HHS issue Final Rule: ICD-10-CM compliance deadline set for October 1, 2015

Post #314 Shortlink: http://wp.me/pKrrB-3ZI

CMS Press Release:  Final Rule July 31, 2014

Coding industry and professional body reaction

ICD-10 Testing: Final rule overshadows CMS testing plans

ICD10 Watch | Carl Natale | August 2, 2014

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Debunking Myths and Misperceptions of ICD-10 – Journal of AHIMA illustrates why it’s time for 10

AHIMA | News Release | July 30, 2014

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DHHS final rule on ICD-10 delay ready for publication

ICD10Watch | Carl Natale | July 31, 2014

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CMS Confirms ICD-10 Deadline

Health Leaders Media | Michelle Leppert | August 1, 2014

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ICD-10 Final Rule Released, October 2015 Official Compliance Deadline

Journal of AHIMA | Mary Butler | July 31, 2014

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ICD-10 Final Rule Stirs Angst, Apprehension

ICD10 Monitor | Chuck Buck | August 1, 2014

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(From June 12, 2014)

SNOMED, ICD-11 Not Feasible Alternatives to ICD-10-CM/PCS Implementation

AHIMA | Sue Bowman | June 12, 2014

“For the US, [2017] is the beginning, not the end, of the process toward adoption of ICD-11.”

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Resources

Federal Register: HHS ICD-10-CM Compliance FINAL RULE

[PDF] DEPARTMENT OF HEALTH AND HUMAN SERVICES, Office of the Secretary
45 CFR Part 162 [CMS-0043-F] RIN 0938-AS31
Administrative Simplification: Change to the Compliance Date for the International Classification of Diseases, 10th Revision (ICD–10–CM and ICD-10-PCS) Medical Data Code Sets

CMS Press Release:  Final Rule July 31, 2014

CMS NEWS

FOR IMMEDIATE RELEASE    Contact: CMS Media Relations

July 31, 2014                                   (202) 690-6145 or press@cms.hhs.gov

 

Deadline for ICD-10 allows health care industry ample time to prepare for change

Deadline set for October 1, 2015

The U.S. Department of Health and Human Services (HHS) issued a rule today finalizing Oct. 1, 2015 as the new compliance date for health care providers, health plans, and health care clearinghouses to transition to ICD-10, the tenth revision of the International Classification of Diseases. This deadline allows providers, insurance companies and others in the health care industry time to ramp up their operations to ensure their systems and business processes are ready to go on Oct. 1, 2015.

The ICD-10 codes on a claim are used to classify diagnoses and procedures on claims submitted to Medicare and private insurance payers. By enabling more detailed patient history coding, ICD-10 can help to better coordinate a patient’s care across providers and over time. ICD-10 improves quality measurement and reporting, facilitates the detection and prevention of fraud, waste, and abuse, and leads to greater accuracy of reimbursement for medical services. The code set’s granularity will improve data capture and analytics of public health surveillance and reporting, national quality reporting, research and data analysis, and provide detailed data to enhance health care delivery. Health care providers and specialty groups in the United States provided extensive input into the development of ICD-10, which includes more detailed codes for the conditions they treat and reflects advances in medicine and medical technology.

“ICD-10 codes will provide better support for patient care, and improve disease management, quality measurement and analytics,” said Marilyn Tavenner, Administrator of the Centers for Medicare & Medicaid Services (CMS). “For patients under the care of multiple providers, ICD-10 can help promote care coordination.”

Using ICD-10, doctors can capture much more information, meaning they can better understand important details about the patient’s health than with ICD-9-CM. Moreover, the level of detail that is provided for by ICD-10 means researchers and public health officials can better track diseases and health outcomes. ICD-10 reflects improved diagnosis of chronic illness and identifies underlying causes, complications of disease, and conditions that contribute to the complexity of a disease. Additionally, ICD-10 captures the severity and stage of diseases such as chronic kidney disease, diabetes, and asthma.

The previous revision, ICD-9-CM, contains outdated, obsolete terms that are inconsistent with current medical practice, new technology and preventive services.

ICD-10 represents a significant change that impacts the entire health care community. As such, much of the industry has already invested resources toward the implementation of ICD-10. CMS has implemented a comprehensive testing approach, including end-to-end testing in 2015, to help ensure providers are ready. While many providers, including physicians, hospitals, and health plans, have completed the necessary system changes to transition to ICD-10, the time offered by Congress and this rule ensure all providers are ready.

For additional information about ICD-10, please visit: http://www.cms.gov/ICD10

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Summary of responses from WHO re: Bodily distress disorder, Bodily stress syndrome, Bodily Distress Syndrome

Post #313 Shortlink: http://wp.me/pKrrB-3YR

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Screenshot: ICD-11 Beta drafting platform, public version, July 31, 2014; Chapter 06 Mental and behavioural disorders: Bodily distress disorder.

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BDD310714

Joint Linerarization for Mortality and Morbidity Statistics view selected; “show availability in main linearizations” view selected. Categories designated with three coloured key hover text: “In Mortality and Morbidity, Primary Care High Resource, Primary Care Low Resource. Categories designated with single blue key hover text: “In Mortality and Morbidity.”

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Summary of responses from Dr Geoffrey Reed, WHO

On July 23, I submitted an analysis and four questions via the ICD-11 Beta drafting platform for the attention of the Managing Editors for Topic Advisory Group (TAG) Mental Health, the advisory group that is revising ICD-10′s Chapter V.

A copy has been posted in Dx Revision Watch Post #311: Questions raised on ICD-11 Beta draft re: Bodily distress disorder http://wp.me/pKrrB-3Yh

Comments and suggestions submitted by registered users of the ICD-11 Beta drafting platform are screened and forwarded to the appropriate TAG Managing Editors for review.

I also sent a copy of my comments to Dr Geoffrey Reed. Dr Reed is Senior Project Officer overseeing the revision of the ICD Mental and behavioural disorders chapter.

On July 24, I received a response from Dr Reed, via email.

Dr Reed’s responses do not address all the points I had raised via the Beta platform and in my covering email. I am providing a summary of selected of Dr Reed’s responses, below.

I had also drawn Dr Reed’s attention to the absence, since early 2013, of the three G93.3 terms from the public version of the Beta draft and collective concerns for ICD Revision’s failure, to date, to respond to multiple requests to provide an explanation for the continued absence of these terms from the Beta draft and to clarify ICD Revision’s intentions and proposals for the classification of these three ICD-10 terms within ICD-11 [i.e. chapter location(s), parent code(s), hierarchies, Definitions, Synonyms, Inclusion terms etc.].

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Dr Reed provided the following information on July 24:

The placement of ME and related conditions within the broader ICD-11 classification is still unresolved.

There has been no proposal and no intention to include ME or other conditions such as fibromyalgia or chronic fatigue syndrome in the classification of mental disorders.

That ME and related conditions be clearly identified as NOT being part of this section of the classification could be made absolutely clear through the use of exclusion terms.

However, Dr Reed will be unable to request that exclusion terms be added to relevant Mental and behavioural disorders categories (e.g., Bodily Distress Disorder) until the conditions that are being excluded exist in the classification. At such time, he would be happy to request exclusion terms.

ICD Revision is currently involved in testing the proposals of the ICD-11 Primary Care Consultation Group* in primary care settings around the world, in part to compare how they work with the proposals of the ICD-11 Expert Working Group on Somatic Distress and Dissociative Disorders**.

Whether the primary care proposal ends up capturing specific groups of patients in primary care who are likely to have underlying medical conditions will certainly be one of the issues for examination and further discussion. Study data would be used as a basis for modifying proposals.

That he considers my analysis is accurate.

That it is not WHO policy to make research protocols for field trial studies that are planned or currently being implemented publicly available for comment.

Details of the study methodology at the time the data are published are expected to be provided, in order that others may examine and critique the methodology, their interpretation of results and their subsequent decisions based on the studies.

Further modifications of the proposals will be based on data evaluation, and justifications made available.

In due course, ICD Revision will make more detailed diagnostic guidelines for all Mental and behavioural disorders available for review and comment before they are finalized, but ICD Revision is not yet ready to do that.

Dr Reed will notify me when that occurs, but anticipates this will be before the end of the year and considers there is plenty of time for review as the approval of ICD-11 is now currently planned for May, 2017.

Dr Reed’s purview does not extend to the section on classification of Diseases of the nervous system or other areas outside the Mental and behavioural disorders chapter, and is therefore unable to provide any information related to how these conditions will be classified in other chapters***.

He is unable to comment about the management of correspondence by other TAG groups**** and signposts to another member of WHO staff [a senior classification expert who had been copied into the joint organizations' letter to WHO/ICD Revision, in March].

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Footnotes:

* Back in 2012, the ICD-11 Primary Care Consultation Group (the PCCG) were proposing a disorder construct that presented a modified version of the Fink et al (2010) Bodily Distress Syndrome (BDS) construct which, at that point, the Primary Care group were proposing to call, “Bodily stress syndrome (BSS).”

The PCCG hasn’t published a progress report since 2012 and the group’s current proposals are not available for scrutiny. If a modified version of BDS is currently being proposed by the PCCG, it isn’t known what changes have been made to the group’s proposals since the Lam et al paper was published in 2012, a paper which is now in the public domain [1].

An editorial co-authored by Prof David Goldberg, in June 2013, implied that Prof Goldberg, at least, was advancing that BDS should be progressed to ICD-11 field testing. It is unclear from Dr Reed’s responses to what extent the PCCG’s most recent proposals correspond to the disorder descriptions and criteria for Fink et al’s, already operationalized, BDS, or whether the group has retained the “BSS” disorder name for the purposes of the field tests and a modified construct/criteria set.

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** In 2012, the ICD-11 Expert Working Group on Somatic Distress and Dissociative Disorders (the S3DWG) were proposing an alternative and divergent disorder construct that had good concordance with DSM-5′s Somatic symptom disorder, and poor concordance with Fink et al’s BDS [2].

Perversely, the S3DWG were proposing to call their disorder construct, “Bodily distress disorder (BDD)” – a term already used outside ICD Revision, interchangeably, with Bodily Distress Syndrome [3].

It is the S3DWG’s BDD disorder construct that has been entered into the ICD-11 Beta drafting platform.

The Beta draft entry for BDD has recently had characterizations inserted for three BDD severity specifiers: BDD, Mild; BDD, Moderate; BDD, Severe. This post (which was written before I received responses from Dr Reed) sets out these recent additions to the draft in the context of the two divergent sets of proposals: Definitions for three severities of Bodily distress disorder now inserted in ICD-11 Beta draft, July 19, 2014 http://wp.me/pKrrB-3X9

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*** This February 8, 2014 post: http://wp.me/pKrrB-3IX tracks the history of the progression of the three ICD-10 G93.3 categories, PVFS, (B)ME and CFS within the ICD-11 drafting platform, from May 2010 to early 2013.

Under the subheading “So why have these three ICD-10 terms disappeared and why is ICD Revision reluctant to respond?” I have suggested a number of potential reasons for the current absence of these three terms from the Beta draft.

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**** On March 17, a joint letter signed by Sonya Chowdhury, CEO, Action for M.E., Annette Brooke MP, Chair, All Party Parliamentary Group on M.E., The Countess of Mar, Chair, Forward M.E. and Dr Charles Shepherd, ME Association, was sent to key Topic Advisory Group for Neurology members and copied to WHO’s Dr Margaret Chan, Dr Geoffrey Reed and Dr Robert Jakob.

The letter had requested, inter alia, clarification for the absence of the three ICD-10 G93.3 terms, Postviral fatigue syndrome, Benign myalgic encephalomyelitis and Chronic fatigue syndrome from the public version of the ICD-11 Beta drafting platform.

Prior to early 2013, in the public version of the Beta draft, Chronic Fatigue Syndrome had been listed in the Beta Foundation Component as an ICD Title entity under the Diseases of the nervous system chapter, with Benign Myalgic encephalomyelitis specified as an Inclusion term to Title term CFS, and Postviral fatigue syndrome listed under Synonyms to Title term, CFS.

The joint letter can be read here:

http://www.actionforme.org.uk/Resources/Action%20for%20ME/Documents/get-informed/who-icd-11-letter-17-3-14-sc.pdf

At the July 1 meeting of the APPG on M.E. it was agreed that in the absence of a response, Annette Brooke MP (Chair) would follow up the correspondence. Minuted here (under 3 Matters arising; d) ICD-11):

http://www.meassociation.org.uk/2014/07/minutes-of-the-appg-on-me-meeting-and-the-agm-held-on-1-july-2014/

I have advised Sonya Chowdhury, Dr Charles Shepherd, Neil Riley and Jane Colby of Dr Reed’s responses and suggested that Annette Brooke MP is updated.

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Forthcoming Symposium:

In September, Professor Oye Gureje, who chairs the ICD-11 Expert Working Group on Somatic Distress and Dissociative Disorders, will be presenting on “Proposals and evidence for the ICD-11 classification of Bodily Distress Disorders” as part of series of symposia on the development of the ICD-11 chapter for mental and behavioural disorders, at the World Psychiatric Association XVI World Congress, in Madrid, Spain, 14–18 September 2014.

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References:

1. Lam TP, Goldberg DP, Dowell AC, Fortes S, Mbatia JK, Minhas FA, Klinkman MS: Proposed new diagnoses of anxious depression and bodily stress syndrome in ICD-11-PHC: an international focus group study. Family Practice (2013) 30 (1): 76-87. Full free text: http://fampra.oxfordjournals.org/content/30/1/76.long

2. Creed F, Gureje O. Emerging themes in the revision of the classification of somatoform disorders. Int Rev Psychiatry. 2012 Dec;24(6):556-67. http://www.ncbi.nlm.nih.gov/pubmed/23244611 [Full text behind paywall]

3. Fink P, Toft T, Hansen MS, Ornbol E, Olesen F. Symptoms and syndromes of bodily distress: an exploratory study of 978 internal medical, neurological, and primary care patients. Psychosom Med. 2007 Jan;69(1):30-9.

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Caveats: The ICD-11 Beta drafting platform is not a static document: it is a work in progress, subject to daily edits and revisions, to field test evaluation and to approval by ICD Revision Steering Group and WHO classification experts. Not all new proposals may survive ICD-11 field testing. Chapter numbering, codes and Sorting codes currently assigned to ICD categories may change as chapters and parent/child hierarchies are reorganized. The public version of the Beta draft is incomplete; not all “Content Model” parameters display or are populated; the draft may contain errors and category omissions.

Questions raised on ICD-11 Beta draft re: Bodily distress disorder

Post #311 Shortlink: http://wp.me/pKrrB-3Yh

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Screenshot: ICD-11 Beta drafting platform, public version, July 31, 2014; Chapter 06 Mental and behavioural disorders: Bodily distress disorder.

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BDD310714

 
Joint Linerarization for Mortality and Morbidity Statistics view selected; “show availability in main linearizations” view selected. Categories designated with three coloured key hover text: “In Mortality and Morbidity, Primary Care High Resource, Primary Care Low Resource. Categories designated with single blue key hover text: “In Mortality and Morbidity.”

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Yesterday, I left the following comments and questions for TAG Mental Health Managing Editors via the ICD-11 Beta drafting platform.

In order to read the comment in situ you will need to be registered with the Beta drafting platform, logged in, then click on the grey and orange quote icon at the end of the category Title.

http://apps.who.int/classifications/icd11/browse/f/en#/http://id.who.int/icd/entity/1121638993

Bodily distress disorder, severe

Comments on title

Suzy Chapman 2014-Jul-23 – 14:01 UTC

Definitions for three uniquely coded severities for Bodily distress disorder: Mild; Moderate; Severe, have recently been inserted into the Beta draft.

The Definition for Bodily distress disorder (BDD) and its three severity characterizations appears to be based on the BDD disorder descriptions in the 2012 Creed, Gureje paper: Emerging themes in the revision of the classification of somatoform disorders [1].

As conceptualized by the ICD-11 Expert Working Group on Somatic Distress and Dissociative Disorders (S3DWG), BDD is proposed to replace the seven ICD-10 Somatoform disorders categories F45.0 to F45.9, and F48.0 Neurasthenia.

The S3DWG’s BDD eliminates the requirement that symptoms be “medically unexplained” as the central defining feature; focuses on identification of positive psychobehavioural responses (excessive preoccupation with bodily symptoms, unreasonable illness fear, frequent or persistent healthcare utilization, activity avoidance for fear of damaging the body) in response to any (unspecific) persistent, distressing, single or multiple bodily symptom(s), resulting in significant impairment of functioning or frequent seeking of reassurance; makes no assumptions about aetiology, and in “[d]oing away with the unreliable assumption of its causality, the diagnosis of BDD does not exclude the presence of (…) a co-occurring physical health condition.”

The S3DWG’s BDD has no requirement for symptom counts, or for symptom patterns or symptom clusters from body or organ systems, which describes a disorder framework with good concordance with DSM-5 Somatic Symptom Disorder (SSD).

According to the Beta draft, BDD’s three severity specifiers are proposed to be characterized on the basis of the extent to which responses to persistent, distressing bodily symptoms are perceived as excessive and on the degree of impairment, not on the basis of number of bodily symptoms and number of body or organ systems affected.

In comparison, psychobehavioural responses do not form part of Fink et al’s (2010) Bodily Distress Syndrome criteria. BDS’s criteria and two severities are based on symptom patterns from body systems (a BDS Modest, single-organ type and a BDS Severe, Multi-organ type).

In 2012, the Lam et al paper [2], set out emerging proposals for the ICD-11 Primary Care Consultation Group’s (PCCG) recommendations for a “Bodily stress syndrome (BSS).”

The PCCG’s proposals described a disorder construct that had good concordance with Fink et al’s Bodily Distress Syndrome, drawing heavily on Fink et al’s criteria set. Although at that point, the PCCG proposed to incorporate some SSD-like psychobehavioural features within their tentative criteria. The PCCG appeared to be proposing a modified version of the Fink et al (2010) BDS construct.

In an Ivbijaro G, Goldberg D (June 2013) editorial [3], the co-authors advance the position that the forthcoming revision of ICD provides an opportunity to include BDS in a revised classification for primary care. According to this June 2013 editorial, the PCCG’s proposal for a modified BDS disorder construct, which it had earlier proposed to call “Bodily stress syndrome (BSS),” appears to have been revised to using the Fink et al “Bodily distress syndrome (BDS)” term.

The editorial implies that BDS (which subsumes the so-called “functional somatic syndromes,” CFS, ME, IBS, Fibromyalgia, chronic pain disorder, MCS and some others, under a single, overarching disorder) was expected to be progressing, imminently, to ICD-11 field trials.

(A revision of the earlier BSS disorder name is not discussed within the editorial; nor whether any modifications to, or deviance from a “pure” BDS construct and criteria were being recommended for the purposes of field testing; nor are the alternative proposals of the S3DWG referenced or discussed; nor are the views of the Revision Steering Group on either set of proposals discussed.)

According to Lam et al (2012) and Ivbijaro and Goldberg (June 2013), the model proposed is that of “autonomic over-arousal,” which the authors consider may be responsible for most or all of the somatic symptoms that are experienced.

Again, compare with the S3DWG’s BDD construct, which makes no assumptions about aetiology and does not exclude the presence of a co-occurring physical health condition, whereas, for both Lam et al’s 2012 BSS and for Fink et al’s BDS, “If the symptoms are better explained by another disease, they cannot be labelled BDS.”

Potential for confusion between divergent disorder constructs:

The term “Bodily distress disorder” and the term “Bodily distress syndrome” (Fink et al, 2010), which is already operationalized in Denmark in research and clinical settings, are often seen being used interchangeably in the literature. For example, in this very recent editorial by Rief and Isaac [4]. Also in papers by Fink and others from 2007 onwards [5].

However, the S3DWG’s defining of a “Bodily distress disorder” construct has stronger conceptual alignment and criteria congruency with DSM-5′s SSD and poor conceptual and criteria congruency with Fink et al’s BDS. That SSD and BDS are very different concepts is acknowledged by Fink, Creed and Henningsen [6] [7].

Although the 2013 Ivbijaro and Goldberg editorial implies that Fink et al’s BDS construct was going forward to ICD-11 field testing, it is the S3DWG’s Bodily distress disorder name and construct that has been entered into the Beta draft – the construct that has stronger conceptual alignment with DSM-5′s SSD.

So the current proposals and intentions for field testing a potential replacement for the SDs remain unclear. This is severely hampering professional and consumer stakeholder scrutiny, discourse and input.

Four questions for TAG Mental Health Managing Editors:

1. Have the S3DWG sub working group, the PCCG working group and the Revision Steering Group reached consensus over a potential replacement framework and disorder construct for ICD-10′s Somatoform disorders and F48.0 Neurasthenia, and the ICD-10-PHC categories: F45 Unexplained somatic symptoms/medically unexplained symptoms, and F48 Neurasthenia?

2. Which recommendations are being progressed to international field testing and does ICD-11 intend to release the protocol or other information on finalized characteristics, diagnostic guidelines, criteria, inclusions, exclusions, differential diagnoses etc, that are planned to be used for the field tests and which would provide the level of detail lacking in the public version of the Beta drafting platform?

3. If, in the context of ICD-11 usage, the S3DWG working group’s proposal for a replacement for the Somatoform disorders remains for a disorder model with good concordance with the DSM-5 SSD construct, what is the rationale for proposing to name this disorder “Bodily distress disorder”?

4. Have the S3DWG, PCCG and Revision Steering Group given consideration to the significant potential for confusion if its replacement construct for the Somatoform disorders has greater conceptual alignment with the SSD construct but is assigned a disorder name that sounds very similar to, and is already being used interchangeably with an operationalized but divergent construct and criteria set?

References:

1. Creed F, Gureje O. Emerging themes in the revision of the classification of somatoform disorders. Int Rev Psychiatry. 2012 Dec;24(6):556-67. http://www.ncbi.nlm.nih.gov/pubmed/23244611 [Full text behind paywall]

2. Lam TP, Goldberg DP, Dowell AC, Fortes S, Mbatia JK, Minhas FA, Klinkman MS: Proposed new diagnoses of anxious depression and bodily stress syndrome in ICD-11-PHC: an international focus group study. Family Practice (2013) 30 (1): 76-87. Full free text: http://fampra.oxfordjournals.org/content/30/1/76.long

3. Ivbijaro G, Goldberg D. Bodily distress syndrome (BDS): the evolution from medically unexplained symptoms (MUS). Ment Health Fam Med. 2013 Jun;10(2):63-4. Full free text available on 2014/6/1: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3822636/pdf/MHFM-10-063.pdf

4. Rief W, Isaac M. The future of somatoform disorders: somatic symptom disorder, bodily distress disorder or functional syndromes? Curr Opin Psychiatry (2014). Full free: http://journals.lww.com/co-psychiatry/Fulltext/2014/09000/The_future_of_somatoform_disorders___somatic.2.aspx

5. Fink P, Toft T, Hansen MS, Ornbol E, Olesen F. Symptoms and syndromes of bodily distress: an exploratory study of 978 internal medical, neurological, and primary care patients. Psychosom Med. 2007 Jan;69(1):30-9.

6. Medically Unexplained Symptoms, Somatisation and Bodily Distress: Developing Better Clinical Services, Francis Creed, Peter Henningsen, Per Fink (Eds), Cambridge University Press, 2011.

7. Discussions between Prof Francis Creed and Prof Per Fink during Research Clinic for Functional Disorders Symposium presentations, Aarhus University Hospital, May 15, 2014, noted that Fink et al BDS and DSM-5 SSD are “very different concepts.”

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September symposium presentation on BDD:

In September, Professor Oye Gureje (who chairs the ICD-11 Expert Working Group on Somatic Distress and Dissociative Disorders), will be presenting on Proposals and evidence for the ICD-11 classification of Bodily Distress Disorders, as part of series of symposia on the development of the ICD-11 chapter for mental and behavioural disorders, at the World Psychiatric Association XVI World Congress in Madrid, Spain, 14–18 September 2014.

Unfortunately, I cannot attend this September symposia but would be pleased to hear from anyone who may be planning to attend.

Caveats: The ICD-11 Beta drafting platform is not a static document: it is a work in progress, subject to daily edits and revisions, to field test evaluation and to approval by ICD Revision Steering Group and WHO classification experts. Not all new proposals may survive ICD-11 field testing. Chapter numbering, codes and Sorting codes currently assigned to ICD categories may change as chapters and parent/child hierarchies are reorganized. The public version of the Beta draft is incomplete; not all “Content Model” parameters display or are populated; the draft may contain errors and category omissions.

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Further reading:

Dx Revision Watch Post: Definitions for three severities of “Bodily distress disorder” now inserted in ICD-11 Beta draft, July 19, 2014 http://wp.me/pKrrB-3X9

Dx Revision Watch Post: Editorial: Bodily distress syndrome (BDS): the evolution from medically unexplained symptoms (Goldberg and ICD-11-PHC), June 3, 2014: http://wp.me/pKrrB-3Uh

Definitions for three severities of “Bodily distress disorder” now inserted in ICD-11 Beta draft

Post #310 Shortlink: http://wp.me/pKrrB-3X9

Caveats: The ICD-11 Beta drafting platform is not a static document: it is a work in progress, subject to daily edits and revisions, to field test evaluation and to approval by ICD Revision Steering Group and WHO classification experts. Not all new proposals may survive ICD-11 field testing. Chapter numbering, codes and Sorting codes currently assigned to ICD categories may change as chapters and parent/child hierarchies are reorganized. The public version of the Beta draft is incomplete; not all “Content Model” parameters display or are populated; the draft may contain errors and category omissions.

This report updates on recent additions to the listing for Bodily distress disorder in the public version of the ICD-11 Beta draft.

This is an edited version of the report published on July 19.

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Bodily distress disorder (BDD) is a new, single diagnostic category that has been proposed for ICD-11. It is intended to subsume the seven ICD-10 Somatoform disorders categories F45.0 – F45.9, and F48.0 Neurasthenia.

Bodily distress disorder (BDD) is the term that has been entered into the Beta drafting platform since February 2012.

It is the term and disorder construct that has been proposed by the ICD-11 Expert Working Group on Somatic Distress and Dissociative Disorders (S3DWG), which is chaired by Professor Oye Gureje [1].

Note: the term Bodily stress syndrome (BSS) (Lam et al, 2012) is an alternative disorder term and diagnostic construct that has been proposed by the ICD-11 Primary Care Consultation Group (PCCG), which is chaired by Professor Sir David Goldberg [2].

The disorder term and construct Bodily distress syndrome (BDS) has also been advanced for ICD-11 in a June 2013 editorial by Ivbijaro G and Goldberg D [3].

Neither of the terms Bodily stress syndrome (BSS) or Bodily distress syndrome (BDS) has been entered into the ICD-11 Beta draft.

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ICD-11 Beta drafting platform (public version):

A Definition for category Bodily distress disorder was inserted into the Beta draft in late January 2014.

At that point, no definitions or characterizations for any of the uniquely coded BDD severity specifiers (currently, BDD, mild; BDD, moderate; BDD, severe) had been inserted.

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How is BDD being defined for the purposes of ICD-11?

The psychological and behavioural features that characterize Bodily distress disorder, as currently defined in the Beta draft, are drawn from the disorder conceptualizations in the 2012 Creed, Gureje paper on emerging proposals for the revision of the classification of somatoform disorders [1].

This paper sits behind a paywall but I have had a copy since it was first published.

The paper describes a disorder model that has poor concordance with Fink et al’s Bodily Distress Syndrome construct.

The 2012 Creed, Gureje paper defines BDD as:

“a much simplified set of criteria”;

eliminates the requirement that symptoms be “medically unexplained” as the central defining feature;

focuses on identification of positive psychobehavioural responses (excessive preoccupation with bodily symptoms, unreasonable illness fear, frequent or persistent healthcare utilization, activity avoidance for fear of damaging the body) in response to any (unspecific) persistent, distressing, single or multiple bodily symptom(s), resulting in significant impairment of functioning or frequent seeking of reassurance;

makes no assumptions about aetiology and in “[d]oing away with the unreliable assumption of its causality the diagnosis of BDD does not exclude the presence of (…) a co-occurring physical health condition”;

has no requirement for symptom counts, or for symptom patterns or symptom clusters from body or organ systems

– which describes a disorder framework into which DSM-5′s “Somatic Symptom Disorder (SSD)” could potentially be integrated, facilitating harmonization between a replacement for the ICD-10 Somatoform disorders and DSM-5′s new SSD.

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Whereas, Fink et al’s 2010 Bodily Distress Syndrome criteria are based on impairment and symptom patterns from body systems. Positive psychobehavioural features do not form part of the Fink et al criteria [4–6].

For ICD-11′s BDD, patients may be preoccupied with any bodily symptoms and the presence of a co-occurring physical health condition is not an exclusion.

But for Fink et al’s BDS, “If the symptoms are better explained by another disease, they cannot be labelled BDS.”

BDD’s three severity specifiers are proposed to be characterized on the basis of the extent to which responses to persistent, distressing symptoms are perceived as excessive and on degree of impairment, not on the basis of the number of bodily symptoms and the number of body or organ systems that are affected by the disorder.

In contrast, BDS’s two severities are based on symptom patterns (a BDS Modest, single-organ type and a BDS Severe, Multi-organ type).

Both BDD and BDS are intended to subsume the Somatoform disorders and Neurasthenia.

But BDS seeks to arrogate the so-called “functional somatic syndromes,” CFS, ME, IBS, Fibromyalgia, chronic pain disorder, MCS and some others, and subsume them under a single, overarching BDS diagnosis [6].

So although the BDD and BDS disorder names sound very similar (and the terms are sometimes seen used interchangeably), as defined in the 2012 Creed, Gureje paper and as defined by the recently inserted Beta draft Definitions, ICD-11′s BDD and Fink et al’s BDS present divergent constructs*.

It is the ICD-11 Primary Care Consultation Group‘s 2012 proposals for a “Bodily stress disorder” [2] that had stronger conceptual alignment and criteria congruency with Fink et al’s BDS.

*Discussions between Profs Creed and Fink during the Research Clinic for Functional Disorders Symposium presentations, Aarhus University Hospital, May 15, 2014, noted that Fink et al’s BDS and DSM-5′s SSD are “very different concepts.” That SSD and BDS are divergent constructs is also discussed in: Medically Unexplained Symptoms, Somatisation and Bodily Distress: Developing Better Clinical Services, Francis Creed, Peter Henningsen, Per Fink (Eds), Cambridge University Press, 2011.

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ICD-11 BDD, mild; moderate and severe specifiers, now defined:

In the last few days, Definitions for the three uniquely coded Severity specifiers:

6B40 Bodily distress disorder, mild

6B41 Bodily distress disorder, moderate

6B42 Bodily distress disorder, severe

have been inserted into the Beta draft.

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The Definition for the Title term Bodily distress disorder remains the same as previously reported:

http://apps.who.int/classifications/icd11/browse/f/en#/http://id.who.int/icd/entity/767044268

http://apps.who.int/classifications/icd11/browse/l-m/en#/http://id.who.int/icd/entity/767044268

Chapter 06 Mental and behavioural disorders

Bodily distress disorder [In Mortality and Morbidity, Primary Care High Resource, Primary Care Low Resource Linearizations]

Foundation Id: http://id.who.int/icd/entity/767044268

Parent(s)

Mental and behavioural disorders            ICD-10 : F45

Definition

Bodily distress disorder is characterized by high levels of preoccupation regarding bodily symptoms, unusually frequent or persistent medical help-seeking, and avoidance of normal activities for fear of damaging the body. These features are sufficiently persistent and distressing to lead to impairment in personal, family, social, educational, occupational or other important areas of functioning. The most common symptoms include pain (including musculoskeletal and chest pains, backache, headaches), fatigue, gastrointestinal symptoms, and respiratory symptoms, although patients may be preoccupied with any bodily symptoms. Bodily distress disorder most commonly involves multiple bodily symptoms, though some cases involve a single very bothersome symptom (usually pain or fatigue).

Synonyms

somatoform disorders
Somatization disorder

Exclusions [Ed: with the exception of Hypochondriasis, Exclusions are imported from ICD-10 F45 Somatoform disorders Exclusions.]

lisping
lalling
psychological or behavioural factors associated with disorders or diseases classified elsewhere
nail-biting
sexual dysfunction, not caused by organic disorder or disease
thumb-sucking
tic disorders (in childhood and adolescence)
Tourette syndrome
trichotillomania
dissociative disorders
hair-plucking
Hypochondriasis

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This is the recently added Definition for 6B40 Bodily distress disorder, mild:

http://apps.who.int/classifications/icd11/browse/f/en#/http://id.who.int/icd/entity/1472866636

http://apps.who.int/classifications/icd11/browse/l-m/en#/http://id.who.int/icd/entity/1472866636

6B40 Bodily distress disorder, mild [In Mortality and Morbidity Linearizations]

Foundation Id: http://id.who.int/icd/entity/1472866636

Parent(s)

Definition 

Bodily distress disorder, mild is a form of Bodily distress disorder in which there is excessive attention to bothersome symptoms and their consequences, which may result in frequent medical visits. The person is not preoccupied with the symptoms (e.g., spends less than an hour per day focusing on them). Although the individual expresses distress about the symptoms and they may have some impact on his or her life (e.g., strain in relationships, less effective academic or occupational functioning, abandonment of specific leisure activities) there is no substantial impairment in the person’s personal, family, social, educational, occupational, or other important areas of functioning.

All Index Terms

  • Bodily distress disorder, mild

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Here’s the Definition for 6B41 Bodily distress disorder, moderate:

http://apps.who.int/classifications/icd11/browse/f/en#/http://id.who.int/icd/entity/1967782703

http://apps.who.int/classifications/icd11/browse/l-m/en#/http://id.who.int/icd/entity/1967782703

6B41 Bodily distress disorder, moderate [In Mortality and Morbidity Linearizations]

Foundation Id : http://id.who.int/icd/entity/1967782703

Parent(s)

Definition 

Bodily distress disorder, moderate is a form of bodily distress disorder in which there is persistent preoccupation with bothersome symptoms and their consequences (e.g., spends more than an hour a day thinking about them), typically associated with frequent medical visits such that the person devotes much of his or her energy to focusing on the symptoms and their consequences, with consequent moderate impairment in personal, family, social, educational, occupational, or other important areas of functioning (e.g., relationship conflict, performance problems at work, abandonment of a range of social and leisure activities).

All Index Terms

  • Bodily distress disorder, moderate

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  And here’s the Definition for 6B42 Bodily distress disorder, severe:

http://apps.who.int/classifications/icd11/browse/f/en#/http://id.who.int/icd/entity/1121638993

http://apps.who.int/classifications/icd11/browse/l-m/en#/http://id.who.int/icd/entity/1121638993

6B42 Bodily distress disorder, severe [In Mortality and Morbidity Linearizations]

Foundation Id: http://id.who.int/icd/entity/1121638993

Parent(s)

Definition

Bodily distress disorder, severe is a form of bodily distress disorder in which there is pervasive and persistent preoccupation to the extent that the symptoms may become the focal point of the person’s life, typically requiring extensive interactions with the health care system. Preoccupation with the experienced symptoms and their consequences causes serious impairment in personal, family, social, educational, occupational, or other important areas of functioning (e.g., unable to work, alienation of friends and family, abandonment of nearly all social and leisure activities). The person’s interests may become so narrow so as to focus almost exclusively on his or her bodily symptoms and their negative consequences.

All Index Terms

  • Bodily distress disorder, severe

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What will ICD-11 be field testing?

Field testing of a potential replacement for the existing ICD-10 Somatoform disorders framework is expected to be conducted over the next year or two. Disorders that survive the ICD-11-PHC field tests must have an equivalent disorder in the main ICD-11 classification.

So whatever replaces the existing ICD-10-PHC categories, F45 Unexplained somatic symptoms/medically unexplained symptoms and F48 Neurasthenia, (which is also proposed to be eliminated for the ICD-11 primary care version), will need an equivalent disorder in the main classification.

International field tests across a range of primary care settings had been anticipated to start from June, last year, but there were reported delays. It isn’t known whether consensus has been reached yet over disorder construct and diagnostic criteria for use in the field tests, or whether field testing is now underway.

I cannot confirm whether ICD-11 intends to release a protocol into the public domain for whatever construct it plans to field test, or may already be field testing.

Currently, there is no publicly available protocol or other information on finalized characteristics, diagnostic guidelines, criteria, inclusions, exclusions, differential diagnoses etc. that are planned to be used for the field tests which would provide the level of detail lacking in the public version of the Beta drafting platform.

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So which construct does ICD-11 Revision Steering Group favour?

Although BDD (and now its three severities) have been defined within the Beta draft, much remains unclear for proposals for the revision of this section of ICD-11 Mental and behavioural disorders.

The ICD-11 Primary Care Consultation Group’s alternative 2012 Bodily stress syndrome (BSS) construct – a near clone of Fink et al’s BDS criteria but with some SSD-like psychobehavioural responses tacked on – isn’t the construct that is entered and defined within the Beta draft.

In June 2013, Prof Gabriel Ivbijaro (not, himself, a member of the PCCG) and Prof Sir David Goldberg (who chairs the PCCG) published a joint editorial in Mental Health in Family Medicine, the official journal of The World Organization of Family Doctors (Wonca) Working Party on Mental Health, for which Prof Ivbijaro is Editor in Chief.

The authors advance the position that the forthcoming revision of ICD “provides an opportunity to include BDS in a revised classification for primary care” and imply that BDS (at least at that point) was progressing, imminently, to ICD-11 field trials.

This brief editorial was embargoed from June 2013 to June 2014 and I was unable to obtain a copy until last month, but you can read it now for free and in full here: Bodily distress syndrome (BDS): the evolution from medically unexplained symptoms (MUS).

Note, firstly, that the editorial does not declare Professor Goldberg’s interest as chair of the ICD-11 Primary Care Consultation Group.

It does not clarify whether the views and opinions expressed within the editorial represent the views of the authors or are the official positions of the PCCG working group, or of the International Advisory Group for the Revision of ICD-10 Mental and Behavioural Disorders, or of the ICD-11 Revision Steering Group (RSG), or of any committees on which co-author, Prof Ivbijaro, sits or of any bodies to which Prof Ivbijaro is affiliated.

No publicly posted progress reports are being issued by ICD-11 or by either of the two groups making recommendations for the revision of this section of ICD and I do not have a second source that confirms the status of proposals as they stood in June 2013.

But taking the editorial at face value, it would appear that the PCCG had revised its earlier proposals for a BSS construct (that drew heavily on Fink et al’s BDS criteria but had included the requirement for some psychobehavioural responses) and were now recommending that the Fink et al BDS construct and criteria should progress for ICD-11-PHC field testing and evaluation, that is, using the same disorder name and (presumably) the same criteria set that is already operationalized in research and clinical settings, in Denmark.

(The rationale for the apparent revision of the earlier BSS disorder name is not discussed within the editorial; nor whether any modifications to, or deviance from a “pure” BDS construct and criteria were being recommended for the purposes of ICD-11 field testing.)

The editorial doesn’t clarify whether the PCCG, the S3DWG and the ICD-11 Revision Steering Group (RSG) had reached consensus – it does not mention the alternative proposals of the S3DWG, at all, or discuss what is entered into the Beta draft, or discuss the views and preferences of the Revision Steering Group for any of recommendations made by the two advisory groups, to date.

It is unclear whether a “pure” BDS construct (as opposed to the PCCG’s earlier BSS modification) had already gained Revision Steering Group approval for progressing to field testing, at the point the editorial was drafted, or whether Prof Goldberg was using this Wonca house journal as a platform on which to promote his own opinions and expectations, in a purely personal capacity.

Crucially, it doesn’t explain why, if a BDS-like construct were anticipated to be progressed to field trials in the second half of 2013, it is the S3DWG’s Bodily distress disorder diagnostic construct that has been listed and defined in the Beta draft for Foundation, Mortality and Morbidity, Primary Care High Resource, Primary Care Low Resource linearizations – not the PCCG’s 2012 BSS modification, or the “pure” BDS that Prof Goldberg evidently champions.

As a source of information on the current status of proposals for the revision of the Somatoform disorders this June 2013 editorial is problematic (and now also over a year out of date).

I suspect the politics between the 12 member PCCG (which includes Marianne Rosendal*), the 17 member S3DWG and the ICD-11 Revision Steering Group are intensely fraught given Professor Goldberg’s agenda for the revision of the Somatoform disorders, since fitting BDS into ICD-11 hasn’t proved to be the shoo in that Fink, Rosendal and colleagues had hoped for**, and given that BDS cannot be harmonized with DSM-5′s SSD, as they are conceptually divergent.

*Dr Marianne Rosendal (Department of Public Health, Aarhus University), who has published with Prof Per Fink, is the European representative on WONCA’s International Classification Committee. The vice-chair of the PCCG is Dr Michael Klinkman, a GP who represents WONCA (World Organization of Family Doctors). Dr Klinkman is current convenor of WONCA’s International Classification Committee (WICC) that is responsible for the development of ICPC-2.
**Presentation, Professor Per Fink, March 19, 2014 Danish parliamentary hearing on Functional Disorders. Prof Fink stated that he and his colleagues had tried to get WHO to incorporate a section for a special group of disorders where BDS could be placed that was located neither in psychiatry nor in general medicine, but had not been successful.

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Requests for clarification repeatedly stonewalled:

ICD Revision has been asked several times, via the Beta drafting platform, to clarify current proposals for the framework and disorder construct for a replacement for the ICD-10 Somatoform disorders and to clarify which construct it intends to take forward to field testing. ICD Revision has also been asked to comment on the following:

“If, in the context of ICD-11 usage, the S3DWG working group’s proposal for a replacement for the Somatoform disorders remains for a disorder model with good concordance with DSM-5′s SSD construct, what is the rationale for proposing to name this disorder “Bodily distress disorder”?

“Have the S3DWG, PCCG and Revision Steering Group given consideration to the significant potential for confusion if its replacement construct for the Somatoform disorders has greater conceptual alignment with the SSD construct but is assigned a disorder name that sounds very similar to, and is already being used interchangeably with an operationalized but divergent construct and criteria set?”

No response has been forthcoming.

Lack of publicly posted progress reports by both working groups, confusion over the content of the Beta draft and ICD Revision’s failure to respond to queries from stakeholders is hampering stakeholder scrutiny, discourse and input. It is time clinicians, researchers, allied professionals and advocacy organizations demanded transparency from ICD Revision around current proposals and field trial intentions.

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September symposium presentation on BDD:

In September, Professor Oye Gureje (who chairs the ICD-11 Expert Working Group on Somatic Distress and Dissociative Disorders), will be presenting on Proposals and evidence for the ICD-11 classification of Bodily Distress Disorders, as part of series of symposia on the development of the ICD-11 chapter for mental and behavioural disorders, at the World Psychiatric Association XVI World Congress, in Madrid, Spain, 14–18 September 2014 [7].

Unfortunately, I cannot attend this symposium presentation but would be pleased to hear from anyone who may be planning to attend.

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References:

1. Creed F, Gureje O. Emerging themes in the revision of the classification of somatoform disorders. Int Rev Psychiatry. 2012 Dec;24(6):556-67. http://www.ncbi.nlm.nih.gov/pubmed/23244611 [Full text behind paywall]

2. Lam TP, Goldberg DP, Dowell AC, Fortes S, Mbatia JK, Minhas FA, Klinkman MS: Proposed new diagnoses of anxious depression and bodily stress syndrome in ICD-11-PHC: an international focus group study. Fam Pract Feb 2013 [Epub ahead of print July 2012]. [Abstract: PMID: 22843638] Full free text: http://fampra.oxfordjournals.org/content/30/1/76.long

3. Ivbijaro G, Goldberg D. Bodily distress syndrome (BDS): the evolution from medically unexplained symptoms (MUS). Ment Health Fam Med. 2013 Jun;10(2):63-4. Full free text available on 2014/6/1: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3822636/pdf/MHFM-10-063.pdf

4. http://funktionellelidelser.dk/en/about/bds/

5. Fink P and Schröder A. One single diagnosis, bodily distress syndrome, succeeded to capture 10 diagnostic categories of functional somatic syndromes and somatoform disorders. Journal of Psychosomatic Research 2010;68:415–26.

6. Fink et al Proposed new BDS diagnostic classification

7. World Psychiatric Association XVI World Congress, Madrid, Spain, 14–18 September 2014.

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Further reading:

Dx Revision Watch Post: Editorial: Bodily distress syndrome (BDS): the evolution from medically unexplained symptoms (Goldberg and ICD-11-PHC), June 3, 2014: http://wp.me/pKrrB-3Uh

Submission: Proposal: Add Somatic symptom disorder as inclusion term to ICD-10-CM

Post #309 Shortlink: http://wp.me/pKrrB-3WD

You have until Friday in which to submit comments on any of the numerous diagnosis proposals presented at the March ICD-10-CM Coordination and Maintenance Committee meeting.

Comments should be sent to NCHS, preferably by email, by June 20th deadline: nchsicd9CM@cdc.gov

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The next public meeting of the ICD-10-CM/PCS Coordination and Maintenance Committee is scheduled for September 23–24, 2014. If you are planning to attend the meeting in person you will need to register online by September 12. Registration opens on August 15.

New proposals for the September 23–24, 2014 meeting must be received by July 18.

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September 2013 meeting Diagnosis Agenda

The fall meeting of the ICD-9-CM/PCS Coordination and Maintenance Committee took place on September 18–19.

The Diagnosis Agenda had included the proposals to add the new DSM-5 disorder terms: Somatic symptom disorder and Illness anxiety disorder to the ICD-10-CM Tabular List and the Alphabetical Index.

Note that the proposal was to add the terms as Inclusion Terms under existing ICD-10-CM Chapter 5 codes, not to create unique new codes for these two terms, or to replace or subsume any existing categories:

ICD10CM 4

Source: Page 45, Diagnosis Agenda (Topic Packet), September 18–19, 2013 ICD-10-CM/PCS Coordination and Maintenance Committee Meeting

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March 2014 meeting Diagnosis Agenda

The spring C & M Committee meeting took place on March 19–20, 2014. I was unable to attend either meeting as I live in the UK, and it is not feasible for me to participate in these public meetings via phone link.

The March Diagnosis Agenda included reiteration of the September proposal to add Somatic symptom disorder to the ICD-10-CM Alphabetical Index, coded to F45.1. (But did not include a resubmission to add to the Tabular List.) The reason for its reiteration in the March Agenda is unclear.

When the March Agenda requests for additions and modifications to the Tabular List were reached, CDC’s Beth Fisher had remarked that some of the proposals for additions to the Tabular List may have been proposed at the September 2013 meeting (though no explanation was given for why some of these September proposals were being duplicated in the March Agenda).

Evidently some Index proposals from the September meeting were also duplicated in the March Agenda, including SSD, but not Illness anxiety disorder.

There were no comments or queries from the floor in relation to proposals for SSD. There were no queries about whether NCHS decisions had already been reached on the requests for additions and modifications submitted via the September meeting.

It remains unclear whether the duplications in the March Agenda were due to administrative oversight, were being included for procedural reasons, or were being re-presented in response to NCHS committee decisions made following the September meeting, to which APA, but not the public at large, might be party to. (The outcome of both the September and March proposals may not be evident until 2015, when the next Addendum is posted.)

March Agenda proposal: Add Somatic symptom disorder to the Index as “– somatic symptom F45.1″ under “Disorders”:

+++
March14 ICD-10-CM Cand M SSD to Index

Source: Diagnosis Agenda (Topic Packet) Page 89, March 19-20, 2014 ICD-10-CM/PCS Coordination and Maintenance Committee Meeting; Screenshot Videocast Three

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F45.1 (SSD) and F45.21 (Illness anxiety disorder) are the ICD-10-CM codes to which these two new APA disorders are already cross-walked in the DSM-5:

+++
SSDcrosswalk

+++
If NCHS rubber stamps the addition of Somatic Symptom Disorder to the ICD-10-CM it could leverage future proposals (either by NCHS/CMS or by external requestors) for the replacement of some or all of the existing Somatoform disorders categories with this new, single SSD diagnostic construct, in order to bring ICD-10-CM in line with DSM-5.

There are implications for ICD-11, too. Once SSD is inserted into ICD-10-CM, the presence of this term within the U.S. adaptation of ICD-10 may make it easier for the ICD-11 Revision Steering Group to justify proposals to replace the existing ICD-10 Somatoform disorders categories with a single, new ICD construct incorporating SSD-like characteristics, to facilitate harmonization between ICD-11 and DSM-5 disorder terms and diagnostic criteria.

Comments by June 20th deadline, preferably by email, to: nchsicd9CM@cdc.gov

Below is my own submission to NCHS in PDF

Click link for PDF document   NCHS Submission Chapman June 14

and as text:


To: NCHS  nchsicd9CM@cdc.gov

Re: Comment on proposals, March 19-20, 2014 meeting of ICD-10-CM Coordination and Maintenance Committee.

Diagnosis Agenda Page 89: Under “Proposed Index Modifications”: Add Somatic symptom disorder to ICD-10-CM Alphabetical Index (F45.1)

Proposal requestor: Unspecified

Comment submitted by Suzy Chapman DipAD, [Address redacted]

Date submitted: June 15, 2014

I write in objection to the proposed addition of Somatic symptom disorder to the ICD-10-CM Alphabetical Index for consideration for implementation on October 1, 2015 [or on and after October 1, 2016 after the partial code freeze has ended, as applicable].

This March 19-20, 2014 meeting proposal duplicates the request at the September 18-19, 2013 meeting for the addition of Somatic symptom disorder to the ICD-10-CM Index (and to the Tabular List) as an Inclusion Term to existing code, F45.1 Undifferentiated somatoform disorder.

Somatic symptom disorder is a new disorder conceptualization created by the American Psychiatric Association (APA) for DSM-5.

For DSM-5, the Somatoform Disorders have been dismantled. Four DSM-IV categories: somatization disorder [300.81], some presentations of hypochondriasis [300.7], pain disorder, and undifferentiated somatoform disorder [300.82] are eliminated and replaced with a single new diagnosis, Somatic symptom disorder (SSD), cross-walked in DSM-5 to ICD-9 300.82 (ICD-10-CM F45.1).

The Somatic symptom disorder construct de-emphasizes “medically unexplained” as the central defining feature of this disorder group. Instead, the focus shifts away from somatic symptoms to emotional, cognitive and behavioral disturbances and “maladaptive” responses to symptoms: high levels of health anxiety; disproportionate and persistent concerns about the medical seriousness of the symptom(s); or an excessive amount of time and energy devoted to symptoms and health concerns.

Symptoms may or may not be associated with another medical condition: SSD allows for the application of a mental disorder diagnosis in patients with “established general medical conditions or disorders” like diabetes, heart disease and cancer or presenting with “somatic symptoms of unclear etiology” if the clinician considers the patient otherwise meets the new criteria.

To meet the requirements for DSM-IV’s Somatization disorder, a rigorous criteria set needed to be fulfilled: a history of many medically unexplained symptoms before the age of thirty, resulting in treatment sought or psychosocial impairment. And a high diagnostic threshold: a total of eight or more medically unexplained symptoms from four, specified symptom groups, with at least four pain, two gastrointestinal, one psychosexual and one pseudoneurological symptom.

In DSM-5, the requirement for eight symptoms has been dropped to just one or more persistent, non specific, distressing somatic symptoms and the clinician’s perception of “excessive” or “maladaptive” response to the symptom or symptoms.

• These changes for DSM-5 represent a radical restructuring of the DSM-IV Somatoform disorders framework and introduce a new construct for which much remains to be determined.

On Day Two of the September 18-19, 2013 ICD-9-CM Coordination and Maintenance Committee meeting, Dr Darrel Regier had presented and discussed rationales, coding proposals and timings for six new DSM-5 disorders that APA has proposed for insertion into ICD-10-CM. But the Diagnosis Agenda proposals to add the new DSM-5 Somatic symptom disorder and Illness anxiety disorder category terms as inclusion terms to ICD-10-CM did not form part of Dr Regier’s presentation.

As it was unspecified within the Diagnosis Agenda and during the meeting presentations, it is unclear whether these two proposals are being requested by APA, by NCHS/CMS, or by other parties or individuals.

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• My first concern is that no description of Somatic symptom disorder, no rationale for why this ICD-10-CM modification is needed (including clinical relevancy) and no supporting clinical and literature references for the validity of Somatic symptom disorder as a new disorder were published in the Diagnosis Agenda for either the September or March meeting.

At the public meeting, no presentation had been made on behalf of APA, or by representatives of NCHS or CMS, or by anyone else for the specific Agenda proposal to add Somatic symptom disorder as an inclusion term under an existing ICD-10-CM Somatoform disorders code and there was no discussion of this proposal during the course of the meeting [1][2].

There is an expectation that the committees overseeing the development and revision of the draft for ICD-10-CM will give due consideration to the applicability, clinical utility, safety and reliability of any proposal for the inclusion of a new disorder construct before granting approval for its addition to the Tabular List and Index, and that the comments and objections received during the public response period will also be considered. The lack of rationales and references for supportive evidence provided by the requestors hinders public participation in the response process.

• The absence from the Diagnosis Agendas and meeting presentations of rationales, clinical relevancy and supporting clinical and literature references to enable proper public scrutiny, consideration and informed responses to this proposal should disqualify Somatic symptom disorder from consideration for implementation once the partial code freeze has lifted.

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The burden of proof before introducing any new diagnosis into a classification system is that it has a favourable risk to benefit ratio. This new diagnostic construct created by APA and introduced into DSM-5 merits the same level of scrutiny and risk to benefit evaluation as would be expected to be applied to any proposed new disorder/disease that is under consideration for inclusion in any chapter of ICD, whether this is for the updating of the ICD-10-CM draft, updating of WHO’s ICD-10, updating of clinical modifications of ICD-10, or drafting of ICD-11.

A number of papers have noted the paucity of rigorous evidence for the validity, reliability, acceptability, safety and utility of the application of the Somatic symptom disorder construct in adults and children across diverse clinical settings and by a spectrum of health and allied professionals. There is no significant body of published research on the epidemiology, clinical characteristics or treatment of the Somatic symptom disorder construct [3][4][5].

In a paper published in the Journal of Psychosomatic Research, September 2013, the DSM-5 Somatic symptom disorder Work Group concedes the lack of clinical evidence for its new construct and acknowledges the “small amount of validity data concerning SSD” and “that much remains to be determined” about the utility and reliability of the specific SSD criteria and its thresholds when applied in busy, general clinical practice, and there are “vital questions that must be answered” as they go forward [6].

• As an under researched, poorly validated disorder construct, Somatic symptom disorder does not meet NCHS/CMS criteria for new diseases/new technology procedures, and any minor revisions to correct reported errors in these classification and should be rejected for consideration for implementation during a partial code freeze and also rejected for consideration for implementation on or after October 1, 2015 [October 1, 2016].

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Concerns for the looseness of the Somatic symptom disorder definition and the ease with which these new criteria can be met have been discussed in a number of published papers and commentaries [7][8][9][10].

The over-inclusiveness of the SSD diagnosis is borne out by the results of the DSM-5 field trial study reported by Joel E Dimsdale, MD, chair of the Somatic symptom disorder Work Group, at the 2012 annual meeting of the American Psychiatric Association.

15% of the ‘diagnosed illness’ study group, comprising patients with cancer or coronary disease, were caught by SSD and would meet the criteria for application of an additional mental disorder diagnosis.

26% of the ‘functional somatic’ study group, comprising patients with irritable bowel syndrome or chronic widespread pain, met the SSD criteria.

SSD has a high false positive rate – capturing 7% of the ‘healthy’ field trial control group.

It is disturbing that the SSD Work Group (which had included no primary care physicians or pediatricians) appears not to have undertaken any field trials into the safety of application of the SSD criteria in children and adolescents.

NCHS/CMS provides no references for data for the application of SSD in children within the Diagnosis Agenda, although the DSM-5 text clearly indicates APA’s intention that SSD is a diagnosis that may also be applied to children with persistent, distressing somatic symptoms.

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Potential implications for the application of a diagnosis of SSD:

I am not persuaded that the new SSD diagnosis can be safely applied outside the optimal conditions of field trials, in settings where practitioners may not necessarily have adequate time for, or instruction in administration of diagnostic assessment tools, and where decisions to code or not to code may hang on the arbitrary and subjective perceptions of a wide range of end-users who may lack clinical training in the application of mental disorder criteria.

Misapplication of highly subjective and loose, easily met criteria, especially in busy primary care practice, may result in inappropriate diagnoses of mental disorder and inappropriate medical decision making, with considerable implications for patients [11].

A recent study (Plouvier et al, 2014) found more frequent presentation with functional somatic symptoms and multiple prodromal symptoms in the two year period prior to diagnosis with Parkinson’s disease than controls [12].

Incautious application or a pre-existing diagnosis of SSD in the patient’s notes may blunt clinician alertness and receptivity to emerging prodromal symptomotology of serious disease.

Patients with chronic, multiple bodily symptoms due to rare diseases, difficult to diagnose conditions, or multi system diseases like Behçet’s disease, for which it can take several years to arrive at a diagnosis, may be especially vulnerable to missed diagnosis or to misdiagnosis with a mental disorder, impeding access to testing, investigations, timely diagnosis and early intervention (and may result in increased claims against practitioners for medical negligence).

With the elimination of the requirement that symptoms be “medically unexplained” and inclusion of the presence of a co-occurring physical health condition, a mental disorder diagnosis of SSD can be applied as a “bolt-on” to any chronic medical diagnosis: to patients with diabetes, angina, cancer, MS, cardiovascular disease, ME and CFS, IBS, chronic widespread pain (aka fibromyalgia), chronic pain conditions or persistent symptoms of unclear etiology.

Patients with Chronic fatigue syndrome (CFS), “almost a poster child for medically unexplained symptoms as a diagnosis,” according to the SSD Work Group chair, or with chronic Lyme disease, Gulf War illness, chemical injury and chemical sensitivity; women with potential symptoms of gynecological disease, like ovarian cancer – already often late-diagnosed because persistent symptoms had been initially dismissed as IBS or a menopausal-related bladder complaint; or women with endometriosis or interstitial cystitis may be particularly vulnerable to misapplication or misdiagnosis with a mental health disorder under SSD criteria.

(There is also a Brief somatic symptom disorder in DSM-5, cross-walked to ICD-9 F45.8, that can be applied where duration of symptoms is less than 6 months. Just one somatic symptom and one “disproportionate” psychobehavioral response to that symptom, for less than 6 months chronicity, now ticks the box for a mental health diagnosis.)

There has been considerable opposition to the introduction of this new, poorly tested construct into the DSM-5 amongst patients, carers, advocates, consumer organizations, mental health practitioners and clinicians and considerable concern for the implications for diverse patient populations that the Somatic Symptom Disorder category will provide a “dustbin diagnosis” for the so-called “functional somatic syndromes,” for those living with chronic pain and for patients with persistent, but as yet undiagnosed, symptoms of disease.

• NCHS/CMS has published no independent field trial data and provided no rationales or clinical and literature references to inform public responses.

Given the lack of published evidence for the validity and safety of SSD, there is insufficient basis for the approval of SSD for inclusion within ICD-10-CM and it would be scientifically unsafe, premature and against the public interest to include this new diagnostic construct within ICD.

The proposal for the addition of Somatic symptom disorder to the ICD-10-CM as an inclusion term to the Index and Tabular List should be rejected. There should be no implementation in October 2016 as an inclusion term to F45.1, or to any other existing code, or with a unique code created.

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Appendix:

Incautious, inept application of criteria resulting in a “bolt-on” psychiatric diagnosis of Somatic symptom disorder has far-reaching implications for diverse patient populations:

Application of highly subjective and difficult to measure criteria could potentially result in misdiagnosis with a mental disorder, misapplication of an additional diagnosis of a mental disorder or missed diagnoses through dismissal and failure to investigate new or worsening somatic symptoms.

Patients with cancer and life threatening diseases may be reluctant to report new symptoms that might be early indicators of recurrence, metastasis or secondary disease for fear of attracting a diagnosis of SSD or being labelled as “catastrophizers.”

Application of an additional diagnosis of SSD may have implications for the types of medical investigations, tests and interventions that clinicians are prepared to consider and for which insurers are prepared to fund.

Application of an additional diagnosis of SSD may impact payment of employment, medical and disability insurance and the length of time for which insurers are prepared to pay out.

 An SSD diagnosis may negatively influence the perceptions of agencies involved with assessment and provision of social care packages, disability adaptations, workplace accommodations, provision of education arrangements tailored to the needs of children with chronic illness, and the perceptions of medical staff during hospital and accident and emergency admission, and prejudice future employment options.

Patients prescribed psychotropic drugs for perceived unreasonable levels of “illness worry” or “excessive preoccupation with symptoms” may be placed at risk of iatrogenic disease or subjected to inappropriate and costly behavioural therapies.

Multi-system diseases like Multiple Sclerosis, Behçet’s disease or Systemic lupus can take several years before a diagnosis is arrived at. In the meantime, patients with chronic, multiple somatic symptoms who are still waiting for a diagnosis would be vulnerable to being labelled with a mental disorder.

The burden of the DSM-5 changes to Somatoform disorders will fall particularly heavily upon women who are more likely to be casually dismissed when presenting with physical symptoms and more likely to be prescribed inappropriate antidepressants and anti-anxiety medications for them.

Somatic symptom disorder allows for the application of a diagnosis of SSD in children and where a parent is perceived as being excessively concerned about a child’s symptoms.

The diagnostic term “Somatic Symptom Disorder” is already being applied to children despite the lack of a body of evidence for the reliability, safety and validity of the DSM-5 SSD criteria [13].

I am deeply concerned that NCHS/CMS is considering inclusion of a new diagnostic term within ICD when no studies have been carried out into the safety of its application in children and adolescents.

Families caring for children and young people with any chronic disease or condition may be placed at increased risk of wrongful accusation of “over-involvement” with their child’s symptomatology.

Where a parent is perceived as responsible for, or encouraging maintenance of “sick role behavior” or “secondary gains” in a child, this can trigger social services investigation, or court intervention for the forced removal of a sick child out of the home environment and into foster care or in-patient rehabilitation, or placement of the child on the “at risk register.”

This is already happening to families in the U.S., UK and Europe with a child or young adult with chronic illness, notably with Chronic fatigue syndrome or ME. It may happen more frequently with a diagnosis of SSD or of chronic childhood illness + SSD.

Where there are disputes between the family and clinicians over an assigned diagnosis or where there is disagreement between clinicians over the etiology of a child’s symptoms, an earlier or concurrent diagnosis of SSD may prejudice the family’s rights and the rights of the child or young person to determine what treatments are administered, where and by whom; or may be used to override or attempt to override the right to consent to treatments, or as a means of limiting parental access to the child and parental involvement in a treatment plan.

A diagnosis of SSD may also impact on a child’s access to suitable educational arrangements, including part-time school attendance, rest periods, reduced curriculum, home tutoring, examination concessions, provision of an amanuensis etc. and access to disability aids and adaptations, or to unhindered use of existing aids, such as wheelchairs.

Again, there is insufficient basis for the approval of SSD for inclusion within ICD-10-CM for application in children or adults. It is scientifically unsafe, premature and against the public interest to include this poorly tested diagnostic construct within ICD.

Thank you for your consideration.

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References:

1.Diagnosis Agenda,September 18-19, 2013 meeting of the ICD-9-CM Coordination and Maintenance Committee.

2.Summary of Diagnosis Presentations, September 18-19, 2013 meeting of the ICD-9-CM Coordination and Maintenance Committee.

3. DSM-5 Somatic Symptom Disorders Work Group Disorder Descriptions and Justification of Criteria – Somatic Symptoms, published May 2011, for second DSM-5 stakeholder review.

4. Robert L. Woolfolk and Lesley A. Allen (2012). Cognitive Behavioral Therapy for Somatoform Disorders, Standard and Innovative Strategies in Cognitive Behavior Therapy, Dr. Irismar Reis De Oliveira (Ed.), ISBN: 978-953-51-0312-7

5. Ghanizadeh A, Firoozabadi A. A review of somatoform disorders in DSM-IV and somatic symptom disorders in proposed DSM-V. Psychiatr Danub. 2012 Dec;24(4):353-8.

6. Dimsdale JE, Creed F, Escobar J, Sharpe M, Wulsin L, Barsky A, Lee S, Irwin MR, Levenson J. Somatic Symptom Disorder: An important change in DSM. J Psychosom Res. 2013 Sep;75(3):223-8. Epub 2013 Jul 25.

7. Frances A. The new somatic symptom disorder in DSM-5 risks mislabeling many people as mentally ill. BMJ. 2013 Mar 18;346:f1580. doi: 10.1136/bmj.f1580.

8. Frances A. DSM-5 Somatic Symptom Disorder. J Nerv Ment Dis. 2013 Jun;201(6):530-1. doi: 10.1097/NMD.0b013e318294827c.

9. Frances A, Chapman S. DSM-5 somatic symptom disorder mislabels medical illness as mental disorder. Aust N Z J Psychiatry. 2013 May;47(5):483-4. doi:10.1177/0004867413484525.

10. Wolfe F, Walitt BT, Katz RS, Häuser W. Symptoms, the nature of fibromyalgia, and diagnostic and statistical manual 5 (DSM-5) defined mental illness in patients with rheumatoid arthritis and fibromyalgia. PLoS One. 2014 Feb 14;9(2):e88740. doi: 10.1371/journal.pone.0088740. eCollection 2014.

11. Dimsdale JE. Medically unexplained symptoms: a treacherous foundation for somatoform disorders? Psychiatr Clin North Am 2011;34:511-3.

12. Plouvier AO, Hameleers RJ, van den Heuvel EA, Bor HH, Olde Hartman TC, Bloem BR, van Weel C, Lagro-Janssen AL2. Prodromal symptoms and early detection of Parkinson’s disease in general practice: a nested case-control study. Fam Pract. 2014 May 28. pii: cmu025. [Epub ahead of print]

13. Commonwealth of Massachusetts Juvenile Court Department, Court document, Honourable Joseph Johnston, March 25, 2014, Re: Care and Protection of Justina Pelletier: http://cbsboston.files.wordpress.com/2014/03/scan.pdf

Interest:

Carer/advocate for adult with long-term medical condition. Owner of website Dx Revision Watch, Monitoring the revision of DSM-5 and ICD-11. Co-author, journal papers and commentaries on the SSD construct (with Professor Allen Frances).

 

Editorial: Bodily distress syndrome (BDS): the evolution from medically unexplained symptoms (Goldberg and ICD-11-PHC)

Post #308 Shortlink: http://wp.me/pKrrB-3Uh

An editorial and four papers on the theme of medically unexplained symptoms, first published in the June 2013 issue of Mental Health in Family Medicine and embargoed until June 1, 2014, are now accessible for free at: http://www.ncbi.nlm.nih.gov/pmc/issues/229531/

Mental Health in Family Medicine is the official journal of The World Organization of Family Doctors (Wonca) Working Party on Mental Health.

The editorial: Bodily distress syndrome (BDS): the evolution from medically unexplained symptoms (MUS), is co-authored by Prof Gabriel Ivbijaro and Prof Sir David Goldberg.

Prof Ivbijaro is Editor in Chief, Mental Health in Family Medicine, a past chair of Wonca Working Party on Mental Health and was elected president elect of the World Federation of Mental Health in August 2013.

Prof Goldberg chairs the WHO Primary Care Consultation Group (PCCG) that is leading the development of the primary care classification of mental and behavioural disorders for ICD-11 (known as ICD-11-PHC).

This report sets the editorial into context.

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ICD-11-PHC

ICD-11-PHC is an abridged version of the ICD-11 classification being developed for use by clinicians and (often non-specialist) health-care workers in a wide range of global primary care settings and low- and middle-income countries.

The primary care version of the ICD-11 mental and behavioural disorders chapter is being developed simultaneously with the specialty settings version. Disorders that survive the ICD-11-PHC field tests must have an equivalent disorder in the main ICD-11 classification.

The PCCG work group is developing and field testing 28 mental disorders for ICD-11-PHC, which includes making recommendations to the International Advisory Group for a potential replacement for the existing ICD-10-PHC category, F45 Unexplained somatic symptoms/medically unexplained symptoms.

A second ICD-11 working group, the Expert Working Group on Somatic Distress and Dissociative Disorders (S3DWG), is advising on the revision of ICD-10′s Somatoform disorders in parallel with the PCCG and has proposed an alternative disorder construct.

Thus far, neither working group has commented publicly on the alternative proposals presented by the other group, how the two groups interrelate, whether they are expected to reach consensus over a potential new conceptual framework to replace the existing Somatoform disorders, or to what extent consensus has been reached.

No public progress reports are being published by either group, or by the International Advisory Group, and those monitoring and reporting on the revision of these ICD-10 Chapter V categories rely on journal papers, editorials, symposia presentations, internal ICD Revision summary reports and meeting materials and on the limited content in the public version of the ICD-11 Beta drafting platform to piece together updates.

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Does this editorial advance our understanding of current proposals?

Key point: this Ivbijaro and Goldberg editorial is now over 12 months old and should be read with the caveat that proposals by the PCCG working group may have been revised since the editorial was first published.

As a source of information on the current status of proposals by the Primary Care Consultation Group (PCCG), this editorial is problematic.

Firstly, it is over 12 months old and the PCCG’s proposals may have undergone further revision since the editorial was submitted for publication.

At the time of submission, the authors anticipated imminent field testing for ICD-11-PHC but the projected start dates for internet and clinic-based field testing, which will assess utility of proposed ICD-11 diagnostic guidelines in different types of primary care settings with particular focus on low- and middle-income countries, may be delayed. (It is on record that field tests were running behind schedule and there have been funding shortfalls, two factors in WHO’s decision, earlier this year, to shift WHA approval of ICD-11 from 2015 to 2017 to allow more time for incorporation of field test results.*)

*WICC ICPC-3 presentation, June 2013, M Klinkman, Slide 29: http://www.ph3c.org/PH3C/docs/27/000312/0000451.pdf
Committee for the Coordination of Statistical Activities, Twenty-second Session 4-6 September 2013, Items for discussion and decision: Item 8 of provisional agenda, Pages 8-10:
http://unstats.un.org/unsd/accsub/2013docs-22nd/SA-2013-12-Add1-Health-WHO.pdf

Secondly, the editorial does not declare Prof Goldberg’s interest as chair of the PCCG. It does not clarify whether the views and opinions expressed within the editorial represent the views and opinions of its authors or represent the official positions of the PCCG working group, or of the International Advisory Group for the Revision of ICD-10 Mental and Behavioural Disorders, or of the ICD-11 Revision Steering Group.

Thirdly, its brevity. This is a short editorial – not a paper:

it does not discuss the PCCG’s rationales for the changes made to its own proposals, as published in 2012.

it does not retrospectively review and compare the PCCG’s 2012 proposals for a construct which the group proposed to call, at that point, Bodily stress syndrome, with the 2012 proposals of the Expert Working Group on Somatic Distress and Dissociative Disorders (S3DWG) for an alternative construct called Bodily distress disorder.

it does not compare the PCCG’s revised proposals, as they stood in June 2013, with the S3DWG’s proposals, at that point.

crucially, it does not clarify why, if the PCCG’s June 2013 proposals were expected to be progressed to field trials, it is the S3DWG’s Bodily distress disorder diagnostic construct that has been listed and defined in the Beta draft for the Foundation, Mortality and Morbidity, Primary Care High Resource, Primary Care Low Resource linearizations.

Key points: It is difficult to disentangle the authors’ views and opinions from official position of the PCCG working group or the International Advisory Group. The editorial provides no discussion of the S3DWG’s alternative proposals or whether any consensus between the two groups had been reached. The opinions of the International Advisory Group on both sets of proposals are not discussed.

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What new information does this June 2013 editorial provide since the 2012 Lam et al paper?

that the authors consider the Fink P, Schröder A. 2010 paper [1] provides evidence that the term Bodily Distress Syndrome has both face and content validity.

that the authors consider the concept Bodily Distress Syndrome as “a possible diagnosis that captures the range of presentations in primary care, which may be acceptable to both patient and medical professional”, for which the authors list “a range of poorly defined disorders [that include] chronic fatigue syndrome (CFS), fibromyalgia, irritable bowel syndrome (IBS), chronic pain syndrome, hyperventilation syndrome, non-cardiac chest pain and somatoform disorder.”

that the authors consider the forthcoming revision of the ICD provides an opportunity to include BDS in a revised classification for primary care, the ICD11-PHC, which is planned to be field tested in eight countries.

• that “not only has BDS replaced ‘medically unexplained symptoms’, but also ‘health anxiety’ has replaced ‘hypochondriasis’” and that the field trials “would examine whether primary care physicians wish to distinguish health anxiety (which may have few or indeed no somatic symptoms) from BDS (which by definition has at least three different somatic symptoms).”

According to the editorial, the PCCG had evidently revised its proposal for what to call its new disorder category since publication of the Lam et al paper, in 2012.

In 2012, the PCCG’s proposed term for ICD-11-PHC was Bodily stress syndrome (BSS). In this June 2013 editorial, the authors are using the term, Bodily distress syndrome (BDS).

In 2012, criteria for the PCCG’s BSS had included the requirement for psychobehavioural responses, which do not form part of the Fink et al 2010 BDS criteria – which are based on symptom patterns.

The editorial does not clarify whether, in June 2013, the PCCG (or its chair) was now advancing that the BDS construct and criteria should progress unmodified for ICD-11-PHC testing and evaluation, that is, in the form already operationalized in research and clinical settings in Denmark or would be modified for the purpose of ICD-11-PHC field trials, or to what extent.

(There is no revised criteria set included in this editorial for comparison with the detailed disorder descriptions and criteria set that had been included in Appendix 2 of the 2012 Lam et al paper.)

 Key point: The editorial provides no details or discussion of a 2013 field trial protocol. The most recent disorder descriptions, diagnostic guidelines and criteria proposed by the PCCG are not in the public domain. It is not known whether a field trial protocol has been finalized, whether or when it will be made available for public scrutiny, or whether field trials have started yet.

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Before reading the editorial please read the appended notes and if you are linking to the editorial on social media or forums, please also include a link back to this report because it is important that this editorial is placed into context.
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Ment Health Fam Med.
2013 Jun;10(2):63-4.
Bodily distress syndrome (BDS): the evolution from medically unexplained symptoms (MUS).
Ivbijaro G, 1 Goldberg D. 2
Author information
1 Editor-in-Chief Mental Health in Family Medicine, Medical Director, Waltham Forest Community and Family Health Services, and Vice President (Europe), World Federation for Mental Health.
2 Professor Emeritus and Fellow, King’s College, London.PMID: 24427171
[PubMed] PMCID: PMC3822636 [Available on 2014/6/1]
Article: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3822636/?report=classic
PubReader: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3822636/?report=reader
PDF – 44KB: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3822636/pdf/MHFM-10-063.pdf

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Two ICD Revision working groups – two sets of proposals published in 2012:

In their respective 2012 journal papers, the two working groups presented divergent conceptual proposals and neither group refers to the work being undertaken by the other group.

The 17 member Expert Working Group on Somatic Distress and Dissociative Disorders (the S3DWG) is an ICD Revision sub working group advising specifically on the revision of ICD-10′s Somatoform disorders.

Prof emeritus Francis Creed (a former DSM-5 Somatic Symptom Disorder work group member) is a member of the S3DWG, and the group is chaired by Prof Oye Gureje.

In late 2012, Creed and Gureje published a paper which had included the S3DWG’s emerging proposals for a new, single diagnostic category that would subsume the existing Somatoform disorders categories F45.0 – F45.9 and Neurasthenia [2].

The S3DWG paper sets out the group’s remit which includes:

“To provide drafts of the content (e.g. definitions, descriptions, diagnostic guidelines) for somatic distress and dissociative disorder categories in line with the overall ICD revision requirements.

“To propose entities and descriptions that are needed for classification of somatic distress and dissociative disorders in different types of primary care settings, particularly in low- and middle-income countries.”

Which suggests that the proposals the S3DWG group are advancing are also being considered for utility in primary care and low resource settings, in parallel with those recommended by the PCCG.

The S3DWG’s 2012 paper had described a disorder model which it proposed to call Bodily distress disorder (BDD).

Key point: Although the Creed, Gureje 2012 paper does not acknowledge the congruency, the BDD disorder descriptions and criteria are conceptually close to DSM-5′s new Somatic symptom disorder (SSD).

With its

“much simplified set of criteria”; no assumptions about causality; elimination of the requirement that symptoms be “medically unexplained” as the central defining feature; inclusion of the presence of a co-occurring physical health condition; focus on identification of positive psychobehavioural responses (excessive preoccupation with symptoms, unreasonable illness fear, frequent or persistent healthcare utilization, activity avoidance for fear of damaging the body) in response to any (unspecific) persistent, distressing, single or multiple bodily symptoms; and with no requirement for symptom counts or symptom patterns from body or organ systems;

the group’s BDD construct had good concordance with DSM-5′s Somatic symptom disorder (SSD) and poor concordance with Fink et al’s Bodily Distress Syndrome.

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The PCCG’s Bodily stress syndrome (BSS):

In contrast, the PCCG’s 2012 paper [3] had described a disorder construct which it proposed to call Bodily stress syndrome (BSS), that drew heavily on Fink et al’s 2010 Bodily Distress Syndrome (BDS) disorder model [4].

BSS would replace ICD-10-PHC’s F45 Unexplained somatic symptoms/medically unexplained symptoms category. Primary care’s Neurasthenia category would also be eliminated for ICD-11-PHC.

Based (theoretically) on the “autonomic over-arousal” model, the PCCG’s BSS required symptom patterns from body systems to meet the diagnosis.

But, “If the symptoms are accounted for by a known physical disease this is not BSS.”

Which also mirrors Fink et al’s BDS – “if the symptoms are better explained by another disease, they cannot be labelled BDS. The diagnosis is therefore exclusively made on the basis of the symptoms, their complexity and duration” [4].

But the tentative BSS criteria, as presented by Lam et al, in 2012, also incorporated some DSM-5 SSD-like psychobehavioural responses, viz, “The patient’s concern over health expresses itself as excessive time and energy devoted to these symptoms.” (A straight lift from DSM-5′s SSD criteria.)

Psychological and behavioural responses do not form part of the Fink et al 2010 BDS criteria and their inclusion within BSS appeared to be a tokenistic nod towards accommodation of DSM-5′s SSD into any new conceptual framework for ICD-11. (The rationale for their insertion into an otherwise BDS-like construct is not discussed within the 2012 paper.)

Key point: In 2012, whilst highly derivative of BDS and the influence of PCCG group member, Marianne Rosendal, is clear, the proposed BSS model could not be described as a “pure” BDS model.

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How viable is BDS for incorporation into ICD-11?

The vice-chair of the PCCG is Dr Michael Klinkman, a GP who represents WONCA (World Organization of Family Doctors). Dr Klinkman is current convenor of WONCA’s International Classification Committee (WICC) that is responsible for the development of ICPC-2.

Dr Marianne Rosendal (Department of Public Health, Aarhus University), who has published with Prof Per Fink, is the European representative on WONCA’s International Classification Committee and a member of the PCCG.

In addition to the revision of ICD-10 and ICD-10-PHC, the ICPC-2 (International Classification of Primary Care, Second edition), which classifies patient data and clinical activity in the domains of general/family practice and primary care, is also under revision.

Per Fink and colleagues have been lobbying for their Bodily Distress Syndrome construct to be integrated into forthcoming classification systems and adopted as a diagnosis by primary care practitioners.*

*Budtz-Lilly A: The Research Unit for General Practice, School of Public Health, Aarhus University, Denmark. Bodily Distress Syndrome: A new diagnosis for functional disorders in primary care, EACLPP 2012 Conference Abstract, p 17.

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Proposed new classification

There are a number of reasons why the International Advisory Group for the Revision of ICD-10 Mental and Behavioural Disorders and the ICD Revision Steering Group might have difficulty justifying approval of any new disorder construct that seeks to arrogate the so-called “functional somatic syndromes,” CFS, IBS and Fibromyalgia, and subsume them under a new, overarching disorder category that also subsumes Neurasthenia and the Somatoform disorders.

limited independent evidence for construct validity, utility and safety of application of BDS in adults and children.

no requirements within BDS criteria for positive psychobehavioural features – location within the ICD-11 mental and behavioural disorders chapter is therefore problematic.

potential data loss, data disaggregation problems and code mapping issues resulting from loss of discretely coded terms currently located within various ICD chapters outside the mental and behavioural disorders chapter; loss of backward compatibility with ICD-10 codes and with ICD-10-CA, ICD-10-GM, ICD-10-AM and other country modifications. (Some countries may take many years to transition to ICD-11, or an adaptation of ICD-11.) Potential incompatibility problems mapping to SNOMED-CT.

• unacceptability to patients and medical professionals

medico-political sensitivities

BDS and SSD are divergent constructs; a hybrid between BDS and SSD-like characteristics is conceptually problematic and would present difficulties if the intention is to harmonize ICD-11 with DSM-5 for this section of the classification [5].

the DSM-5 to ICD-9/ICD-10-CM cross-walk already maps DSM-5 Somatic symptom disorder to ICD-9 code 300.82 (ICD-10-CM F45.1).

It has been proposed that Somatic symptom disorder is added to the U.S.’s forthcoming clinical modification as an inclusion term to F45.1, in the Tabular List and Index.* If approved by NCHS, ICD-10-CM and ICD-11 would lack congruency if a BDS-like disorder model were incorporated into ICD-11 to replace the existing Somatoform disorders, rather than an SSD-like model.**

*September 18-19, 2013 and March 19-20, 2014 NCHS/CMS ICD-10-CM Coordination and Management Committee meetings.
**Note: since early 2009, I have strongly opposed the introduction of SSD into the DSM-5, ICD-11 and ICD-10-CM, and I am not arguing, here, in favour of an SSD-like model to replace the existing ICD-10 Somatoform disorders. There is no public domain documentary evidence that the two ICD working groups are currently considering any alternative models as potential replacements for the Somatoform disorders.

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Has Professor Fink achieved his goal?

Disorders that survive the ICD-11-PHC field tests must have an equivalent disorder in the main ICD-11 classification.

With the criteria’s lack of positive psychobehavioural features presenting barriers for location within the ICD-11 mental and behavioural disorders chapter and with a hybrid between BDS and SSD-like features conceptually problematic, fitting BDS into ICD-11 isn’t the shoo in that Rosendal, Fink and colleagues had hoped for.

At the presentations on Functional Disorders held at the Danish parliament (March 19, 2014), Prof Fink had stated that he and his colleagues had tried to get WHO to incorporate a section for a special group of disorders where BDS could be placed that was located neither in psychiatry nor in general medicine, but had not been successful. [Creating a new ICD chapter or new parent class within an existing chapter for "interface" disorders may possibly have been proposed to ICD Revision.]*

But if a “pure” BDS (or a modification of BDS for ICD usage) is progressed to field testing over the next year or two, it should perhaps be considered whether ICD Revision has agreed to field test the PCCG’s proposal as a “straw man” construct to disprove its clinical utility, reliability and acceptability, with the intention of defaulting, after field trial evaluation, to a disorder construct that is conceptually closer to SSD, if the latter is already the preference of the International Advisory Group and the ICD Revision Steering Group.

*See: Constanze Hausteiner-Wiehle and Peter Henningsen. Irritable bowel syndrome: Relations with functional, mental, and somatoform disorders World J Gastroenterol 2014 May 28; 20(20): 6024-6030 Full free text
“An overarching category of general (medical-psychiatry) interface disorders could be a helpful conceptualization for the many phenomena that are neither only somatic nor only mental [32,56,79]. The ICD-11, awaited in 2015, offers a new chance to do that. The concept of a bodily distress syndrome (BDS) offers another scientifically coherent common basis for the classification of different dimensional graduations of IBS [80].

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WHO on Twitter:

On Feb 12, 2014, @WHO Twitter admin stated: “Fibromyalgia, ME/CFS are not included as Mental & Behavioural Disorders in ICD-10, there is no proposal to do so for ICD-11″. This position was additionally confirmed by Mr Gregory Härtl, Head of Public Relations/Social Media, WHO.

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So what has been entered into the Beta drafting platform?

The term entered into the Beta platform (since February 2012) is Bodily distress disorder (the term favoured by the S3DWG working group) – not the term Bodily stress syndrome or Bodily Distress Syndrome.

A Definition for Bodily distress disorder was inserted around four months ago. There are no definitions or characterizations inserted yet for any of the three, uniquely coded severity specifiers (Mild; Moderate; Severe).

The psychological and behavioural features that characterize the disorder, as per the BDD Definition, are drawn from the disorder conceptualizations in the 2012 Creed, Gureje paper on emerging proposals for Bodily distress disorder which had described a disorder model with good concordance with DSM-5′s Somatic symptom disorder construct and poor concordance with Fink et al’s Bodily Distress Syndrome construct.

Key point: The term entered into the Beta drafting platform is Bodily distress disorder (the term favoured by the S3DWG working group) with a Definition based on disorder conceptualizations in the 2012 Creed, Gureje paper which had described a disorder model with good concordance with DSM-5′s Somatic symptom disorder and poor concordance with Fink et al’s Bodily Distress Syndrome construct.

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This Dx Revision Watch post sets out (with screenshots) the most recent changes to the Beta drafting platform for the listing of BDD and the current Definition:

Recent changes to ICD-11 Beta drafting platform for “Bodily distress disorder”

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Forthcoming symposium presentation:

In September, Oye Gureje (chair ICD-11 Expert Working Group on Somatic Distress and Dissociative Disorders), will be presenting on Proposals and evidence for the ICD-11 classification of Bodily Distress Disorders, as part of series of symposia on the development of the ICD-11 chapter on mental and behavioural disorders, at the World Psychiatric Association XVI World Congress, in Madrid, Spain, 14–18 September 2014 [6].

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Field testing:

Field testing on a potential replacement for the ICD-10 Somatoform disorder categories is expected to be conducted over the next couple of years. Currently, there is no publicly available protocol or other information on the finalized characteristics, diagnostic guidelines, criteria, inclusions, exclusions, differential diagnoses etc. that are planned to be used for the field tests which would provide the level of detail lacking in the public version of the Beta drafting platform.

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Requests for clarification repeatedly stonewalled:

ICD Revision has been asked several times, via the Beta drafting platform, to clarify its current proposals for the framework and disorder construct for a replacement for the ICD-10 Somatoform disorders. ICD Revision has also been asked to comment on the following:

“If, in the context of ICD-11 usage, the S3DWG working group’s proposal for a replacement for the Somatoform disorders remains for a disorder model with good concordance with DSM-5′s SSD construct, what is the rationale for proposing to name this disorder “Bodily distress disorder”?

“Have the S3DWG, PCCG and Revision Steering Group given consideration to the significant potential for confusion if its replacement construct for the Somatoform disorders has greater conceptual alignment with the SSD construct but is assigned a disorder name that sounds very similar to, and is already being used interchangeably with an operationalized but divergent construct and criteria set?”

No clarifications have been forthcoming to date. Lack of progress reports by both working groups and the degree of confusion over the content of the Beta draft is hampering stakeholder scrutiny, discourse and input. It’s not surprising few papers have been published to date reviewing and discussing ICD Revision’s proposals for a potential replacement for the ICD-10 Somatoform disorders when information on the most recent proposals for both working groups is proving so difficult to obtain.

It’s time medical and allied professionals and advocacy organizations demanded transparency from ICD Revision for its current intentions.

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Caveats:

ICD-11 Beta is a work in progress, updated daily, not finalized. Proposals for new categories are subject to ongoing revision and refinement, to field test evaluation, may not survive field testing, and are not approved by ICD Revision or WHO.

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References:

1. Fink P and Schröder A. One single diagnosis, bodily distress syndrome, succeeded to capture 10 diagnostic categories of functional somatic syndromes and somatoform disorders. Journal of Psychosomatic Research 2010;68:415–26.

2. Creed F, Gureje O. Emerging themes in the revision of the classification of somatoform disorders. Int Rev Psychiatry. 2012 Dec;24(6):556-67. [Abstract: PMID: 23244611]

3. Lam TP, Goldberg DP, Dowell AC, Fortes S, Mbatia JK, Minhas FA, Klinkman MS: Proposed new diagnoses of anxious depression and bodily stress syndrome in ICD-11-PHC: an international focus group study. Fam Pract Feb 2013 [Epub ahead of print July 2012]. [Abstract: PMID: 22843638] Full free text: http://fampra.oxfordjournals.org/content/30/1/76.long

4. http://funktionellelidelser.dk/en/about/bds/

5. Creed F, Fink P: Research Clinic for Functional Disorders Symposium presentations, Aarhus University Hospital, May 15, 2014.

That SSD and BDS are divergent constructs is also discussed in: Medically Unexplained Symptoms, Somatisation and Bodily Distress: Developing Better Clinical Services, Francis Creed, Peter Henningsen, Per Fink (Eds), Cambridge University Press, 2011.

6. World Psychiatric Association XVI World Congress, Madrid, Spain, 14–18 September 2014.

 

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