Changes to ICD-11 Beta drafting platform: Bodily Distress Disorders (1)


ICD11-PHC (Primary Care version)

Professor, Sir David Goldberg, M.D., Emeritus Professor, Institute of Psychiatry, King’s College, London, is a member of the DSM-5 Mood Disorders Work Group.

Prof Goldberg also chairs the WHO Advisory Group for Classification in Primary Care that is making recommendations for the mental and behavioural disorders section of the forthcoming ICD11-PHC – a condensed classification system being developed for use in general practice and primary health care settings which revises the existing ICD10-PHC.

Dr Marianne Rosendal is also a member of the WHO Advisory Group for Classification in Primary Care for ICD11-PHC and the European representative on WONCA (the World Organization of National Colleges, Academies and Academic Associations of General Practitioners/Family Physicians), where classification is concerned.

The majority of patients with mental health problems are diagnosed and managed by general practitioners in primary care – not by psychiatrists and mental health specialists. The Primary Care version of ICD-10 is used both in developed and developing countries in general medical settings and also used in the training of medical officers, nurses and multi purpose health workers.

The ICD10-PHC is a much simplified version of ICD-10 and the system has modified but not exact equivalence to the main ICD classification. The ICD10-PHC mental and behavioural disorders chapter lists and describes 26 disorders commonly managed within primary care as opposed to around 450 listed in Chapter V of ICD-10.

A chart showing the grouping of categories adapted from the full ICD-10 version for the existing ICD10-PHC mental health categories can be found here. (See Page 8 for ICD10-PHC version equivalents to the ICD-10 Somatoform Disorder categories.)

According to a guest editorial published in February 2011, in International Psychiatry, Prof Goldberg’s working group was proposing to introduce the following categories for the ICD11-PHC version grouped under new terms, Dysphoric Disorders and Bodily distress disorders.

At that point, 28 disorders were anticipated to be field tested for ICD11–PHC, including:

Dysphoric disorders

10 Anxious depression (new)
11 Depressive disorder
12 Anxiety disorder
13 Distress disorder (replaces F42.2 [Mixed anxiety and depression], F43 [Adjustment disorder], F48 [Neurasthenia])
14 Post-traumatic stress disorder (PTSD) (new)
15 Panic/agoraphobia (was panic disorder)

Body distress disorders

16 Bodily distress syndrome (new – was unexplained somatic complaints)
17 Health preoccupation (new) [described as a new disorder similar to hypochondriasis]
18 Conversion disorder (was dissociative disorder)

“…Each proposed category will be commented upon by experts who are not part of the group, as well as by the main advisory group responsible for ICD–11. Final amendments will be made by the primary care group before the revised classification is released for field tests. The field tests are likely to be quite extensive, and to involve studies in both high-income and low- and middle-income countries. A second set of revisions will be made after the field tests. Disorders that survive the field tests must have an equivalent disorder in the main classification – a requirement which may cause a problem with the new concept of anxious depression, since it requires some modification to the meta-structure of diagnoses used in the main classification.”

According to this February 2011 report, the following categories were proposed not to be included in ICD11-PCH:

F40 Phobic disorders; F42.2 Mixed anxiety and depression; F43 Adjustment disorder; F45 Unexplained somatic complaints (Somatoform Disorders in ICD-10 full version); F48 Neurasthenia; Z63 Bereavement.

With reference to the new proposed term Bodily distress disorders the report says:

“…A new category called bodily distress disorders will include conversion disorder (fairly common in some lower-income countries), health preoccupation (a new disorder similar to hypochondriasis) and the less severe ‘bodily distress syndrome’. In the syndrome, the patient is both distressed and concerned and has three or more somatic symptoms in one bodily system. This is diagnosed only if the patient does not have one of the three dysphoric disorders…”

“…However, some of the ICD10–PHC disorders were equivalent to existing categories in the parent classification, and did not take into account developments in diagnostic thinking. An interesting example of this concerns ‘medically unexplained symptoms’, which appear to have fallen out of favour with our GP colleagues, who have taken the view that even some medically explained symptoms can be abnormally prolonged and accentuated. Psychiatrists have taken a similar view: the new concept of ‘complex somatic symptom disorder’ being field tested for DSM–V also draws attention not to whether somatic symptoms can be explained, but to the cognitive components that may accompany them, whether they are part of a known physical disease or not…”

For full report see: Guest editorial: Goldberg D. A revised mental health classification for use in general medical settings: the ICD11–PHC 1. International Psychiatry Page 1, Volume 8 Number 1 February 2011.

The report notes that not all these proposals may survive evaluation of the field tests.


Update at July 9: Second list of proposals for ICD11-PHC

In August 2012, Jones and Bartlett Learning will be publishing a new title called 21st Century Global Mental Health by Dr Eliot Sorel, Professor, George Washington University, Washington D.C.

Publication details and contributors:

Sample Chapter 2:

Chapter 2 “Comparison Between ICD and DSM Diagnostic Systems for Mental Disorders” by David Goldberg

On Page 51 are set out 28 disorders proposed for ICD11-PHC. In some cases, notably “Dysphoric disorders” and “Body distress disorders” this list does not concord with the categories as proposed for field testing in the Guest editorial by Professor Goldberg that was published in February 2011.

On July 9, I approached Professor Goldberg for clarification of which is the most recent iteration.

Professor Goldberg has clarified that the list of 28 potential disorders as tabled on Page 51 of Chapter 2 supersedes the list of disorders published in February 2011, in International Psychiatry, but stresses that these proposals are still in draft and liable for further revision in the light of field tests. 

See Sample Chapter 2, Page 51:

According to the chapter author, many of the disorders in ICD10-PHC are recommended to be retained, often with amendments; two new adult disorders proposed for inclusion are PTSD and Health anxiety (was Hypochondriasis).

Chapter 2 “Comparison Between ICD and DSM Diagnostic Systems for Mental Disorders” by David Goldberg

Table 2.5 The 28 Disorders Proposed for ICD11-PHC


Dysphoric disorders

10 Anxious depression
11 Depressive disorder
12 Anxiety disorder
13 Health anxiety

Body distress disorders

15 Bodily stress syndrome*
16 Acute stress syndrome
17 Dissociative disorder
18 Self-harm


*Ed: According to Chapter 2, this category is proposed to include “milder somatic symptom disorders” as well as DSM-5’s “Complex somatic symptom disorder” and would replace “medically unexplained somatic symptoms.” Bodily stress syndrome (BSS) would be “defined as being diagnosed only in the absence of a dysphoric disorder.” (See Page 50 for expansion.)

This is the first confirmation that the Topic Advisory Group for Mental Health, its sub workgroups, its external advisors or the Consultation Group for the Primary Care version of ICD-11 have been working towards concordance with, or accommodation of DSM-5 proposals for the revision of the DSM-IV “Somatoform Disorders” section.

I further enquired of Prof Goldberg whether this revised list had intended to include a Bodily stress syndrome as opposed to the Bodily distress syndrome of the earlier, February 2011 draft, and was advised that Bodily stress syndrome was indeed the intended proposed term for this iteration.

So, potentially, across the three classification systems…

[Complex] Somatic Symptom Disorder (SSD) (DSM-5)
Bodily Distress Disorder (BDD) (ICD-11)
Body distress disorders (BDD) (ICD11-PHC) under which disorder section would sit
Bodily stress syndrome (BSS)

Concluded on Page Four


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