Developing a science of clinical utility in diagnostic classification systems field study strategies for ICD-11 mental and behavioral disorders

Prolonged Grief Disorder: Addressing Misconceptions With Evidence

There are many misconceptions about Prolonged Grief Disorder (PGD). We show with data that PGD is a diagnosis that applies to a rare few of mourners who are at risk of significant distress and dysfunction. Those mourners who meet criteria for PGD have been shown to benefit from specialized, targeted treatment for it. The case against PGD is empirically unsubstantiated, and the need for scientific examination of effective treatments is warranted.

Evidence Base Update on the Assessment of Irritability, Anger, and Aggression in Youth

OBJECTIVE

Irritability, anger, and aggression have garnered significant attention from youth mental health researchers and clinicians; however, fundamental challenges of conceptualization and measurement persist. This article reviews the evidence base for assessing these transdiagnostic constructs in children and adolescents.

METHOD

We conducted a preregistered systematic review of the evidence behind instruments used to measure irritability, anger, aggression, and related problems in youth. Searches were conducted in PsycINFO and PubMed, identifying 4,664 unique articles. Eligibility criteria focused on self- and proxy-report measures with peer-reviewed psychometric evidence from studies in English with youths ages 3-18. Additional measures were found through ancillary search strategies (e.g. book chapters, review articles, test publishers). Measures were screened and coded by multiple raters with acceptable reliability.

RESULTS

Overall, 68 instruments met criteria for inclusion, with scales covering irritability (n = 15), anger (n = 19), aggression (n = 45), and/or general overt externalizing problems (n = 27). Regarding overall psychometric support, 6 measures (8.8%) were classified as Excellent, 46 (67.6%) were Good, and 16 (23.5%) were Adequate. Descriptive information (e.g. informants, scales, availability, translations) and psychometric properties (e.g. reliability, validity, norms) are summarized.

CONCLUSIONS

Numerous instruments for youth irritability, anger, and aggression exist with varying degrees of empirical support for specific applications. Although some measures were especially strong, none had uniformly excellent properties across all dimensions, signaling the need for further research in particular areas. Findings promote conceptual clarity while also producing a well-characterized toolkit for researchers and clinicians addressing transdiagnostic problems affecting youth.

Autism spectrum disorder in ICD-11-a critical reflection of its possible impact on clinical practice and research

This perspective article compares and contrasts the conceptualization of Autism Spectrum Disorder (ASD) in ICD-11 and DSM-5. By guiding the user through the ICD-11 text, it is argued that, in contrast to DSM-5, ICD-11 allows a high variety in symptom combinations, which results in an operationalization of ASD that is in favor of an extreme diverse picture, yet possibly at the expense of precision, including unforeseeable effects on clinical practice, care, and research. The clinical utility is questionable as this conceptualization can hardly be differentiated from other mental disorders and autism-like traits. It moves away from an observable, behavioral, and neurodevelopmental disorder to a disorder of inner experience that can hardly be measured objectively. It contains many vague and subjective concepts that lead to non-falsifiable diagnoses. This bears a large danger of false positive diagnoses, of further increased prevalence rates, limitations of access to ASD-specific services and of increasing the non-specificity of treatments. For research, the hypothesis is that the specificity of ASD will be reduced and this will additional increase the already high heterogeneity with the effect that replication of studies will be hampered. This could limit our understanding of etiology and biological pathways of ASD and bears the risk that precision medicine, i.e., a targeted approach for individual treatment strategies based on precise diagnostic markers, is more far from becoming reality. Thus, a more precise, quantitative description and more objective measurement of symptoms are suggested that define the clinical ASD phenotype. Identification of core ASD subtypes/endophenotypes and a precise description of symptoms is the necessary next step to advance diagnostic classification systems. Therefore, employing a more finely grained, objective, clinical symptom characterization which is more relatable to neurobehavioral concepts is of central significance.

Psychosis superspectrum II: neurobiology, treatment, and implications

Alternatives to traditional categorical diagnoses have been proposed to improve the validity and utility of psychiatric nosology. This paper continues the companion review of an alternative model, the psychosis superspectrum of the Hierarchical Taxonomy of Psychopathology (HiTOP). The superspectrum model aims to describe psychosis-related psychopathology according to data on distributions and associations among signs and symptoms. The superspectrum includes psychoticism and detachment spectra as well as narrow subdimensions within them. Auxiliary domains of cognitive deficit and functional impairment complete the psychopathology profile. The current paper reviews evidence on this model from neurobiology, treatment response, clinical utility, and measure development. Neurobiology research suggests that psychopathology included in the superspectrum shows similar patterns of neural alterations. Treatment response often mirrors the hierarchy of the superspectrum with some treatments being efficacious for psychoticism, others for detachment, and others for a specific subdimension. Compared to traditional diagnostic systems, the quantitative nosology shows an approximately 2-fold increase in reliability, explanatory power, and prognostic accuracy. Clinicians consistently report that the quantitative nosology has more utility than traditional diagnoses, but studies of patients with frank psychosis are currently lacking. Validated measures are available to implement the superspectrum model in practice. The dimensional conceptualization of psychosis-related psychopathology has implications for research, clinical practice, and public health programs. For example, it encourages use of the cohort study design (rather than case-control), transdiagnostic treatment strategies, and selective prevention based on subclinical symptoms. These approaches are already used in the field, and the superspectrum provides further impetus and guidance for their implementation. Existing knowledge on this model is substantial, but significant gaps remain. We identify outstanding questions and propose testable hypotheses to guide further research. Overall, we predict that the more informative, reliable, and valid characterization of psychopathology offered by the superspectrum model will facilitate progress in research and clinical care.

Do We Need a Novel Framework for Classifying Psychopathology? A Discussion Paper

Introduction

The ICD-11 and DSM-5 are the leading systems for the classification of mental disorders, and their relevance for clinical work and research, as well as their impact for policy making and legal questions, has increased considerably. In recent years, other frameworks have been proposed to supplement or even replace the ICD and the DSM, raising many questions regarding clinical utility, scientific relevance, and, at the core, how best to conceptualize mental disorders.

Method

As examples of the new approaches that have emerged, here we introduce the Hierarchical Taxonomy of Psychopathology (HiTOP), the Research Domain Criteria (RDoC), systems and network approaches, process-based approaches, as well as a new approach to the classification of personality disorders.

Results and Discussion

We highlight main distinctions between these classification frameworks, largely related to different priorities and goals, and discuss areas of overlap and potential compatibility. Synergies among these systems may provide promising new avenues for research and clinical practice.

Making chronic pain count: empirical support for the ICD-11 classification of chronic pain

PURPOSE OF REVIEW

The purpose is to review the evidence that has been collected with regard to the new classification of chronic pain. In 2022, the World Health Assembly endorsed the 11 th revision of the International Classification of Diseases and Related Health Problems (ICD-11), and with it a new classification of chronic pain.

RECENT FINDINGS

The evidence from the formative field testing indicated that the categories were clearly delineated and the coverage of chronic pain excellent (<3% in remainder categories). Official WHO field tests showed that the classification works well within the technical parameters WHO classifications must conform to and outperformed the ICD-10 diagnoses in all respects. International field tests, in which clinicians diagnosed consecutive patients in settings of medium and high resources, showed substantial interrater reliability (κ = 0.596 to κ = 0.783) for the diagnoses and the clinicians rated their clinical utility as very high. Studies using complete hospital records demonstrated that with the information they contain, retrospective coding of the new diagnoses is possible and provides much more meaningful information than the ICD-10 diagnoses.

SUMMARY

The evidence supports the use of the new classification and highlights its informational gains - using it will contribute to making chronic pain count in many contexts.

Case-controlled field study of the ICD-11 clinical descriptions and diagnostic requirements for Bodily Distress Disorders

AIMS

Mental disorders characterized by preoccupation with distressing bodily symptoms and associated functional impairment have been a target of major reconceptualization in the ICD-11, in which a single category of Bodily Distress Disorder (BDD) with different levels of severity replaces most of the Somatoform Disorders in ICD-10. This study compared the accuracy of clinicians' diagnosis of disorders of somatic symptoms using either the ICD-11 or ICD-10 diagnostic guidelines in an online study.

METHODS

Clinically active members of the World Health Organization's Global Clinical Practice Network (N = 1065) participating in English, Spanish, or Japanese were randomly assigned to apply ICD-11 or ICD-10 diagnostic guidelines to one of nine pairs of standardized case vignettes. The accuracy of the clinicians' diagnoses as well as their ratings of the guidelines' clinical utility were assessed.

RESULTS

Overall, clinicians were more accurate using ICD-11 compared to ICD-10 for every presentation of a vignette characterized primarily by bodily symptoms associated with distress and impairment. Clinicians who made a diagnosis of BDD using ICD-11 were generally correct in applying the severity specifiers for the condition.

LIMITATIONS

This sample may represent some self-selection bias and thus may not generalize to all clinicians. Additionally, diagnostic decisions with live patients may lead to different results.

CONCLUSIONS

The ICD-11 diagnostic guidelines for BDD represent an improvement over those for Somatoform Disorders in ICD-10 in regard to clinicians' diagnostic accuracy and perceived clinical utility.

The cultural supplement: A new method for assessing culturally relevant prolonged grief disorder symptoms

Background

The new diagnosis of prolonged grief disorder (PGD) is both an opportunity and a challenge for researchers, clinicians, and bereaved individuals. The latest definition of PGD includes a refreshing and novel feature: the cultural caveat, i.e., clinicians must determine that the grief presentation is more severe and of longer duration than would be expected by an individual’s culture and context. Currently, there are no guidelines on how to operationalize the cultural caveat in mental health care settings.

Method

To respond to this important demand we have developed, piloted, and tested the cultural supplement module of the International Prolonged Grief Disorder scale (IPGDS). The cultural supplement aims to provide clinicians with a catalogue of culturally relevant symptoms of grief that indicate probable PGD alongside a simple framework for cultural adaptation for use in specific clinical settings.

Results

In this short report we outline the rationale and aim of the cultural supplement and provide a summary of our latest validation studies of the IPGDS with bereaved German-speaking, Chinese and Swiss migrant individuals. We also provide a step-by-step framework for adaptation of the cultural supplement that clinicians and researchers may use when working with different cultural groups.

Conclusion

To date, this is the first PGD questionnaire based on the ICD-11, and the first to include a cultural supplement that can be adapted to different contexts and groups. This cultural supplement will provide clinicians and researchers an easy-to-use assessment tool with the aim to improve the global applicability of the ICD-11 PGD definition.

Bipolar disorder in the International Classification of Diseases-Eleventh version: A review of the changes, their basis, and usefulness

The World Health Organization’s 11^th revision of the International Classification of Diseases (ICD-11) including the chapter on mental disorders has come into effect this year. This review focuses on the “Bipolar or Related Disorders” section of the ICD-11 draft. It describes the benchmarks for the new version, particularly the foremost principle of clinical utility. The alterations made to the diagnosis of bipolar disorder (BD) are evaluated on their scientific basis and clinical utility. The change in the diagnostic requirements for manic and hypomanic episodes has been much debated. Whether the current criteria have achieved an optimum balance between sensitivity and specificity is still not clear. The ICD-11 definition of depressive episodes is substantially different, but the lack of empirical support for the changes has meant that the reliability and utility of bipolar depression are relatively low. Unlike the Diagnostic and Statistical Manual of Mental Disorders, 5^th edition (DSM-5), the ICD-11 has retained the category of mixed episodes. Although the concept of mixed episodes in the ICD-11 is not perfect, it appears to be more inclusive than the DSM-5 approach. Additionally, there are some uncertainties about the guidelines for the subtypes of BD and cyclothymic disorder. The initial results on the reliability and clinical utility of BD are promising, but the newly created diagnostic categories also appear to have some limitations. Although further improvement and research are needed, the focus should now be on facing the challenges of implementation, dissemination, and education and training in the use of these guidelines.

Chronic Pain in the ICD-11: New Diagnoses That Clinical Psychologists Should Know About

Background

In the 10th revision of the International Classification of Diseases and Related Health Problems (ICD-10), chronic pain was not represented adequately. Pain was left undefined and not recognized as a biopsychosocial phenomenon. Instead, a flawed dualism between psychological and somatic factors was implied. Individual diagnoses were ill-defined and scattered randomly through different chapters. Many patients received diagnoses in remainder categories devoid of meaningful clinical information.

Method

The International Association for the Study of Pain launched a Task Force to improve the diagnoses for the 11th revision of the ICD and this international expert team worked from 2013-2019 in cooperation with the WHO to develop a consensus based on available evidence and to improve the diagnoses.

Results

A new chapter on chronic pain was created with a biopsychosocial definition of pain. Chronic pain was operationalized as pain that persists or recurs longer than three months and subdivided into seven categories: Chronic primary pain and six types of chronic secondary pain. All diagnoses were based on explicit operationalized criteria. Optional extension codes allow coding pain-related parameters and the presence of psychosocial aspects together with each pain diagnosis.

Conclusion

First empirical studies demonstrated the integrity of the categories, the reliability, clinical utility, international applicability and superiority over the ICD-10. To improve reliability and ease of diagnosis, a classification algorithm is available. Clinical psychologists and other clinicians working with people with chronic pain should watch the national implementation strategies and advocate for multimodal and interdisciplinary treatments and adequate reimbursement for all providers involved.

To Utility and Beyond! Specifying and Advancing the Utility of Measurement-Based Care for Youth

Mental health organizations that serve youth are under pressure to adopt measurement-based care (MBC), defined as the continuous collection of client-report data used to support clinical decision-making as part of standard care. However, few frameworks exist to help leadership ascertain how to select an MBC approach for a clinical setting. This paper seeks to define how an MBC approach can display clinical utility to provide such a framework. Broadly, we define clinical utility as evidence that an MBC approach assists stakeholders in fulfilling clinical goals related to care quality (i.e., improve client-clinician alliance and clinical outcomes) at the client (i.e., youth and caregiver), clinician, supervisor, and administrator levels. More specifically, our definition of clinical utility is divided into two categories relevant to the usability and usefulness of an MBC approach for a specific setting: (a) implementability (i.e., evidence indicating ease of use in a clinical setting) and (b) usefulness in aiding clinical activities (i.e., evidence indicating the potential to improve communication and make clinical activities related to care quality easier or more effective). These categories provide valuable information about how easy an MBC approach is to use and the potential benefits that the MBC data will confer. To detail how we arrived at this definition, we review prior definitions of clinical utility, discuss how previous definitions inform our definition of clinical utility for MBC, and provide examples of how the concept of clinical utility can be applied to MBC. We finish with a discussion of future research directions.

Fear of COVID-19, stress and depression: A meta-analytic test of the mediating role of anxiety

OBJECTIVES

The COVID-19 pandemic has negatively affected the lives of millions of individuals physiologically, behaviorally, socially, and/or psychologically. Moreover, there is now much empirical evidence that mental health problems have increased during the pandemic period and these problems have various consequences. The changes in the mood states of individuals due to the pandemic underpins the rationale of the present study. The aim of the study was to identify the cross-sectional associations between fear of COVID-19, stress, anxiety, and depression by using two stage-meta-analytic structural equation modeling (TS-MASEM).

DESIGN

This is a meta-analytic structural equation modelling study.

METHOD

A systematic literature review initially identified 4840 studies. As a result of applying inclusion and exclusion criteria, 25 studies comprising 28 samples (reporting 120 effect sizes) were eligible for inclusion in the current TS-MASEM (N = 16,452).

RESULTS

The results showed significant associations between fear of COVID-19, stress, anxiety, and depression. Additionally, the mediation role of anxiety in the association between depression and fear of COVID-19 and stress was explored.

CONCLUSIONS

Although the results did not allow for causal inferences regarding depression, they provide insight into the possible consequences of fear of COVID-19 and comorbid problems for clinicians and researchers.

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.

An international field study of the ICD-11 behavioural indicators for disorders of intellectual development

BACKGROUND

The World Health Organization (WHO) has approved the 11th Revision of the International Classification of Diseases (ICD-11). A version of the ICD-11 for Mental, Behavioural and Neurodevelopmental Disorders for use in clinical settings, called the Clinical Descriptions and Diagnostic Requirements (CDDR), has also been developed. The CDDR includes behavioural indicators (BIs) for assessing the severity of disorders of intellectual development (DID) as part of the section on neurodevelopmental disorders. Reliable and valid diagnostic assessment measures are needed to improve identification and treatment of individuals with DID. Although appropriately normed, standardised intellectual and adaptive behaviour assessments are considered the optimal assessment approach in this area, they are unavailable in many parts of the world. This field study tested the BIs internationally to assess the inter-rater reliability, concurrent validity, and clinical utility of the BIs for the assessment of DID.

METHODS

This international study recruited a total of 206 children and adolescents (5-18 years old) with a suspected or established diagnosis of DID from four sites across three countries [Sri-Lanka (n = 57), Italy (n = 60) and two sites in India (n = 89)]. Two clinicians assessed each participant using the BIs with one conducting the clinical interview and the other observing. Diagnostic formulations using the BIs and clinical utility ratings were collected and entered independently after each assessment. At a follow-up appointment, standardised measures (Leiter-3, Vineland Adaptive Behaviour Scales-II) were used to assess intellectual and adaptive abilities.

RESULTS

The BIs had excellent inter-rater reliability (intra-class correlations ranging from 0.91 to 0.97) and good to excellent concurrent validity (intra-class correlations ranging from 0.66 to 0.82) across sites. Compared to standardised measures, the BIs had more diagnostic overlap between intellectual and adaptive functioning. The BIs were rated as quick and easy to use and applicable across severities; clear and understandable with adequate to too much level of detail and specificity to describe DID; and useful for treatment selection, prognosis assessments, communication with other health care professionals, and education efforts.

CONCLUSION

The inclusion of newly developed BIs within the CDDR for ICD-11 Neurodevelopmental Disorders must be supported by information on their reliability, validity, and clinical utility prior to their widespread adoption for international use. BIs were found to have excellent inter-rater reliability, good to excellent concurrent validity, and good clinical utility. This supports use of the BIs within the ICD-11 CDDR to assist with the accurate identification of individuals with DID, particularly in settings where specialised services are unavailable.

Local understandings of PTSD and complex PTSD among health professionals working with adolescents in violent neighbourhoods of São Paulo city, Brazil

BACKGROUND

Adolescents in low-resource urban settings in Brazil are often exposed to high levels of trauma that can result in post-traumatic stress disorder (PTSD). However, preliminary evidence indicates that PTSD tends to be under-reported in Brazilian health services, despite the high prevalence of trauma. Additionally, little is known about the perceived applicability among clinicians of the new ICD-11 diagnosis of complex PTSD (CPTSD), despite its potential relevance for contexts of chronic trauma. The current study investigated local understandings of PTSD and CPTSD among health professionals working with adolescents in violent neighbourhoods of São Paulo city.

METHODS

Semi-structured interviews were conducted with 58 health professionals working at both the primary care and specialized mental health levels in two areas of São Paulo city with high levels of community violence.

RESULTS

Most participants knew about PTSD, but most did not know about CPTSD. There were mixed views concerning the commonality of PTSD among adolescents exposed to community violence. Many participants reported having no experience working with patients with the PTSD diagnosis. According to some, community violence was normalized by adolescents and health professionals, and did not result in PTSD. Others highlighted how they did not use psychiatric diagnoses in their practice, had critical perspectives towards psychiatric diagnoses and/or PTSD, or simply knew little about PTSD. Furthermore, many highlighted how the chronic nature of multiple traumas experienced by adolescents often resulted in complex clinical presentations characterised by many symptoms beyond PTSD. The diagnosis of CPTSD was considered appropriate to the context by many participants as it captured the complex traumatic histories and symptom presentations of adolescents exposed to community violence in Brazil.

CONCLUSIONS

These findings have important implications for the assessment and treatment of mental health among adolescents exposed to community violence in Brazil.

Reliability and clinical utility of the chronic pain classification in the 11th Revision of the International Classification of Diseases from a global perspective: results from India, Cuba, and New Zealand

ABSTRACT

Chronic pain affects 1 in 5 persons and contributes substantially to the global burden of disease. The 11th Revision of the International Classification of Diseases (ICD-11) includes a comprehensive classification of chronic pain. The aim of this ecological implementation field study was to evaluate the classification's interrater reliability and clinical utility in countries with different income levels. The study was conducted in 4 pain clinics in Cuba, India, and New Zealand. Twenty-one clinicians used the ICD-11 to diagnose and code n = 353 patients with chronic pain. Of these, 111 were assessed by 2 clinicians, and Fleiss' kappa was calculated to establish interrater reliability for any diagnosis assigned to ≥15 patients. The clinicians rated the clinical utility of all diagnoses. The interrater reliability could be calculated for 11 diagnoses. It was substantial for 10 diagnoses and moderate for 1 (kappa: 0.596-0.783). The mean clinical utility of the ICD-11 chronic pain diagnoses was rated as 8.45 ± 1.69/10. Clinical utility was rated higher for ICD-11 than for the commonly used classification systems (P < 0.001, η2 = 0.25) and differed between all centers (P < 0.001, η2 = 0.60). The utility of the ICD-11 diagnoses was rated higher than the commonly used diagnoses in Dunedin and Havana, and no difference was found in Kolkata and Hyderabad. The study showed the high interrater reliability of the new chronic pain diagnoses. The perceived clinical utility of the diagnoses indicates their superiority or equality compared with the classification systems currently used in pain clinics. These results suggest the global applicability of the classification in specialized pain treatment settings.

Validity and utility of Hierarchical Taxonomy of Psychopathology (HiTOP): III. Emotional dysfunction superspectrum

The Hierarchical Taxonomy of Psychopathology (HiTOP) is a quantitative nosological system that addresses shortcomings of traditional mental disorder diagnoses, including arbitrary boundaries between psychopathology and normality, frequent disorder co-occurrence, substantial heterogeneity within disorders, and diagnostic unreliability over time and across clinicians. This paper reviews evidence on the validity and utility of the internalizing and somatoform spectra of HiTOP, which together provide support for an emotional dysfunction superspectrum. These spectra are composed of homogeneous symptom and maladaptive trait dimensions currently subsumed within multiple diagnostic classes, including depressive, anxiety, trauma-related, eating, bipolar, and somatic symptom disorders, as well as sexual dysfunction and aspects of personality disorders. Dimensions falling within the emotional dysfunction superspectrum are broadly linked to individual differences in negative affect/neuroticism. Extensive evidence establishes that dimensions falling within the superspectrum share genetic diatheses, environmental risk factors, cognitive and affective difficulties, neural substrates and biomarkers, childhood temperamental antecedents, and treatment response. The structure of these validators mirrors the quantitative structure of the superspectrum, with some correlates more specific to internalizing or somatoform conditions, and others common to both, thereby underlining the hierarchical structure of the domain. Compared to traditional diagnoses, the internalizing and somatoform spectra demonstrated substantially improved utility: greater reliability, larger explanatory and predictive power, and greater clinical applicability. Validated measures are currently available to implement the HiTOP system in practice, which can make diagnostic classification more useful, both in research and in the clinic.

Classification of chronic pain for the International Classification of Diseases (ICD-11): results of the 2017 international World Health Organization field testing

ABSTRACT

Because chronic pain has been poorly represented in the International Statistical Classification of Diseases and Related Health Problems (ICD) despite its significant contribution to the burden of disease worldwide, the International Association for the Study of Pain (IASP) developed a classification of chronic pain that was included in the ICD-11 version as "MG30" and approved by the World Health Assembly in 2019. The objective of this field test was to determine how well the classification of chronic pain works in the context of the ICD-11. A web-based survey using the WHO-FiT platform recruited 177 healthcare professionals from all WHO regions. After a training on coding chronic pain hosted by the IASP Web site, participants evaluated 18 diagnostic codes (lines) of the 2017 frozen version of the ICD-11 and 12 vignettes (cases) describing chronic pain conditions. Correctness, ambiguity, and perceived difficulty of the coding were compared between the ICD-11 and the ICD-10 and the applicability of the morbidity rules for the ICD-11 verified. In the line coding, 43.0% of correct chronic pain diagnoses assigned with the ICD-10 contrasted with 63.2% with the ICD-11. Especially in cases in which the chronic pain is regarded as the symptom of an underlying disease, the ICD-11 (63.5%) commanded more correct diagnoses than the ICD-10 (26.8%). The case coding was on average 83.9% accurate, only in 1.6% of cases any difficulty was perceived. The morbidity rules were applied correctly in 74.1% of cases. From a coding perspective, the ICD-11 is superior to the ICD-10 in every respect, offering better accuracy, difficulty, and ambiguity in coding chronic pain conditions.

Confirmatory factor analysis of the Clinician-Administered PTSD Scale (CAPS-5) based on DSM-5 vs. ICD-11 criteria

INTRODUCTION

Many studies have investigated the latent structure of the DSM-5 criteria for posttraumatic stress disorder (PTSD). However, most research on this topic was based on self-report data. We aimed to investigate the latent structure of PTSD based on a clinical interview, the Clinician-Administered PTSD Scale (CAPS-5).

METHOD

A clinical sample of 345 participants took part in this multi-centre study. Participants were assessed with the CAPS-5 and the Posttraumatic Stress Disorder Checklist (PCL-5). We evaluated eight competing models of DSM-5 PTSD symptoms and three competing models of ICD-11 PTSD symptoms.

RESULTS

The internal consistency of the CAPS-5 was replicated. In CFAs, the Anhedonia model emerged as the best fitting model within all tested DSM-5 models. However, when compared with the Anhedonia model, the non-nested ICD-11 model as a less complex three-factor solution showed better model fit indices.

DISCUSSION

We discuss the findings in the context of earlier empirical findings as well as theoretical models of PTSD.

Validity, reliability and clinical utility of mental disorders: The case of ICD-11 schizophrenia

Diagnostic classification systems categorise mental psychopathology in mental disorders. Although these entities are clinical constructs developed by consensus, it has been pointed out that in practice they are usually managed as natural entities and without evaluating aspects related to their nosological construction. The objectives of the study are to review a) the conceptualisation of mental disorders, b) the indicators of validity, reliability and clinical utility, and c) the values ​​of these indicators in ICD-11 schizophrenia. The results show that mental disorders are conceptualised as discrete entities, like the diseases of other areas of medicine; however, differences are observed between these diagnostic categories in clinical practice. The reliability and clinical utility of mental disorders are adequate; however, the validity is not yet clarified. Similarly, ICD-11 schizophrenia demonstrates adequate reliability and clinical utility, but its validity remains uncertain. The conceptualisation of psychopathology in discrete entities may be inadequate for its study, therefore dimensional and mixed models have been proposed. The indicators of validity, reliability and clinical utility enable us to obtain an accurate view of the nosological state of mental disorders when evaluating different aspects of their nosological construction.

Item response model validation of the German ICD-11 International Trauma Questionnaire for PTSD and CPTSD

Background

In the 11th revision of the International Classification of Diseases (ICD-11) posttraumatic stress disorder (PTSD) and the complex variant (CPTSD) were newly conceptualised. The International Trauma Questionnaire (ITQ) was developed as a brief self-report measure to screen for both disorders. The English original version has been rigorously tested and presents convincing psychometric properties. The aim of the current study was to validate the German version by means of item response theory (IRT).

Method

This is a secondary analysis of a representative, trauma-exposed adult sample from the German general population (N = 500). 1- and 2-parameter logistic IRT models (i.e. examination on an item level), diagnostic rates and confirmatory factor analyses were calculated.

Results

All items showed good model fit and acceptable to good performance aligning with the items of the English original except for item C1 (Long time to calm down) which had a high endorsement rate and a low discriminatory power yielding low information gain. CPTSD diagnostic rate of 3.2% was lower than in comparable literature. Confirmatory factor analysis deemed the six first-order, two second-order factors model superior.

Conclusion

Measurement and factorial validity of the German version of the ITQ was confirmed. The German translation matches the English original in most psychometric properties and can thus be used for research and clinical practice.

A global field study of the international classification of diseases (ICD-11) mood disorders clinical descriptions and diagnostic guidelines

BACKGROUND

We 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.

METHODS

1357 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.

RESULTS

Clinicians 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.

LIMITATIONS

Standardized case vignettes were manipulated to evaluate specific changes. The degree of accuracy of clinicians' diagnostic judgments may not reflect clinical decision-making with patients.

CONCLUSIONS

Alignment 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.

Client and Clinical Utility of the Assessment of Personality Disorders

ABSTRACT

Clinical utility and client utility are important desirable properties when developing and evaluating a new classification system for mental disorders. This study reports on four focus groups followed up by a Delphi study among clinicians working with clients with personality disorders (PD) and clients with PD themselves to harness both user groups' perspectives on the utility of PD diagnosis. Our findings show that the client and clinician views of the concept of utility were closely aligned and include aspects of transparency of communication and the ability of an assessment to enhance hope, curiosity, motivation, and insight into a client's personality patterns. Unique to clinicians' appraisal was the ability of an assessment to capture both vulnerabilities and resilience of clients and to give information about the prognosis in treatment. Unique to clients' appraisal was the ability of an assessment to be destigmatizing and collaborative. These findings may serve to expand our definition and measurement of clinical utility, in that collaborative and nonstigmatizing procedures likely promote client acceptability. To capture both aspects, we offer two preliminary questionnaires (i.e., item sets open to further empirical testing) based on the data derived from the Delphi procedure.

The clinical utility of the ICD-11 classification of personality disorders and related traits: A preliminary scoping review

OBJECTIVES

A diagnostic system that fails to deliver clinically useful information will not be utilized and consequently will be unable to provide valuable data for health policy and clinical decision making. Therefore, it is imperative to obtain an accurate depiction of the clinical utility of the eleventh revision of the International Classification of Diseases (ICD-11) Personality Disorder (PD) model. The current mixed-methods systematic review aimed to determine the clinical utility of the ICD-11 PD classification system.

METHOD

An electronic screening of six databases was conducted and resulting studies were subjected to specific exclusion criteria, which elicited eight studies of interest. Study characteristics were tabulated and methodological quality was appraised.

RESULTS

Four studies offered strong support for the model's clinical utility, three offered some support accompanied by notable limitations and one study could only offer criticisms.

CONCLUSION

Future investigation of the ICD-11 PD classification system's (a) communicative value between clinicians and their patients, and between clinicians and their patient's families; (b) ease of use; and (c) feasibility in terms of practical application is required to achieve a complete understanding of its clinical utility and ultimately bring clarity to the current ambiguous findings.

Can Clinicians Use Dimensional Information to Make a Categorical Diagnosis of Paraphilic Disorders? An ICD-11 Field Study

BACKGROUND

The diagnosis of paraphilic disorder is a complicated clinical judgment based on the integration of information from multiple dimensions to arrive at a categorical (present/absent) conclusion. The recent update of the guidelines for paraphilic disorders in ICD-11 presents an opportunity to investigate how mental health professionals use the diagnostic guidelines to arrive at a diagnosis which thereby can optimize the guidelines for clinical use.

AIM

This study examined clinicians' ability to use the ICD-11 diagnostic guidelines for paraphilic disorders which contain multiple dimensions that must be simultaneously assessed to arrive at a diagnosis.

METHODS

The study investigated the ability of 1,263 international clinicians to identify the dimensions of paraphilic disorder in the context of written case vignettes that varied on a single dimension only.

OUTCOMES

Participants provided diagnoses for the case vignettes along with dimensional ratings of the degree of presence of five dimensions of paraphilic disorder (arousal, consent, action, distress, and risk).

RESULTS

Across a series of analyses, clinicians demonstrated a clear ability to recognize and appropriately integrate the dimensions of paraphilic disorders; however, there was some evidence that clinicians may over-diagnose non-pathological cases.

CLINICAL TRANSLATION

Clinicians would likely benefit from targeted training on the ICD-11 definition of paraphilic disorder and should be cautious of over-diagnosing.

STRENGTHS AND LIMITATIONS

This study represents a large international sample of health professionals and is the first to examine clinicians' ability to apply the ICD-11 diagnostic guidelines for paraphilic disorders. Important limitations include not generalizing to all clinicians and acknowledging that results may be different in direct clinical interactions vs written case vignettes.

CONCLUSION

These results indicate that clinicians appear capable of interpreting and implementing the diagnostic guidelines for paraphilic disorders in ICD-11.

Classification algorithm for the International Classification of Diseases-11 chronic pain classification: development and results from a preliminary pilot evaluation

ABSTRACT

The International Classification of Diseases-11 (ICD-11) chronic pain classification includes about 100 chronic pain diagnoses on different diagnostic levels. Each of these diagnoses requires specific operationalized diagnostic criteria to be present. The classification comprises more than 200 diagnostic criteria. The aim of the Classification Algorithm for Chronic Pain in ICD-11 (CAL-CP) is to facilitate the use of the classification by guiding users through these diagnostic criteria. The diagnostic criteria were ordered hierarchically and visualized in accordance with the standards defined by the Society for Medical Decision Making Committee on Standardization of Clinical Algorithms. The resulting linear decision tree underwent several rounds of iterative checks and feedback by its developers, as well as other pain experts. A preliminary pilot evaluation was conducted in the context of an ecological implementation field study of the classification itself. The resulting algorithm consists of a linear decision tree, an introduction form, and an appendix. The initial decision trunk can be used as a standalone algorithm in primary care. Each diagnostic criterion is represented in a decision box. The user needs to decide for each criterion whether it is present or not, and then follow the respective yes or no arrows to arrive at the corresponding ICD-11 diagnosis. The results of the pilot evaluation showed good clinical utility of the algorithm. The CAL-CP can contribute to reliable diagnoses by structuring a way through the classification and by increasing adherence to the criteria. Future studies need to evaluate its utility further and analyze its impact on the accuracy of the assigned diagnoses.

Engagement of Russian Mental Health Professionals in the Development of WHO’s ICD-11

The World Health Organization (WHO) has officially approved the next version of its global diagnostic system, the International Classification of Diseases and Related Health Problems, Eleventh Revision (ICD-11). Processes to implement the ICD-11 are now underway. Developing the ICD-11 chapter on Mental, Behavioural and Neurodevelopmental Disorders, in line with WHOs core priorities to enhance the clinical utility, reliability, and global applicability of the guidelines, necessitated a large-scale scientifically-rigorous research program. Such a program of global field studies engaged mental health professionals from across the world, with substantial contributions from clinicians in the Russian Federation. This paper systematically highlights the substantive roles played by Russian clinicians in all steps of development of the mental, behavioural, and neurodevelopmental disorder guidelines, including their participation in the following: 1) early formative field studies that informed the organizing principles and overarching structure of the ICD-11; 2) large-scale online studies that used a case-controlled methodology to evaluate the guidelines clinical utility and the accuracy with which the new ICD-11 guidelines could be applied by global clinicians; 3) an online network of mental health professionals who provided direct feedback on the ICD-11 to WHO (also known as the Global Clinical Practice Network, www.globalclinicalpractice.net) with over 16,000 members from 160 countries, and with the Russian Federation being in the top five most represented countries in the network; 4) clinic-based field studies that tested the reliability and clinical utility of the ICD-11 diagnostic guidelines; and 5) development and participation in training programs that prepare clinicians in implementing the diagnostic guidelines in clinical settings. In these many ways, Russian clinicians have substantively and directly contributed to efforts to maximize the clinical usefulness, consistency, acceptability, and applicability of the ICD-11s mental, behavioural, and neurodevelopmental disorder guidelines. This substantial engagement of clinicians will conceivably facilitate the adoption and use of the guidelines by clinicians in the Russian Federation and other Russian-speaking countries, as the ICD-11 is implemented over the coming years.

Cultural Issues Related to ICD-11 Mental, Behavioural and Neurodevelopmental Disorders

The challenge of producing a classificatory system that is truly representative of different regions and cultural variations is difficult. This can be conceptualized as an ongoing process, achievable by constant commitment in this regard from various stakeholders over successive generations of the classificatory systems. The objective of this article is to conduct a qualitative review of the process and outcome of the efforts that resulted in the ICD-11 classification of mental, behavioural and neurodevelopmental disorders becoming a global classification. The ICD-11 represents an important, albeit iterative, advance in the classification of mental, behavioural and neurodevelopmental disorders. Significant changes have been incorporated in this regard, such as the introduction of new, culturally-relevant categories, modifications of the diagnostic guidelines, based on culturally informed data and the incorporation of culture-related features for specific disorders. Notwithstanding, there are still certain significant shortcomings and areas for further improvement and research. Some of the key limitations of ICD-11 relate to the paucity of research on the role of culture in the pathogenesis of illnesses. To ensure a classificatory system that is fair, reliable and culturally useful, there is a need to generate empirical evidence on diversity in the form of illnesses, as well as mechanisms that explain these in all the regions of the world. In this review, we try to delineate the various cultural challenges and their influences in the formulation of ICD-11, along with potential shortcomings and areas in need of more improvement and research in this regard.

Diagnostic classification of irritability and oppositionality in youth: a global field study comparing ICD-11 with ICD-10 and DSM-5

BACKGROUND

Severe irritability has become an important topic in child and adolescent mental health. Based on the available evidence and on public health considerations, WHO classified chronic irritability within oppositional defiant disorder (ODD) in ICD-11, a solution markedly different from DSM-5's (i.e. the new childhood mood diagnosis, disruptive mood dysregulation disorder [DMDD]) and from ICD-10's (i.e. ODD as one of several conduct disorders without attention to irritability). In this study, we tested the accuracy with which a global, multilingual, multidisciplinary sample of clinicians were able to use the ICD-11 classification of chronic irritability and oppositionality as compared to the ICD-10 and DSM-5 approaches.

METHODS

Clinicians (N = 196) from 48 countries participated in an Internet-based field study in English, Spanish, or Japanese and were randomized to review and use one of the three diagnostic systems. Through experimental manipulation of validated clinical vignettes, we evaluated how well clinicians in each condition could identify chronic irritability versus nonirritable oppositionality, episodic bipolar disorder, dysthymic depression, and normative irritability.

RESULTS

Compared to ICD-10 and DSM-5, ICD-11 led to more accurate identification of severe irritability and better differentiation from boundary presentations. Participants using DSM-5 largely failed to apply the DMDD diagnosis when it was appropriate, and they more often applied psychopathological diagnoses to developmentally normative irritability.

CONCLUSIONS

The formulation of irritability and oppositionality put forth in ICD-11 shows evidence of clinical utility, supporting accurate diagnosis. Global mental health clinicians can readily identify ODD both with and without chronic irritability.

Taxonomy and utility in the diagnostic classification of mental disorders

OBJECTIVE

One strategy for improving the clinical utility of mental health diagnostic systems is to better align them with how clinicians conceptualize psychopathology in practice. This approach was used in International Classification of Diseases 11th Revision (ICD-11) development, but its underlying assumption-a link between taxonomic "fit" and clinical utility-remains untested.

METHODS

Using data from global mental health clinician samples (combined N = 5404), we investigated the association between taxonomic fit and clinical utility in mental disorder categories.

RESULTS

The overall association between fit and utility was positive (r = 0.19) but statistically not different from zero (95% confidence interval [CI]: -0.06, 0.43) in this small sample (N = 39 ICD/DSM categories). However, a positive association became clear after correcting for outliers (r = 0.34 [0.05, 0.58] or higher). Further insights were apparent for specific diagnoses given their locations in the scatterplot.

CONCLUSIONS

Results suggest a positive link between taxonomic fit and clinical utility in mental disorder diagnoses, highlighting future research directions.

Responding to the new International Classification of Diseases-11 prolonged grief disorder during the COVID-19 pandemic: a new bereavement network and three-tiered model of care

The field of bereavement research and care is at a tipping point. The introduction of prolonged grief disorder (PGD) in the International Classification of Diseases (ICD-11) has ignited clinical interest in this new disorder, along with debate over challenges in validating and implementing these new criteria. At the same time, the global COVID-19 pandemic has launched several local and international efforts to provide urgent support and comfort for individuals and communities suffering from grief. Recently, grief experts have called for a collective response to these complicated bereavements and possible increase in PGD due to COVID-19. Here we outline a new European network that aims to unite a community of grief researchers and clinicians to provide accessible, evidence-based support particularly during times of unprecedent crisis. The Bereavement Network Europe (BNE) has been developed with two main aims. Firstly, to develop expert agreed, internationally acceptable guidelines for bereavement care through a three-tiered approach. Secondly, to provide a platform for researchers and clinicians to share knowledge, collaborate, and develop consensus protocols to facilitate the introduction of PGD to diverse stakeholders. This article outlines the current status and aims of the BNE along with the plans for upcoming network initiatives and the three-tiered bereavement care guidelines in response to the COVID-19 pandemic.

Cross-cultural applicability of ICD-11 and DSM-5 personality disorder

PURPOSE OF REVIEW

This review explores recent literature on the applicability of the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5) and International Classification of Disease, 11th Revision (ICD-11) personality disorder classification systems across countries and cultural contexts.

RECENT FINDINGS

Several studies examining the cultural validity and utility of DSM-5 and ICD-11 personality disorder have been conducted in a number of language and cultural groups that are different from those in which the tools were originally developed. These studies, using quantitative methods, have largely supported the applicability of the new dimensional and trait approaches to classifying personal disorders. Studies qualitatively exploring the views of service users and clinicians on the development or operationalization of DSM-5 and ICD-11 personality disorder report that a lay summary of diagnostic constructs thatreflect concern about language of diagnostic criteria as well the lived experience of service users would be found useful. Clinicians found the dimensional system of ICD-11 slightly more useful than the categorical system of ICD-10 on several utility scales, but the studies on ICD-11 have been much less in view of its latter appearance.

SUMMARY

DSM-5 and ICD-11 personality disorder have shown a preliminary evidence of improved utility across cultures. More studies, including those reflecting the views of service users, are needed to confirm this early observation across many more cultural and linguistic groups.

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

PURPOSE OF REVIEW

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.

RECENT FINDINGS

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.

SUMMARY

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.

Development of the international prolonged grief disorder scale for the ICD-11: Measurement of core symptoms and culture items adapted for chinese and german-speaking samples

BACKGROUND

Prolonged grief disorder (PGD) is a new mental health disorder included in the WHO ICD-11 however, the operationalization of the guidelines still needs to be empirically validated, particularly in different cultural contexts. Here we provide a preliminary validation study of the new International Prolonged Grief Disorder Scale (IPGDS) that serves to be the first self-report questionnaire directly based on the ICD-11 PGD and contains culturally adapted items.

METHODS

In addition to core symptom items new culturally specific items were developed in two phases. Phase 1: key informant interviews with 10 German-speaking and 14 Chinese experts in grief and mental health, followed by a focus group with four bereaved German-speaking participants. Phase 2: 214 German-speaking and 325 Chinese bereaved participants completed self-report questionnaires.

RESULTS

Phase 1 resulted in 19 potential culturally relevant items (e.g. feeling stuck in grief). Phase 2 exploratory factor analysis confirmed the one-dimensional nature of the IPGDS, additionally the 32-item scale revealed two factors (core grief and culturally specific symptoms). Psychometric analysis revealed strong internal consistency, concurrent validity and criterion validity.

LIMITATIONS

The German-speaking and Chinese samples significantly differed in terms of several demographic variables including age, gender and type of loss.

CONCLUSIONS

This preliminary validity study confirms that the IPGDS is a valid and reliable measure of the new ICD-11 PGD guidelines. This is the first scale of disordered grief to contain both core items and culturally specific supplementary items and aims to improve the clinical utility of the ICD-11 narrative approach.

Validity, Reliability and Clinical Utility of Mental Disorders: The Case of ICD-11 Schizophrenia

Diagnostic classification systems categorise mental psychopathology in mental disorders. Although these entities are clinical constructs developed by consensus, it has been pointed out that in practice they are usually managed as natural entities and without evaluating aspects related to their nosological construction. The objectives of the study are to review a) the conceptualisation of mental disorders, b) the indicators of validity, reliability and clinical utility, and c) the values of these indicators in ICD-11 schizophrenia. The results show that mental disorders are conceptualised as discrete entities, like the diseases of other areas of medicine; however, differences are observed between these diagnostic categories in clinical practice. The reliability and clinical utility of mental disorders are adequate; however, the validity is not yet clarified. Similarly, ICD-11 schizophrenia demonstrates adequate reliability and clinical utility, but its validity remains uncertain. The conceptualisation of psychopathology in discrete entities may be inadequate for its study, therefore dimensional and mixed models have been proposed. The indicators of validity, reliability and clinical utility enable us to obtain an accurate view of the nosological state of mental disorders when evaluating different aspects of their nosological construction.

Bereavement and reactions of grief among children and adolescents: Present data and perspectives

Losing a loved one is among the most common and stressful traumatic events that a child or and adolescent can experience and can be associated with mental health and somatic disorders, as well as a range of life issues and potentially negative outcomes that may impact longitudinal development. Complicated grief, a disorder that has been studied primarily among adults, has received increasing recognition among children and adolescents in recent years. The demonstration of the distinctive character of grief reactions in relation to major depressive disorder and posttraumatic stress disorder has resulted in the inclusion of "persistent complex bereavement disorder" in an annex section of DSM-5 and of "prolonged grief disorder" in ICD-11. The grieving process in children and adolescents is not linear and is often characterised by periods of regression. Developmental phases should be taken into account to understand and clinically describe grief reactions occurring during childhood and adolescence. There are currently numerous interventions for bereaved children and adolescents, but little evidence to support them. More research focusing on the understanding of the underlying mechanisms and the risk factors for complicated grief among children and adolescents, as well as the implementation of evidence-based interventions, is definitely warranted.

Accuracy of diagnostic judgments using ICD-11 vs. ICD-10 diagnostic guidelines for obsessive-compulsive and related disorders

BACKGROUND

We 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.

METHODS

1,717 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.

RESULTS

Participants 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.

LIMITATIONS

Standardized 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.

CONCLUSIONS

Overall, 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.

Fractures in the framework: limitations of classification systems in psychiatry

This article examines the limitations of existing classification systems from the historical, cultural, political, and legal perspectives. It covers the evolution of classification systems with particular emphasis on the DSM and ICD systems. While pointing out the inherent Western bias in these systems, it highlights the potential of misuse of these systems to subserve other agendas. It raises concerns about the reliability, validity, comorbidity, and heterogeneity within diagnostic categories of contemporary classification systems. Finally, it postulates future directions in alternative methods of diagnosis and classification factoring in advances in artificial intelligence, machine learning, genetic testing, and brain imaging. In conclusion, it emphasizes the need to go beyond the limitations inherent in classifications systems to provide more relevant diagnoses and effective treatments.


Evaluation of the International Classification of Diseases-11 chronic pain classification: study protocol for an ecological implementation field study in low-, middle-, and high-income countries

Introduction

The purpose of the present ecological implementation field study is to evaluate the new classification of chronic pain as implemented in the 11th revision of the International Classification of Diseases (ICD-11) with regard to clinical utility and interrater reliability. To evaluate the classification in a variety of settings, the study will be implemented in different low-, middle-, and high-income countries.

Methods

The study will be conducted in 2 phases. Participating pain clinics of the first phase are located in India, Cuba, and New Zealand. Two or more clinicians per study center will use the ICD-11 classification of chronic pain to diagnose 75 to 100 consecutive new chronic pain patients per center. A structured classification algorithm will guide the diagnostic process. Interrater reliability will be analyzed for the first 20 consecutive new patients per center. Before the coding, a training workshop will introduce the clinicians to the new classification. The main outcome parameter of the ecological implementation field study is clinical utility. More specifically, this entails clinical utility ratings, interrater reliability, as well as the exhaustiveness of the classification and the mutual exclusiveness of the new chronic pain categories. Differences between countries with different cultural backgrounds and income levels will be analyzed.

Perspective

The ecological implementation field study presented here will be implemented in several countries with different income levels. This increases the generalizability of the results and allows initial insight into the global applicability of the new chronic pain classification. A positive evaluation can facilitate the implementation of the classification.

Validity and utility of Hierarchical Taxonomy of Psychopathology (HiTOP): I. Psychosis superspectrum

The Hierarchical Taxonomy of Psychopathology (HiTOP) is a scientific effort to address shortcomings of traditional mental disorder diagnoses, which suffer from arbitrary boundaries between psychopathology and normality, frequent disorder co-occurrence, heterogeneity within disorders, and diagnostic instability. This paper synthesizes evidence on the validity and utility of the thought disorder and detachment spectra of HiTOP. These spectra are composed of symptoms and maladaptive traits currently subsumed within schizophrenia, other psychotic disorders, and schizotypal, paranoid and schizoid personality disorders. Thought disorder ranges from normal reality testing, to maladaptive trait psychoticism, to hallucinations and delusions. Detachment ranges from introversion, to maladaptive detachment, to blunted affect and avolition. Extensive evidence supports the validity of thought disorder and detachment spectra, as each spectrum reflects common genetics, environmental risk factors, childhood antecedents, cognitive abnormalities, neural alterations, biomarkers, and treatment response. Some of these characteristics are specific to one spectrum and others are shared, suggesting the existence of an overarching psychosis superspectrum. Further research is needed to extend this model, such as clarifying whether mania and dissociation belong to thought disorder, and explicating processes that drive development of the spectra and their subdimensions. Compared to traditional diagnoses, the thought disorder and detachment spectra demonstrated substantially improved utility: greater reliability, larger explanatory and predictive power, and higher acceptability to clinicians. Validated measures are available to implement the system in practice. The more informative, reliable and valid characterization of psychosis-related psychopathology offered by HiTOP can make diagnosis more useful for research and clinical care.

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.

Accuracy of diagnostic classification and clinical utility assessment of ICD-11 compared to ICD-10 in 10 mental disorders: findings from a web-based field study

In this web-based field study, we compared the diagnostic accuracy and clinical utility of 10 selected mental disorders between the ICD-11 Clinical Descriptions and Diagnostic Guidelines (CDDG) and the ICD-10 CDDG using vignettes in a sample of 928 health professionals from all WHO regions. On average, the ICD-11 CDDG displayed significantly higher diagnostic accuracy (71.9% for ICD-11, 53.2% for ICD-10), higher ease of use, better goodness of fit, higher clarity, and lower time required for diagnosis compared to the ICD-10 CDDG. The advantages of the ICD-11 CDDG were largely limited to new diagnoses in ICD-11. After limiting analyses to diagnoses existing in ICD-11 and ICD-10, the ICD-11 CDDG were only superior in ease of use. The ICD-11 CDDG were not inferior in diagnostic accuracy or clinical utility compared to the ICD-10 CDDG for any of the vignettes. Diagnostic accuracy was consistent across WHO regions and independent of participants' clinical experience. There were no differences between medical doctors and psychologists in diagnostic accuracy, but members of other health professions had greater difficulties in determining correct diagnoses based on the ICD-11 CDDG. In sum, there were no differences in diagnostic accuracy for diagnoses existing in ICD-10 and ICD-11, but the introduction of new diagnoses in ICD-11 has improved the diagnostic classification of some clinical presentations. The favourable clinical utility ratings of the ICD-11 CDDG give reason to expect a positive evaluation by health professionals in the implementation phase of ICD-11. Yet, training in ICD-11 is needed to further enhance the diagnostic accuracy.

Anxiety and Fear-Related Disorders in the ICD-11: Results from a Global Case-controlled Field Study

BACKGROUND

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).

AIMS OF THE STUDY

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.

METHODS

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.

RESULTS

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.

CONCLUSIONS

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.

The Italian ICD-11 field trial: clinical utility of diagnostic guidelines for schizophrenia and related disorders

Background

The 11th revision of the International Classification of Diseases and Related Disorders (ICD-11) has been released. In order to test the clinical consistency and the clinical utility of the proposed guidelines the World Health Organization (WHO) has carried out the Ecological Implementation Field Studies in various countries. In this paper the results of the Italian field trials on the clinical utility of the ICD-11 diagnostic guideline concerning schizophrenia and related disorders will be presented.

Methods

In Italy, field trials have been carried out at the Department of Psychiatry of the University of Campania “L. Vanvitelli”. All patients showing any psychotic symptom and referring to the outpatient and inpatient units have been recruited. Patients were interviewed by two clinicians with whom they had not had any prior clinical contact. At the end of each interview, clinicians were asked to complete 12 questions about the clinical utility of the diagnostic guidelines as applied to each patient.

Results

Fourteen clinicians and 100 patients have been involved. The ICD-11 clinical guidelines were perceived as easy to use, with an adequate goodness of fit, clear and understandable and with an adequate level of details and specificity to describe the essential features of the diagnoses. Clinicians rated very positively their usefulness in describing the threshold between patient’s disorder and normality. Despite still very positive, the guidelines have been perceived as less useful to select a treatment, to assess patients’ prognosis and to communicate with other mental health professionals.

Conclusions

The 11th revision of the chapter on Mental, Behavioural and Neurodevelopmental Disorders has made substantive changes to the conceptualization of mental disorders which could have impacted on their reliability and clinical utility. Results of the Italian field studies, in line with those reported by the international sample, highlight that ICD-11 has been rated as highly clinically useful by participating clinician, more than the ICD-10. This could be considered a good reason to be optimistic about the implementation of the ICD-11 among global clinicians.

Trial registration The study has been approved by the Ethical Review Board of the University of Campania “L. Vanvitelli” (N. 416, 2016)