The diagnostic stability of ICD-10 psychiatric diagnoses in clinical practice

Pattern of psychiatric in-patient admissions in Al Ain, United Arab Emirates

An understanding of the current state of mental health services in the United Arab Emirates (UAE) from a clinical perspective is an important step in advising government and stakeholders on addressing the mental health needs of the fast-growing population. We conducted a retrospective study of data on all patients admitted to a regional psychiatric in-patient unit between June 2012 and May 2015. More Emiratis (UAE nationals) were admitted compared with expatriates. Emiratis were diagnosed more frequently with substance use disorders and expatriates with stress-related conditions. Psychotic and bipolar disorders were the most common causes for admission and had the longest in-patient stays; advancing age was associated with longer duration of in-patient stay.

Diagnostic Stability in Bipolar Disorder: A Narrative Review

LEARNING OBJECTIVES

After participating in this activity, learners should be better able to:• Evaluate diagnostic stability in bipolar disorder• Analyze the factors contributing to diagnostic stability OBJECTIVE: Diagnostic stability is the degree to which a diagnosis remains unchanged during follow-up. It is an important measure of predictive validity in bipolar disorder (BD). In this study, we review the literature concerning diagnostic stability in BD, analyze the factors contributing to diagnostic stability, and describe the implications of diagnostic boundaries and diagnostic delay.

METHODS

A comprehensive literature search of MEDLINE and EMBASE databases was conducted, including all studies published from 1980 to 2016, to evaluate the diagnostic stability of BD. Thirty-seven articles were included: 6 focusing mainly on BD, 18 on psychotic disorders, 10 on depression, and 3 on diagnostic stability in psychiatric disorders in general. Data analysis was performed in standardized fashion using a predefined form.

RESULTS

Despite a high variability of the methodological approaches taken, an acceptable degree of diagnostic stability was found. The most common criteria for evaluating diagnostic stability were prospective consistency and retrospective consistency. The mean prospective and retrospective consistencies were 77.4% and 67.6%, respectively. A large majority of studies were performed in Europe or in North America (67.5%), compared to 21.6% in Asia and only 10.8% in Africa, Oceania, and South America. Extreme ages, female gender, psychotic symptoms, changes to treatment, substance abuse, and family history of affective disorder have been related to diagnostic instability.

CONCLUSIONS

Several factors appear to have a negative impact on the diagnostic stability, but the evidence is insufficient to draw any robust conclusions. Nevertheless, despite variable prospective and retrospective consistencies, the overall diagnostic stability is good. Standardized methods need to be used to obtain more accurate assessments of stability.

Schizophrenia in ICD-11: Comparison of ICD-10 and DSM-5

The conceptualization of schizophrenia has changed from its initial conception in the 19th century to the recent publication of the ICD-11. The changes incorporated in this latest version were made based on the evaluation of the current ICD, the available scientific evidence, and the consensus reached by its developers. In this paper we describe the conceptualization changes (diagnostic criteria and specifiers) of ICD-11 schizophrenia with respect to those of ICD-10 and DSM-5. The changes found are discussed based on the scientific literature published in Medline, Scopus and Scielo until July 2019 and the information on the Wordl Health Organization and American Psychiatric Association websites. Given that the diagnosis of schizophrenia is based on the diagnostic criteria of the diagnostic classification systems, it is important to know the changes made in its conceptualization and the evidence supporting such modifications.

Diagnostic stability of schizophrenia: A systematic review

The objective is to systematically review previous literature on the diagnostic stability of schizophrenia, particularly to investigate prospective and retrospective consistency. We carried out a systematic literature search in PubMed and other minor sources from 1980 to July 2017. Specifically, prospective and retrospective consistency were examined. Thirty-nine studies were included, 5 focused on schizophrenia, 23 on psychotic episodes and 11 on psychiatric disorders in general. Samples sizes range from 60 to 10 058 subjects (total N = 39 965). The majority of studies (n = 26, 66.67%) were performed in Europe and North America and they had a prospective design (n = 27, 69.23%), with a median follow-up of 3 years. Prospective and retrospective consistency means were 84.29% and 67.15% respectively. Diagnostic change was also frequently measured (n = 12, mean 31.28%). The factors more commonly associated with diagnostic stability were: male sex, older age at the study inception, older age at onset, late stages of illness, family history of mental illness, poorer functioning and longer length of stay. Schizophrenia was found to have high diagnostic stability over time, although research on this topic is mainly focused in first psychotic episodes. More standardized methods are needed to further research diagnostic stability of schizophrenia over time and its determinants.

First rank symptoms for schizophrenia

BACKGROUND

Early and accurate diagnosis and treatment of schizophrenia may have long-term advantages for the patient; the longer psychosis goes untreated the more severe the repercussions for relapse and recovery. If the correct diagnosis is not schizophrenia, but another psychotic disorder with some symptoms similar to schizophrenia, appropriate treatment might be delayed, with possible severe repercussions for the person involved and their family. There is widespread uncertainty about the diagnostic accuracy of First Rank Symptoms (FRS); we examined whether they are a useful diagnostic tool to differentiate schizophrenia from other psychotic disorders.

OBJECTIVES

To determine the diagnostic accuracy of one or multiple FRS for diagnosing schizophrenia, verified by clinical history and examination by a qualified professional (e.g. psychiatrists, nurses, social workers), with or without the use of operational criteria and checklists, in people thought to have non-organic psychotic symptoms.

SEARCH METHODS

We conducted searches in MEDLINE, EMBASE, and PsycInfo using OvidSP in April, June, July 2011 and December 2012. We also searched MEDION in December 2013.

SELECTION CRITERIA

We selected studies that consecutively enrolled or randomly selected adults and adolescents with symptoms of psychosis, and assessed the diagnostic accuracy of FRS for schizophrenia compared to history and clinical examination performed by a qualified professional, which may or may not involve the use of symptom checklists or based on operational criteria such as ICD and DSM.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened all references for inclusion. Risk of bias in included studies were assessed using the QUADAS-2 instrument. We recorded the number of true positives (TP), true negatives (TN), false positives (FP), and false negatives (FN) for constructing a 2 x 2 table for each study or derived 2 x 2 data from reported summary statistics such as sensitivity, specificity, and/or likelihood ratios.

MAIN RESULTS

We included 21 studies with a total of 6253 participants (5515 were included in the analysis). Studies were conducted from 1974 to 2011, with 80% of the studies conducted in the 1970's, 1980's or 1990's. Most studies did not report study methods sufficiently and many had high applicability concerns. In 20 studies, FRS differentiated schizophrenia from all other diagnoses with a sensitivity of 57% (50.4% to 63.3%), and a specificity of 81.4% (74% to 87.1%) In seven studies, FRS differentiated schizophrenia from non-psychotic mental health disorders with a sensitivity of 61.8% (51.7% to 71%) and a specificity of 94.1% (88% to 97.2%). In sixteen studies, FRS differentiated schizophrenia from other types of psychosis with a sensitivity of 58% (50.3% to 65.3%) and a specificity of 74.7% (65.2% to 82.3%).

AUTHORS' CONCLUSIONS

The synthesis of old studies of limited quality in this review indicates that FRS correctly identifies people with schizophrenia 75% to 95% of the time. The use of FRS to diagnose schizophrenia in triage will incorrectly diagnose around five to 19 people in every 100 who have FRS as having schizophrenia and specialists will not agree with this diagnosis. These people will still merit specialist assessment and help due to the severity of disturbance in their behaviour and mental state. Again, with a sensitivity of FRS of 60%, reliance on FRS to diagnose schizophrenia in triage will not correctly diagnose around 40% of people that specialists will consider to have schizophrenia. Some of these people may experience a delay in getting appropriate treatment. Others, whom specialists will consider to have schizophrenia, could be prematurely discharged from care, if triage relies on the presence of FRS to diagnose schizophrenia. Empathetic, considerate use of FRS as a diagnostic aid - with known limitations - should avoid a good proportion of these errors.We hope that newer tests - to be included in future Cochrane reviews - will show better results. However, symptoms of first rank can still be helpful where newer tests are not available - a situation which applies to the initial screening of most people with suspected schizophrenia. FRS remain a simple, quick and useful clinical indicator for an illness of enormous clinical variability.

Diagnosis of adjustment disorder: reliability of its clinical use and long-term stability

BACKGROUND

Adjustment disorder is a common diagnosis in mental health services. However, the diagnostic reliability and stability of this nosological construct are unclear.

SAMPLING AND METHODS

Clinical chart records of patients who had been discharged with a clinical diagnosis of adjustment disorder were re-evaluated by two independent raters using ICD-10 criteria. On the basis of the chart material, the frequency of readmissions and diagnostic changes were recorded.

RESULTS

Of 142 patients with a clinical diagnosis of adjustment disorder, only 91 (64.1%) retrospectively met ICD-10 criteria for this diagnosis. Eighteen of these 91 patients (19.8%) were readmitted to a mental health hospital within a 5-year period and 9 (9.9%) showed a diagnostic change at readmission, 5 of them to substance use disorders (5.5%).

CONCLUSIONS

The dramatic divergence between the clinical diagnosis and ICD-10 criteria challenges the validity and usefulness of the current nosological concept of adjustment disorder.

The Munich 15-year follow-up study (MUFUSSAD) on first-hospitalized patients with schizophrenic or affective disorders: assessing courses, types and time stability of diagnostic classification

OBJECTIVE

In the context of the development of DSM-V and ICD-11 it appears to be useful to get further data on the validity of the diagnostic differentiation between schizophrenic and affective disorders. This study investigated the relevance of the main diagnostic groups schizophrenia, schizoaffective psychosis and affective disorder in the context of different diagnostic systems (ICD-9, ICD-10, DSM -IV), assessing their time stability, long-term courses, types and functional outcome.

METHODS

A total of 323 first hospitalized inpatients of the Psychiatric Department of the University Munich were recruited at index time. The full follow-up evaluation including standardized assessment procedures could be performed in 197 patients.

RESULTS

The re-diagnosis of the patients' disorders shows that with the transition from ICD-9 to ICD-10 or DSM-IV, the group of affective disorders increased numerically while the diagnostic groups of schizophrenia and schizoaffective disorders decreased in size. The structured clinical interview for DSM-IV (SCID) analysis showed that altogether ICD-10 and DSM-IV had a relatively high diagnostic stability. Of the patients with an ICD-10 diagnosis of schizophrenia, 57% had a chronic course; 61% of the patients with a DSM-IV diagnosis of schizophrenia. Patients with affective disorders, according either to ICD-10 or DSM-IV, had in more than 90% of the cases an episodic-remitting course. In terms of prediction of long-term outcome regarding the differentiation between chronic and non-chronic course, the ICD-10 diagnoses did give a slightly better predictive result than a dimensional approach based on the key psychopathological syndrome scores.

CONCLUSIONS

The differentiation between schizophrenic and affective disorders seems meaningful especially under predictive aspects. A dimensional syndromatological description does not exceed the predictive power of the investigated main diagnostic categories, but might increase the clinically relevant information.

Acute and transient psychotic disorders: comparison with schizophrenia

Concept and nosologic status of acute and transient psychotic disorders, as they appear in the tenth edition of the International Classification of Disease, have seen review from the standpoint of validation and delineation from schizophrenia and affective disorders. Current research, particularly on the epidemiology, course, and outcome, and family genetic studies indicate that these disorders are common among women in developing countries, as well as among lower socioeconomic status and rural subjects. These patients have greater frequency of exposure to stress before childbirth, a family history of acute and transient psychotic disorder (and not of schizophrenia), and a course and outcome that is different from that of schizophrenia. The findings so far support the argument that acute and transient psychotic disorders are different from schizophrenia.

Schizophrenia and related disorders: experience with current diagnostic systems

Schizophrenia and related disorders include a variety of psychotic disorders in the major classification systems, ICD-10 and DSM-IV, with only partial concordance between the two systems. They both rely on demonstrated reliability, but which disorders are the most valid still has to be determined. Particularly for the ICD-10 disorders, only few studies examining external validity have appeared. Disorders of uncertain validity include 'schizo-affective disorders' which in ICD-10 contain the DSM-IV psychotic mood disorders with first-rank symptoms or bizarre delusions; ICD-10 'schizotypal disorder' which in DSM-IV is a personality disorder; the ICD-10 'acute and transient psychotic disorders' and the DSM-IV 'brief psychotic disorder'. Concerning diagnostic criteria, the reliability and validity of Schneiderian first-rank symptoms, 'bizarre' delusions and the Bleulerian 'negative' symptoms have been questioned. Validity studies in these areas are needed before it will be possible to provide major reconstructions for future diagnostic systems. One may hope that, eventually, one common worldwide psychiatric classification will be available.