Post #265 Shortlink: http://wp.me/pKrrB-3cr
Update on ICD-11 Beta drafting: Bodily Distress Disorder: emerging proposals: Part One
Before reading this report, please note the caveats at the end of the post.
The technical work associated with the preparation of ICD-11, the field testing and trials evaluation will need to be completed next year if WHO is going to meet its target of presenting ICD-11 for World Health Assembly approval in May 2015, with pilot implementation by 2016.
Three distinct versions of the ICD-11 classification of Mental and Behavioural Disorders are under development: an abridged version for use in primary care, a detailed version for use in specialty settings and a version for use in research.
The ICD-10 Somatoform Disorders are under revision for all three versions and the primary care and speciality versions are being developed simultaneously.
ICD10-PC, the abridged version of ICD, is used in developed and developing countries and in the training of medical officers, nurses and multi-purpose health workers. Globally, more than 90% of patients with mental health problems are managed by general practitioners or health workers in primary care settings – not by psychiatrists.
Over 400 mental disorders are classified in the speciality version of ICD-10 Chapter V. These are condensed to 26 mental disorders for the primary care version – a list can be found on Page 49 of this book chapter, in Table 2.4.
Each disorder in ICD10-PC provides information on patient presentation, clinical descriptions, differential diagnoses, treatments, indications for referrals and information sheets for patients and families.
A revised list of disorders proposed for inclusion in the forthcoming ICD-11-PHC can be viewed on Page 51, in Table 2.5 .
For new and revised disorders included in the primary care version there will need to be an equivalent disorder in the core ICD-11 classification.
Existing Somatoform Disorders in the core ICD-10 version can be viewed here: ICD-10 Version: 2010 browser: Somatoform Disorders or from Page 129 in The ICD-10 Classification of Mental and Behavioural Disorders, Clinical descriptions and diagnostic guidelines.
A chart showing the grouping of the detailed core version categories and the 26 corresponding disorders in ICD10-PC can be found here, see Page 8, for F45 Unexplained somatic complaints and F45 Somatoform disorders (ICD-10): Connections between ICD-10 PC and ICD-10 Chapter V.
Where reports of emerging proposals for ICD-11 have been published by ICD revision working group members, the recommendations within them may be subject to refinement or revision following analysis of focus group studies, external review and multicentre field trials to assess the validity and clinical utility of proposals for application in developed and developing countries, in high and low resource settings and across general, speciality and research settings .
Not all proposals for new or revised disorders are expected to survive the field trials.
Two working groups are making recommendations for the revision of ICD-10′s Somatoform Disorders:
A WHO Primary Care Consultation Group (known as the PCCG) has been appointed to lead the development of the revision of ICD10-PC, the abridged classification of mental and behavioural disorders for use in primary care settings. The PCCG is charged with developing and field testing the full set of disorders for inclusion in ICD-11-PHC, for which 28 mental disorders are currently proposed.
The PCCG members are SWC Chan, AC Dowell, S Fortes, L Gask, KS Jacob, M Klinkman (Vice Chair), TP Lam, JK Mbatia, FA Minhas, G Reed, and M Rosendal. The PCCG is chaired by Prof, Sir David Goldberg.
A WHO Expert Working Group on Somatic Distress and Dissociative Disorders (known as the S3DWG) was constituted in 2011 to review the scientific evidence for, and clinical utility of the ICD-10 somatoform and dissociative disorders; to review proposals for the DSM-5 somatic symptom disorders and dissociative disorders categories and to consider their suitability or not for global applications; to review proposals and provide draft content for the somatic distress and dissociative disorder categories in line with the overall ICD revision requirements; to propose entities and descriptions for the classification of somatic distress and dissociative disorders for use in diverse global and primary care settings. External reviewers are also consulted on proposals and content.
The full S3DWG membership list is not publicly available but the group is understood to comprise 17 international behavioural health professionals, of which Prof Francis Creed is a member. The S3DWG is Chaired by Prof Oye Gureje.
Responsibilities of ICD-11 working groups are set out on Page 3 (1.1.) of document  in the References. Document  also includes information on the ICD-11 field trials, from Page 8 (4.).
Emerging proposals from the WHO Primary Care Consultation Group (PCCG)
I have previously reported that for the primary care version a new disorder group called Body distress disorders has been proposed, under which would sit a new primary care category, tentatively defined as Bodily stress syndrome (BSS). (Note that for the ICD-11 core version, the current proposal is for a new ICD entity called Bodily distress disorder. The two groups appeared not to have reached consensus, last year, over a name for this proposed new ICD disorder, or how it should be defined and characterized.)
Extract: Page 51, Table 2.5: Proposed disorders for ICD-11-PHC 
13 Health anxiety
Body distress disorders:
15 Bodily stress syndrome [Replaces F45 Unexplained somatic symptoms]
16 Acute stress reaction
17 Dissociative disorder
[F48 Neurasthenia proposed to be eliminated for ICD11-PHC]
This new recommendation for ICD-11-PHC has been proposed to include “milder somatic symptom disorders” as well as “DSM-5′s complex somatic symptom disorder” and replace “medically unexplained somatic symptoms” (ICD10-PC F45 Unexplained somatic symptoms) .
The PCCG proposals were evidently supportive, last year, of accommodating (selective of) the defining characteristics of DSM-5′s Somatic Symptom Disorder within the framework of its own recommendations, despite the lack of a body of evidence for the validity of Somatic Symptom Disorder, as a construct, and for its safety of application in diverse primary health care settings, in both adults and children.
Extract: The World Organization of Family Physicians (WONCA) Classification Committee
Wonca International Classification Committee, 2010 Annual Meeting, Ghent, Belgium
11-15 October, 2010
Chapter P and Z- Report of work of WHO Primary Care Consultation Group to ICD-11 Mental Health Classification.
Presentation and discussion led by Mike Klinkman.
The work of this 10-member group, composed of 5 GPs and 5 psychiatrists, was presented. The group is charged with recommending the list of mental health conditions to be included as the ICD-11-PC mental health classification. This list is to be integrated with the full ICD mental health classification. MK is deputy Chair of this group and MR is a member. The draft list of 28 terms was presented, and compared to the rubrics included in Chapter P of ICPC-2. Differences and similarities in the lists of conditions were highlighted. One important issue is how to address somatization, as there has been much work by Marianne Rosendal and her research colleagues* in defining the category of Body Distress Disorder (BDD) as an alternative to somatization/somatiform [sic] disorder. Another issue is the new formulation of anxiety – depression – anxious depression – distress disorder.
General discussion on the topic of BDD and its main disorders, body distress syndrome and health preoccupation disorder – and the fact that these reflect the failure of ICD to accommodate symptom diagnoses.
*Marianne Rosendal is a member of Wonca’s International Classification Committee and of the Primary Care Consultation Group. See Part Two of Dx Revision Watch Post: ICD-11 Beta draft and BDD, Per Fink and Bodily Distress Syndrome for more information on Fink et al’s Bodily Distress Syndrome, which is already in use in research studies and clinical settings, in Denmark.
Neither the PCCG or the S3DWG were proposing, last year, to replace the ICD-10 Somatoform Disorders with Fink et al’s Bodily Distress Syndrome, per se.
The proposals of the PCCG describe a new disorder which combines selected of DSM-5′s SSD and Fink et al’s BDS type characteristics; the S3DWG proposals describe a disorder that has more in common with the DSM-5 SSD construct (which differs significantly from Fink et al’s BDS), though both suggestions were proposed to have similar names to Fink et al’s Bodily Distress Syndrome, namely, Bodily stress syndrome, and Bodily distress disorder.
Were ICD-11 to introduce a new disorder with a similar name to Fink et al’s BDS, but where the definition, criteria and construct differ from BDS, this would likely result in considerable diagnostic and nosological confusion.
Having a primary care version disorder group named Body distress disorders under which four discrete disorders are located (15 Bodily stress syndrome; 16 Acute stress reaction; 17 Dissociative disorder; 18 Self-harm), might also result in potential confusion with Fink et al’s Bodily Distress Syndrome construct.
More information is known about emerging proposals from the PCCG. I shall be reporting on this in Part Two, in a forthcoming report. Read on for what is currently displaying in the ICD-11 Beta drafting platform.
No definition of BDD in the Beta drafting platform for the core ICD-11
In a previous report (ICD-11 Beta draft and Bodily Distress Disorders; Per Fink and Bodily Distress Syndrome Parts One and Two) I provided an update on the proposal for ICD-11 to replace a number of existing ICD-10 somatoform categories with a single new disorder.
As the ICD-11 Beta drafting platform stands at the time of compiling this report, the proposal for ICD-11 is to subsume the ICD-10 categories F45.0 – F45.9 under a single category, with the new ICD Entity Title term, Bodily distress disorder (BDD). So the following ICD categories are proposed to be eliminated for ICD-11:
Somatization disorder [F45.0 in ICD-10]
Undifferentiated somatoform disorder [F45.1 in ICD-10]
Somatoform autonomic dysfunction [F45.3 in ICD-10]
Persistent somatoform pain disorder [F45.4 in ICD-10]
> Persistent somatoform pain disorder
> Chronic pain disorder with somatic and psychological factors [Not in ICD-10]
Other somatoform disorders [F45.8 in ICD-10]
Somatoform disorder, unspecified [F45.9 in ICD-10]
Neurasthenia [F48.0 in ICD-10] is also proposed to be subsumed in the core version of ICD-11 and eliminated from the primary care version.
Up until a few days ago, three proposed, discretely coded ICD-11 entities had been listed as child categories under proposed, new parent term, Bodily distress disorders, and psychological and behavioural factors associated with disorders or diseases classified elsewhere:
Department of Mental Health and Substance Abuse, World Health Organization
1 April 2013
Psychological and behavioural factors associated with disorders or diseases classified elsewhere is a legacy category from ICD-10 (F54), where it is coded under parent class: Behavioural syndromes associated with physiological disturbances and physical factors (F50-F59). Inclusions and Exclusions for this category are largely imported from ICD-10, and the Definition remains currently unrevised.
Although the proposal to subsume seven ICD-10 categories under a new ICD Entity, Bodily distress disorder, has been displaying in the public version of the ICD-11 Beta drafting platform since February 2012, ICD-11 Revision has yet to define BDD, characterize its three Severity specifiers, or populate any other Content Model fields for them.
The overall section description, here, remains unchanged from ICD-10′s Somatoform Disorders section and has not been revised to reflect the proposal to subsume seven existing categories under a new ICD entity.
In the public version of the iCAT Alpha drafting platform, it had been possible to track changes to category hierarchies, definitions and other revisions through “Note tree” and “Change history” popup windows. In the public Beta drafting platform, these elements are absent and categories are shuffled around within chapters, and in some cases, shifted to other chapters, with no facility for the public to track edits or proposed edits, or rationales for proposed edits, or to determine the intention for categories that are no longer displaying in the draft.
Since no Definition, characterization of Severity specifiers, Inclusions, Exclusions or any other Content Model parameters have thus far been populated for these proposed BDD categories (despite their being new entities for ICD), it is difficult for professional and lay stakeholders to evaluate and comment on proposals.
Why has no BDD Definition been entered into the drafting platform?
A number of possibilities:
The two groups cannot agree on a construct or framework for ICD-11 Bodily distress disorder and how it should be defined; the Managing Editor for the Topic Advisory Group for Mental and Behavioural Disorders has yet to approve a proposed Definition and Severity specifiers (if consensus between the two groups has been reached); the groups are finding it difficult to assimilate the DSM-5 construct of Somatic Symptom Disorder within the framework of its own recommendations; the groups are waiting until the focus group studies and field trials have been completed and evidence for the validity and clinical utility of their proposals evaluated before entering a proposed Definition and other Content Model fields into the draft for stakeholder comment; or, cognisant of intense controversy surrounding revision of the somatoform disorders for both ICD-11 and DSM-5 (with which some degree of harmonization or accommodation might be anticipated), and the Fink et al concept of Bodily Distress Syndrome, ICD-11 Revision is reluctant to publicly post its current proposals.
Whatever the reason(s) for the delay, there has been a recent change to the draft: within the last few days, the proposal for three, discretely coded Severities for BDD: Mild bodily distress disorder; Moderate bodily distress disorder; Severe bodily distress disorder, has been revised.
Currently, only two specifiers: Bodily distress disorder; Severe bodily distress disorder are listed in the drafting platform (but still no Definition for BDD or characterization for either of these specifiers).
This is how the public version of the Beta drafting platform is currently listing this proposed new ICD disorder:
05 Mental and behavioural disorders
Bodily distress disorders, and psychological and behavioural factors associated with disorders or diseases classified elsewhere [ID : http://id.who.int/icd/entity/767044268]
Note: The sorting codes assigned to categories (for example, QL5, QL6) are subject to frequent change as chapters undergo reorganization.
For the ICD-11 core version (Foundation View), Hypochondriasis is currently proposed to be renamed to Illness anxiety disorder.
Illness anxiety disorder has been assigned two parents. It is currently listed under parents:
Obsessive-compulsive and related disorders [primary parent]
(New rules for ICD-11 permit categories to be assigned multiple parents. For example, a skin tumour is both a skin disease and a neoplasm; diseases of the eye due to diabetes may also be assigned two parent classes.)
(For ICD11-PHC, Hypochondriasis is proposed to be replaced with a category called Health anxiety.)
Note that the ICD-11 chapter numbering beyond Chapter 05 has been reorganized; Chapter 06 Diseases of the nervous system is currently renumbered to Chapter 07:
05 Mental and behavioural disorders
06 Sleep-wake disorders
07 Diseases of the nervous system
More information is known about emerging proposals from the S3DWG. I shall be reporting on this in Part Three, in a forthcoming report. Key points from Part One, below, and Caveats.
Key points from Part One:
• Two WHO working groups are advising on the revision of the ICD-10 and ICD10-PC Somatoform Disorders: the Primary Care Consultation Group (PCCG); the Expert Working Group on Somatic Distress and Dissociative Disorders (S3DWG). External reviewers are also consulted on proposals and content.
• Six ICD-10 somatoform disorders are proposed to be subsumed under a new ICD term, Bodily distress disorders, under parent category, Bodily distress disorders, and psychological and behavioural factors associated with disorders or diseases classified elsewhere; Neurasthenia is also proposed to be subsumed under BDD.
• No Definition for the ICD-11 construct of Bodily distress disorder has been entered into the Beta drafting platform.
• Three Severity specifiers for the core ICD-11 Bodily distress disorder category: Mild bodily distress disorder; Moderate bodily distress disorder; Severe bodily distress disorder have been recently revised to two: Bodily distress disorder and Severe bodily distress disorder but remain undefined and uncharacterized.
• The primary care group (PCCG) has proposed a new disorder, Bodily stress syndrome, that sits under new disorder group, Body distress disorders; Neurasthenia is proposed to be eliminated as a discrete disorder for ICD-11-PHC.
1. Goldberg DP. Comparison Between ICD and DSM Diagnostic Systems for Mental Disorders. In: Sorel E, (Ed.) 21st Century Global Mental Health. Jones & Bartlett Learning, 2012: 37-53. Free PDF, Sample Chapter Two: http://samples.jbpub.com/9781449627874/Chapter2.pdf
3. Responsibilities of ICD-11 working groups set out on Page 3 of 2012 Annual Report of the International Union of Psychological Science to the American Psychological Association, Revision of World Health Organization’s ICD-10 Mental and Behavioural Disorders, Pierre L.-J. Ritchie, Ph.D., Main Representative to the World Health Organization, International Union of Psychological Science, January, 2013
The version of the ICD-11 Beta drafting platform that the public can access is here: ICD11 Beta draft
The day to day drafting of ICD-11 is being undertaken by ICD Revision on the more complex, multi-author iCAT platform where edit histories can be tracked, progress of proposals monitored, and on which more content associated with categories displays.
The drafting of ICD-11 Beta is a work in progress: content in the publicly viewable platform is in a state of flux and subject to daily updating; sorting codes assigned to categories will change as chapter hierarchies are rearranged and new category names incorporated. Not all classifications and the descriptive content being generated for them may have been entered into the public version of the drafting platform. There may be errors and omissions. The draft is not finalized and not approved by WHO.
Where reports of emerging proposals have been published, the recommendations within them may be subject to revision following analysis of focus group studies, external review and multicentre field trials to assess the clinical utility, feasibility, reliability and validity of proposals for application in developed and developing countries and across various health care settings. Proposals contained within published reports, papers and presentations may have since been superseded by revised proposals not yet visible in the public draft.