Update on ICD-11 Beta drafting: Bodily Distress Disorder: emerging proposals: Part One

Neither the PCCG nor the S3DWG were proposing, last year, to replace the ICD-10 Somatoform Disorders with Fink et al’s Bodily Distress Syndrome, per se.

The proposals of the PCCG describe a new disorder which combines selected of DSM-5’s SSD and Fink et al’s BDS type characteristics; the S3DWG proposals describe a disorder that has more in common with the DSM-5 SSD construct (which differs significantly from Fink et al’s BDS), though both suggestions were proposed to have similar names to Fink et al’s Bodily Distress Syndrome, namely, Bodily stress syndrome, and Bodily distress disorder.

Were ICD-11 to introduce a new disorder with a similar name to Fink et al’s BDS, but where the definition, criteria and construct differ from BDS, this would likely result in considerable diagnostic and nosological confusion.

Having a primary care version disorder group named Body distress disorders under which four discrete disorders are located (15 Bodily stress syndrome; 16 Acute stress reaction; 17 Dissociative disorder; 18 Self-harm), might also result in potential confusion with Fink et al’s Bodily Distress Syndrome construct.

More information is known about emerging proposals from the PCCG. I shall be reporting on this in Part Two, in a forthcoming report. Below: What’s currently displaying in the ICD-11 Beta drafting platform?

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No definition of BDD in the Beta drafting platform for the core ICD-11

In a previous report (ICD-11 Beta draft and Bodily Distress Disorders; Per Fink and Bodily Distress Syndrome Parts One and Two) I provided an update on the proposal for ICD-11 to replace a number of existing ICD-10 somatoform categories with a single new disorder.

To recap:

As the ICD-11 Beta drafting platform stands at the time of compiling this report, the proposal for ICD-11 is to subsume the ICD-10 categories F45.0 – F45.9 under a single category, with the new ICD Entity Title term, Bodily distress disorder (BDD). So the following ICD categories are proposed to be eliminated for ICD-11:

Somatization disorder [F45.0 in ICD-10]
Undifferentiated somatoform disorder [F45.1 in ICD-10]
Somatoform autonomic dysfunction [F45.3 in ICD-10]
Persistent somatoform pain disorder [F45.4 in ICD-10]
   > Persistent somatoform pain disorder
   > Chronic pain disorder with somatic and psychological factors [Not in ICD-10]
Other somatoform disorders [F45.8 in ICD-10]
Somatoform disorder, unspecified [F45.9 in ICD-10]

Neurasthenia [F48.0 in ICD-10] is also proposed to be subsumed in the core version of ICD-11 and eliminated from the primary care version.

Up until a few days ago, three proposed, discretely coded ICD-11 entities had been listed as child categories under proposed, new parent term, Bodily distress disorders, and psychological and behavioural factors associated with disorders or diseases classified elsewhere:

Department of Mental Health and Substance Abuse, World Health Organization

1 April 2013

Linear Structure 1 April 2013

Psychological and behavioural factors associated with disorders or diseases classified elsewhere is a legacy category from ICD-10 (F54), where it is coded under parent class: Behavioural syndromes associated with physiological disturbances and physical factors (F50-F59). Inclusions and Exclusions for this category are largely imported from ICD-10, and the Definition remains currently unrevised.

Although the proposal to subsume seven ICD-10 categories under a new ICD Entity, Bodily distress disorder, has been displaying in the public version of the ICD-11 Beta drafting platform since February 2012, ICD-11 Revision has yet to define BDD, characterize its three Severity specifiers, or populate any other Content Model fields for them.

The overall section description, here, remains unchanged from ICD-10’s Somatoform Disorders section and has not been revised to reflect the proposal to subsume seven existing categories under a new ICD entity.

In the public version of the iCAT Alpha drafting platform, it had been possible to track changes to category hierarchies, definitions and other revisions through “Note tree” and “Change history” popup windows. In the public Beta drafting platform, these elements are absent and categories are shuffled around within chapters, and in some cases, shifted to other chapters, with no facility for the public to track edits or proposed edits, or rationales for proposed edits, or to determine the intention for categories that are no longer displaying in the draft.

Since no Definition, characterization of Severity specifiers, Inclusions, Exclusions or any other Content Model parameters have thus far been populated for these proposed BDD categories (despite their being new entities for ICD), it is difficult for professional and lay stakeholders to evaluate and comment on proposals.

Why has no BDD Definition been entered into the drafting platform?

A number of possibilities:

The two groups cannot agree on a construct or framework for ICD-11 Bodily distress disorder and how it should be defined; the Managing Editor for the Topic Advisory Group for Mental and Behavioural Disorders has yet to approve a proposed Definition and Severity specifiers (if consensus between the two groups has been reached); the groups are finding it difficult to assimilate the DSM-5 construct of Somatic Symptom Disorder within the framework of its own recommendations; the groups are waiting until the focus group studies and field trials have been completed and evidence for the validity and clinical utility of their proposals evaluated before entering a proposed Definition and other Content Model fields into the draft for stakeholder comment; or, cognisant of intense controversy surrounding revision of the somatoform disorders for both ICD-11 and DSM-5 (with which some degree of harmonization or accommodation might be anticipated), and the Fink et al concept of Bodily Distress Syndrome, ICD-11 Revision is reluctant to publicly post its current proposals.

Whatever the reason(s) for the delay, there has been a recent change to the draft: within the last few days, the proposal for three, discretely coded Severities for BDD: Mild bodily distress disorder; Moderate bodily distress disorder; Severe bodily distress disorder, has been revised.

Currently, only two specifiers: Bodily distress disorder; Severe bodily distress disorder are listed in the drafting platform (but still no Definition for BDD or characterization for either of these specifiers).

This is how the public version of the Beta drafting platform is currently listing this proposed new ICD  disorder:

05 Mental and behavioural disorders

[…]

http://apps.who.int/classifications/icd11/browse/l-m/en#/http%3a%2f%2fid.who.int%2ficd%2fentity%2f767044268

http://apps.who.int/classifications/icd11/browse/l-m/en#/http%3a%2f%2fid.who.int%2ficd%2fentity%2f1472866636

Bodily distress disorders, and psychological and behavioural factors associated with disorders or diseases classified elsewhere [ID : http://id.who.int/icd/entity/767044268]

BDDJune1413

Note: The sorting codes assigned to categories (for example, QL5, QL6) are subject to frequent change as chapters undergo reorganization.

Hypochondriasis

(ID : http://id.who.int/icd/entity/675329566)

For the ICD-11 core version (Foundation View), Hypochondriasis is currently proposed to be renamed to Illness anxiety disorder.

Illness anxiety disorder has been assigned two parents. It is currently listed under parents:

Obsessive-compulsive and related disorders [primary parent]

and

Bodily distress disorders, and psychological and behavioural factors associated with disorders or diseases classified elsewhere [secondary parent]

(New rules for ICD-11 permit categories to be assigned multiple parents. For example, a skin tumour is both a skin disease and a neoplasm; diseases of the eye due to diabetes may also be assigned two parent classes.)

(For ICD11-PHC, Hypochondriasis is proposed to be replaced with a category called Health anxiety.)

Chapter renumbering

Note that the ICD-11 chapter numbering beyond Chapter 05 has been reorganized; Chapter 06 Diseases of the nervous system is currently renumbered to Chapter 07:

05 Mental and behavioural disorders

06 Sleep-wake disorders

07 Diseases of the nervous system

More information is known about emerging proposals from the S3DWG. I shall be reporting on this in Part Three, in a forthcoming report. Below, key points from Part One and Caveats.

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Key points from Part One:

• Two WHO working groups are advising on the revision of the ICD-10 and ICD10-PC Somatoform Disorders: the Primary Care Consultation Group (PCCG); the Expert Working Group on Somatic Distress and Dissociative Disorders (S3DWG). External reviewers are also consulted on proposals and content.

• Six ICD-10 somatoform disorders are proposed to be subsumed under a new ICD term, Bodily distress disorders, under parent category, Bodily distress disorders, and psychological and behavioural factors associated with disorders or diseases classified elsewhere; Neurasthenia is also proposed to be subsumed under BDD.

• No Definition for the ICD-11 construct of Bodily distress disorder has been entered into the Beta drafting platform.

• Three Severity specifiers for the core ICD-11 Bodily distress disorder category: Mild bodily distress disorder; Moderate bodily distress disorder; Severe bodily distress disorder have been recently revised to two: Bodily distress disorder and Severe bodily distress disorder but remain undefined and uncharacterized.

• The primary care group (PCCG) has proposed a new disorder, Bodily stress syndrome, that sits under new disorder group, Body distress disorders; Neurasthenia is proposed to be eliminated as a discrete disorder for ICD-11-PHC.

Caveats:

The version of the ICD-11 Beta drafting platform that the public can access is here: ICD11 Beta draft

The day to day drafting of ICD-11 is being undertaken by ICD Revision on the more complex, multi-author iCAT platform where edit histories can be tracked, progress of proposals monitored, and on which more content associated with categories displays.

The drafting of ICD-11 Beta is a work in progress: content in the publicly viewable platform is in a state of flux and subject to daily updating; sorting codes assigned to categories will change as chapter hierarchies are rearranged and new category names incorporated. Not all classifications and the descriptive content being generated for them may have been entered into the public version of the drafting platform. There may be errors and omissions. The draft is not finalized and not approved by WHO.

Where reports of emerging proposals have been published, the recommendations within them may be subject to revision following analysis of focus group studies, external review and multicentre field trials to assess the clinical utility, feasibility, reliability and validity of proposals for application in developed and developing countries and across various health care settings. Proposals contained within published reports, papers and presentations may have since been superseded by revised proposals not yet visible in the public draft.

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