Abstract: WPA Congress 2014: ICD-11 Symposia: Proposals and evidence for the ICD-11 classification of bodily distress disorders

Post #320 Shortlink: http://wp.me/pKrrB-43v

Edited version of the text published on 13.01.15.

Screenshot: ICD-11 Beta drafting platform, public version, 13.01.15; Chapter 07 Mental and behavioural disorders: Bodily distress disorder. Joint Linerarization for Mortality and Morbidity Statistics (JLMMS) view selected.

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BDD130115

“Show availability in main linearizations” view selected. Hover text for categories designated with three coloured key reads: “In Mortality and Morbidity, Primary Care High Resource, Primary Care Low Resource.” Hover text for categories designated with single blue key reads: “In Mortality and Morbidity.”

Two working groups, two sets of recommendations

The Expert Working Group on Somatic Distress and Dissociative Disorders (S3DWG) is one of two working groups advising the Mental Health Topic Advisory Group (TAG) on the potential revision of the ICD-10 Somatoform disorders categories for ICD-11.

The other group tasked with making recommendations on the revision of the Somatoform disorders is the Primary Care Consultation Group (PCCG), led by Prof Sir David Goldberg [1].

The S3DWG’s disorder construct is the construct that has been entered into the ICD-11 Beta drafting platform since 2012 [2].

Perversely, the S3DWG is proposing to call its disorder construct, “Bodily distress disorder” (BDD) – a term already being used outside ICD Revision, interchangeably, with Bodily Distress Syndrome (BDS), which is conceptually different.

To further muddy the waters, the PCCG has proposed calling its construct (which in 2012 had drawn heavily on the Fink et al BDS concept but with some DSM-5 SSD-like psychobehavioural features tacked on), “Bodily stress syndrome” (BSS).

So four very similar terms in play:

Bodily distress disorder (S3DWG, the construct entered into the Beta draft)

Body distress disorders (PCCG primary care disorder group heading*)

Bodily stress syndrome (PCCG disorder category sitting under Body distress disorders*)

Bodily Distress Syndrome (Fink et al, 2010)

*As proposals of the Primary Care Consultation Group had stood in mid 2012 [1].

The co-chair of the Mental Health TAG agrees that the S3DWG’s BDD and Fink et al’s (2010) BDS construct [3] are conceptually different; that there is potential for confusion between the two constructs and he will be discussing the issue of BDD terminology with the working group.

I shall be reporting on some recently proposed revisions to the definition text for BDD and its three Severities in my next post.

ICD-11 Symposia, XVI World Congress of Psychiatry, Madrid 2014

The have been no progress reports from either the S3DWG or the PCCG since emerging proposals for both working groups were published in 2012.

In September, Professor Oye Gureje, who chairs the ICD-11 Expert Working Group on Somatic Distress and Dissociative Disorders, presented 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.

In the absence of progress reports, I have requested that WHO/WPA make a transcript, slides or summary of this presentation publicly available.

In the meantime, the Abstracts for these ICD-11 symposia presentations can be found here:

http://www.tilesa.es/wpamadrid2014/abstracts/volume8/files/assets/basic-html/page352.html

also: http://www.tilesa.es/wpamadrid2014/abstracts/volume8/index.html#/352/zoomed

XVI World Congress of Psychiatry. Madrid 2014
Volume 2. Abstracts Regular Symposia

[…]

http://www.tilesa.es/wpamadrid2014/abstracts/volume8/files/assets/basic-html/page354.html

Session: Regular Symposium SPEAKER 3 Code SY469

Title: Proposals and evidence for the ICD-11 classification of bodily distress disorders

Speaker O. Gureje University of Ibadan, Ibadan, Nigeria Abstract Objectives:

The disorder categories currently classified in the group of Somatoform Disorders in ICD-10 have been the subject of controversy relating to their names, utility, reliability and acceptability.

The ongoing development of ICD-11 presents an opportunity to revise these categories so as to enhance their utility and overall acceptability.

Methods: The WHO ICD-11 Working Group on Somatic Distress and Dissociative Disorders has conducted a comprehensive review of the current status of Somatoform Disorders, drawing on literature from across the world and considered within diverse clinical experiences of experts who were consulted for the revision exercise. Proposals for DSM-5 and their suitability for global application were also considered.

Results: Important areas for improving the utility and reliability of disorders grouped under Somatoform Disorders were identified. These areas encompass name, content, structure and clarity of the phenomenology. A simplified category of Bodily Distress Disorder with an improved set of guidelines for making the diagnosis has been proposed to replace current Somatoform Disorders categories.

Bodily Distress Disorder may be described as Mild, Moderate, or Severe based on the extent of focus on bodily symptoms and their interference with personal functioning. Bodily Distress Disorder is currently a subject of tests of its utility and reliability in internet- and clinic-based studies via the extensive network that WHO has developed.

Conclusions: Bodily Distress Disorder holds the promise of addressing the various concerns that have been expressed in regard to the utility and applicability of categories currently classified under Somatoform Disorders. The overarching goal of the new category is to enhance the clinical care of patients presenting with these common and disabling conditions. Bodily Distress Disorder is currently a subject of tests of its utility and reliability in internet- and clinic-based studies, including in primary care settings, via the extensive network that WHO has developed.

References Creed F, Gureje O. Emerging themes in the revision of the classification of somatoform disorders. International Review of Psychiatry 2012; 24:556-567

Further reading:

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;24:556-67. [Abstract: PMID: 23244611]

3 Fink P, Schröder A. One single diagnosis, bodily distress syndrome, succeeded to capture 10 diagnostic categories of functional somatic syndromes and somatoform disorders. J Psychosom Res. 2010 May; 68(5):415-26.  [Abstract: PMID: 20403500].

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.

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.

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

Post #307 Shortlink: http://wp.me/pKrrB-3Ts

This post updates on further changes in the public version of the ICD-11 Beta drafting platform to the listing of proposed new ICD category, Bodily distress disorder.

Caveat: The ICD-11 Beta draft 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 Topic Advisory Group Managing Editors, the International Advisory Group, the ICD Revision Steering Group and WHO classification experts. “Sorting codes” assigned to categories are subject to frequent change as chapters and categories are reorganized.

The revision of the Somatoform disorders categories has undergone a number of iterations since the release of the initial iCAT drafting platform, in May 2010.

Two working groups

The ICD-11 Expert Working Group on Somatic Distress and Dissociative Disorders (S3DWG) is one of two WHO convened groups charged with making recommendations for the revision of the ICD-10 Somatoform disorders categories.

The second group, the Primary Care Consultation Group (PCCG), leads the development of the revision of the mental and behavioural disorders publication known as “ICD-10 PHC”.

The PCCG is making recommendations for the revision of ICD-10 PHC’s primary care diagnostic category, F45 Unexplained somatic symptoms/medically unexplained symptoms. Disorders included in the abridged primary care version will require an equivalent category within the core ICD-11 classification.

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What has the S3DWG work group been proposing?

The S3DWG has proposed Bodily distress disorder as a single diagnostic category to replace all of the ICD-10 Somatoform disorders between F45.0 – F45.9 and F48.0 Neurasthenia [1].

So initially, in the drafting platform, these ICD-10 legacy categories were removed.

As the Beta draft stood in mid 2013, Bodily distress disorder had been assigned three, uniquely coded severity specifiers: Mild BDD, Moderate BDD and Severe BDD. These were then reduced to just two: Bodily distress disorder and Severe bodily distress disorder.

So in January 2014, the Beta drafting platform had stood like this:

BDD at 02.02.14

Source: ICD-11 Beta drafting platform at January 29, 2014

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On February 18, I reported that Severe bodily distress disorder was no longer listed in the Beta drafting platform and had been replaced with the ICD-10 legacy category Somatization disorder.

I also reported that the ICD-10 category, Neurasthenia, previously proposed to be eliminated for both the ICD-11 core and Primary Care versions, had been inserted back into the Beta draft.

It was unclear how these two ICD-10 legacy categories were intended to relate to a single new diagnostic category whose conceptual framework had originally been proposed to replace both of them. The Definition texts displaying for both legacy categories had been imported unedited from ICD-10 and provided no clues to the (evidently revised) proposed framework.

So by February 2014, the draft stood like this:

BDD 240214

Source: ICD-11 Beta drafting platform at February 24, 2014

with Neurasthenia back in the draft under parent Mental and behavioural disorders:

Neurasthenia240214

Source: ICD-11 Beta drafting platform at February 24, 2014

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Since these changes, there have been several further modifications to the Beta draft:

Circa May 9, 2014:

Somatization disorder remained listed as a uniquely coded child category under Bodily distress disorder, with a definition comprising unedited text imported from the ICD-10 F45.0 classification.

But three uniquely coded severity specifiers had been added back in:

Bodily distress disorder, mild
Bodily distress disorder, moderate
Bodily distress disorder, severe

So by May 9, the Beta draft Joint Linearization for Mortality and Morbidity Statistics looked like this:

May_9_14_BDD

*Note that the “Sorting codes” assigned to categories change daily as chapters and category hierarchies are reorganized.

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Circa May 15, 2014:

Somatization disorder has now been removed from the Beta draft Linearizations as a uniquely coded child category under Bodily distress disorder.

Somatization disorder is now listed with the ICD-10 term somatoform disorders under Synonyms to Bodily distress disorder and both ICD-10 legacy terms are listed as Index Terms.

Update at June 6, 2014: The ICD-10 legacy terms, Somatoform disorders and somatization disorder are no longer listed under Index Terms to Bodily distress disorder in the Beta drafting platform or print version of the draft Alphabetical Index but remain listed under Synonyms. Both terms have been relocated under Index Terms to 6B4Z Bodily distress disorder, unspecified.

The three severity specifiers for BDD, (Mild, Moderate, Severe) remain.

So at May 27, the Beta draft Joint Linearization for Mortality and Morbidity Statistics looks like this:

May_15_14_BDD

Neurasthenia has also been removed from the Beta draft Linearizations. Nor is it listed in the PDF of the print version of the draft Alphabetical Index.

This might suggest that the most recent proposal has reverted back to eliminating Neurasthenia from ICD-11, but to retain both Somatization disorder and the term somatoform disorders under Synonyms to BDD, and as Index Terms (as opposed to retaining and coding specifically for Somatization disorder under new ICD parent term, Bodily distress disorder).

[Neurasthenia remains specified as an Exclusion to Generalized anxiety disorder (currently Chapter 06) and to Fatigue (currently Chapter 20) but this may be an oversight.]

You can view the entry for Bodily distress disorder here, in the Foundation Linearization, which also displays a Definition, Synonyms and Exclusions:

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

(Click on the small grey arrow to the left of the BDD category term to display the three severity specifiers.)

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Current ICD-11 Definition:

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

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

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

“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).”

The psychological and behavioural features that characterize the disorder, as per this definition, are drawn from disorder conceptualizations in the 2012 Creed, Gureje paper on emerging proposals for Bodily distress disorder.

The paper 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 [1,2].

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In sum:

At the point of publishing this post, we can say that the public version of the Beta draft displays:

 a single Bodily distress disorder category with three uniquely coded (but as yet uncharacterized) severities replacing all the ICD-10 Somatoform disorders between F45.0 – F45.9 and ICD-10’s Neurasthenia (F48.0);

that the ICD-10 legacy terms, somatoform disorders (F45) and Somatization disorder (F45.0), are listed under Synonyms and under Index Terms to Bodily distress disorder.

Update at June 6, 2014: The ICD-10 legacy terms, Somatoform disorders and somatization disorder are no longer listed under Index Terms to Bodily distress disorder in the Beta drafting platform and print version of the Alphabetical Index but remain listed under Synonyms. Both terms have been relocated under Index Terms to 6B4Z Bodily distress disorder, unspecified.

that ICD-10’s Neurasthenia is no longer displaying in any Linearization and may remain proposed to be eliminated for ICD-11 (but remains anomalously specified in two chapters as an Exclusion term);

that an ICD-11 Definition for Bodily distress disorder has been entered into the draft, the wording for which is based on disorder conceptualizations in the 2012 paper: Creed F, Gureje O. Emerging themes in the revision of the classification of somatoform disorders. Int Rev Psychiatry. 2012 Dec;24(6):556-67.

Apart from scrutinizing the Definition, that is all we can safely determine about the current, proposed construct of Bodily distress disorder, in the context of ICD-11’s deployment of the term, solely from the content of the public version of the Beta drafting platform.

I’ll be writing more about this Definition and the 2012 proposals by both ICD-11 working groups in the next post (Post #308).

These recent changes are a good example of why the public version of the Beta drafting platform needs to be viewed with the WHO’s caveats in mind – the draft is in a state of flux, it is incomplete, it contains errors, omissions and anomalies and is subject to frequent rejiggery.

The entry for BDD may undergo further changes over the coming year or so and following field trials evaluation.

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iCAT ICD Collaborative authoring platform:

Note that ICD Revision staff and external editors are developing the draft on a separate, multi-authoring electronic platform called “iCAT ICD Collaborative authoring tool” — a platform considerably more technically sophisticated than the version of the draft that the public sees. In the editors’ version, more Content Model parameters display and there are tabs for change histories, category notes and discussions, and for reviews of proposals. 

So revisions to category chapter locations, hierarchies, internal and external peer review of proposals, drafting and revisions of textual content and rationales for these revisions can be tracked by users of the platform with editing rights or viewing access. The absence of this level of detail in the public version of the draft makes it very difficult for stakeholders to monitor changes and rationales for changes, or to account for missing or no longer displaying category terms.

iCAT ICD Collaborative authoring platform screencast:

This link ICD-11 iCAT screencast will open a 1:55 minute animated screencast intended as a demo for iCAT users but in the public domain. It shows the iCAT platform that the Managing Editors for the various chapters of ICD-11 are developing the draft on. Note the larger number of function tabs along the top of the screen and at 17 secs in, note the larger number of Content Model tabs load under “Details for Test 1” in the category description pane, on the right.

What you see in the Beta draft is a cut down version for public viewing and public interaction that omits many of the functions and much of the detail of the ICD Revision iCAT platform.

To be continued in Post #308.

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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. [Abstract: PMID: 23244611]

2. Fink P, Schröder A. One single diagnosis, bodily distress syndrome, succeeded to capture 10 diagnostic categories of functional somatic syndromes and somatoform disorders. J Psychosom Res. 2010 May;68(5):415-26. [Abstract: PMID: 20403500].

Proposals and evidence for the ICD-11 classification of Bodily Distress Disorders: WHO ICD-11 Symposium IV, WPA XVI World Congress, Madrid

Post #299 Shortlink: http://wp.me/pKrrB-3Oe

Update at March 16, 2014: I am advised that Justice For Karina Hansen on Facebook has added a note of correction to its Facebook post.

BDD 240214

Image source: Chapter 06: Bodily distress disorder > Somatization disorder, ICD-11 Beta drafting platform at March 17, 2014

I am still seeing considerable confusion, misunderstanding and misreporting around what can and what cannot be determined from the public version of the ICD-11 Beta drafting platform on emerging proposals for revision of ICD-10’s Somatoform disorders.

Two recent examples: a media report (since pulled) and an incorrect statement posted by an admin for the Justice For Karina Hansen Facebook page:

“We are sad to share that bodily distress syndrome has made it one step closer to being part of the ICD. It appeared january 29th on ICD-11 Beta Drafting Platform…”

No. It didn’t.

The term Bodily distress syndrome does not appear in the public version of the ICD-11 Beta drafting platform.

The term entered into the Beta draft is Bodily distress disorder.

Bodily distress disorder did not appear in the Beta draft on January 29. It was entered into the draft, two years ago, in February 2012.

January 29 is the date on which I reported that an ICD-11 “Short Definition” had recently been inserted for the (long-standing) entry for a proposed Bodily distress disorder category.

If you have already written about proposals for the revision of the Somatoform disorders in the context of the ICD-11 Beta drafting platform or if you are planning to write, please read this post.

If writing about complex classificatory revision processes, I suggest you first familiarize yourself with how the several ICD-11 Beta drafting platform linearizations function and interrelate; that you inform yourself about the proposals of both ICD-11 working groups charged with making recommendations for potential revision of the ICD-10 Somatoform disorders, including obtaining and scrutinizing key journal papers, reports or presentations on emerging proposals published by members of both working groups; and that for comparison, you have an understanding of the existing F45 Somatoform disorders framework and the disorder descriptions and criteria for categories located within this section of ICD-10, in order that you can provide evidenced based, accurate and up to date information and analysis, within the limitations of what information is public domain.

Reiteration of misinformation and inaccurate reporting on blogs, websites and social media platforms helps no-one. It delegitimizes patient and carer concerns; it undermines the work of advocates committed to providing accurate, referenced and timely information; it panics patients and provokes knee jerk “activism” and “slacktivism.”

And if you are shrugging and thinking Ho, hum, the (undefined) term, Bodily distress disorder and Fink et al’s (operationalized) Bodily Distress Syndrome are sometimes used interchangeably outside of ICD-11, so… ICD-11’s proposed flavour of BDD must mean that a similar disorder model to Fink’s BDS is intended in the Beta draft, read on…

Please note that it is not within the scope of this post to review or discuss the implications for retaining the ICD-10 status quo for ICD-11, or for adopting SSD-like or BDS-like constructs (or any variations on all three) – but to set out what can and what cannot safely be determined from the Beta draft and associated literature.

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Key points for this report:

• In September, 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 a series of ICD-11 Symposia at the World Psychiatric Association’s XVI World Congress, in Madrid.

• There are two working groups advising ICD-11 on the revision of ICD-10’s Somatoform disorders

The Primary Care Consultation Group (PCCG);

The ICD-11 Expert Working Group on Somatic Distress and Dissociative Disorders (S3DWG).

• In 2012, the PCCG published a paper proposing a new disorder construct to replace ICD-10-PHC’s F45 “Unexplained somatic symptoms/medically unexplained symptoms” which the group proposed to call Bodily stress syndrome (BSS) [1]. 

F48 Neurasthenia was also proposed to be eliminated for the ICD-11-PHC.

• In 2012, the PCCG’s Bodily stress syndrome category was proposed to sit under a new Mental and behavioural disorder grouping called Body distress disorders, under which were grouped three other, unrelated disorders, like so:

Extract: Goldberg DP. Comparison Between ICD and DSM Diagnostic Systems for Mental Disorders. In: Sorel E, (Ed.) 21st Century Global Mental Health. Jones & Bartlett Learning, 2012: 37-53 [Free PDF, Sample Chapter Two] [2]

Page 51, Table 2.5 The 28 Disorders Proposed for ICD11-PHC (the abridged Primary Care version of ICD-11)

Body distress disorders

15 Bodily stress syndrome [Replaces F45 Unexplained somatic symptoms/medically unexplained symptoms]
16 Acute stress reaction
17 Dissociative disorder
18 Self-harm

[F48 Neurasthenia proposed to be eliminated for ICD11-PHC]

So the PCCG group were proposing the use of a new term, Body [sic] distress disorders, as a disorder group name for a number of unrelated ICD-11-PHC primary care disorders, whilst proposing the term Bodily stress syndrome as a new ICD-11-PHC disorder category listed under that group.

[Leaving aside the issue of the current lack of evidence for the validity, reliability and utility of the BSS construct, this presents providers, payers, coders and patients with potentially confusing terminology. Given there is already an operationalized definition and criteria for Bodily Distress Syndrome, WHO classification experts should have qualms about the potential for confusion between disorder group names and disorder category names, and between proposed disorder names that sound similar to, but which may lack conceptual congruency with similarly named disorders for which definitions and criteria have already been published and which are already in limited use in research and clinical settings.]

• In 2012, the PCCG’s tentative new BSS disorder drew heavily on Fink et al’s Bodily Distress Syndrome’s (BDS) construct and criteria. Based on physical symptom clusters or patterns from various body systems and (theoretically) on the autonomic arousal or “over-arousal” illness model.

Though not explicit, BSS appeared to have the capacity for capturing the so-called functional somatic syndromes; and in common with BDS, if the symptoms “were better accounted for by a known physical disease this is not BSS.”

But the tentative BSS criteria also featured some DSM-5 SSD-like psychobehavioural characteristics, which do not form part of Fink et al’s BDS criteria. There were other, minor criteria discrepancies between BSS and BDS.

• In 2012, the second working group, the S3DWG, also published a paper presenting a new disorder construct which they proposed to call Bodily distress disorder (BDD) [3]. Again, a similar term to one already in use.

The S3DWG group proposed to subsume all of the ICD-10 Somatoform disorders categories of F45.0 – F45.9, plus F48.0 Neurasthenia, under a new, single BDD disorder category, with a number of severity specifiers (initially, Mild, Moderate and Severe).

• But the S3DWG’s emerging BDD construct was quite different to the PCCG group’s BSS. It was characterized by a simplified criteria set based on excessive preoccupation and psychobehavioural responses to single or multiple, non specific bodily symptoms. The BDD construct shared characteristics with DSM-5’s Somatic symptom disorder (SSD) – not with Fink et al’s BDS.

• In common with DSM-5’s SSD, the BDD diagnosis eliminated the “unreliable assumption of causality” and did not exclude the presence of a co-occurring physical health condition. BDD, as described in the 2012 Gureje, Creed paper, and Fink et al’s BDS are divergent constructs.

• So by late 2012, there were two sets of recommendations – BSS, drawing heavily on Fink’s BDS model, but with a nod towards DSM-5’s SSD, and BDD – with notable similarity to DSM-5’s SSD.

• In early 2012, the disorder name entered into the ICD-11 Beta drafting platform was Bodily distress disorder, (not Bodily stress syndrome or Bodily Distress Syndrome). No Definition for BDD was added at the time.

• In early 2014, a Definition for Bodily distress disorder was inserted into the Beta drafting platform. The Definition wording was drawn from the Gureje, Creed (S3DWG) 2012 BDD paper, which had described an SSD-like disorder construct.

• There is currently insufficient evidence in the Beta drafting platform to assert that, in the context of ICD-11 Beta drafting platform, BDD is being defined as a BDS-like construct. The defining BDD characteristics: 

high levels of preoccupation regarding bodily symptoms;
unusually frequent or persistent medical help-seeking;
avoidance of normal activities for fear of damaging the body;

are psychological and behavioural responses. Psychological and behavioural responses are not required for Fink et al’s BDS and these characteristics have greater congruency with DSM-5 SSD’s “B type”criteria. There is no evident requirement for symptom patterns or clusters from one or more body systems, as required to meet BDS criteria; examples of BDD symptoms are non specific and patients may be “preoccupied with any bodily symptoms.”

From the limited content displaying in the Beta draft, it simply isn’t possible to determine that BDD, in the context of ICD-11 Beta draft usage, is being defined as a Fink et al BDS-like disorder construct.

An additional layer of complexity: recently, the BDD severity specifier “Severe bodily distress disorder” has been removed from the draft and ICD-10’s Somatization disorder reinserted. Neurasthenia, previously proposed by both groups to be eliminated or subsumed for ICD-11, has also been inserted back into the Mental and behavioural disorders chapter, which is (currently numbered Chapter 06).

Neurasthenia240214

Image source: Chapter 06: Neurasthenia, ICD-11 Beta drafting platform at March 17, 2014

The Definition assigned to Somatization disorder remains unrevised from legacy text recently imported, unedited, from ICD-10. It is currently unclear how Somatization disorder and Neurasthenia are now intended to integrate within the core ICD-11 and the ICD-11 Primary Care framework, given that a new, single disorder construct had earlier been proposed by both groups to subsume Somatization disorder and all of the ICD-10 Somatoform Disorders categories between F45.0 – F45.9, and to subsume F48.0 Neurasthenia.

No other F45.x categories have been restored to the Beta draft. (There is a reference in the legacy Definition for Somatization disorder to F45.1 Undifferentiated somatoform disorder but this text has yet to be edited from the text as it had stood under ICD-10’s Somatoform disorders framework.) 

• The development of a replacement for the ICD-10 Somatoform Disorders is a work in progress and proposals may go through several iterations over the next two or three years. The two groups may or may not be striving to reach consensus. The construct favoured by ICD-11 Revision Steering Group may or may not be the construct that is put out for initial field testing.

• Without full disorder descriptions, criteria, inclusions, exclusions, differential diagnoses etc, there is currently insufficient content in the Beta drafting platform to determine the precise nature of whatever construct and criteria is currently favoured by ICD-11 Revision Steering Group; or whether the two groups have reached consensus over a new disorder name and concept; or whether and to what extent the groups’ two (divergent) constructs have been revised since publication of their respective 2012 papers.

Possibly the ICD-11 Symposium IV presentation, later this year, in Madrid, may elucidate. If there is a transcript, summary report or presentation slides of Dr Oye Gureje’s presentation to the World Psychiatric Association XVI World Congress in September, I will post presentation materials, when available. There are some additional notes below the WPA XVI World Congress details.

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The World Psychiatric Association’s XVI World Congress of Psychiatry will be held in Madrid, on September 14–18, 2014.

XVI World Congress of Psychiatry website: http://www.wpamadrid2014.com/

There will be a number of Symposia dedicated to the development of ICD-11

Scientific Programme

Topic 10. Diagnostic Systems (Updated)

Proposals Diagnostic Systems

Extracts:

Page 2:

000464 WHO ICD-11 Symposium I: An overview of the World Health Organization’s development of the ICD-11 classification of mental and behavioural disorders

000466: WHO ICD-11 Symposium III: Proposals and Evidence for ICD-11 – Neurodevelopmental Disorders, Disruptive Behaviour

000468: WHO ICD-11 Symposium IV: Proposals and Evidence for ICD-11– Schizophrenia Spectrum and Other Primary Psychotic Disorders, Mood Disorders, Anxiety Disorders, and Common Mental Disorders in Primary Care

[…]

Speaker: Goldberg, David P., King’s College London – UK

Proposals and evidence for the ICD-11 classification of mental and behavioural disorders in primary care (ICD-11 PHC)

000469: WHO ICD-11 Symposium V: Proposals and Evidence for ICD-11 – Obsessive-Compulsive and Related Disorders, Disorders Specifically Associated with Stress, Bodily Distress Disorders, and Dissociative Disorders

[…]

Speaker: Gureje, Oye, University of Idaban – NG

Proposals and evidence for the ICD-11 classification of Bodily Distress Disorders

Notes:

The ICD-11 Primary Care Consultation Group:

The 12 member PCCG leads the development and field testing of the revision of all 28 mental and behavioural disorders proposed for inclusion in the next ICD primary care classification (ICD-11-PHC), an abridged version of the core ICD-11 classification. Per Fink’s colleague, Marianne Rosendal, is a member of the PCCG group.

The members of the PCCG are: SWC Chan, AC Dowell, S Fortes, L Gask, D Goldberg (Chair), KS Jacob, M Klinkman (Vice Chair), TP Lam, JK Mbatia, FA Minhas, G Reed, and M Rosendal.

New disorders that survive the primary care field tests must have an equivalent disorder in the main ICD-11 classification.

The PCCG’s 2012 paper on emerging proposals for BSS and international focus group responses to these tentative proposals can be accessed for free here:

http://fampra.oxfordjournals.org/content/30/1/76.long

http://fampra.oxfordjournals.org/content/30/1/76.full.pdf+html

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The ICD-11 Expert Working Group on Somatic Distress and Dissociative Disorders:

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

The S3DWG is chaired by Prof Oye Gureje. DSM-5 Somatic Symptom Disorder (SSD) work group member, Prof Francis Creed, is a member of this group. Other than Athula Sumathipala, MD, PhD (UK) and Joan E. Broderick, PhD (Stony Brook University, NY) all other members of this sub working group have yet to be identified. Their names are not listed in the Gureje, Creed 2012 paper [3] and a list of members is not available from the ICD Revision website.

The term entered into the Beta draft is Bodily distress disorder not Bodily stress syndrome or Bodily Distress Syndrome.

Current Definition for Bodily distress disorder, as displaying in the Beta draft at March 16, 2014:

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).

This BDD Definition wording is based – in some places verbatim – on the construct descriptions presented in the Gureje, Creed (S3DWG) “Emerging themes…” paper, published in late 2012 [3]. Unfortunately this journal paper remains behind a paywall but I do have a copy.

Extract, Creed F, Gureje O. Emerging themes in the revision of the classification of somatoform disorders. Int Rev Psychiatry. 2012:

“…At the time of preparing this review, a major highlight of the proposals of the S3DWG for the revision of the ICD-10 somatoform disorders is that of subsuming all of the ICD-10 categories of F45.0 – F45.9 and F48.0 under a single category with a new name of ‘bodily distress disorder’ (BDD).

“In the proposal, BDD is defined as ‘A disorder characterized by high levels of preoccupation related to bodily symptoms or fear of having a physical illness with associated distress and impairment. The features include preoccupation with bothersome bodily symptoms and their significance, persistent fears of having or developing a serious illness or unreasonable conviction of having an undetected physical illness, 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 of functioning or frequent seeking of reassurance.'”

This 2012 paper goes on to say that the S3DWG’s emerging proposals specify a much simplified set of criteria for a diagnosis of Bodily distress disorder (BDD) that requires the presence of:

1. High levels of preoccupation with a persistent and bothersome bodily symptom or symptoms; or unreasonable fear, or conviction, of having an undetected physical illness; plus,

2. The bodily symptom(s) or fears about illness are distressing and are associated with impairment of functioning.

And that in doing away with the “unreliable assumption of its causality” the diagnosis of BDD “does not exclude the presence of depression or anxiety, or of a co-occurring physical health condition.”

This is not a BDS model – it’s a disorder framework into which DSM-5’s “Somatic Symptom Disorder” (SSD) could comfortably be integrated, thus smoothing harmonization between ICD-11 and DSM-5.

(If you want to compare the extent to which the BDS construct and criteria diverges from DSM-5’s SSD construct and criteria, see my graphic here.)

For the S3DWG’s emerging proposals for BDD, as presented in late 2012, there was no evident requirement for specific symptom counts, or for BDS-like symptom clusters from one or more body systems. Examples of symptoms are non specific and patients may be “preoccupied with any bodily symptoms.”

As with DSM-5’s SSD, the focus was not on the number of symptoms, or on symptom patterns or clusters from one or more body systems, or whether symptoms were determined as “medically explained” or “medically unexplained” or of undetermined aetiology, but on the perception of “disproportionate” and “maladaptive” responses to, or “excessive” preoccupation with any troublesome chronic bodily symptom(s).

So in 2012, the two groups lacked agreement not only over what to call any new, single disorder replacement for ICD-10’s Somatoform disorders, but also on what disorder construct and criteria should be recommended to ICD Revision.

Given that the wording of the Definition for Bodily distress disorder as entered into the draft, in January, is based on text from the Gureje, Creed 2012 paper, which had described an SSD-like construct, one might argue that the disorder name and Definition currently displaying in the draft potentially better describes an SSD-like construct – not Fink et al’s BDS.

And with the recent reintroduction into the Beta drafting platform of Somatization disorder and Neurasthenia, one might further argue that there is perhaps a recent consideration for a construct that doesn’t veer too far away from the status quo, which could be moulded to accommodate selected of the ICD-10 legacy Somatoform disorders categories, but which removes the requirement for symptoms to be “medically unexplained” in order that SSD might be shoehorned into an ICD-11 framework for “harmonization” with DSM-5.

But at the moment and in the absence of documentary evidence or clarification by WHO/ICD Revision, what cannot safely be said is that in the context of ICD-11 usage, Bodily distress disorder equates with Fink et al’s Bodily Distress Syndrome.

Caveats: The ICD-11 Beta drafting platform is not a static document: as a work in progress over the next two to three years, it is subject to daily edits and revisions, to field test evaluation and to approval by Topic Advisory Group (TAG) Managing Editors, ICD Revision Steering Group and WHO classification experts.

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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. Fam Pract Feb 2013 [Epub ahead of print July 2012].
Abstract: http://www.ncbi.nlm.nih.gov/pubmed/22843638
Full free text: http://fampra.oxfordjournals.org/content/30/1/76.long
PDF: http://fampra.oxfordjournals.org/content/30/1/76.full.pdf+html

2. Goldberg DP. Comparison Between ICD and DSM Diagnostic Systems for Mental Disorders. In: Sorel E, (Ed.) 21st Century Global Mental Health. Jones & Bartlett Learning, 2012: 37-53 [Free PDF, Sample Chapter Two] http://samples.jbpub.com/9781449627874/Chapter2.pdf

3. 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 [Abstract only. Full text behind paywall]

4. ICD-11 Beta drafting platform public version: Bodily distress disorder: http://apps.who.int/classifications/icd11/browse/f/en#/http%3a%2f%2fid.who.int%2ficd%2fentity%2f767044268

Update on ICD-11 Beta drafting platform listing for “Bodily distress disorder”

Post #296 Shortlink: http://wp.me/pKrrB-3M2

This post is an update to Post #291, January 29, 2014, titled:

Between a Rock and a Hard Place: ICD-11 Beta draft: Definition added for “Bodily distress disorder”

Caveat: 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 Topic Advisory Group Managing Editors, the ICD Revision Steering Group and WHO classification experts.

Since the release of the initial iCAT drafting platform, in 2010, the Somatoform disorders section of Chapter 05 has undergone numerous iterations.

In Post #291, I reported on the status of the Beta drafting platform at January 29, when it had stood like this:

BDD at 02.02.14

Source: ICD-11 Beta drafting platform, Chapter 05, at January 29, 2014

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There has been a further recent change to this section of the drafting platform and the draft currently stands like this:

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

BDD 240214

Source: ICD-11 Beta drafting platform, Chapter 05, at February 24, 2014

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In the Foundation Component, the severity specifier, Severe bodily distress disorder, has now been removed.

ICD-10’s Somatization disorder has been reinserted as a child category under Bodily distress disorder.

The term Bodily distress disorder is cross referenced to ICD-10 F45 Somatoform disorders.

Somatoform disorders is listed under Synonyms to Bodily distress disorder.

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

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

“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).”

Note: these psychobehavioural responses that characterize the disorder are based on text in the 2012 Creed and Gureje paper on emerging proposals for Bodily distress disorder [1].

That paper also says that in doing away with the “unreliable assumption of its causality” the diagnosis of BDD does not exclude the presence of a co-occurring physical health condition – which describes a disorder framework into which DSM-5′s “Somatic Symptom Disorder” (SSD) would be capable of integration, allowing harmonization between ICD-11 and DSM-5.

The Exclusions listed under Bodily distress disorder are legacy terms imported from ICD-10’s Somatoform disorders section. Hypochondriasis has also been inserted as an Exclusion to Bodily distress disorder.

If you open the description display pane for child category, Somatization disorder:

http://apps.who.int/classifications/icd11/browse/f/en#/http%3a%2f%2fid.who.int%2ficd%2fentity%2f967191413

you’ll see that the Definition that has been reinserted is legacy text imported from ICD-10’s F45.0 Somatization disorder.

The Definition includes the text: “Short-lived (less than two years) and less striking symptom patterns should be classified under undifferentiated somatoform disorder (F45.1).”

Note: there is no Undifferentiated somatoform disorder listed in the ICD-11 Beta draft. I cannot confirm whether ICD-11 Revision also intends to reinsert Undifferentiated somatoform disorder to the ICD-11 Beta draft, or whether this represents an oversight on the part of the Beta draft Managing editors to edit the text that has been imported from ICD-10 to accord with ICD-11 proposals.

If you go to the Foundation Component view:

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

and hover over the blue, red, yellow, green button at the top right of the chapter listings, the hover reads

“show/hide availability in main linearizations”.

Click on the button and coloured tags will display at the beginning of each category term which indicate the availability of that term within the various linearizations.

For example, hovering over the colour tags for Bodily distress disorder  indicates that this Foundation Component term is available in “In Mortality and Morbidity, Primary Care High Resource, Primary Care Low Resource” linearizations.

Hovering over the recently re-inserted Somatization disorder indicates that this Foundation Component term is available “In Mortality and Morbidity, Primary Care High Resource, Primary Care Low Resource” linearizations. (On February 18, it was displaying as available only in Foundation, Primary Care High Resource and Primary Care Low Resource.)

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Neurasthenia

A further change – Neurasthenia has also been reinserted into the Beta draft!

Neurasthenia had previously been proposed to be eliminated for ICD-11 or subsumed under Bodily distress disorder along with seven Somatoform disorder categories:

Somatization disorder;
Undifferentiated somatoform disorder;
Somatoform autonomic dysfunction;
Persistent somatoform pain disorder;
Chronic pain disorder with somatic and psychological factors [not in ICD-10 but had been proposed for ICD-11];
Other somatoform disorders;

Somatoform disorder, unspecified

Neurasthenia has also been proposed to be eliminated from the Primary Care version (ICD-11-PHC), according to the 2012 proposals of the Primary Care Consultation Group, but now its back in the draft and listed for Foundation Component, Primary Care High Resource and Primary Care Low Resource linearizations (but not Mortality and Morbidity).

It is currently listed thus:

http://apps.who.int/classifications/icd11/browse/f/en#/http://id.who.int/icd/entity/1784516726

Neurasthenia240214

The Long Content Model Definition that displays in the disorder description pane is the legacy F48.0 text unmodified from ICD-10.

Fatigue syndrome* is specified as the Inclusion term, as per ICD-10. [If you hover over the asterisk in the draft it displays the hover: “This term is an inclusion term in the linearizations”.]

ICD-10 G93.3 category, postviral fatigue syndrome, remains listed as an Exclusion to Neurasthenia, as it does in ICD-10.

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So what are the implications?

Without clarifications from ICD Revision it cannot be determined from what displays in the public version of the Beta draft what the current intentions are, or how these revised proposals would accommodate the restoration of Somatization disorder and Neurasthenia within the BDD framework (at least as the BDD framework stood in the 2012 Creed and Gureje emerging proposals paper).

All that can safely be said in relation to this section of the draft is:

that the section parent category remains Bodily distress disorder;

that a child category, Somatization disorder, which was previously one of a handful of SDs proposed to be replaced by a single new BDD category, has now been reinserted for the Foundation Component, Mortality and Morbidity, Primary Care High Resource and Primary Care Low Resource linearizations, with its Definition text unmodified from ICD-10.

that currently, the Definition text for Somatization disorder is unmodified from ICD-10 and includes an unexplained reference to F45.1 Undifferentiated somatoform disorder*.

that Severe bodily distress disorder is no longer listed in any linearization, at least in the public version of the Beta drafting platform.

that Neurasthenia, which was previously proposed to be eliminated for both the core and primary care versions, is now back in the Beta draft for Foundation Component, Primary Care High Resource and Primary Care Low Resource linearizations, with its Definition text unmodified from ICD-10.

But I have no clarification of intention or any information on what definition, disorder descriptions and criteria set will be going forward to ICD-11 field tests, and it could all change again, next week…

*In DSM-5, Somatic symptom disorder is cross-walked to ICD-10-CM F45.1 Undifferentiated somatoform disorder.

NCHS/CMS has proposed to insert the term Somatic symptom disorder into ICD-10-CM as an Inclusion to F45.1 Undifferentiated somatoform disorder.

References:

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]

Between a Rock and a Hard Place: ICD-11 Beta draft: Definition added for “Bodily distress disorder”

Post #291 Shortlink: http://wp.me/pKrrB-3Gl

Update on February 2, 2014:

Since publishing my report, below, the Chapter 5 parent class:

“Bodily distress disorders, and psychological and behavioural factors associated with disorders or diseases classified elsewhere”

has been reverted by ICD-11 Revision to read, “Bodily distress disorders”.

The category, 5C70 Psychological and behavioural factors associated with disorders or diseases classified elsewhere [F54 in ICD-10], which had been, and remains listed as an Exclusion to class “Bodily distress disorders”, is now coded towards the end of the list of Chapter 5 Mental and behavioural disorders categories, rather than listed as a hierarchical child category under:

“Bodily distress disorders, and psychological and behavioural factors associated with disorders or diseases classified elsewhere”.

Note that the Definition and Inclusions for “5C70 Psychological and behavioural factors associated with disorders or diseases classified elsewhere” are legacy text carried over from ICD-10. The Fxx codes listed under “Exclusions” for this category have not yet been updated to reflect the new ICD-11 coding structure.

This section of Chapter 5 now displays as in this screenshot, immediately below, when viewed in the ICD-11 Beta drafting platform Foundation View, at February, 2, 2014:

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

BDD at 02.02.14

A change also for Hypochondriasis – which has also been removed from under parent class, Bodily distress disorders, and is currently assigned dual parentage under: Obsessive-compulsive and related disorders; and Anxiety and fear-related disorders.

This means that the only categories currently coded under parent term “Bodily distress disorders” (previously, “Bodily distress disorders, and psychological and behavioural factors associated with disorders or diseases classified elsewhere”) are “Bodily distress disorder” and “Severe bodily distress disorder

Update on February 1, 2014:

In June 2013, Prof David Goldberg co-authored a paper: Bodily distress syndrome (BDS): the evolution from medically unexplained symptoms (MUS) in Mental Health in Family Medicine. Co-author, Gabriel Ivbijaro, is Editor in Chief, Mental Health in Family Medicine and a past Chair of the Wonca Working Party on Mental Health. Mental Health in Family Medicine is the official journal of The World Organization of Family Doctors (Wonca) Working Party on Mental Health. I don’t have access to this paper, which is currently embargoed, but it should be free in PMC on June 1, 2014 [5].

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BDDJan_28_14

Screenshot: Chapter 5, ICD-11 Beta drafting platform, public version: January 29, 2014

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Between a Rock and a Hard Place

A definition for “Bodily distress disorder” has very recently been entered into the public version of the ICD-11 Beta drafting platform by ICD-11 Revision.

You can view the definition text, as it stands at January 29, in the public version of the Beta drafting platform, here:

Joint Linearization for Mortality and Morbidity Statistics view

Bodily distress disorder

Parent(s)

Bodily distress disorders, and psychological and behavioural factors associated with disorders or diseases classified elsewhere

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).

All Index Terms

  • Bodily distress disorder

Or here, in the Beta Foundation view

—————-

Only the ICD-11 Short (100 word) Definition for this proposed new ICD category has been inserted. At this point, no Inclusion Terms, Exclusions, Synonyms, Narrower Terms, Diagnostic Criteria or other potential Content Model descriptors have been populated.

No Definition or severity characteristics have yet been assigned to Severe bodily distress disorder to differentiate between the two coded severities: “Bodily distress disorder” and “Severe bodily distress disorder.” (Unique codes for a “Mild bodily distress disorder” and a “Moderate bodily distress disorder” were dropped in mid 2013.)

In order to place this development into context here are some notes:

It’s important to understand that there are two working groups reporting to the International Advisory Group for the Revision of ICD-10 Mental and Behavioural Disorders that are charged with making recommendations on the revision of the Somatoform Disorders for the primary care version and core version of ICD-11:

The 12 member Primary Care Consultation Group (PCCG) leads the development and field testing of the revision of all 28 mental and behavioural disorders for inclusion in the next ICD primary care classification (ICD-11-PHC), an abridged version of the core ICD classification. The PCCG is chaired by Prof Sir David Goldberg. Per Fink’s colleague, Marianne Rosendal, is a member of this group.

The 17 member Expert Working Group on Somatic Distress and Dissociative Disorders (S3DWG) is advising on the revision of ICD-10’s Somatoform Disorders. The S3DWG is chaired by Prof Oye Gureje. DSM-5 Somatic Symptom Disorder work group member, Prof Francis Creed, is a member of this group.

In 2011, the Primary Care Consultation Group’s proposals for a replacement for the “Unexplained somatic symptoms/medically unexplained symptoms” category were put out for review and evaluation in primary care settings to nine  international focus groups* in seven countries [1].

*Austria, Brazil, Hong Kong, New Zealand, Pakistan, Tanzania and United Kingdom.

The PCCG anticipated refining their recommendations in the light of focus group responses before progressing to field testing the new disorder.

New disorders that survive the primary care field tests must have an equivalent disorder in the main ICD-11 classification.

Since any new primary care disorder concept will need to integrate into the ICD-11 core version, one might expect some cross-group collaboration between these two advisory committees.

But in their respective 2012 journal papers, the groups presented divergent constructs and neither group refers to the work being undertaken by the other group, or sets out how the two groups relate to each other, or how the primary care group relates to the overall revision process for the Somatoform Disorders.

The specific tasks of the S3DWG include, among others:

“3. 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.

“4. 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.”

It is unclear how ICD-11 Revision is co-ordinating the input from the two groups, that is, will it be the PCCG’s revised recommendations that progress to field testing, this year, and if so, how would a divergent set of proposals, developed in parallel by the S3DWG group, relate to the field testing and to the overall revision of the SDs?

Or, will ICD-11 Revision require the PCCG group and the S3DWG group to agree on what to call any proposed, single disorder replacement for six or seven SD categories and to reach consensus over what construct, definition, characteristics and criteria will go forward to ICD-11 field testing, and if so, has consensus now been reached?

Field tests are expected to start this year. Currently, there is no publicly available 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 this Beta draft definition.

It has been crafted with sufficient elasticity to allow either group’s construct to be shoehorned into it.

ICD-11 Revision is possibly hedging its bets depending on the outcome of its field tests. But the devil’s in the detail and without the detail, it isn’t clear whether this definition describes the construct favoured by the S3DWG in late 2012, or by the PCCG in mid 2012, or a more recent revision by one of the groups, or a compromise between the two.

The definition wording is based – in some places verbatim – on the construct descriptions presented in the Gureje, Creed (S3DWG) “Emerging themes…” paper, published in late 2012 [2].

Extract, Creed F, Gureje O. Emerging themes in the revision of the classification of somatoform disorders. Int Rev Psychiatry. 2012:

“…At the time of preparing this review, a major highlight of the proposals of the S3DWG for the revision of the ICD-10 somatoform disorders is that of subsuming all of the ICD-10 categories of F45.0 – F45.9 and F48.0 under a single category with a new name of ‘bodily distress disorder’ (BDD).

“In the proposal, BDD is defined as ‘A disorder characterized by high levels of preoccupation related to bodily symptoms or fear of having a physical illness with associated distress and impairment. The features include preoccupation with bothersome bodily symptoms and their significance, persistent fears of having or developing a serious illness or unreasonable conviction of having an undetected physical illness, 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 of functioning or frequent seeking of reassurance.'”

This 2012 paper goes on to say that the S3DWG’s emerging proposals specify a much simplified set of criteria for a diagnosis of Bodily distress disorder (BDD) that requires the presence of: 1. High levels of preoccupation with a persistent and bothersome bodily symptom or symptoms; or unreasonable fear, or conviction, of having an undetected physical illness; plus 2. The bodily symptom(s) or fears about illness are distressing and are associated with impairment of functioning.

And that in doing away with the “unreliable assumption of its causality” the diagnosis of BDD does not exclude the presence of depression or anxiety, or of a co-occurring physical health condition.

Which is a disorder construct into which DSM-5’s “Somatic Symptom Disorder” (SSD) could be integrated, thus facilitating harmonization between ICD-11 and DSM-5.

But without clarification from ICD-11 Revision (or further published papers, reports or sight of the field test protocol) I do not think one can safely extrapolate that it is the current proposals of the S3DWG group that are going forward to field testing, this year, in preference to a construct and criteria favoured by the PCCG group.

With the caveat that proposals by both groups are likely to have been modified since publication of their respective 2012 papers, or may have since converged into a consensus concept, to recap briefly:

In mid 2012, the Goldberg led PCCG primary care group was proposing a new term called “Bodily stress syndrome (BSS),” to replace ICD’s primary care category, “F45 Unexplained somatic symptoms.” This single BSS category would also absorb F48 Neurasthenia, which is proposed to be eliminated for ICD-11-PHC.

In late 2012, the S3DWG group was proposing to subsume the six ICD-10 categories F45.0 – F45.9, plus F48.0 Neurasthenia, under a single disorder category, but under the disorder name, “Bodily distress disorder” (BDD).

So at that point, the two groups differed on what term should be used for this new disorder.

The two group’s proposed constructs, criteria and exclusions also diverged, with the PCCG group incorporating characteristics of Fink et al’s “Bodily Distress Syndrome” [3] construct, and based on the “autonomic arousal” (or “over-arousal”) illness model, with symptom clusters or symptom patterns from one or more body systems, but also requiring some SSD-like psychobehavioural responses to meet the diagnosis. But, “If the symptoms are accounted for by a known physical disease this is not BSS.”

While the emerging proposals of the S3DWG group leaned more towards a “pure” DSM-5 SSD-like construct that could be diagnosed in patients with persistent “excessive” psychobehavioural responses to bodily symptoms in the presence of any diagnosed disease, patients with so-called “functional somatic syndromes” and patients with somatic symptoms of unclear etiology, but with no evident requirement for specific symptom counts, or for symptom clusters from one or more body systems or for the symptoms to be “medically unexplained.” [4]

What wasn’t explicitly set out in the PCCG’s 2012 paper was whether the group intended to mirror the Fink et al BDS construct to the extent of extending the diagnosis to be inclusive of the so-called “functional somatic syndromes,” FM, CFS and IBS (which are currently discretely coded or indexed within ICD-10 in chapters outside the mental and behavioural disorders chapter).

This 2013 paper, below, interprets that it is the intention of the Primary Care Consultation Group to capture FM, CFS and IBS:

http://www.ncbi.nlm.nih.gov/pubmed/24295235

Free PDF: http://www.uam.es/becarios/jbarrada/papers/hads.pdf

Psychol Assess. 2013 Dec 2. [Epub ahead of print] Bifactor Analysis and Construct Validity of the HADS: A Cross-Sectional and Longitudinal Study in Fibromyalgia Patients. Luciano JV, Barrada JR, Aguado J, Osma J, García-Campayo J.

“[…] In the upcoming primary healthcare version of the ICD-11 (ICD-11-PHC), FM will be classified as part of bodily stress syndrome (BSS; Lam et al., 2013). This new diagnosis will group patients who might have previously been considered different (e.g., those with FM, chronic fatigue syndrome, irritable bowel syndrome, and so on). Frontline clinicians (e.g., GPs) will need reliable tools to identify possible/probable clinical cases of anxiety (i.e., cognitive over-arousal) among patients with BSS who are characterised by elevated somatic over-arousal…”

Prof Tony Dowell, New Zealand, is a member of the PPCG. In this slide presentation Prof Dowell lists IBS, Fibromylagia and CFS under “Bodily Stress Syndromes.” Prof Dowell is already promoting the use of the BSS construct, in New Zealand, despite its current lack of validation:

Slide presentation

Slide 29

Bodily Stress Syndromes

• Gastroenterology – IBS, Non ulcer dyspepsia
• Rheumatology – Fibromyalgia
• Cardiology – Non cardiac chest pain
• Respiratory – hyperventilation
• Dental – TMJ syndrome
• Neurology – ‘headache’
• Gynaecology – chronic pelvic pain
• Psychiatry – somatiform [sic] disorders
• Chronic fatigue Syndrome

Reading the responses of the focus groups, as reported in the Lam et al paper [1], it is evident that some focus group participants understood the proposed BSS construct as a diagnosis under which IBS, Fibromylagia and CFS patients could potentially be assigned; though one of the New Zealand focus groups noted there was quite a strong feeling that CFS did not fit the paradigm as well as other [FSS] disorders, particularly when there was a good history of preceding viral infection.

Whilst a number of diseases are listed in the PCCG criteria, as proposed in 2012, under “Differential diagnoses,” including multiple sclerosis, hyperparathyroidism, systemic lupus erythematosus and Lyme disease – IBS, Fibromylagia, CFS and ME are omitted from the list of “Differential diagnoses” examples.

In June 2013, Prof David Goldberg co-authored a paper: Bodily distress syndrome (BDS): the evolution from medically unexplained symptoms (MUS) in Mental Health in Family Medicine. Co-author, Gabriel Ivbijaro, is Editor in Chief, Mental Health in Family Medicine and a past Chair of the Wonca Working Party on Mental Health. Mental Health in Family Medicine is the official journal of The World Organization of Family Doctors (Wonca) Working Party on Mental Health.

I don’t have access to this paper, which is currently embargoed, but it should be free in PMC on June 1, 2014 [5].

—————-

When viewing the Beta drafting platform, note that the descriptive text for the ICD-11 Beta draft parent term, “Bodily distress disorders, and psychological and behavioural factors associated with disorders or diseases classified elsewhere,” which can be viewed here: ICD-11 Beta drafting platform Foundation view is the legacy text from the beginning of the ICD-10 Somatoform Disorders section (compare in ICD-10 here):

This F45 section introduction text has not yet been revised to reflect the proposed dismantling and reorganization of the ICD-10 Somatoform Disorders section for ICD-11.

Caveat: The ICD-11 Beta draft is not a static document – it is a work in progress, subject to daily revisions and refinements and to approval by the International Advisory Group for the Revision of ICD-10 Mental and Behavioural Disorders, the ICD-11 Revision Steering Group, and WHO classification experts. Proposals for some new or revised disorders may be subject to re-evaluation and revision following ICD-11 field testing.

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. Fam Pract Feb 2013 [Epub ahead of print July 2012]. http://www.ncbi.nlm.nih.gov/pubmed/22843638 [Full text behind paywall]

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 et al’s Bodily Distress Syndrome

Per Fink and colleagues are lobbying for their “Bodily Distress Syndrome” (BDS) construct to be integrated into forthcoming classification systems and adopted as a diagnosis by primary care practitioners. They propose the reclassification of the somatoform disorders, pain disorder, neurasthenia and the so-called functional somatic syndromes, including fibromyalgia (FM), irritable bowel syndrome (IBS) and chronic fatigue syndrome (CFS), under a single, unifying diagnosis, “Bodily Distress Syndrome,” already in use in clinical and research settings in Denmark.

4. BDS, BDDs, BSS, BDD unscrambled

5. 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. No abstract available. [PMID: 24427171] Currently embargoed: Free in PMC on June 1, 2014. PMC Archives

G Ivbijaro is Editor in Chief, Mental Health in Family Medicine and a past Chair of the Wonca Working Party on Mental Health. D Goldberg chairs the Primary Care Consultation Group (PCCG) leading the development and field testing of the next ICD primary care classification (ICD-11-PHC).

6. General information on ICD-11 Field Tests:

2012 Annual Report of the International Union of Psychological Science to the American Psychological Association Revision of World Health Organization’s ICD-10 Mental and Behavioural Disorders, Pierre L.-J. Ritchie, Ph.D, January, 2013, Pages 8-11

Click to access icd-report-2012.pdf

WHO ICD Revision Information Note: Field Trials, 23 January 2013

Click to access 15.Field_Trials.pdf

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