accuracy suggesting sufficient detail of the proposed guidelines. LimitationsStandardized case vignettes were manipulated to include specific characteristics; the degree of accuracy of clinicians’ diagnostic judgments about these vignettes may not generalize to application in routine clinical practice. ConclusionsOverall, use of the ICD-11 guidelines resulted in more accurate diagnosis of case vignettes compared to the ICD-10 guidelines, particularly in differentiating OCRD presentations from one another. Specific areas in which the ICD-11 guidelines did not perform as intended provided the basis for further revisions to the guidelines.

Anxiety and Fear-Related Disorders in the ICD-11: Results from a Global Case-controlled Field Study

This article reports the results of one of a series of global field studies implemented by the World Health Organization (WHO) to evaluate the accuracy, clinical utility, and global applicability of the new diagnostic guidelines for Mental, Behavioural and Neurological Disorders included in the next version of WHO's International Classification of Diseases (ICD-11). The purpose of this study was to compare the diagnostic accuracy and clinical utility ratings of global clinicians implementing the ICD-11 diagnostic guidelines for Anxiety and Fear-Related Disorders, relative to those applying ICD-10 guidelines. The study also aimed to identify elements of the guidelines that required further refinement or clarification. 1840 global mental health professionals registered with WHO's Global Clinical Practice Network completed the study in one of six study languages. Participants were randomly assigned to apply either the ICD-11 or ICD-10 guidelines to diagnose standardized case vignettes, and to rate the clinical utility of their assigned guidelines. ICD-11's diagnostic accuracy and clinical utility were equivalent or superior to that of ICD-10. Global clinicians were significantly more accurate in diagnosing Generalized Anxiety Disorder, Specific Phobia and adult cases of Separation Anxiety Disorder when using ICD-11 and provided high clinical utility ratings for these disorders. Clinicians also found the ICD-11 guidelines easy to use, clear, and a good fit to patients they see in their clinical practice. However, clinicians had difficulty with distinguishing the boundary between disorder and normality for subthreshold cases of anxiety, and also with applying the new ICD-11 guidelines on panic attacks. The new diagnostic guidelines for Anxiety Disorders in ICD-11 can be applied in an acceptably consistent manner by global clinicians and perform as well or better than the previous guidelines for ICD-10. Study findings also helped identify aspects of the ICD-11 guidelines that required refinement prior to their publication and areas that should be emphasized in training programs.

The classification of feeding and eating disorders in the ICD-11: results of a field study comparing proposed ICD-11 guidelines with existing ICD-10 guidelines

BackgroundThe World Health Organization (WHO) International Classification of Diseases and Related Health Problems (ICD) is used globally by 194 WHO member nations. It is used for assigning clinical diagnoses, providing the framework for reporting public health data, and to inform the organization and reimbursement of health services. Guided by overarching principles of increasing clinical utility and global applicability, the 11th revision of the ICD proposes major changes that incorporate empirical advances since the previous revision in 1992. To test recommended changes in the Mental, Behavioral, and Neurodevelopmental Disorders chapter, multiple vignette-based case-controlled field studies have been conducted which examine clinicians’ ability to accurately and consistently use the new guidelines and assess their overall clinical utility. This manuscript reports on the results from the study of the proposed ICD-11 guidelines for feeding and eating disorders (FEDs).MethodParticipants were 2288 mental health professionals registered with WHO’s Global Clinical Practice Network. The study was conducted in Chinese, English, French, Japanese, and Spanish. Clinicians were randomly assigned to apply either the ICD-11 or ICD-10 diagnostic guidelines for FEDs to a pair of case vignettes designed to test specific clinical questions. Clinicians selected the diagnosis they thought was correct for each vignette, evaluated the presence of each essential feature of the selected diagnosis, and the clinical utility of the diagnostic guidelines.ResultsThe proposed ICD-11 diagnostic guidelines significantly improved accuracy for all FEDs tested relative to ICD-10 and attained higher clinical utility ratings; similar results were obtained across all five languages. The inclusion of binge eating disorder and avoidant-restrictive food intake disorder reduced the use of residual diagnoses. Areas needing further refinement were identified.ConclusionsThe proposed ICD-11 diagnostic guidelines consistently outperformed ICD-10 in distinguishing cases of eating disorders and showed global applicability and appropriate clinical utility. These results suggest that the proposed ICD-11 guidelines for FEDs will help increase accuracy of public health data, improve clinical diagnosis, and enhance health service organization and provision. This is the first time in the revision of the ICD that data from large-scale, empirical research examining proposed guidelines is completed in time to inform the final diagnostic guidelines.

Do mental health professionals use diagnostic classifications the way we think they do? A global survey.

We report on a global survey of diagnosing mental health professionals, primarily psychiatrists, conducted as a part of the development of the ICD-11 mental and behavioural disorders classification. The survey assessed these professionals' use of various components of the ICD-10 and the DSM, their attitudes concerning the utility of these systems, and usage of "residual" (i.e., "other" or "unspecified") categories. In previous surveys, most mental health professionals reported they often use a formal classification system in everyday clinical work, but very little is known about precisely how they are using those systems. For example, it has been suggested that most clinicians employ only the diagnostic labels or codes from the ICD-10 in order to meet administrative requirements. The present survey was conducted with clinicians who were members of the Global Clinical Practice Network (GCPN), established by the World Health Organization as a tool for global participation in ICD-11 field studies. A total of 1,764 GCPN members from 92 countries completed the survey, with 1,335 answering the questions with reference to the ICD-10 and 429 to the DSM (DSM-IV, DSM-IV-TR or DSM-5). The most frequent reported use of the classification systems was for administrative or billing purposes, with 68.1% reporting often or routinely using them for that purpose. A bit more than half (57.4%) of respondents reported often or routinely going through diagnostic guidelines or criteria systematically to determine whether they apply to individual patients. Although ICD-10 users were more likely than DSM-5 users to utilize the classification for administrative purposes, other differences were either slight or not significant. Both classifications were rated to be most useful for assigning a diagnosis, communicating with other health care professionals and teaching, and least useful for treatment selection and determining prognosis. ICD-10 was rated more useful than DSM-5 for administrative purposes. A majority of clinicians reported using "residual" categories at least sometimes, with around 12% of ICD-10 users and 19% of DSM users employing them often or routinely, most commonly for clinical presentations that do not conform to a specific diagnostic category or when there is insufficient information to make a more specific diagnosis. These results provide the most comprehensive available information about the use of diagnostic classifications of mental disorders in ordinary clinical practice.

ICD-11 psychotic disorders: Preliminary results of the case-controlled studies and the Russian opinion

IntroductionOne of the WHO's innovations for improving the ICD-11 chapter Mental and Behavioral Disorders was the creation of the Global Clinical Practice Network (GCPN), an international network of more than 12,000 mental health and primary care professionals from 144 countries.Aims and objectivesIn order to evaluate perceived clinical utility of the ICD-11 guidelines, the case-controlled field studies that involved the application of the proposed diagnostic guidelines to standardized case material were implemented via the Internet in different languages.MethodTwo hundred and seventy-eight Russian mental health care professionals, the GCPN members, have participated in case controlled Internet study for the chapter “Schizophrenia and Other Primary Psychotic Disorders”. Russian participants were represented by psychiatrists mostly (89%) and much less by psychologists (8%) which corresponds with the general situation in the Russian mental health care system.ResultsRussian clinicians have used the proposed ICD-11 diagnostic guidelines successfully to assess delusional disorder as well as schizophrenia. But there were certain categories (schizoaffective disorder, subthreshold delusions) with which the participants seemed to struggle. The critical comments were focused on opposing so called syndrome-based assessment and nosological diagnostics. Most concerns were about elimination of Schizophrenia subtypes.ConclusionRussian mental health care professionals proved to be interested in ICD revision process and demonstrated their special diagnostics opinion based on rich clinical traditions and psychopathological approach. In order to use ICD-11 guidelines in clinical practice more efficiently supplementary appropriate training would be needed.Disclosure of interestThe authors have not supplied their declaration of competing interest.

Editorial: globalisation and the journal of eating disorders.

Author(s): Phillipa Hay[sup.1] and Stephen Touyz[sup.2] Editorial This year's Editorial began its life in Antipodean summer in a bay close to where sounds of bell birds and tui, the most melodious wild music first received international attention from records of Cook's journeys in eighteenth century [1]. At that time global journeys were dangerous and rare and their scientific discoveries took years to reach a publisher. Now we live in a world community with rapid communications that means that (on a good day) one can communicate to anywhere with an internet connection from shores Cook took refuge in in 1770. Eating Disorders, like communications, are now global. By its inherent qualities of open access Journal of Eating Disorders is in a position to disseminate and reach every corner of world, and people within them working in field of eating disorders who have access to internet. Alongside this there is an imperative that we understand eating disorders and how to manage them in ways that are helpful beyond our own perspective. In 2015 Journal of Eating Disorders published its first special series on Current Status of Eating Disorders: General and Special Population studies. Many of papers that were submitted were from Asia and accompanying review by Pike and Dunne [2] underscores rise in eating disorders across Asia in particular. Another article in special series points to increasing prevalence of eating disorders across all age groups, both sexes and throughout all socio-economic groups in Australia [3]. Furthermore throughout 2015 Journal's website conveyed an invitation from World Health Organization Global Clinical Practice network for readers to contribute their expertise in Eating and Feeding Disorders to current revisions to ICD-11 [4]. Whilst similar to DSM-5 [5] there will be differences in diagnostic criteria reflecting global cultural and clinical diversity. In 2016 researchers and clinicians working across world thus have opportunity to have input into ICD-11 and its final criteria scheduled to be published in 2017. Along with globalisation and revisions to diagnostic criteria there are increasing challenges to our conceptualisation of What is an eating disorder. Pike and Dunne's [2] review points to diversity of expression of an eating disorder within population samples in Asia. For example, they report a study which found no body image disorder and/or no fat phobia in a large minority of Japanese women with anorexia nervosa. In their review they also point to factors of industrialization and urbanization as being as great if not more significant than Westernization cultural values in understanding rise of eating disorders in Asia and other parts of globe. Taken together this underscores degree to which eating disorders classification is in a state of flux and subject to diverse socio and cultural influences. With Research Domain Criteria (RDoC) [6] movement leading way we may come closer to an understanding of neuroscience of appetite, satiety and its relationship to eating and weight facilitating a new understanding of disorders of feeding and eating. We anticipate increasing science in this area written and published in Journal. It is also important to distil science and disseminate it to clinicians and wider community and in this regard systematic and scientific review is imperative. The Pike and Dunne, and other reviews published in journal reflect this and for first time this year we gave a prize both for a primary research paper and for a review paper. We congratulate again our prize winners, for 2015: Dr Loa Clausen [7] and Dr Carmel Harrison [8]. Finally, reflecting growing globalisation of science, journal encourages and endeavours to support papers from non-English speaking countries. We recognise however that it is imperative to better develop processes that allow that to occur, and to have efficient processes in place. …

The ICD-11 beta draft is available online.

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)).

S.01.03 Neurobiology of adult separation anxiety disorder

This article reports the results of one of a series of global field studies implemented by the World Health Organization (WHO) to evaluate the accuracy, clinical utility, and global applicability of the new diagnostic guidelines for Mental, Behavioural and Neurological Disorders included in the next version of WHO's International Classification of Diseases (ICD-11).The purpose of this study was to compare the diagnostic accuracy and clinical utility ratings of global clinicians implementing the ICD-11 diagnostic guidelines for Anxiety and Fear-Related Disorders, relative to those applying ICD-10 guidelines. The study also aimed to identify elements of the guidelines that required further refinement or clarification.1840 global mental health professionals registered with WHO's Global Clinical Practice Network completed the study in one of six study languages. Participants were randomly assigned to apply either the ICD-11 or ICD-10 guidelines to diagnose standardized case vignettes, and to rate the clinical utility of their assigned guidelines.ICD-11's diagnostic accuracy and clinical utility were equivalent or superior to that of ICD-10. Global clinicians were significantly more accurate in diagnosing Generalized Anxiety Disorder, Specific Phobia and adult cases of Separation Anxiety Disorder when using ICD-11 and provided high clinical utility ratings for these disorders. Clinicians also found the ICD-11 guidelines easy to use, clear, and a good fit to patients they see in their clinical practice. However, clinicians had difficulty with distinguishing the boundary between disorder and normality for subthreshold cases of anxiety, and also with applying the new ICD-11 guidelines on panic attacks.The new diagnostic guidelines for Anxiety Disorders in ICD-11 can be applied in an acceptably consistent manner by global clinicians and perform as well or better than the previous guidelines for ICD-10. Study findings also helped identify aspects of the ICD-11 guidelines that required refinement prior to their publication and areas that should be emphasized in training programs.

ICD-11 symposia at the World Congress of Psychiatry.

Within the 16th World Congress of Psychiatry, held in Madrid from 14 to 18 September 2014, a series of symposia took place, providing information on the ongoing development of the chapter on mental disorders of the ICD-11. The symposia summarized the proposals for the various sections of the chapter, which are being produced by the fourteen working groups appointed by the World Health Organization (WHO) in consultation with relevant stakeholders, including WHO's member countries, several professional groups, and users of mental health services and their families. A list of scientific papers presenting and discussing these proposals, and of other relevant publications, is provided at the end of this article (1–99). The symposia also presented the field studies for the development of the ICD-11 chapter on mental disorders, which can be subdivided into three groups: formative field studies, Internet-based field studies, and clinic-based field studies. Formative field studies aimed to guide decisions about the basic structure and content of the classification, exploring clinicians' conceptualizations of the interrelationships among categories of mental disorders. In the first study (100), 1,371 psychiatrists and psychologists from 64 countries rated the similarity between mental disorders presented as paired comparisons. The results indicated that the participants' mapping of mental disorders was remarkably consistent across professions, languages and WHO regions. The degree of similarity between clinicians' views and the structures provided by the DSM-IV and ICD-10 was moderate (kappa + .42). The proposed structure for ICD-11 was found to more closely align with clinicians' understanding of the relationships among disorders (kappa + .51). In the second study (101), 517 mental health professionals recruited by field study centres in eight countries were asked to sort a set of 60 cards containing the names of mental disorders, based on their own clinical experience, and then to form a hierarchical structure by aggregating and disaggregating these groupings. The hierarchical organizations produced by clinicians were remarkably consistent across countries, diagnostic systems currently used and professions. Clinicians' consensus classification structure was different from ICD-10 and DSM-IV and in several respects consistent with proposals for ICD-11. Internet-based field studies are being implemented through the Global Clinical Practice Network, which currently includes about 12,000 practitioners from all regions of the world. Physicians, primarily psychiatrists, represent 59% of the Network, and psychologists 30%. All other mental health disciplines (e.g., nursing, social work and occupational therapy) are also represented. One third of the members are from Asia, one third from Europe, and 20% from the Americas, equally divided between Latin and North America. About 41% come from low- or middle-income countries. Members have registered through nine languages (Arabic, Chinese, English, French, German, Japanese, Portuguese, Spanish and Russian). These Internet-based studies are using vignette methodologies to examine clinical decision-making in relationship to the proposed ICD-11 diagnostic categories and guidelines. Data collection has been completed for the first study, dealing with disorders specifically associated with stress, which has been conducted in English, Japanese and Spanish with the participation of 1,738 Network registrants. Clinic-based studies will assess the clinical utility of proposed ICD-11 diagnostic guidelines in real-life settings, with a special focus on low- and middle-income countries. More specifically, the studies will assess: the ability of the diagnostic categories to aid clinicians' understanding of the person's condition; how well the guidelines fit the presentation of actual clinical cases; the feasibility of using the guidelines in regular clinical interactions; and the adequacy of the guidelines for assessing individuals' conditions. A major multi-country study has also been conducted concerning the utility and reliability of key changes being recommended for the primary health care version of the ICD-11 chapter on mental disorders. This study focused on the most common mental disorders seen in primary care settings (in particular, depression, anxiety and somatic symptoms).

An empirically based alternative to DSM-5's disruptive mood dysregulation disorder for ICD-11.

The World Health Organization (WHO)'s priorities for the development of the classification of mental and behavioural disorders in the ICD-11 include increasing its clinical utility in global mental health settings (1) and improving the identification and diagnosis of mental disorders among children and adolescents (2). An issue that has been hotly debated in the area of childhood psychopathology is the assessment, diagnosis and treatment of children with severe irritability and anger (3,4). Although virtually all children display irritable and angry behaviours at times, some children exhibit them more frequently and more intensely, to the extent that they become an impairing form of emotional dysregulation. Recent findings indicate that these children with chronic and severe irritability/anger have not been adequately identified through existing classification systems, are at an increased risk for particular negative outcomes, and have not received appropriate treatment. To the extent that ICD-11 can help clarify the clinical picture of irritability/anger, children and families will benefit from more accurate diagnoses, more useful prognoses, and more effective interventions. This paper provides a brief overview of the issue, followed by several possible options and the current proposal for the classification of childhood irritability/anger in ICD-11. This proposal represents a markedly different – but we believe more scientifically justifiable – solution to the problems in this area than that selected for DSM-5 (5).