ICD-11 Classification Research Articles

AS13-01 - Towards ICD-11: world health organization field studies on clinicians’ conceptualizations of mental disorders

The World Health Organization Department of Mental Health and Substance Abuse has been conducting an active program of field studies and international surveys as a part of developing the ICD-11 classification of mental and behavioural disorders. A key priority for WHO is that the ICD-11 serve as a more effective tool for reducing the global disease burden of mental and behavioural disorders. In support of this objective, a major goal of the revision is to improve the classification's clinical utility. To provide relevant information on clinical utility, WHO has worked to assess the perspectives of practicing clinicians throughout the world. Two global field studies have been conducted regarding how clinicians conceptualize the relationships among mental disorders based on their clinical experience. The first study included 1371 psychiatrists and psychologists from 64 countries, and used a paired comparisons methodology. The second study used a ‘folk taxonomy’ method, and was administered with 480 psychiatrists and psychologists in Brazil, China, India, Japan, Mexico, Nigeria, Spain, and the USA. Highly similar results were obtained across two large international studies using different methodologies. Clinicians’ conceptualizations are rational and highly stable, regardless of country, language, profession, and country income level. Differences between clinicians’ judgments and classification system are not due to idiosyncratic clinician error, but rather to systematic differences. The presentation will discuss how empirical data on clinician judgments are contributing to the development of a new and more clinically useful classification of mental disorders, without sacrificing validity.

New era or false dawn?

There is little doubt that experts in the field have had an appetite for changing the classification of personality disorders (Bernstein, Iscan, Maser, & Boards of Directors of the Association for Research in Personality Disorders International Society for the Study of Personality Disorders, 2007), but if the DSM-5 debate is any indication, it is not clear whether this is shared by rank-and-file clinicians. Many agree that the existing ICD-10 (WHO, 1992) and DSM-IV-TR (APA, 2000) systems are unsatisfactory. Tyrer and colleagues’ (this issue) diagnosis of the problem is precise, but this does not ensure that the treatment will be palatable. Indeed, some might now regret what they wished for as they read Tyrer and colleagues’ radical proposal for reclassifying personality disorder in ICD-11. Change, whether radical or not, must offer some advantage over the previous system, and although discussion regarding the DSM-5 is well advanced, the ICD-11 proposal is only just beginning to take shape and will no doubt be the subject of strenuous debate. The proposed ICD-11 classification of personality disorders has the welcome aims of improving the clinical utility of the diagnosis of personality disorder, reducing stigma and helping in the development and selection of appropriate treatment. Such practical aims are in large part due to the wide constituency of the ICD-11, which is intended for use across the globe in primary through to specialist health-care settings. This contrasts with the DSM-5, which is being produced by the American Psychiatric Association and is primarily intended for use in specialist psychiatric practice. Clinical experience suggests that the requisite skills for diagnosing personality disorders are not always available, even in specialist settings, and a more straightforward approach might improve confidence and usage of these diagnoses. ICD-10 was never really satisfactory. It imitated aspects of the DSM but without clear operational criteria was perhaps more unwieldy. The use of ICD coding internationally is not a good index of its acceptability, as in many countries these codes are used through ‘back translation’ from the DSM codes. Despite this, Tyrer and colleagues refer to the low level of usage of all the current personality disorder categories, except borderline (emotionally unstable) and antisocial (dissocial) as evidence of the shortcomings of both ICD and DSM. The ICD-11 proposal introduces a primary classification based upon five levels of severity. This is a very constructive innovation and is similar to that proposed for DSM-5, providing an opportunity to develop common ground between the two systems. Although they are likely to be separate but overlapping constructs, personality traits and personality dysfunction are often confounded (Clark, 2007), and assessing severity separately to trait domains is a significant improvement.

The WPA-WHO Global Survey of Psychiatrists' Attitudes Towards Mental Disorders Classification.

This article describes the results of the WPA-WHO Global Survey of 4,887 psychiatrists in 44 countries regarding their use of diagnostic classification systems in clinical practice, and the desirable characteristics of a classification of mental disorders. The WHO will use these results to improve the clinical utility of the ICD classification of mental disorders through the current ICD-10 revision process. Participants indicated that the most important purposes of a classification are to facilitate communication among clinicians and to inform treatment and management. They overwhelmingly preferred a simpler system with 100 or fewer categories, and over two-thirds preferred flexible guidance to a strict criteria-based approach. Opinions were divided about how to incorporate severity and functional status, while most respondents were receptive to a system that incorporates a dimensional component. 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 represents an important focus for the ICD revision, as does ensuring that the ICD-11 classification of mental disorders is acceptable to psychiatrists throughout the world.

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

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

P02-245 - Late-Onset Schizophrenia: a Case Report

IntroductionLate-onset psychoses are a heterogeneous group of disorders whose nosology has been controversial throughout history. Several methodological limitations have made difficult the comparison among studies and, as a consequence, the research interest has been little, leading to the absence of late-onset schizophrenia and paraphrenia in current official classifications.Aims and methodologyTo highlight the specific symptoms of late-onset schizophrenia as well as its differences with other psychoses though the study of a case report.ResultsA 70-year-old woman developed psychotic symptoms during the last seven years, consisting of auditory and olfactory hallucinations, telepathic phenomena and injury delusions, erotomania and thought control, with a high level of systematization and fantasy. She was admitted in an inpatient unit. She was treated with risperidone and the psychotic symptoms got better. At the time of hospital discharge, hallucinations and delusional thoughts had disappeared and no behavioral or emotional disorder was observed. Some weeks later, risperidone had to be substituted by paliperidone due to side effects, such as tremor, sialorrhea and parkinsonism.ConclusionsLate-onset schizophrenic psychosis is not as exceptional as it has been traditionally considered. One of the main problems is that current classifications do not include specific diagnostic categories for cases of late or very-late-onset psychoses. It would be necessary that future ICD-11 and DSM-V classifications will include different-age criteria when diagnosing mental disorders.

PL01-01 Progress in the development of ICD-11 and DSM-V classifications of mental disorders

The International classification of diseases - which includes a chapter dealing with mental disorders - will be revised and its 11th Revision will be published in 2014.A special unit within the World Health Organization coordinates the process of revision and the numerous tasks that have to be undertaken to ensure full participation of the WHO member states in the process of revision as well as the consideration of evidence on which the classification is to be based.The Department of Mental Health and Substance Abuse Control of the WHO has created a special advisory group that should help it in considering the evidence and proposals made by scientists, governments, organizations and interested individuals and in producing the draft of the classification of mental disorders for inclusion into the 11th Revision of the ICD: This group has, in turn, developed several structures that will deal with the tasks that will arise in the revision process. At the same time the American Psychiatric Association has created a DSM 5 Task Force that should develop proposals for the 5th Revision of the Diagnostic and Statistical Manual that will be published in 2012.The lecture will describe the processes and structures that have been put in place by the two organizations and refer to the issues that have arisen or are likely to arise in the course of work that should lead to the proposals for the ICD 11 and the DSM 5.

Towards innovative international classification and diagnostic systems: ICD‐11 and person‐centered integrative diagnosis

Towards innovative international classification and diagnostic systems: ICD‐11 and person‐centered integrative diagnosis

An empirical literature review of definitions of severe and persistent mental illness

Seventeen definitions of the severely and persistently mentally ill have appeared in the literature over the past decade. These definitions have been used by 13 authors to formulate service programs and to estimate the prevalence of serious mental illness in the population. To test the applicability of these definitions, the authors operationalized each definition and applied it to a representative sample of 222 patients receiving services in one of Philadelphia's inner-city neighborhoods. The analysis showed estimates of prevalence of serious mental illness ranging from 4% to 88% of the treated population, depending on the definition applied. The NIMH (1987) definition was representative of the middle-range estimates of 45% to 55% arrived at by eight authors.