ICD-11 Guidelines Research Articles

The effectiveness of Reconsolidation of Traumatic Memories for Complex PTSD – A pilot quasi-experimental study from a wellness centre in India

Complex Post-Traumatic Stress Disorder (CPTSD), based on ICD-11 guidelines, is differentiated from PTSD by several unique characteristics. Prolonged or frequent exposure to an event or series of events of extremely threatening or horrific nature increases the risk for CPTSD in adults. For PTSD, Reconsolidation of Traumatic Memories (RTM) has emerged as an effective intervention. There are limited studies on how to address CPTSD. Hence, RTM's effectiveness for CPTSD has not yet been established. In India, there are very few studies on PTSD (focusing mainly on natural disasters and violence), none on CPTSD and none on the effectiveness of RTM. Unfortunately, India, with >400 million young individuals and with high prevalence and limited identification of mental health issues, has a major gap in this area. This quasi-experimental pilot study aimed to assess the effectiveness of the RTM intervention for individuals with CPTSD at a wellness centre in India.The participants (>18 years, n = 107) who reached out to a wellness center for help were assessed by two trained therapists (including a psychologist) based on the presenting problems for CPTSD using the International Trauma Questionnaire. Additional assessments included Major Depression Inventory and Generalized Anxiety Disorder-7. Based on the index-trauma framework, RTM intervention was delivered. Post-measurements were done (a) after one month or at least after five sessions and (b) after three months.After one month (or five sessions), the CPTSD status changed to “none” (no diagnosis) for 80 and “PTSD” for 2 individuals. The results were sustained post-three months (n = 30). The paired t-test confirmed the overall reduction in CPTSD score after one month compared to baseline and even after three months compared to after one month, based on statistical significance (p < .01). The findings confirmed the effectiveness of RTM intervention for individuals with CPTSD. The study's limitations (quasi-experimental design, urban, English-speaking Indians) could be addressed in future work.

Verification of five-factor models and reference scores for personality dysfunction and trait domains of the Personality Assessment Questionnaire for ICD-11 (PAQ-11), revised version.

A brief self-reported measure of the Personality Assessment Questionnaire for the 11th edition of the World Health Organization's International Classification of Disease (ICD-11) (PAQ-11) was developed to evaluate ICD-11 personality traits. The aim of this study was to investigate the validity of the revised PAQ-11 version (PAQ-11R) with an additional item in the Dissociality domain and thresholds for the severity of personality dysfunction and domains. Study 1 examined the construct validity of the PAQ-11R in 192 university students in Korea. Study 2 estimated tentative reference scores of personality dysfunction and domains of the PAQ-11R in 91 patients in Korea. In study 1, the PAQ-11R had a five-factor structure and the revised Dissociality scale had better convergent and discriminant validities than the previous version. In study 2, the receiver operating characteristic (ROC) curve of the PAQ-11R identified a threshold score of 35. Reference scores for domains were estimated as 15 for Negative Affectivity, 10 for Detachment, 8 for Anankastia, and 5 each for Disinhibition and Dissociality. These scores contribute to severity of personality disturbance but remain qualifiers only; they are not diagnostic. The results suggest that the PAQ-11R is useful as a quick assessment tool for identifying the domains of personality dysfunction in clinical practice in harmony with the ICD-11 guidelines.

Comparison of the accuracy of inpatient morbidity coding with ICD-11 and ICD-10.

One of the challenges when transitioning from International Statistical Classification of Diseases and Related Health Problems, 10th Revision (ICD-10) to International Classification of Diseases, 11th Revision (ICD-11) is to ensure clinical coding accuracy. To determine the accuracy of clinical coding with ICD-11 in comparison with ICD-10 and identify causes of coding errors in real clinical coding environments. The study was conducted prospectively in two general hospitals. Medical records of discharged inpatients were coded by hospital clinical coders with both ICD-11 and ICD-10 on different days. These medical records were recoded by five mentors. Codes assigned by mentors were used as the gold standard for the evaluation of accuracy. The accuracy of ICD-10 and ICD-11 coding for 1578 and 2168 codes was evaluated. Coding accuracy was 89.1% and 74.2% for ICD-10 and ICD-11. In ICD-11, the lowest accuracy was observed in chapters 22 (injuries), 10 (ear) and 11 (circulatory) (51.1%, 53.8% and 62.7%, respectively). In both ICD-10 and ICD-11, the most important cause of the coding errors was clinical coders' mistakes (79.5% and 81.8% for ICD-10 and ICD-11, respectively). Accuracy of clinical coding with ICD-11 was lower relative to ICD-10. Hence, it is essential to carry out initial preparations, particularly the training of clinical coders based on their needs, as well as the necessary interventions to enhance the documentation of medical records according to ICD-11 before or simultaneous with the country-wide implementation. Clinical coders need complete training, especially in using extension codes and post-coordination coding. Local ICD-11 guidelines based on the needs of local users and reporting policies should be developed. Furthermore, documentation guidelines based on ICD-11 requirements should be developed.

Motor problems in autism: Co-occurrence or feature?

Motor features of autism have long been acknowledged by clinicians, researchers, and community stakeholders. Current DSM-5 and ICD-11 guidelines allow clinicians to assign a co-occurring diagnosis of developmental [motor] coordination disorder (DCD) for autistic individuals with significant motor problems. DCD is characterized by poor motor proficiency with an onset of symptoms in early development. Studies have shown considerable overlap in the behavioral motor features observed in autism and DCD. However, others indicate that motor problems in autism and DCD may stem from different underlying sensorimotor mechanisms. Regardless of whether autism has a unique motor phenotype or an overlap with DCD, changes need to be made in the clinical pipeline to address motor problems in autism at the stages of recognition, assessment, diagnosis, and intervention. Consensus is needed to address unmet needs in research on the etiology of motor problems in autism and their overlap with DCD, to optimize clinical practice guidelines. The development of screening and assessment tools for motor problems that are valid and reliable for use with autistic individuals is essential, and an evidence-based clinical pipeline for motor problems in autism is urgently needed. WHAT THIS PAPER ADDS: Motor problems in autism are highly prevalent, yet underdiagnosed and poorly managed. An evidence-based clinical pipeline for motor problems in autism is urgently needed.

Comparing ICD-11 and DSM-5 eating disorder diagnoses with the Munich eating and feeding disorder questionnaire (ED-Quest).

The new ICD-11 eating disorders (ED) guidelines are similar to the DSM-5 criteria. One difference to the DSM-5 is the inclusion of subjective binges in the definition of bulimia nervosa (BN) and binge-eating disorder (BED). The aim of this study was to identify differences between the ICD-11 guidelines and DSM-5 ED criteria, which could impact access to medical care and early treatment. Data of 3863 ED inpatients who completed the Munich Eating and Feeding Disorder Questionnaire were analyzed using standardized diagnostic algorithms for DSM-5 and ICD-11. Agreement of diagnoses was high (Krippendorff's α = .88, 95% CI [.86, .89]) for anorexia nervosa (AN; 98.9%), BN (97.2%) and BED (100%), and lower for other feeding and eating disorders (OFED; 75.2%). Of the 721 patients with a DSM-5 OFED, 19.8% were diagnosed with AN, BN or BED by the ICD-11 diagnostic algorithm, reducing the number of OFED diagnoses. One-hundred and twenty-one patients received an ICD-11 diagnosis of BN or BED because of subjective binges. For over 90% of patients, applying either DSM-5 or ICD-11 diagnostic criteria/guidelines resulted in the same full-threshold ED diagnosis. Sub-threshold and feeding disorders exhibited a discrepancy of 25%. For about 98% of inpatients, the ICD-11 and DSM-5 agree on the same specified eating disorder diagnosis. This is important when comparing diagnoses made by different diagnostic systems. Including subjective binges in the definition of bulimia nervosa and binge-eating disorder contributes to improved ED diagnoses. Clarifying the wording of diagnostic criteria at several places could further increase this agreement.

Who feels affected by "out of control" sexual behavior? Prevalence and correlates of indicators for ICD-11 Compulsive Sexual Behavior Disorder in the German Health and Sexuality Survey (GeSiD).

The purpose of this study was to examine the prevalence and correlates of indicators consistent with Compulsive Sexual Behavior Disorder (CSBD)-defined and operationalized according to the ICD-11 guidelines-in a large (n = 4,633; 50.5% male; 49,5% female) probability-based German national sample. Participants were asked if they had ever experienced "intense and recurring sexual impulses or sexual urges that I had difficulty controlling and resulted in sexual behavior" over a period of several months. Those who reported this experience were queried about theassociated distress. Overall, 4.9% of men [95% CI = 3.9-6.1] and 3.0% of women [95% CI=2.3-3.9] reported experiences consistent with ICD-11 diagnostic requirements for lifetime diagnosis. In the 12 months preceding the study, 3.2% of men [95% CI = 2.4-4.2] and 1.8% of women [95% CI = 1.2-2.5] reported experiences consistent with CSBD requirements. Compared to controls and participants who reported elements of compulsive sexuality but without accompanying distress, strict religious upbringing was most prevalent in the CSBD group. The CSBD group was more likely to view sexual practices like men having sex with men as unacceptable and to report the belief that pornography has negative impacts on their sex life and life in general. Compared to the other two groups, the CSBD group was significantly more likely to have received psychiatric treatment for depression or another mental health problem during the past 12 months. The current study provides novel and important insights into the prevalence and characteristics of CSBD in the general population.

The New ICD-11 Prolonged Grief Disorder Guidelines in Japan: Findings and Implications from Key Informant Interviews

Prolonged grief disorder (PGD) is a new mental health disorder, recently introduced in the International Classification of Diseases (ICD-11), World Health Organization Classification of Diseases (WHO). The new ICD-11 guidelines reflect an emerging wave of interest in the global applicability of mental disorders. However, the selection of diagnostic core features in different cultural contexts has yet to be determined. Currently, there is debate in the field over the global applicability of these guidelines. Using semi-structured interviews with 14 key informants, we explored the acceptability of ICD-11 guidelines for PGD according to Japanese health professionals as key informants. The interviews revealed symptoms of grief possibly missing in the ICD-11 PGD guidelines including somatization and concepts such as hole in the heart. Additionally, sociocultural barriers such as stigma and beliefs about the social desirability of emotions may challenge patients’ and clinicians’ acceptance of the new ICD-11 criteria.

Sexual Motivations Underlying Compulsive Sexual Behavior in Women and Men From Germany and Hungary

BackgroundThere are ongoing debates about conflicting models on how to conceptualize compulsive sexual behavior. At the heart of these discussions is the question about the sexual motivations underlying compulsive sexual behavior, as different models assume different motivations. AimThe aim of the present study was to understand sexual motivations underlying compulsive sexual behavior and their relation to the most prominent conceptualizations of compulsive sexual behavior (eg, compulsive sexual behavior disorder [CSBD], sex addiction). MethodsWe used self-reported data from 2 large samples of Hungarian and German populations (N = 9814). The Sexual Motivation Scale (SexMS), a 24-item self-report measure based on self-determination theory, was used to assess a diverse set of sexual motivations. Compulsive sexual behavior was assessed with the 19-item Compulsive Sexual Behavior Disorder Scale (CSBD-19), that is based on the ICD-11 diagnostic guidelines of CSBD. We used structural equation modeling to examine the hypothesized associations between sexual motivations and compulsive sexual behavior and examined potential gender differences in these associations. OutcomesCompulsive sexual behavior was assessed in relation to a set of sexual motivations. ResultsAmotivation had the strongest positive association with compulsive sexual behavior, but integrated, introjected, and intrinsic motivations were also positively related to it. Importantly, these associations did not differ for women and men, and between the 2 samples. Clinical ImplicationsFuture research and treatment should also consider sexual motivations that are not listed among the ICD-11 guidelines for CSBD, including high levels of sexual interest, continuing the behavior despite having little satisfaction from it and coping with sex. Strengths & LimitationsAlthough we used large samples of general populations in 2 Western countries, this motivational background of compulsive sexual behavior awaits replication in a clinical sample of individuals experiencing CSBD. ConclusionThe identified sexual motivations underlying compulsive sexual behavior are relevant for assessing and treating patients as motivations may be integrated into psychotherapeutic interventions. Koós M, Fuss J, Klein V, et al. Sexual Motivations Underlying Compulsive Sexual Behavior in Women and Men From Germany and Hungary. J Sex Med 2022;19:170–181.

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.

ICD-11 Guidelines for Mental and Behavioral Disorders of Children and Adolescents: Reliability and Clinical Utility.

ICD-11 clinical guidelines for mental and behavioral disorders must be tested in clinical settings to guarantee their usefulness worldwide. The purpose of this study was to evaluate interrater reliability and clinical utility of the ICD-11 guidelines for children and adolescents in assessing and diagnosing mood, anxiety, and fear-related disorders; attention-deficit hyperactivity disorder (ADHD); and disruptive behavioral disorder (DBD). Children and adolescents ages 6-17 from two specialized settings in Mexico City were interviewed. Each was interviewed by a pair of psychiatrists (interviewer and observer), who independently codified established diagnoses and evaluated the clinical utility of the guidelines with each participant. Kappa values were calculated to determine the level of general diagnostic correlation between the two clinicians. A total of 25 psychiatrists evaluated 52 children and adolescents. Kappa values between clinicians ranged from 0.46 to 0.53 for mood, anxiety, and fear-related disorders and for ADHD; the kappa value was 0.81 for DBD guidelines. Over 80% of psychiatrists reported that the guidelines, qualifiers, and descriptions of developmental presentations were quite useful. ICD-11 guidelines for mental and behavioral disorders of children and adolescents demonstrated mostly moderate interrater reliability and strong interrater reliability in the case of DBD. A large proportion of clinicians regarded the guidelines as quite useful clinical tools.

What is autism?

The term "Autism spectrum disorder" (ASD), in vogue at present, has evolved after continual substantial developments taking place over more than a century. ASD is a heterogeneous, multi-factorial, developmental disability in which an unusual pattern of development takes place during infant and toddler years. As per DSM-5, Autism spectrum disorder is a combined phrase for a family of complex developmental disabilities inclusive of "Autistic Disorder, Pervasive Developmental Disorder not Otherwise Specified (PDD-NOS), and Asperger's Disorder". "ASD is characterized not only by persistent impairments in reciprocal social communication and social interactions, but is also manifested by restricted, repetitive patterns of behavior, interests, or activities". The classical clinical signs that exist in two major domains, viz. the 'social domain' and the 'behavioral domain' for the precise diagnosis of ASD have been tabulated and major differences between DSM-5 and DSM-4 are depicted with the help of a figure in this basic review article. A sharp rise in the incidence of ASD cases has been observed worldwide owing to various risk factors such as genetic predisposition coupled with adverse environmental conditions, gynecological interventions, etc. Two official manuals viz. the "Diagnostic and Statistical Manual of Mental Disorders" (DSM) (published by the American Psychiatric Association), and the "International Classification of Diseases" (ICD) (published by the World Health Organization) is being regularly updated to facilitate diagnosis of ASD. ICD-11 guidelines being prospectively implemented with effect from January 2022 have attracted global attention.

Does requiring trauma exposure affect rates of ICD-11 PTSD and complex PTSD? Implications for DSM–5.

There is little evidence that posttraumatic stress disorder (PTSD) is more likely to follow traumatic events defined by Criterion A than non-Criterion A stressors. Criterion A events might have greater predictive validity for International Classification of Diseases (ICD)-11 PTSD, which is a condition more narrowly defined by core features. We evaluated the impact of using Criterion A, an expanded trauma definition in line with ICD-11 guidelines, and no exposure criterion on rates of ICD-11 PTSD and Complex PTSD (CPTSD). We also assessed whether 5 psychologically threatening events included in the expanded definition were as strongly associated with PTSD and CPTSD as standard Criterion A events. A nationally representative sample from Ireland (N = 1,020) completed self-report measures. Most participants were trauma-exposed based on Criterion A (82%) and the expanded (88%) criterion. When no exposure criterion was used, 13.7% met diagnostic requirements for PTSD or CPTSD, 13.2% when the expanded criterion was used, and 13.2% when Criterion A was used. The 5 psychologically threatening events were as strongly associated with PTSD and CPTSD as the Criterion A events. In a multivariate analysis, only the psychologically threatening events were significantly associated with PTSD (stalking) and CPTSD (bullying, emotional abuse, and neglect). Certain non-Criterion A events involving extreme fear and horror should be considered traumatic. The ICD-11 approach of providing clinical guidance rather than a formal definition offers a viable solution to some of the problems associated with the current and previous attempts to define traumatic exposure. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

How does level of personality functioning inform clinical management and treatment? Implications for ICD-11 classification of personality disorder severity.

The International Classification of Diseases, 11th Edition (ICD-11) classifies personality disturbance according to levels of severity. This article reviews the literature on levels of personality functioning in relation to clinical management and treatment, and proposes how these findings apply to the ICD-11 classification of personality disorders. Findings were primarily derived from studies using the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5) Level of Personality Functioning Scale (LPFS), Kernberg's Level of Personality Organization, and the general P-factor of personality disorder. Severity of personality dysfunction is related to treatment outcome, risk of dropout, therapeutic alliance, readiness for treatment, risk of harm to self or others, risk of dissociation and psychotic-like breaks, coherence in narrative identity, reflective functioning, and epistemic trust. The overall level of personality disorder severity indicates risk of negative outcomes and may be used as decision tool for 'personalized medicine' and required treatment intensity (e.g., strength of alliance and the need for establishing epistemic trust). Beyond the ICD-11 guidelines for determining personality disorder severity, these implications also apply to practitioners using comparable frameworks such as the DSM-5 LPFS and Kernberg's Level of Personality Organization. Future research should focus on the interaction of severity with trait qualifiers in relation to clinical management.

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.

Estimating the Prevalence of Sexual Dysfunction Using the New ICD-11 Guidelines.

The 11th edition of the International Statistical Classification of Diseases (ICD-11) is due to come into force in 2022. The goal of the present partial evaluation of the GeSiD study findings is to provide the first ever estimate of the prevalence of different types of sexual dysfunction in Germany as defined by the diagnostic guidelines that are soon to take effect. The representative GeSiD study was carried out in 4955 men and women who belonged to a doubly stratified random sample of data from residence registration offices across Germany. The participation rate was 30.2%. Various types of sexual dysfunction were ascertained for the first time by means of a screening instrument based on the new ICD-11 guidelines. The reported prevalence of one or more sexual problems, including mild distress, in the previous 12 months was 33.4% in men (95% confidence interval [31.0; 35.9]) and 45.7% in women [43.0; 48.4]. Some 80.4% of men and 72.1% of women stated that they had had at least one sexual contact in the past year. Sexual dysfunction causing marked distress, as per the ICD-11 guidelines, was reported by 13.3% [11.6; 15.1] of the sexually active men (most commonly, erectile dysfunction in 6.6% and early ejaculation in 4.5%), and by 17.5% [15.6; 19.6] of the sexually active women (most commonly, hypoactive sexual desire in 6.9% and orgasmic dysfunction in 5.8%). Orgasmic dysfunction was approximately twice as common in women as delayed ejaculation was in men. The prevalence of erectile dysfunction increased with age, while that of early ejaculation decreased. Women felt particularly impaired by pain associated with sexual activity. The findings of this study indicate the importance of sexual dysfunction as an obstacle to sexual health. The study provides the first prevalence estimates for the new ICD-11 guidelines and simultaneously offers a screening instrument for sexual dysfunction that can be used economically in routine practice.

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.

Legal and Policy Implications in Mexico of Changes in ICD-11 Paraphilic Disorders

IntroductionThe World Health Organization (WHO) has made substantial changes to the classification of paraphilic disorders for the Eleventh Revision of the International Classification of Diseases and Related Health Problems (ICD-11), recently approved by the World Health Assembly. The most important is to limit paraphilic disorders primarily to persistent and intense patterns of atypical sexual arousal involving non-consenting individuals, manifested through persistent sexual thoughts, fantasies, urges, or behaviors, that have resulted in action or significant distress. AimTo analyze the legal, regulatory, and policy implications of the changes in the ICD-11 classification of paraphilic disorders for forensic practice, health systems, adjudication of sex offenders, and the provision of treatment in Mexico. MethodsAn expert Mexican advisory group was appointed to conduct this evaluation following an assessment guide provided by the WHO. Main Outcome MeasuresThe WHO assessment guide covered (i) laws related to sexual behaviors; (ii) the relationship between legal and clinical issues for non-forensic health professionals; (iii) implications of mental disorder classification for forensic practice; (iv) other implications of ICD-11 paraphilic disorders proposals; and (v) contextual issues. ResultsA variety of factors in Mexico make it highly unlikely that appropriate, evidence-based treatments for paraphilic disorders will be provided to those who need them, even if they seek treatment voluntarily and have not committed a crime. Mexican law focuses on the punishment of specific sexual behaviors rather than on underlying disorders. A paraphilic disorder would not be considered sufficient grounds for exemption from criminal responsibility. The application and scope of mental health evaluations in Mexican legal proceedings are quite limited, and individuals who commit sexual crimes almost never undergo forensic evaluations to establish the presence of paraphilic disorders. Psychiatric services may be mandated for sex offenders in highly specific circumstances but cannot exceed the duration of the criminal sentence. Clinical ImplicationsEvaluation and treatment guidelines should be developed based on international evidence and standards and promulgated for use with individuals with paraphilic disorders in forensic and non-forensic poopulations. The much greater specificity and operationalization of the ICD-11 guidelines as compared with the ICD-10 guidelines provide a better basis for identification and case formulation. Strengths & LimitationsMajor strengths of this analyses were that it was conducted to facilitate international comparability across several participating countries and the fact that it was conducted by a diverse multidisciplinary group representing various relevant legal, forensic and and clinical sectors. A limitation was that it was only possible to examine relevant federal laws and those of Mexico City rather than those of all 32 Mexican states. ConclusionThe descriptions of paraphilic disorders in the ICD-11 could support substantial improvements in the treatment of individuals with paraphilic disorders and the adjudication of sex offenders in Mexico, but specific changes in Mexican law would be required.Martínez-López JNI, Robles R, Fresán A, et al. Legal and Policy Implications in Mexico of Changes in ICD-11 Paraphilic Disorders. J Sex Med 2019;16:1623–1637.

Current Legal Situation for Patients with Paraphilic disorders and Implications of the ICD-11 for Paraphilic Disorders for Germany

IntroductionRecently the guidelines for the diagnosis of paraphilic disorders in the International Classification of Diseases and Related Health Problems, Eleventh Revision (ICD-11), have been published. AimThis article analyzes legal, regulatory, and policy issues relevant to the potential effects of the changes for the classification of paraphilic disorders in the ICD-11 in Germany. MethodsA forensic and a legal expert in Germany worked with other international experts to conduct this evaluation using an assessment guide provided by the World Health Organization. Main Outcome MeasuresPossible effects of the changes for the classification of paraphilic disorders in the ICD-11 on forensic practice, health systems, adjudication of individuals who have committed a sexual offense, and the provision of treatment in Germany. ResultsResults highlight the special situation of medical confidentiality in the German health system that facilitates the establishment of preventive networks for the treatment of pedophilic patients. The ICD-11 guidelines will help to clarify the boundary between pedophilic disorder and crimes of child sexual abuse. These will also establish a boundary with other paraphilic diagnostic concepts. We describe the central construct of criminal responsibility in the German legal system in relation to paraphilic disorders, the prominent role of expert witnesses, and the differences in the conceptualization of medical confidentiality within the health care system and within the legal system. Clinical ImplicationsThe ICD-11 proposals for paraphilic disorders provide a clearer differentiation, as compared with ICD-10, between variants of normal sexual behavior and sexual behavior that involves a non-consenting person or entity. Particular patterns of sexual preference that are not of relevance to public health, the health care system, or the legal system, such as masochism and fetishism, will no longer be named psychiatric entities and will, therefore, be regarded as private behaviors and destigmatized. Strengths & LimitationsThe assessment shows the specific legal situation in Germany for the treatment of paraphilic patients in a sexual medicine, psychiatric, and legal discourse. However, it was done only by a small number of experts. ConclusionA conclusion of the analysis was that the more specific and narrower definitions in the ICD-11 diagnostic guidelines, compared with those in ICD-10, particularly for pedophilic disorder and coercive sexual sadism disorder, will result in a reduction in false-positive diagnoses. It is unlikely that significant unintended and negative consequences will occur as a result of implementing the ICD-11 guidelines for paraphilic disorders.Briken P, Boetticher A, Krueger RB, et al. Current Legal Situation for Patients with Paraphilic disorders and Implications of the ICD-11 for Paraphilic Disorders for Germany. J Sex Med 2019;16:1615–1622.

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.