Proposals for ICD-11: a report for WPA membership
Authors: Mario Luciano
Journal: World Psychiatry (2014)

The production of the chapter on mental and behavioural disorders of the 11th edition of the International Classification of Diseases (ICD-11) is actively ongoing. The approval of the entire classification by the World Health Assembly is now expected in May 2017. There will be at least two versions of the chapter: one for use in specialty settings (Clinical Descriptions and Diagnostic Guidelines) and one for use in primary care. Whether a specific version for research purposes will also be produced is still being discussed. An important new development is that sleep-wake disorders and sexuality-related conditions and dysfunctions will be covered in separate chapters of the classification. In the ICD-10, “non-organic” sleep disorders are included in the chapter on mental and behavioural disorders, while most “organic” sleep disorders appear in the chapter on diseases of the nervous system. This distinction has been regarded as obsolete. The new ICD-11 chapter on sleep-wake disorders will acknowledge that sleep disorders are a distinct area of practice requiring independent clinical attention. Similarly, “non-organic” sexual dysfunctions are included in the ICD-10 chapter on mental and behavioural disorders, while most “organic” sexual dysfunctions appear in the chapter on diseases of the genitourinary system. The new ICD-11 chapter on sexuality-related conditions and dysfunctions will more appropriately reflect current clinical practice, acknowledging that sexual dysfunctions have both psychological and biological components. The development of the ICD-11 chapter on mental disorders is being guided by an International Advisory Group, which is being supported by eleven working groups, dealing respectively with primary care, child and adolescent disorders, intellectual developmental disorders, personality disorders, psychotic disorders, somatic distress and dissociative disorders, stress-related disorders, substance-related and addictive disorders, mood and anxiety disorders, obsessive-compulsive and related disorders, feeding and eating disorders. Furthermore, there is a consultation group on older adults; two working groups, on neurocognitive disorders and on sleep disorders, report to the Advisory Groups for both Mental and Behavioural Disorders and Diseases of the Nervous System; and a working group on sexual disorders and sexual health reports to the Advisory Groups for both Mental and Behavioural Disorders and Reproductive Health. The ICD-11 chapter on mental disorders is being produced in consultation with relevant stakeholders, including World Health Organization's member countries, several professional groups, and users of mental health services and their families. Attention to the cultural framework is being a key element. The revision is being seen as an opportunity to improve the classification's clinical utility, particularly in low- and middle-income countries 1-3. The chapter will remain based on definitions and diagnostic guidelines for the various mental disorders, rather than on operational diagnostic criteria as in the DSM. The advantages and possible limitations of the two approaches have been recently discussed 4-10. A major argument in favour of the former approach is that it is congruent with the spontaneous clinical process, which does not involve checking in a given patient whether each of a series of symptoms is present or not, but rather checking whether the characteristics of the patient match the templates of mental disorders that the clinician has built in his/her mind. A major effort has been made to harmonize the groups of disorders (“blocks”) proposed for the ICD-11 with those included in the DSM-5. There will be, however, several differences at the level of specific diagnostic categories. Although final decisions concerning the contents of the ICD-11 have not been taken as yet, several expected convergences and divergences between the ICD-11 and the DSM-5 have been already discussed in the literature. In the area of psychotic disorders, in the ICD-11 as in the DSM-5, Schneider's first-rank symptoms are going to be deemphasized in the description of schizophrenia, and the subtypes of that disorder are going to be omitted. Contrary to the DSM-5, the ICD-11 is expected to keep the one month duration criterion for the diagnosis of schizophrenia, and not to include functional impairment as a mandatory criterion 11, 12. In the area of mood disorders, in the ICD-11 as in the DSM-5, activation/increased energy is expected to be included as a defining symptom for mania, and it will be acknowledged that a manic/hypomanic syndrome emerging during antidepressant treatment, and persisting beyond the physiological effect of that treatment, qualifies for the diagnosis of manic/hypomanic episode. Furthermore, bipolar II disorder is going to be recognized as a distinct diagnostic entity in the ICD-11 (while it is just mentioned among “other bipolar affective disorders” in the ICD-10). Expected divergences between the ICD-11 and the DSM-5 will include a different characterization of mixed states and schizoaffective disorders. Moreover, the ICD-11 is going to exclude from the diagnosis of depressive episode, in line with the ICD-10 but differently from the DSM-5, “normal bereavement reactions appropriate to the culture of the individual concerned” 13-21. In the ICD-11, acute stress reaction will be conceptualized as a normal reaction and thus classified in the section on “Factors influencing health status and encounters with health services”, while “acute stress disorder” is still included in the section on trauma- and stress-related disorders in the DSM-5. Furthermore, a new diagnostic category will be introduced in the ICD-11, named complex post-traumatic stress disorder (PTSD), marked by disturbance in the domains of affect, self-concept and relational functioning in addition to the three core features of PTSD 22. In the area of eating disorders, the category of anorexia nervosa is expected to be broadened in the ICD-11 through dropping the requirement for amenorrhoea, extending the weight criterion to any significant underweight, and extending the cognitive criterion to include developmentally and culturally relevant presentations. Furthermore, a severity qualifier “with dangerously low body weight” is expected to distinguish the severe cases of anorexia nervosa that carry the riskiest prognosis. The bulimia nervosa category is likely to be extended to include subjective binge eating, and binge eating disorder is going to be included as a specific diagnostic category, in agreement with the DSM-5 23. Intellectual developmental disorders (a term replacing “mental retardation”) will be defined as “a group of developmental conditions characterized by significant impairment of cognitive functions, which are associated with limitations of learning, adaptive behaviour and skills”. Current subcategories based on clinical severity are going to be maintained, while problem behaviours will be described as associated features 24. Preliminary reports from the working groups on somatic distress and dissociative disorders and on personality disorders are also available in the literature 25, 26, and a more general discussion of diagnostic topics related to the ICD-11 and the DSM-5 can be found in recent issues of World Psychiatry and other journals (e.g., 21-41). Two formative field studies have been undertaken early in the process of development of the ICD-11 chapter, in order to examine the views of mental health professionals around the world on the relationships among mental disorders, and to inform decisions about the structure of the classification 42, 43. Two global surveys of professionals' attitudes towards mental disorder classification have been carried out, one in collaboration with the WPA, involving nearly 5,000 psychiatrists in 44 countries 44, and one in collaboration with the International Union of Psychological Science, with the participation of 2,155 psychologists from 23 countries 45. Field testing of proposals for the ICD-11 is being conducted using two approaches. The first is Internet-based field testing, which is being implemented through the Global Clinical Practice Network, a network of individual mental health and primary care practitioners currently including almost 10,000 registered participants from 127 countries. These Internet-based studies are using vignette methodologies to examine clinical decision-making in relationship to the proposed ICD-11 diagnostic categories and guidelines. The second approach is clinic-based field testing, which will assess the utility of proposed ICD-11 diagnostic guidelines in real-life clinical settings, with a special focus on low- and middle-income countries. A series of symposia on the development of the ICD-11 chapter on mental disorders will take place within the World Congress of Psychiatry to be held in Madrid, Spain from 14 to 18 September 2014.