Following the development of ICD-11 through<i>World Psychiatry</i>(and other sources)
Authors: Valeria Del Vecchio
Journal: World Psychiatry (2014)

The World Health Organization (WHO) is developing the 11th edition of the International Classification of Diseases and Related Health Problems (ICD-11), whose publication is currently expected in the year 2015. The WPA is partnering with the WHO in the production of the chapter on mental and behavioural disorders. The principles guiding the development of that chapter have been summarized by the International Advisory Group for the Revision of ICD-10 Mental and Behavioural Disorders in a paper published in World Psychiatry in June 2011 1. That paper emphasizes that the chapter is being produced in consultation with relevant stakeholders, including WHO 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 seen as an opportunity to improve the classification's clinical utility, particularly in primary care settings and in low- and middle-income countries (see also 2, 3). The ICD-11 classification will remain based on descriptions of the prototypes of the various mental disorders rather than on operational diagnostic criteria. The advantages and possible limitations of this approach have been discussed in several World Psychiatry articles and commentaries (e.g., 4-11). A major argument in favour of this 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 one of the templates of mental disorders that the clinician has built up in his/her mind through his/her training and clinical experience (see also 12). Moreover, some recent research focusing on various classes of mental disorders (i.e., personality, eating, anxiety and mood disorders) suggests that a diagnostic system based on refined prototypes may be as reliable as one based on operational criteria, while being more user friendly and having greater clinical utility (e.g., 13, 14). Eleven Working and Consultation Groups have been appointed by the WHO for the development of the ICD-11 chapter on mental and behavioural disorders. These groups include several WPA officers and experts among their chairpersons and members (see 15, 16). Several of these groups have recently published background papers or preliminary reports on their activities. Highlights of the expected convergences and divergences between the ICD-11 and DSM-5 approaches to the classification of mood disorders have been presented in several papers in various journals (e.g., 17, 18) and in a supplement to World Psychiatry 19. Among the convergences are the inclusion of activation/energy as a defining symptom for mania, and the acknowledgement 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, the ICD-11, as the DSM-5, will allow the clinician to record the occurrence of a subsyndromal anxiety syndrome in a patient with a major depressive episode, by using a specifier. Bipolar II disorder is expected to be recognized as a distinct diagnostic entity in the ICD-11, while in ICD-10 it is just mentioned among “other bipolar affective disorders”. Expected divergences between the ICD-11 and the DSM-5 will include a different characterization of mixed states and schizoaffective disorders. Furthermore, 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” (see 20-26). Highlights of the expected convergences and divergences between the ICD-11 and the DSM-5 in the classification of stress-related disorders have been presented in a recent World Psychiatry paper 27. In the ICD-11, the proposed new grouping of “disorders specifically associated with stress” will include adjustment disorder (whose description will undergo a major revision, involving an increased specification of symptoms), post-traumatic stress disorder (PTSD) (whose diagnosis is going to be based on three well-identified core symptoms), and complex PTSD (a new category marked by disturbance in the domains of affect, self-concept and relational functioning in addition to the three core features of PTSD). Acute stress reaction will be conceptualized as a normal reaction and thus classified in the chapter corresponding to ICD-10 “Factors influencing health status and contact with services” (while “acute stress disorder” is still included in the section on trauma- and stress-related disorders in the DSM-5). Proposals for the ICD-11 section on feeding and eating disorders have been summarized in another World Psychiatry article 28. These include a broadening of the category of anorexia nervosa 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 will be included as a specific diagnostic category, in agreement with the DSM-5. The input of the ICD-11 Working Group on Intellectual Developmental Disorders has been presented in a paper published in World Psychiatry in 2011 29 and is further discussed in this issue of the journal 30. Intellectual developmental disorders (a term replacing “mental retardation”) are proposed to 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”. The Working Group further advised that intellectual developmental disorders be incorporated in the larger grouping of neurodevelopmental disorders, that current subcategories based on clinical severity be maintained, and that problem behaviours be described as associated features. The Chairman of the ICD-11 Working Group on Psychotic Disorders recently reported 31 about the expected convergences and divergences in the ICD-11 and DSM-5 approaches to the classification of those 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 the disorder are going to be omitted. These subtypes will be replaced by six symptom specifiers (positive symptoms, negative symptoms, depressive symptoms, manic symptoms, psychomotor symptoms, and cognitive impairment). 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. Preliminary reports about the development of the ICD-11 sections on mental disorders in children and adolescents 32, somatic distress and dissociative disorders 33 and personality disorders 34 are also available in the recent literature. A more general discussion of diagnostic topics related to DSM-5 and ICD-11 classifications can be found in recent issues of World Psychiatry 35-45. Internet-based field testing of proposals for ICD-11 will be implemented through the Global Clinical Practice Network, currently consisting of more than 7,000 individual mental health and primary care practitioners (www.globalclinicalpractice.net).