APA Announces Start of Field Trials for DSM-5; MedPage Today commentary

October 26, 2010 by

APA Announces Start of Field Trials for DSM-5; MedPage Today commentary

Post #50 Shortlink: http://wp.me/pKrrB-QC

APA News Release

PDF: News Release 05.10.10

American Psychiatric Association (APA)

For Information Contact:
Eve Herold, 703-907-8640
press@psych.org
Jaime Valora, 703-907-8562
jvalora@psych.org

For Immediate Release:
Oct. 5, 2010
Release No. 10-65

APA Announces Start of Field Trials for DSM-5

Sites to Test Proposed Diagnostic Criteria in Real-World Clinical Settings

ARLINGTON, Va. (Oct. 5, 2010) – The American Psychiatric Association today announced the start of field trials to test proposed diagnostic criteria for the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM). Field trials will help assess the practical use of proposed DSM-5 criteria in real-world clinical settings.

The field trials follow a public comment period in which more than 8,000 written comments on the draft diagnostic criteria were submitted to the DSM-5 website by clinicians, researchers and family and patient advocates. Submitted comments were reviewed by DSM-5 Work Groups and resulted in further refinement of the criteria.

Evaluation measures

For the diagnostic criteria that are being evaluated, the results of the field trials will address:

. Feasibility: are the proposed criteria easy for clinicians to understand and to use?
. Clinical Utility: do the proposed criteria do a good job in describing patients’ psychiatric problems and help clinicians make decisions about treatment plans?
. Reliability: are the same conclusions reached consistently when the criteria are used by different clinicians?
. Validity: how accurately do the diagnostic criteria reflect the mental disorders they are designed to describe?

In addition, the field trials will help assess severity measures and cross-cutting dimensional measures.

Severity measures are questionnaires and other tools intended to help clinicians evaluate how severe the symptoms of an individual are on a rating scale.

Cross-cutting dimensional measures are tools for assessing symptoms that occur across a wide range of diagnoses, such as anxiety or sleep problems. Field trials will help determine whether these proposed tools provide useful information for clinicians and their patients, and whether they capture changes in symptoms over time to evaluate progress in treatment.

Two rigorous study designs

Since the DSM is used in many care settings, two standardized and methodologically rigorous study designs were developed by the DSM-5 Research Group to gather data from a wide range of clinicians and settings.

“It is important that the proposed diagnostic criteria are subjected to rigorous and empirically sound field trials before DSM-5 is published in 2013,” said David Kupfer, M.D., chair of the DSM-5 Task Force.

“The two field trial designs will allow us to better understand how the proposed revisions affect clinicians’ practices and, most importantly, patient care.”

One study design was developed for use in academic or other large clinical settings, and will be employed at 11 sites, chosen from among 65 centers that responded to APA’s call for proposals. Another study design was developed for use by individual practitioners and smaller clinical practices. These field trials will be conducted in diverse care settings by 3,900 mental health professionals: 1,400 psychiatrists selected from a randomly selected sample, as well as an additional 2,500 volunteer clinicians, including psychiatrists, psychologists, social workers, and advanced practice psychiatric-mental health nurses.

Participating clinicians must meet eligibility criteria and complete a web-based training seminar.

Clinicians in the field trials will evaluate new and existing patients at different stages of treatment using the proposed DSM-5 diagnostic criteria and measures.

All patients considered for participation in the field trial will receive information about the trial and must give their consent. None of the patients will have their identities revealed in the results of the studies.

In the field trials conducted in the academic and large medical centers, patient evaluations will begin with an initial baseline assessment by a clinician. A different clinician will conduct a second assessment 4 hours to 2 weeks later, to help determine reliability of the diagnostic criteria. This assessment will be repeated in a follow-up visit (4 to 12 weeks after the second evaluation) to test whether the severity and cross-cutting measures are sensitive to changes in treatment progression.

Academic and Large Medical Centers

The 11 large academic medical settings participating in field trials are:

Pediatric Sites

. Baystate Medical Center, Springfield, Mass.
. Columbia University/New York State Psychiatric Institute, Child Psychiatry Division, in collaboration with colleagues at New York Presbyterian

. Hospital/Weill Cornell Medical Center, New York Presbyterian
. Hospital/Westchester Division, and the North Shore Child and Family Guidance Center, Roslyn Heights, New York

. Stanford University, Lucile Packard Children’s Hospital, Palo Alto, Calif.
. The Children’s Hospital, Aurora, Colo.

Adult Sites

. Centre for Addiction and Mental Health, Toronto
. Dallas Veterans Affairs Medical Center
. DeBakey Veterans Affairs Medical Center and Menninger Clinic, Baylor College of Medicine,   Houston
. Mayo Clinic, Rochester, Minn.
. University of California, Los Angeles
. University of Pennsylvania, Philadelphia
. University of Texas Health Science Center, San Antonio

More information on the participating academic large medical centers and the specific disorders being tested in field trials is available on www.dsm5.org .

Disseminating the Field Trial Findings

The DSM-5 Field Trials team will disseminate the results of these initial field trials through presentations at scientific meetings, with professional and consumer groups and in articles published in peer-reviewed scientific journals and DSM-5 source books.

After completion of the first phase of field trials and another period of public comment via the DSM5.org web site, work group members will make any necessary revisions to their draft criteria. This will be followed by a second phase of field trials for further examination of selected criteria, scheduled to take place in 2011 and 2012.

“The process for developing DSM-5 continues to be deliberative, thoughtful and inclusive,” said Darrel Regier, M.D., M.P.H., vice-chair of the DSM-5 Task Force, and APA research director. “Large-scale field trials are the next critical phase in this important process and will give us the information we need to ensure the diagnostic criteria are both useful and accurate in real-world clinical settings.”

The American Psychiatric Association is a national medical specialty society whose physician members specialize in the diagnosis, treatment, prevention and research of mental illnesses, including substance use disorders.

Visit the APA at http://www.psych.org and www.healthyminds.org .

[Ends]

Commentary and previous commentaries on the development of DSM-5 from MedPage Today here:

http://www.medpagetoday.com/Psychiatry/DSM-5/
http://www.medpagetoday.com/Psychiatry/DSM-5/22579

DSM-5 Field Trials Off to Late Start

By John Gever, Senior Editor, MedPage Today
Published: October 05, 2010

“Testing of new diagnostic criteria proposed for DSM-5, the revision of the psychiatric profession’s manual for patient assessment, is finally underway, more than two months behind schedule…”

(With thanks to Kelly Latta for alerting me to the MedPage Today commentary.)

———-

Current proposals by the DSM-5 Work Group for disorders related to the diagnostic category, Somatoform Disorders, can be found here:

http://www.dsm5.org/ProposedRevisions/Pages/SomatoformDisorders.aspx 

and here, in Post #17, on Dx Revision Watch site:

Proposed revisions and draft criteria for DSM-5 categories were published by the American Psychiatric Association on 10 February

 

DSM-5 Submissions to the public review process

There were considerable concerns, earlier this year, in response to the proposal of the DSM-5 Work Group for “Somatic Symptom Disorders” to combine several existing somatoform disorder categories into one larger category, Complex Somatic Symptom Disorder (CSSD).

Patient organisations, professionals and advocates submitting comments in the DSM-5 draft proposal public review process were invited to provide copies of their submissions for publication on this page:

http://wp.me/PKrrB-AQ

———-

This table sets out how the current versions of classification systems, DSM-IV and ICD-10, have corresponded for Somatoform Disorders:

Current DSM-IV Codes and Categories for Somatoform Disorders and ICD-10 Equivalents

Source: Mayou R, Kirmayer LJ, Simon G, Kroenke K, Sharpe M: Somatoform disorders: time for a new approach in DSM-V. Am J Psychiat. 2005;162:847-855.

 

ICD-11 Alpha Draft

According to sources, in July, a print version of the ICD-11 Alpha Draft was expected to be made available around the time that the rescheduled iCamp2 meeting took place in September.

In August, ICD Revision confirmed that a “draft print version will be available in September 2010”.

iCamp2 has now concluded, but it remains unclear whether a print version has been produced. ICD Revision has been asked to clarify the status and availability of an Alpha Draft, whether it is intended for internal use only or is going to be made available for public scrutiny, and if so, when, and in what format(s).

For update on status and availability of ICD-11Alpha Draft see: Post #53

The publication of DSM-5 is currently timelined for May 2013.

Implementation of ICD-10-CM, the US specific “Clinical Modification” of ICD-10, is scheduled for October 2013.

According to the APA’s DSM-5 website Timeline:

http://www.dsm5.org/about/Pages/Timeline.aspx

[…]

As the Phase 1 field trials are underway, members of the DSM-5 Task Force and Work Group will begin drafting their initial text for DSM-5. During this time, case studies will also be developed, which will be published after DSM-5’s release in a series of case books.

March – April 2011: Revisions to Proposed Criteria. Based on results from the first phase of field trials, the DSM-5 Task Force and Work Group members will make revisions to the proposed DSM-5 diagnostic criteria and dimensional measures. These revised criteria and measures will be tested in a second phase of field trials.

April – May 2011: Review of Revised Criteria. Revised proposed criteria will be subjected to internal review, including a review by the DSM-5 Task Force and Research Group and by other relevant work groups.

May-July 2011: Online Posting of Revised Criteria. Following the internal review, revised draft diagnostic criteria will be posted online for approximately one month to allow the public to provide feedback. This site will be closed for feedback by midnight on June 30, 2011.

[…]

 

Filed under American Psychiatric Association (APA), CFSAC meetings, Criticism of DSM-V, DSM-5, DSM revision process, DSM-5, DSM-5 consultation, DSM-5 draft proposals, DSM-5 in the media, DSM-V, Joel Dimsdale, Somatic Symptom Disorder, Somatoform Disorders

Update on the ICD-11 Alpha Draft 06.09.10

September 6, 2010 by

Update on the ICD-11 Alpha Draft at 06.09.10

Post #47 Shortlink: http://wp.me/pKrrB-MD

The information in this update relates only to proposals for ICD-11.

This information does not apply to ICD-10-CM, the forthcoming “Clinical Modification” of ICD-10, which is scheduled for implementation in October 2013 and is specific to the US.

Post #45 is intended to clarify any confusion between ICD-10, ICD-11 and the forthcoming US specific “Clinical Modification”, ICD-10-CM.

See: US “Clinical Modification” ICD-10-CM 

On 7 June, in Post #46, I published a report that includes 13 screenshots from the iCAT, the wiki-like Web 2.0 collaborative authoring platform through which ICD-11 is being drafted.

To view proposals as they currently appear in the iCAT, see the screenshots and my brief notes here:

PVFS, ME, CFS: the ICD-11 Alpha Draft and iCAT Collaborative Authoring Platform

Note that what currently appears in the iCAT and in my June report may be subject to revision by the ICD Revision Steering Group and Topic Advisory Groups prior to an alpha draft being publicly released or presented at the forthcoming September iCamp2 meeting.

 

Update on the ICD-11 Alpha Draft

ICD Revision maintains a website at: http://sites.google.com/site/icd11revision/

where the public can access minutes of iCamp and Topic Advisory Group (TAG) meetings, meeting agendas, key documents and presentations.

Text on this website had read:

“ICD-11 alpha draft will be ready by 10 May 2010
ICD-11 beta draft will be ready by 10 May 2011
ICD final draft will be submitted to WHA by 2014”

This text has recently been changed to read:

“ICD-11 alpha draft process began September 2009
ICD-11 beta draft process will begin in 2011
ICD final draft will be submitted to WHA by 2014”

No detailed timeline has been published but there is a “Project milestones and budget, and organizational overview” on page 7 of this document:

ICD-11 Revision Project Plan – Draft 2.0 (v March 10) PDF: ICD Revision Project Plan

or: http://www.who.int/classifications/icd/ICDRevisionProjectPlan_March2010.pdf

which projects a Beta Draft release for May 2012.

Release of ICD-11 Alpha Draft

No ICD-11 Alpha Draft was publicly released in May. But a hard copy “snapshot” of the alpha, as it stood at that point, was presented by the WHO at the 63rd World Health Assembly meeting, between 17 and 25 May.

September iCamp2 meeting

An ICD Revision iCamp2 meeting had been scheduled for April but was postponed. The meeting has been rescheduled for later this month.

iCamp2 is now scheduled for 27 September – 1 October 2010, in Geneva.

The revised Agenda for this meeting is here:

http://sites.google.com/site/icd11revision/home/face-to-face-meetings/icamp2-2010

http://sites.google.com/site/icd11revision/home/face-to-face-meetings/icamp2-2010/icamp-2-agenda

Following iCamp meetings, PowerPoint presentations are sometimes made publicly available on the website.

According to sources, the print version of the alpha draft is now expected to be made available around the time that the iCamp2 meeting takes place, later this month.

ICD Revision maintains a blog, here, which hasn’t been updated since last October and a Facebook presence here

In response to some questions raised several months ago, ICD Revision confirmed, on 6 August, that:

“A draft print version will be available in September 2010.”

On 7 August, I raised the following:

“ICD Revision has clarified that a draft print version will be available in September 2010.

Clarification would also be welcomed on whether this Alpha Draft will be available for internal use only or intended for public viewing, and if for public viewing, in what format(s)?

According to the Revision document ICD Revision Project Plan [1], published on the ICD Revision Google site, in March:

‘The Alpha draft will be produced in a traditional print and electronic format. The Alpha Draft will also include a Volume 2 containing the traditional sections and including a section about the new features of ICD-11 in line with the style guide [2]. An index for print will be available in format of sample pages. A fully searchable electronic index using some of the ontological features will demonstrate the power of the new ICD.’

Since 2007, it has been possible for stakeholders in the development of ICD-11 to submit proposals and comments, supported by citations, via the ICD Update and Revision Platform Intranet. It was understood last year, that for some Topic Advisory Groups a proposal form for ICD-11 was being prepared for use by stakeholders. Information about the availability of proposal forms for the various Topic Advisory Groups, up to what stage in the development process timeline these might be used, and which stakeholders would be permitted to make use of proposal forms would be welcomed.

It remains unclear what will be ready by September, whether it will be available for public scrutiny, and in what format(s), and by what various means stakeholders might submit proposals prior to and following the release of an Alpha Draft.”

This request for clarification has yet to receive a response.

 

Current proposals for the classification and coding of PVFS, ME and CFS for the ICD-11 Alpha Draft

On my DSM-5 and ICD-11 Watch website, at Post #46, is a report I published on 7 June that includes screenshots from the iCAT, the wiki-like collaborative authoring platform through which ICD-11 is being drafted.

To view what is currently visible in the iCAT, see the screenshots and my brief notes here:

PVFS, ME, CFS: the ICD-11 Alpha Draft and iCAT Collaborative Authoring Platform, 7 June 2010

Caveat

For better understanding, it is important that the brief iCAT Glossary page is read in conjunction with the iCAT screenshots, especially the Glossary entries for ICD-10 Code; ICD Title; Definition; Terms: Synonyms, Inclusions and Exclusions [4].

Read the iCAT Glossary here: http://apps.who.int/classifications/apps/icd/icatfiles/iCAT_Glossary.html

Secondly, it needs to be understood that the alpha draft is a “work in progress”. Not all content will have been compiled yet and entered into the iCAT and there are many blank fields awaiting population for all chapters and for all categories. It also needs to be understood that some text already entered into the various “Details” fields may still be in the process of internal review and subject to revision.

Because Topic Advisory Groups are still in the process of entering content into the iCAT not all listings and content that is intended to be included in the print version of the alpha draft may be visible to us, at this point, in the iCAT drafting platform.

ICD-10 > ICD-11

One of the biggest changes between ICD-10 and ICD-11 is that in ICD-11, Categories will be defined through the use of multiple parameters.

In ICD-10, there is no textual content for the three terms “Postviral fatigue syndrome”, “Benign myalgic encephalomyelitis” and “Chronic fatigue syndrome”. There are no definitions and the relationship between the three terms is not specified.

But in ICD-11, categories will be defined through the use of multiple parameters: Title & Definition, Terms: Synonyms, Inclusions, Exclusions, Clinical Description, Signs and Symptoms, Diagnostic Criteria and so on, according to a common “Content Model” [2] and as evidenced by the screenshots.

So have a look at Post #46 if you have not already done so. Or have a poke around in the iCAT wiki production server. The public has no editing rights so you can’t break anything [3].

 

Request for clarification to Advisory Group for Neurology

On 28 June, I contacted Dr Raad Shakir who chairs the ICD Revision Topic Advisory Group for Neurology, for clarifications in respect of current proposals for ICD-11 Chapter 6 (VI).

Dr Shakir has been asked if he would disambiguate current proposals for ICD-11 for the classification of, and relationships between the three terms, “Postviral fatigue syndrome”, “Chronic fatigue syndrome” and “Benign myalgic encephalomyelitis”, since this is not explicit from the information as it currently displays in the iCAT, nor from the Discussion Note for “Gj92 Chronic fatigue syndrome”, which has been listed in Chapter 6 (VI) under

Chapter 6 (VI) Disorders of the nervous system

             > GN Other disorders of the nervous system

(“Gj92” is a “Sorting label”. It is understood that a “Sorting label” is a string that can be used to sort the children of a category and is not the ICD code.)

I was advised by Dr Shakir, on 5 July, by email, that my queries have been passed to the Advisory Group for a response. I have yet to receive a clarification.

To: Dr Raad Shakir, West London Neurosciences Centre, Charing Cross
Hospital, Fulham Palace Road, London W6 8RF raad.shakir@imperial.nhs.uk

Re: Query in relation to Topic Advisory Group for Neurology proposals for ICD-11 Chapter 6 (VI)

28 June 2010

Dear Dr Shakir,

I am writing to you in your capacity as Chair, ICD Revision TAG Neurology, with a request for clarification of current proposals for the restructuring of categories classified in ICD-10 under G93 Others disorders of brain, specifically those at G93.3. That is:

Diseases of the nervous system (G00-G99)

      > Other disorders of the nervous system (G90-99)

             > G93 Other disorders of brain

[…]

G93.3 Postviral fatigue syndrome
Benign myalgic encephalomyelitis

(with Chronic fatigue syndrome indexed to G93.3 in ICD-10: Volume 3: The Alphabetical Index)

In the absence of the release of an ICD-11 Alpha Draft, I rely on information as it currently displays in the ICD Categories listed in the iCAT production server at: http://icat.stanford.edu/

My understanding is that what is being proposed at this point for ICD-11 is that ICD categories coded between G83.9 thru G99.8 in ICD-10 Chapter VI: Diseases of the nervous system, are being reorganised.

That in ICD-11, Chapter 6 (VI) codings beyond G83.9 are represented by new parent classes numbered GA thru to GN thus:

Chapter 6 (VI) Disorders of the nervous system

[…]
G80-G83 Cerebral palsy and other paralytic syndromes
GA Infections of the nervous system
GB Movement disorders and degenerative disorders
GC Dementias
[…]
GN Other disorders of the nervous system

That “GN Other disorders of the nervous system” is parent to five child classes that are assigned the “Sorting labels” Gj90-Gj94.

(It is understood that a “Sorting label” is a string that can be used to sort the children of a category and is not the ICD code.)

At Gj92, sits “Chronic fatigue syndrome”

That “Gj92 Chronic fatigue syndrome” displays no child classes of its own.

The Category Note associated with “Gj92 Chronic fatigue syndrome” records a Change in hierarchy for class: G93.3 Postviral fatigue syndrome because its parent category (G93 Other disorders of brain) is removed.*

[*Ed: Note that the removal of the parent “G93 Other disorders of brain” affects many other categories also classified under G93 in ICD-10, not just G93.3, which have also been assigned “Sorting labels”.]

According to the iCAT ICD Categories “Details for Gj92 Chronic fatigue syndrome”

“Gj92 Chronic fatigue syndrome” displays as a ICD Title term.

“Gj92 Chronic fatigue syndrome” has a Definition field populated.**

[**Ed: Which may be subject to revision and in response to proposals.]

It has an External Definitions field populated which includes definitions imported from other classification systems, the text of which includes “Also known as myalgic encephalomyelitis”.

It has “Benign myalgic encephalomyelitis” specified under Inclusions.

It has no Synonyms, Exclusions or other descriptor fields populated yet.

That at this point and as far as the iCAT version displays, there is no explicit accounting for “Postviral fatigue syndrome”, as an entity, other than that “Postviral fatigue syndrome” is specified under Exclusions to Chapter 5 (V) F48.0 Neurasthenia and to Chapter 18 (XVIII) R53 Malaise and fatigue and is referenced in these chapters as

            postviral fatigue syndrome G93.3 -> Gj92 Chronic fatigue syndrome

It is further understood, from the iCAT Glossary at
http://apps.who.int/classifications/apps/icd/icatfiles/iCAT_Glossary.html

that:

“Inclusion terms appear in the tabular list of the traditional print version and show users that entities are included in the relevant concept. All of the ICD-10 inclusion terms have been imported and accessible in the iCat. These are either synonyms of the category titles or subclasses which are not represented in the classification hierarchy. Since we have synonyms as a separate entity in our ICD-11 content model, the new synonyms suggested by the users should go into the synonyms section. In the future, iCat will provide a mechanism to identify whether an inclusion is a synonym or a subclass.”

I should be most grateful if you could clarify the following for me:

1] In ICD-10 Volume 3: The Alphabetical Index, “Chronic fatigue syndrome” is indexed to G93.3 but does not appear in the Tabular List.

In ICD-11, is it being proposed that “Chronic fatigue syndrome” will be included in the Tabular List in Chapter 6 (VI) Diseases of the nervous system under “(GN) Other disorders of the nervous system”?

2] In ICD-11, is it being proposed that rather than “Postviral fatigue syndrome” being the ICD Category Title term (previously coded at G93.3, but which has now lost its parent class, G93) that “Gj92 Chronic fatigue syndrome” is proposed as a new ICD Category Title term?

If this is the case, what is the current proposed relationship between the terms “Postviral fatigue syndrome” and “Gj92 Chronic fatigue syndrome”?

That is, is it proposed that in the tabular list, “Postviral fatigue syndrome” would still appear as a discrete Category Title term or is it intended that it should be subsumed under “Gj92 Chronic fatigue syndrome” or become a Subclass of, or Synonym to “Chronic fatigue syndrome”, or to have some other relationship?

3] In the iCAT, the term “Benign myalgic encephalomyelitis” (previously coded at G93.3, but which has now lost its parent class G93) is listed as an Inclusion under “Details for Gj92 Chronic fatigue syndrome” but does not appear listed under “GN Other disorders of the nervous system” in the ICD Category List with a Sorting label of its own, nor as a child to “Gj92 Chronic fatigue syndrome”.

What is currently being proposed for ICD-11 for the classification and coding of “Benign myalgic encephalomyelitis”, as an entity, and its relationship to “Chronic fatigue syndrome”?

Since this is not explicit from the information as it currently displays in the iCAT, nor from the Discussion Note to Gj92, I should be pleased if you could disambiguate current proposals for the classification of, and relationships between these three terms for ICD-11.

Sincerely,

etc

 

I will update when a response has been received and when further information about a print version of the alpha draft becomes available.

Other than making general enquiries around the development of ICD-11 and the operation of the iCAT and this request for clarification of current proposals, I have made no representations to any ICD Topic Advisory Group, nor submitted any proposals through any means nor have I had any discussions with WHO personnel or Topic Advisory Group members in relation to current or future proposals for the three terms of interest to us.

References:

PVFS, ME, CFS: the ICD-11 Alpha Draft and iCAT Collaborative Authoring Platform, 7 June 2010, Post # 46: http://wp.me/pKrrB-KK

[1] ICD-11 Revision Project Plan – Draft 2.0 (v March 10):
Describes the ICD revision process as an overall project plan in terms of goals, key streams of work, activities, products, and key participants: ICD Revision Project Plan
http://www.who.int/classifications/icd/ICDRevisionProjectPlan_March2010.pdf

[2] Content Model Specifications and User Guide (v April 10):
Identifies the basic properties needed to define any ICD concept (unit, entity or category) through the use of multiple parameters: http://tinyurl.com/ICD11ContentModelApril10

[3] iCAT production server and Demo and Training iCAT Platform:
http://sites.google.com/site/icd11revision/home/icat
iCAT production server: http://icat.stanford.edu/

[4] iCAT Glossary
http://apps.who.int/classifications/apps/icd/icatfiles/iCAT_Glossary.html

Filed under American Psychiatric Association (APA), Clinical Modification, iCAT, ICD revision process, ICD-10, ICD-10-CM, ICD-11, ICD-11 Alpha Draft, ICD-11 consultation, ICD-11 revision docs, Somatic Symptom Disorder, Somatoform Disorders, WHO (World Health Organization), WHO Somatisation Project

US “Clinical Modification” ICD-10-CM

June 6, 2010 by

US “Clinical Modification” ICD-10-CM

Post #45 Shortlink: http://wp.me/pKrrB-Ka

This post is intended to clarify any confusion between ICD-10, ICD-11 and the forthcoming US Clinical Modification of ICD-10, ICD-10-CM.

The WHO published ICD-10 in 1992. The current version of ICD-10 (Version for 2007) is used in the UK and in many countries throughout the world.

ICD-10 is under revision and the development of the structure and content of ICD-11 has been underway since 2007. ICD-11 is scheduled for completion in 2014.

 
Clinical Modifications

Several countries are permitted to publish adaptations of the ICD called “Clinical Modifications” (sometimes known as “national modifications”).

Countries using Clinical Modifications of ICD-10 include Canada (ICD-10-CA), Australia (ICD-10-AM) and Germany (ICD-10-GM).

The United States currently uses an adaptation of the WHO’s now retired ICD-9, called ICD-9-CM, and has been slow to move onto ICD-10.

Rather than skip ICD-10 and move straight onto ICD-11 in 2014+, the US CDC has been developing a modification of ICD 10 called ICD-10-CM which will replace ICD-9-CM.

ICD-10-CM is US specific and is due for implementation in October 2013.

According to one report, the US should not expect to move on to ICD-11 (or a modification of ICD-11) until well after 2020, assuming that ICD-11 is published around the 2014-2015 projection:

Why move to ICD-10, if ICD-11 is on the horizon?
http://www.healthcarefinancenews.com/news/why-move-icd-10-if-icd-11-horizon
 

What are the proposed classifications and codings for PVFS, (Benign) ME and Chronic fatigue syndrome for ICD-10-CM?

In March 2001, the document:

“A Summary of Chronic Fatigue Syndrome and Its Classification in the International Classification of Diseases Prepared by the Centers for Disease Control and Prevention, National Center for Health Statistics, Office of the Center Director, Data Policy and Standards”

provided a concise “summary of the classification of Chronic Fatigue Syndrome in the International Classification of Diseases (ICD), ninth and tenth revisions, and their clinical modifications.”

That document is archived here: http://www.co-cure.org/ICD_code.pdf

In 2001, the proposal had been:

“In keeping with the placement in the ICD-10, chronic fatigue syndrome (and its synonymous terms) will remain at G93.3 in ICD-10-CM.”

So at that point, it was being proposed for the forthcoming US ICD-10-CM that PVFS, (Benign) ME and Chronic fatigue syndrome would be coded at G93.3, which would have placed all three terms in Chapter VI: Diseases of the nervous system (the Neurological chapter).

But the current proposals for ICD-10-CM propose classifying Chronic fatigue syndrome in Chapter 18, under R53 Malaise and fatigue, at R53.82.

The “R” codes are classified under

CHAPTER 18 (XVIII)
Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified (R00-R99)

This chapter includes symptoms, signs, abnormal results of clinical or other investigative procedures, and ill defined conditions regarding which no diagnosis classifiable elsewhere is recorded…

Note: this is not the ICD-10-CM Mental and Behavioural chapter, which is:

CHAPTER 5 (V)
Mental and behavioral disorders (F01-F99)
Includes: disorders of psychological development
Excludes2: symptoms, signs and abnormal clinical laboratory findings, not elsewhere classified (R00-R99)

which specifically excludes the R00-R99 codes.

So the current proposal for ICD-10-CM separates CFS and Postviral fatigue syndrome into mutually exclusive categories:

“Chronic fatigue, unspecified” and “Chronic fatigue syndrome not otherwise specified” appear in Chapter 18, under R53 Malaise and fatigue, at R53.82.

Whilst “Postviral fatigue syndrome” and “benign myalgic encephalomyelitis” appear in Chapter 6, under G93 Other disorders of brain, at G93.3.

At some point before October 2013, ICD-10-CM revision will be “frozen” for Centers for Medicare and Medicaid Services (CMS) and insurance companies to prepare for the October 1, 2013 implementation.

See Tom Sullivan at ICD10 Watch.com (no connection with my site) here:

CMS, CDC call for ICD-9 and ICD-10 code freeze
http://icd10watch.com/headline/cms-cdc-call-icd-9-and-icd-10-code-freeze

“CMS, the Centers for Medicare and Medicaid Services, along with CDC, the Centers for Disease Control and Prevention, proposed that both ICD-9-CM and ICD-10-CM/PCS code sets be frozen two years before the compliance deadline.

“What that means: As of October 1, 2011, only limited updates would be instituted into the code sets so that providers, payers, clearinghouses, and health IT vendors, will not have to simultaneously keep pace with code updates while also reconfiguring their existing systems for ICD-10-CM/PCS.” ICD10 Watch.com

During the last ten minutes of the CFSAC meeting on Monday, 10 May, Dr Lenny Jason raised his concerns with the committee that the placement of CFS in ICD-10-CM in the Chapter 18 “R” codes could be problematic.

Videocast of full CFSAC meeting here:
http://videocast.nih.gov/Summary.asp?File=15884

In August 2005, CFSAC had submitted the following recommendation to the Secretary:

http://www.hhs.gov/advcomcfs/recommendations/082005.html

“Recommendation 10: We would encourage the classification of CFS as a ‘Nervous System Disease,’ as worded in the ICD-10 G93.3.”

I suggest that US advocates with concerns about current proposals for the placement of CFS within ICD-10-CM keep a close eye on decisions about the date by which ICD-10-CM is to be frozen.

For the most recent ICD-10-CM proposals see:

http://www.cdc.gov/nchs/icd/icd10cm.htm

The 2010 update of ICD-10-CM is now available and replaces the July 2009 version.

The file for the Tabular List is in a Zipped file which is not that easy to locate on the site. A non Zipped PDF can be downloaded from this site:

http://www.cms.gov/ICD10/12_2010_ICD_10_CM.asp#TopOfPage
http://www.cms.gov/ICD10/Downloads/6_I10tab2010.pdf

or open the PDF on my DSM-5 and ICD-11 Watch site, here
https://dxrevisionwatch.com/wp-content/uploads/2009/12/i10tab2010.pdf

ICD-10-CM CHAPTER 18

Tabular List of Diseases and Injuries Page 1165 (Update for 2010)

      R53 Malaise and fatigue

      […]

      R53.8 Other malaise and fatigue

          Excludes1: combat exhaustion and fatigue (F43.0)
          congenital debility (P96.9)
          exhaustion and fatigue due to:
          depressive episode (F32.-)
          excessive exertion (T73.3)
          exposure (T73.2)
          heat (T67.-)
          pregnancy (O26.8-)
          recurrent depressive episode (F33)
          senile debility (R54)

      R53.81 Other malaise

          Chronic debility
          Debility NOS
          General physical deterioration
          Malaise NOS
          Nervous debility
          Excludes1: age-related physical debility (R54)

     R53.82 Chronic fatigue, unspecified

          Chronic fatigue syndrome NOS
          Excludes1: postviral fatigue syndrome (G93.3)

      R53.83 Other fatigue

          Fatigue NOS
          Lack of energy
          Lethargy
          Tiredness

 

ICD-10-CM CHAPTER 6 Page 325 (Update for 2010)

Diseases of the nervous system (G00-G99)

Excludes2:

[…]
symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified (R00-R94)

     […]

     G93 Other disorders of brain

      […]

      G93.3 Postviral fatigue syndrome

          Benign myalgic encephalomyelitis
          Excludes1: chronic fatigue syndrome NOS (R53.82)

For comparison:

German Modification ICD-10-GM
http://www.dimdi.de/static/de/klassi/diagnosen/icd10/htmlgm2010/block-g90-g99.htm

ICD-10-GM Version 2010

Kapitel VI
Krankheiten des Nervensystems
(G00-G99)

G93.- Sonstige Krankheiten des Gehirns

[…]

G93.3 Chronisches Müdigkeitssyndrom

Benigne myalgische Enzephalomyelitis
Chronisches Müdigkeitssyndrom bei Immundysfunktion
Postvirales Müdigkeitssyndrom

For comparison:

Canadian Modification ICD-10-CA

(Version 2009 of ICD-10-CA/CCI replaces version 2006)

http://secure.cihi.ca/cihiweb/dispPage.jsp?cw_page=codingclass_e

Version 2009 ICD-10-CA Tabular List, Volume 1 PDF (4.9MB)
http://secure.cihi.ca/cihiweb/en/downloads/ICD-10-CA_Vol1_2009.pdf

Version 2009 ICD-10-CA Alphabetical Index, Volume 2 PDF (4.3MB)
http://secure.cihi.ca/cihiweb/en/downloads/ICD-10-CA_Vol2_2009.pdf

Chapter VI

Diseases of the nervous system
(G00-G99)

Other disorders of the nervous system
(G90-99)

[…]

G93 Other disorders of brain

[…]

G93.3 Postviral fatigue syndrome

Includes: Benign myalgic encephalomyelitis
Chronic fatigue syndrome

Excludes: fatigue syndrome NOS (F48.0)

For comparison with WHO ICD-10:

Current ICD-10 codings for the three terms are set out on my site, here, together with extracts from Chapter V (the “F” codes) and Chapter XVIII (the “R” codes):

https://dxrevisionwatch.wordpress.com/icd-11-me-cfs/

or go here for the full ICD-10 Volume 1: Tabular List

http://apps.who.int/classifications/apps/icd/icd10online/

ICD-10 Version for 2007 online
http://apps.who.int/classifications/apps/icd/icd10online/?gg90.htm+g933

Chapter VI

Diseases of the nervous system
(G00-G99)

Other disorders of the nervous system
(G90-99)

[…]

G93 Other disorders of brain

[…]

G93.3 Postviral fatigue syndrome
           Benign myalgic encephalomyelitis

Note that in ICD-10, Chronic fatigue syndrome is not included in Volume 1: The Tabular List, Chapter VI under the parent term:

             G93 Other Disorders of brain

but “Chronic fatigue syndrome” does appear in Volume 3: The Alphabetical Index, where it is indexed to G93.3.

In a forthcoming post, I shall be publishing important information about proposals for parent terms, classifications and codings in the ICD-11 Alpha Draft.

 

Related material:

ICD-9-CM

For information on the current codings in ICD-9-CM (US Clinical Modification) see the NAME U.S. page:  WHO ICD Codes section

American Psychiatric Association on DSM-5

In a 10 December Press Release, the American Psychiatric Association said:

“Extending the timeline [for DSM-5] will allow more time for public review, field trials and revisions”

and

“The extension will also permit the DSM-5 to better link with the U.S. implementation of the ICD-10-CM codes for all Medicare/Medicaid claims reporting, scheduled for October 1, 2013. Although ICD-10 was published by the WHO in 1990, the “Clinical Modification” version (ICD- 10-CM) authorized by the U.S. Centers for Medicare and Medicaid Services (CMS) and the Centers for Disease Control (CDC) is not being implemented in the U.S. until 23 years later.

“The ICD-10-CM includes disorder names, logical groupings of disorders and code numbers but not explicit diagnostic criteria. The APA has already worked with CMS and CDC to develop a common  structure for the currently in-use DSM-IV and the mental disorders section of the ICD- 10-CM.

“The International Classification of Diseases (ICD) is published by the WHO for all member countries to classify diseases and medical conditions for international health care, public health, and statistical use. The WHO plans to release its next version of the ICD, the ICD-11, in 2014.

“APA will continue to work with the WHO to harmonize the DSM-5 with the mental and behavioral disorders section of the ICD-11. Given the timing of the release of both DSM-5 and ICD-11 in relation to the ICD-10-CM, the APA will also work with the CDC and CMS to propose a structure for the U.S. ICD-10 CM that is reflective of the DSM-5 and ICD-11 harmonization efforts. This will be done prior to the time when the ICD-10-CM revisions are “frozen” for CMS and insurance companies to prepare for the October 1, 2013, adoption.”

Filed under American Psychiatric Association (APA), CFSAC meetings, Clinical Modification, DSM-5, DSM-V, ICD-10, ICD-10-CM, ICD-11, ICD-11 Alpha Draft, WHO (World Health Organization)

Revision of DSM-5 and ICD-10-CM raised at 10 May CFSAC meeting

May 11, 2010 by

Revision of DSM-5 and ICD-10-CM raised at 10 May CFSAC meeting

Post #43 Shortlink: http://wp.me/pKrrB-HA

A one day public meeting of the US Chronic Fatigue Syndrome Advisory Committee (CFSAC) was held on Monday, 10 May. Minutes of the previous two day meeting and a Videocast of the proceedings of both days (with subtitles) can be accessed here and here.

The Chronic Fatigue Syndrome Advisory Committee (CFSAC) provides advice and recommendations to the Secretary of Health and Human Services via the Assistant Secretary for Health of the U.S. Department of Health and Human Services on issues related to chronic fatigue syndrome (CFS). More information here [PDF].

Towards the end of Monday’s meeting, Dr Leonard Jason, PhD, raised concerns in response to current proposals for the placement of CFS within the forthcoming US “Clinical Modification”, ICD-10-CM, due to be implemented in October 2013. (See this Dx Revision Watch page for current ICD-10-CM proposals.)

Agenda for this Spring 2010 meeting here

CFSAC Agenda – May 10, 2010
Chronic Fatigue Syndrome Advisory Committee
US Department of Health and Human Services

Meeting was webcast live at http://videocast.nih.gov 

Webcast of entire meeting with subtitles is now available to view here

Chronic Fatigue Syndrome Advisory Committee
Monday, May 10, 2010
HHS Office on Women’s Health (OWH)
Total Running Time: 05:47:57

More information here: http://videocast.nih.gov/Summary.asp?File=15884

Presentations, Public Testimonies and Written Testimonies here

Transcripts are being compiled on a dedicated Facebook site here

YouTubes videos here:

 

New Hillary Johnson blog post – “Sif-Sac, again.” here

Cort Johnson’s blog

A very different looking federal advisory committee on CFS (CFSAC) discussed its charter, its recommendations, XMRV and the blood supply, what the CDC program will look and more. Asst Secretary of Health Dr. Koh, Annette Whittemore and Kim McCleary spoke. Check out the goings on at the CFSAC meeting in

‘The CFSAC on Itself, XMRV, the CDC and More’ from the Bringing the Heat blog:

http://blog.aboutmecfs.org/?p=1540

Phoenix Rising forum thread here

CFSAC Agenda – May 10, 2010

May 10, 2010

9:00 am
Call to Order
Opening Remarks

Roll Call, Housekeeping
Dr. Christopher Snell
Chair, CFSAC

Dr. Wanda Jones
Designated Federal Official

9:15 am
Welcome Statement from the Assistant Secretary for Health

New Members Statement on CFSAC Interests/Goals
Dr. Howard K. Koh

CFSAC New Members

10:00 am
Remarks from Dr. Elizabeth Unger
Dr. Elizabeth Unger

10:30 am
Blood Safety Update on XMRV
Dr. Jerry Holmberg

11:00 am
Review/Update of past CFSAC recommendations
Committee Members

12:30 pm
Subcommittee Lunch
Subcommittee Members

1:30 pm
Public Comment
(on CFSAC charter)
Public

2:00 pm
Review and Discussion of CFSAC Charter and ByLaws
Committee Members

4:00 pm
Adjourn

Filed under American Psychiatric Association (APA), CFSAC meetings, Criticism of DSM-V, DSM-5, DSM revision process, DSM-5, DSM-5 consultation, DSM-5 draft proposals, DSM-V, Functional Somatic Syndrome (FSS), ICD revision process, ICD-11, MUS, WHO (World Health Organization)

Whittemore Peterson Institute submission to DSM-5 draft proposals

April 24, 2010 by

Whittemore Peterson Institute submission to DSM-5 draft proposals

Post #41 Shortlink: http://wp.me/pKrrB-Gv

Submissions

Patient organisations, professionals and advocates submissions are being collated on this dedicated Dx Revision Watch page: http://wp.me/PKrrB-AQ

If you would like your submission added please get in touch via the Contact form

Open Whittemore Peterson Institute response here in PDF format: WPI DSM-5 statement

or here: http://www.wpinstitute.org/news/docs/DSM-5WPIaw2.pdf

April 16, 2010

DSM-5 Task Force
American Psychiatric Association
1000 Wilson Boulevard Suite 1825
Arlington, VA 22209

Members of the DSM-5 Task Force:

The Whittemore Peterson Institute would like to address the potential revision of the American Psychiatric Association’s (APA)’s Diagnostic and Statistical Manual for Mental Disorders (DSM-5). The APA’s proposed changes would combine several existing somatic categories into one larger category, Complex Somatic Symptom Disorder, adding language that closely resembles the CDC’s criteria for Chronic Fatigue Syndrome with additional sickness related behaviors that are often evidenced by those who are ill with a disease when it is poorly understood and characterized symptomatically.

The following language has been proposed:

To meet criteria for CSSD, criteria A, B, and C are necessary.

A. Somatic symptoms:

Multiple somatic symptoms that are distressing or one severe symptom

B. Misattributions, excessive concern or preoccupation with symptoms and illness: At least two of the following are required to meet this criterion:

High level of health-related anxiety.

Normal bodily symptoms are viewed as threatening and harmful

A tendency to assume the worst about their health (Catastrophizing)

Belief in the medical seriousness of their symptoms despite evidence to the contrary.

Health concerns assume a central role in their lives

C. Chronicity: Although any one symptom may not be continuously present, the state of being symptomatic is chronic and persistent (at least six months).

Recent findings by researchers at the Whittemore Peterson Institute, the Cleveland Clinic and the National Cancer Institute have found a link between those who have been previously diagnosed with Chronic Fatigue Syndrome, (ME/CFS) and a new human retrovirus, XMRV. Yet ME/CFS is currently diagnosed symptomatically and requires the patient experience 6 months of severe fatigue. This disease is chronic and often causes a great deal of anxiety for those who suffer from its debilitating symptoms. Therefore, an individual suffering from ME/CFS could be erroneously classified within the new DSM-5 category as a somatic disorder when in fact they clearly suffer from a chronic infectious disease process, evidenced by many physical abnormalities. (Low grade fever, sore throat, severe headache, cognitive dysfunction, and enlarged lymph nodes, and painful joints and muscles).

The new language also adds undue concern about one’s health as criteria for establishing the diagnosis of complex somatic disorder. This is an immeasurable description of behavior that suggests that if one is suffering from an unknown illness and expresses deep concern or seeks answers from multiple sources (a potentially perfectly natural response to such a circumstance) that one could then be classified as having a somatic disorder. Yet, newly recognized diseases require time to develop the appropriate conformational laboratory tests. During that period of time, does it not remain the responsibility of physicians to recognize the patient’s illness and reassure the patient that they will do all they can to alleviate their suffering?

A person who is afflicted with Myalgic Encephalomyelitis/Chronic Fatigue Syndrome is often incapable of taking care of their own most basic needs. The swiftness with which one is incapacitated without relief often results in accompanying depression and anxiety. If this patient is advised not to believe their own symptoms of illness they may become further traumatized by the doctors whose sworn duty is to “first do no harm”.

The Whittemore Peterson Institute is deeply concerned that there will be future complex biological diseases of unknown origin, which could too easily be ignored as the result of the diagnosis of “complex somatic disorders”. This would result in serious consequences for those patients who continue to decline in health without appropriate medical interventions.

The term CSSD may also serve as a diagnosis to be used by physicians who currently lack the sophisticated diagnostic tools to describe a new and emerging illness, causing serious harm to those who are ill. Two such recent examples of diseases once categorized as somatic illnesses are multiple sclerosis which was originally called, “hysterical women’s disease” and gastrointestinal ulcers. Only after these diseases were pursued by those who believed in their physical causes with subsequent biological research, were medically effective treatments made available. Thus creating a somatic diagnosis, when there is in fact a physical illness, would relegate a population of patients to many more years of suffering, while basic biological research funding is denied.

For these reasons, the WPI requests that the APA thoughtfully examine the purpose and possible unintended consequences for the encompassing somatic category of illness, Complex Somatic Disorder, and emphatically requests that the DSM-5 task force reject CSSD, as a medical or psychiatric diagnosis.

Sincerely,

Annette Whittemore
Founder and CEO
Whittemore Peterson Institute
6600 North Wingfield Parkway
Sparks Nevada 89436
Phone: 775.348.2335

Fax: 775.348.2350
www.wpinstitute.org  

On the subject of the use of the word “somatic”, Angela Kennedy published this note, in June 2009:

I’ve noticed for some time that various people have been using the term ‘somatic’ as if it signified a ‘psychosomatic’ or ‘psychogenic’ condition.

This is incorrect. The OED definition of ‘somatic’ is “of or relating to the body, especially as distinct from the mind” (my italics). The word comes from the Greek ‘soma’ meaning ‘body’.

Even when proponents of ‘psychogenic’ explanations (it’s in your mind, you’re imagining it, misinterpreting it, faking it, caused it by your own beliefs etc. etc. etc.) use the term ‘somatic illness’ they actually do mean an illness of the body. They may then claim this somatic (or bodily illness) is caused by psychological dysfunction, but the word ‘somatic’ does not mean “illness caused by psychological dysfunction”. It merely means illness of a body, or a bodily illness.

It is important that this word is used correctly, especially when people write to the media, government, the medical establishment etc. Otherwise we are in danger of seeing apparent objections published, from advocates, to saying ME/CFS is a bodily illness, purely because someone has used the word ‘somatic’ incorrectly!

Filed under American Psychiatric Association (APA), Criticism of DSM-V, DSM-5, DSM revision process, DSM-5, DSM-5 consultation, DSM-5 draft proposals, DSM-V, Functional Somatic Syndrome (FSS), MUS, Somatic Symptom Disorder, Somatoform Disorders

News release: APA Closes Public Comment Period for Draft Diagnostic Criteria for DSM-5

April 22, 2010 by

News release: APA Closes Public Comment Period for Draft Diagnostic Criteria for DSM-5

Post #40 Shortlink: http://wp.me/pKrrB-Gl

News Release

http://tinyurl.com/DSM5reviewcloses

or open PDF here:  APA Closes Public Comment Period for DSM-5 Release No. 10-31

For Information Contact:

Eve Herold, 703-907-8640

press@psych.org  Release No. 10-31

Jaime Valora, 703-907-8562

jvalora@psych.org

EMBARGOED For Release Until: April 20, 2010, 12:01 AM EDT

APA Closes Public Comment Period for Draft Diagnostic Criteria for DSM-5

DSM-5 Work Groups to Review Comments

ARLINGTON, Va. (April 20, 2010) -The American Psychiatric Association received 6,400 comments on a draft of the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders during a 2½ month public comment period, which ends today.

“This period of public review and comment of diagnostic criteria is unprecedented in both the field of psychiatry and in medicine,” said Alan F. Schatzberg, M.D., president of the American Psychiatric Association. “It demonstrates the APA’s commitment to an inclusive and transparent process of development for DSM-5.”

The criteria have been available for comment since they were published online on Feb. 10. The draft criteria will continue to be available for review on the DSM-5 Web site, www.dsm5.org , and updates to the draft will be posted on an ongoing basis. The public will have another opportunity to comment on the criteria and any changes after the first round of field trials.

A number of clinicians, researchers and family and patient advocates participated in the public comment period, contributing more than 6,400 comments on various aspects of DSM-5.

All comments submitted via the Web site were assigned to a topic-specific expert from one of the thirteen DSM-5 work groups for review. In their review, work group members will note submissions that need additional consideration from the work group as a whole. Upon evaluation from the entire work group, draft criteria may be revised.

For example, the Eating Disorders Work Group has proposed additional revisions to criteria for Anorexia Nervosa and Bulimia Nervosa based on comments received.

“The goal of DSM-5 is to create an evidence-based manual that is useful to clinicians and represents the best science available,” said David J. Kupfer, M.D., DSM-5 Task Force chair.

“The comments we received provide the task force and work groups with additional information and perspectives, ensuring that we have fully considered the impact any changes would have on clinical practice and disorder prevalence, as well as other real-world implications of revised criteria.”

Most of the comments that were submitted were diagnosis-specific, while nearly one-fourth were general. Distribution of the comments varied across the 13 work groups.

The work groups with the largest number of submitted comments include:

. Neurodevelopmental Disorders Work Group (23% of comments)

. Anxiety Disorders Work Group (15% of comments)

. Psychosis Disorder Work Group (11% of comments)

. Sexual and Gender Identity Disorders (10% of comments)

Following a review of all submitted comments and possible revisions to the draft criteria, the APA will begin a series of field trials to test some of the proposed diagnostic criteria in clinical settings. The proposed criteria will continue to be reviewed and refined over the next two years.

Final publication of DSM-5 is planned for May 2013

[Ends]

Filed under American Psychiatric Association (APA), Criticism of DSM-V, DSM-5, DSM revision process, DSM-5, DSM-5 consultation, DSM-5 draft proposals, DSM-5 in the media, DSM-V

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