Clinical Utility of ICD-11 Clinical Descriptions and Diagnostic Requirements for the Classification of Mental, Behavioral or Neurodevelopmental Disorders: A Systematic Review

Case-controlled field studies, ecological implementation field studies, and qualitative or mixed methodology studies have been conducted to evaluate the clinical utility of the ICD-11 clinical descriptions and diagnostic requirements (ICD-11 CDDR) for the diagnosis of mental disorders. This systematic review sought to analyze and synthesize the clinical utility indices of these guidelines from the perspectives of mental health professionals (MHPs) and patients from different regions of the world. A systematic search was carried out in five databases Science Direct, Google Scholar, PubMed, Web of Science and Scopus. The relevant studies were subjected to explicit eligibility criteria, resulting in 19 included studies. The study characteristics were tabulated, methodological quality was assessed, and findings were summarized using convergent narrative synthesis. The overall findings indicated that the clinical utility of the ICD-11 CDDR was positive for the majority of studies (78.95%) that analyzed a wide range of mental disorders. Analyses at the level of the disorder groups also revealed the same trend. Almost only qualitative or mixed studies have identified negative aspects or obstacles of this diagnostic system. The clinical utility of the ICD-11 CDDR for the diagnosis of mental disorders is supported. Future research could resolve concerns regarding the isolated negative outcomes of ICD-11 CDDR performance. Finally, it is necessary to expand the scope of the training programs for MHPs and policymakers regarding the use of these guidelines in clinical practice.

An evolutionary analysis of the applicability and utility of the clinico-pathological method in psychiatry

Unlike other medical specialties, psychiatry has not been involved in the theoretical shift that replaced the syndromal approach with the clinico-pathological method, which consists in explaining clinical manifestations by reference to morbid anatomical and physiological changes. Past and present discussions on the applicability of the clinico-pathological method in psychiatry are based on a pre-Darwinian concept of biology as the study of proximate causation. Distinguishing between mediating mechanisms and evolved functions, an evolutionary perspective offers an original contribution to the debate by overcoming the opposite views of dualism (i.e., the clinico-pathological method is not applicable to disorders of the mind) and neuroessentialism (i.e., the definitive way of explaining psychiatric disorders is by reference to the brain and its activity). An evolutionary perspective offers original insights on the utility of the clinico-pathological method to solve critical questions of psychiatric research and clinical practice, including the distinction between mental health and illness, a better understanding of the etiology and pathophysiology, the classification and differential diagnosis of psychiatric disorders, and the development of more efficacious psychiatric treatments.

Connecting DSM-5 and ICD-11 trait domains with schema therapy and dialectical behavior therapy constructs

The DSM-5 Section III alternative model of personality disorder (AMPD) and the International Classification of Diseases - 11th Edition's (ICD-11) personality disorder classification allow clinicians to identify individual trait domains in which people score highly. However, how these domains relate to constructs associated with efficacious treatment approaches is unclear. The current study aimed to determine whether constructs from two evidence-based treatments (schema therapy [ST] and dialectical behavior therapy [DBT]) were associated with maladaptive personality traits in a way consistent with underlying theories. We examined associations between ST constructs, DBT skill use and maladaptive coping styles, and personality traits in a sample of 525 adults. Bivariate intercorrelations and a series of multiple regression analyses were conducted to investigate the associations. As hypothesized, maladaptive coping was strongly associated with all trait domains. Surprisingly, poor DBT-skill use was only associated with negative affectivity, detachment, and disinhibition trait domains. Specific schema domains were associated with each personality trait domain, supporting trait domain-schema domain specificity. The current study highlights the potential clinical utility of the AMPD and ICD-11 trait models and ultimately contributes to the dearth of evidence on their likely usefulness for treatment selection, planning, and applications.

Context v. algorithm: evidence that a transdiagnostic framework of contextual clinical characterization is of more clinical value than categorical diagnosis

BACKGROUND

A transdiagnostic and contextual framework of 'clinical characterization', combining clinical, psychopathological, sociodemographic, etiological, and other personal contextual data, may add clinical value over and above categorical algorithm-based diagnosis.

METHODS

Prediction of need for care and health care outcomes was examined prospectively as a function of the contextual clinical characterization diagnostic framework in a prospective general population cohort (n = 6646 at baseline), interviewed four times between 2007 and 2018 (NEMESIS-2). Measures of need, service use, and use of medication were predicted as a function of any of 13 DSM-IV diagnoses, both separately and in combination with clinical characterization across multiple domains: social circumstances/demographics, symptom dimensions, physical health, clinical/etiological factors, staging, and polygenic risk scores (PRS). Effect sizes were expressed as population attributable fractions.

RESULTS

Any prediction of DSM-diagnosis in relation to need and outcome in separate models was entirely reducible to components of contextual clinical characterization in joint models, particularly the component of transdiagnostic symptom dimensions (a simple score of the number of anxiety, depression, mania, and psychosis symptoms) and staging (subthreshold, incidence, persistence), and to a lesser degree clinical factors (early adversity, family history, suicidality, slowness at interview, neuroticism, and extraversion), and sociodemographic factors. Clinical characterization components in combination predicted more than any component in isolation. PRS did not meaningfully contribute to any clinical characterization model.

CONCLUSION

A transdiagnostic framework of contextual clinical characterization is of more value to patients than a categorical system of algorithmic ordering of psychopathology.

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.

Trading Patients: Applying the Alternative Model for Personality Disorders to Two Cases of DSM-5 Borderline Personality Disorder Over Time and Across Therapists

The DSM-5 Alternative Model for Personality Disorders (AMPD) dimensionally defines personality pathology using severity of dysfunction and maladaptive style. As the empirical literature on the clinical utility of the AMPD grows, there is a need to examine changes in diagnostic profiles and personality expression in treatment over time. Assessing these changes in individuals diagnosed with borderline personality disorder (BPD) is complicated by the tendency for patients to cycle through multiple therapists over the course of treatment leaving the potential for muddled diagnostic clarity and disjointed case conceptualizations. Following patient trajectories across therapists offers a unique opportunity to examine the AMPD’s sensitivity to and utility for capturing personality stability and change over time for patients with BPD. This article demonstrates the utility of the AMPD for two clinical cases in three distinct ways: (i) highlighting heterogeneity in BPD between patients, (ii) comparing improvements in personality severity and style over time, and (iii) elucidating profile change across therapist ratings. We present two patients diagnosed with DSM-5 Section II BPD, crossing between two therapists over the course of 3 years of psychodynamic psychotherapy. Treating clinicians rated patients for their respective treatment phases using the Level of Personality Functioning Scale (LPFS), capturing severity, and the Personality Inventory for the DSM-5 (PID-5), capturing style. AMPD diagnostic profiles differentiated patients with BPD in both severity and style, and captured within-patient change beyond within-therapist response bias. Results indicated greater improvements in personality severity while personality style remained more stable. Implications for the patients’ treatment progress and associated challenges are discussed, as are considerations for the utility of the AMPD in therapy.

Rumination as a transdiagnostic process: The role of rumination in relation to antisocial and borderline symptoms

The present study examined the influence of several forms of repetitive negative thinking on antisocial and borderline symptoms to identify underlying mechanisms that may contribute to the presentation and cooccurrence of these symptoms. Participants (N = 403), completed the Personality Assessment Inventory, the Personality Diagnostic Questionnaire-4, and several measures of rumination/worry. Path analyses were conducted in which different forms of rumination/worry predicted antisocial and borderline symptoms across two personality disorder measures. Across both models tested, anger rumination emerged as the strongest predictor of both antisocial and borderline symptoms while worry negatively predicted antisocial symptoms. Rumination and worry explained substantially more variance in borderline symptoms compared to antisocial symptoms. This study is the first study to examine antisocial symptoms in relation to forms of rumination/worry and highlights the differential relations of rumination/worry to antisocial and borderline symptoms using a multi-measure approach. Further, this study highlights the importance of examining types of repetitive negative thinking, specifically rumination, as potential transdiagnostic processes.

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.

Case Report: Pathological Personality Traits Through the Lens of the ICD-11 Trait Qualifiers and the DSM-5 Section III Trait Model: Two Patients Illustrating the Clinical Utility of a Combined View

We report on two individuals presenting for treatment as part of everyday clinical practice, comparing their pathological personality traits through the lens of the ICD-11 trait qualifiers and the DSM-5 Section III personality trait model. We compare higher order pathological personality domains and lower order pathological personality trait facets of patient M (diagnosed with borderline personality traits according to DSM-5 Section II), and patient L (diagnosed with obsessive-compulsive personality traits according to DSM-5 Section II) with normative data and with each other. Findings highlight the clinical utility of a ICD-11/DSM-5 combined view, including: (1) the Disinhibition/Anankastia personality domain distinction as advocated in the ICD-11 model, (2) the Psychoticism personality domain as conceptualized in the DSM-5 Section III personality trait model, as well as (3) the use of lower order personality trait facets within each higher order personality domain.

The Role of Personality Functioning on Early Drop out in Outpatient Substance Misuse Treatment

Treatment initiation is a major factor contributing to positive outcomes, but the supporting literature remains limited. It is difficult to draw conclusions regarding predictors of dropout, and there is a need to target clients' major early attrition vulnerabilities. Despite empirically validated models for assessing personality, little is known about its role in the treatment process. Studies that have been conducted in this area have focused mainly on stable personality traits and provide conflicting evidence. Aims: The aim of this study is to examine to what extent service users' personality functioning are potential determinants of early drop out. Methodology: A cross-sectional multi-site design examined the therapy process in a naturalistic setting in 5 outpatient preparation treatment centers with 210 service users. The current study adopts a contemporary dimensional-based framework, similar to the Alternative Model of Personality Disorder of the DSM-V and examines the role of characteristic adaptations (SIPP-118) on early drop out (CEST-Intake). Findings: From the broad spectrum of personality traits, only Depression remained significant predictor of drop out. Higher dysfunctional levels in Social Concordance [OR] = 1.85, Wald =19.87, p =.002, 95% CI [1.1, 1.9] as well as the facets Aggression Regulation, Respect and Purposefulness were also predictors of early drop out, while Treatment Readiness and Desire for Help accounted for a significant amount of variance. Conclusions: These findings extend our knowledge of the predictive role of characteristic adaptations in treatment and suggest it may be important to assess these individual differences early on and to design personalized-informed interventions.

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)

Beyond descriptions: selected aspects of science and practice in clinical psychology and personality psychopathology

EDITORIAL Beyond Descriptions: Selected Aspects of Science and Practice in Clinical Psychology EDITORIAL Beyond Descriptions: Selected Aspects of Science and Practice in Clinical Psychology EDITORIAL Beyond Descriptions: Selected Aspects of Science and Practice in Clinical Psychology EDITORIAL Beyond Descriptions: Selected Aspects of Science and Practice in Clinical Psychology EDITORIAL Beyond Descriptions: Selected Aspects of Science and Practice in Clinical Psychology EDITORIAL Beyond Descriptions: Selected Aspects of Science and Practice in Clinical Psychology EDITORIAL Beyond Descriptions: Selected Aspects of Science and Practice in Clinical Psychology EDITORIAL Beyond Descriptions: Selected Aspects of Science and Practice in Clinical Psychology EDITORIAL Beyond Descriptions: Selected Aspects of Science and Practice in Clinical Psychology EDITORIAL Beyond Descriptions: Selected Aspects of Science and Practice in Clinical Psychology

Prolonged grief disorder for ICD-11: the primacy of clinical utility and international applicability

A new mental health disorder, prolonged grief disorder (PGD), will be included in the 11th edition of the International Classification of Diseases (ICD-11). We provide a brief overview of the historical conceptualizations of disordered grief and the previous research efforts to assess and define this condition. We describe the new ICD-11 PGD symptom criteria and how they are conceptualized in terms of the World Health Organization's call for improved clinical utility. Finally, we review the research evidence for the clinical utility of the new ICD-11 PGD symptom structure and usability in the international arena.

Understanding the DSM-5: stasis and change

This paper aims to understand the DSM-5 through situating it within the context of the historical development of the DSM series. When one looks at the sets of diagnostic criteria, the DSM-5 is strikingly similar to the DSM-IV. I argue that at this level the DSM has become 'locked-in' and difficult to change. At the same time, at the structural, or conceptual, level there have been radical changes, for example in the definition of 'mental disorder', in the role of theory and of values, and in the abandonment of the multiaxial approach to diagnosis. The way that the DSM-5 was constructed means that the overall conceptual framework of the classification only barely constrains the sets of diagnostic criteria it contains.

PTSD in Court I: Introducing PTSD for Court

The first part of the series of three articles on posttraumatic stress disorder (PTSD) in Court to appear in the journal reviews the history of the construct of PTSD and its presentation in the DSM-5 (Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition; American Psychiatric Association, 2013) and the ICD-11 (International Classification of Diseases, 11th Edition; World Health Organization, 2018). There are 20 symptoms of PTSD in the DSM-5. PTSD symptoms are arranged into a four-cluster model, which has received partial support in the literature. Other four-factor models have been found that fit the data even better than that of the DSM-5. There is a five-factor dysphoria model and two six-factor models that have been found to fit better the DSM-5 PTSD symptoms. Finally, research is providing support for a hybrid seven-factor model. An eighth factor on dissociation seems applicable to the minority of people who express the dissociative subtype. At the epidemiological level, individuals can expect trauma exposure to take place about 70% over one's lifetime. Also, traumatic exposure leads to traumatic reactions in about 10% of cases, with PTSD being a primary diagnosis for trauma. Once initiated, PTSD becomes prolonged in about 10% of cases. Polytrauma and comorbidities complicate these prevalence statistics. Moreover, the possibility of malingered PTSD presents confounds. However, the estimate for malingered PTSD varies extensively, from 1 to 50%, so that the estimate is too imprecise for use in court without further research. This first article in the series of three articles appearing in the journal on PTSD in Court concludes with discussion of complications related to comorbidities and heterogeneities, in particular. For example, PTSD and its comorbidities can be expressed in over one quintillion ways. This complexity in its current structure in the DSM-5 speaks to the individual differences involved in its expression.

The latent structure of Acute Stress Disorder symptoms in trauma-exposed children and adolescents

BACKGROUND

The revision of Acute Stress Disorder (ASD) in the DSM-5 (DSM-5, 2013) proposes a cluster-free model of ASD symptoms in both adults and youth. Published evaluations of competing models of ASD clustering in youth have rarely been examined.

METHODS

We used Confirmatory Factor Analysis (combined with multigroup invariance tests) to explore the latent structure of ASD symptoms in a trauma-exposed sample of children and young people (N = 594). The DSM-5 structure was compared with the previous DSM-IV conceptualization (4-factor), and two alternative models proposed in the literature (3-factor; 5-factor). Model fit was examined using goodness-of-fit indices. We also established DSM-5 ASD prevalence rates relative to DSM-IV ASD, and the ability of these models to classify children impaired by their symptoms.

RESULTS

Based on both the Bayesian Information Criterion, the interfactor correlations and invariance testing, the 3-factor model best accounted for the profile of ASD symptoms. DSM-5 ASD led to slightly higher prevalence rates than DSM-IV ASD and performed similarly to DSM-IV with respect to categorising children impaired by their symptoms. Modifying the DSM-5 ASD algorithm to a 3+ or 4+ symptom requirement was the strongest predictor of impairment.

CONCLUSIONS

These findings suggest that a uni-factorial general-distress model is not the optimal model of capturing the latent structure of ASD symptom profiles in youth and that modifying the current DSM-5 9+ symptom algorithm could potentially lead to a more developmentally sensitive conceptualization.