ICD-11 Beta draft: Rationale for Proposal for Deletion of proposed new category: Bodily distress disorder

Post #328 Shortlink: http://wp.me/pKrrB-4dc

ICD-11 Beta draft Proposal Mechanism:

https://tinyurl.com/ICD11BDDsubmission

(Registration with the Beta draft required in order to view proposals)

  ICD-11 Bodily distress disorder submission

Proposal submitted by Suzy Chapman, Dx Revision Watch, via ICD-11 Beta draft Proposal Mechanism

Submitted: March 1, 2017

The author has no affiliations or conflicts of interest to declare.

Rationale for Proposal for Deletion of the Entity: Bodily distress disorder

1: The acronym “BDD” is already in use to indicate Body Dysmorphic Disorder [1].

2: With limited field studies, there is currently no substantial body of evidence for the validity, reliability, utility, prevalence, safety and acceptability of the S3DWG’s proposed disorder construct. However, the focus of this rationale is the proposed nomenclature.

The Somatic Distress and Dissociative Disorders Working Group (S3DWG) proposes to name its construct, “bodily distress disorder (BDD)” – a term that is already used by researchers and in the field interchangeably with the disorder term, “bodily distress syndrome (BDS).”

“Bodily distress syndrome” is a conceptually divergent disorder construct: differently defined and characterized, with different criteria that are already operationalized in Denmark and beyond, in research and clinical settings, and which potentially include a different patient set to that described in the S3DWG’s proposal [2].

As defined for the ICD-11 core version, the S3DWG’s “bodily distress disorder” construct has stronger conceptual and characterization alignment with DSM-5 “somatic symptom disorder (SSD)” than with Fink et al. (2010) “bodily distress syndrome” [3][4].

It is noted that “Somatic symptom disorder” is listed under Synonyms for the BDD entry in the ICD-11 Beta draft.

The defining feature of both the S3DWG’s “bodily distress disorder” and DSM-5 “somatic symptom disorder” is the removal of the distinction between “medically explained” and “medically unexplained” somatic complaints. Rather than define the disorder on the basis of the absence of a known medical cause, instead, specific psychological features are required in order to fulfill the criteria.

The S3DWG’s BDD is characterized by “the presence of bodily symptoms that are distressing to the individual and excessive attention directed toward the symptoms which may be manifest by repeated contact with health care providers.”

“Excessive attention is not alleviated by appropriate clinical examination and investigations and appropriate reassurance.”

“If a medical condition is causing or contributing to the symptoms, the degree of attention is clearly excessive in relation to its nature and progression.”

“Bodily symptoms and associated distress are persistent, being present on most days for at least several months and are associated with significant impairment in personal, family, social, educational, occupational or other important areas of functioning.”

The S3DWG’s “bodily distress disorder” may involve a single unspecified somatic symptom or multiple unspecified symptoms that may vary over time, in association with the disorder’s other defining features.

For DSM-5 “somatic symptom disorder,” the centrality of medically unexplained symptoms in order to meet the criteria is similarly de-emphasized and replaced by psychological responses to distressing, persistent symptoms: “excessive thoughts, behaviours and feelings” or “excessive preoccupation” with the bodily symptom or associated health concerns [5].

As with BDD, for SSD, the symptoms may or may not be associated with another medical condition. Some patients with general medical  diagnoses, such as cancer, cardiovascular disease or diabetes, or patients diagnosed with the so-called “functional somatic syndromes” may qualify for a diagnosis of SSD if they are perceived as experiencing disproportionate and excessive thoughts and feelings or using maladaptive coping strategies in response to their illness, despite the reassurance of their clinicians [6].

As with the S3DWG’s defining of BDD, for SSD, there is no requirement for a specific number of complaints from among specified symptom groups to meet the criteria: so no symptoms counts or symptom clusters from body systems required for either.

To meet the SSD criteria: at least one symptom of at least six months duration and at least one of three psychological criteria are required: disproportionate thoughts about the seriousness of the symptom(s); or a high level of health anxiety; or devoting excessive time and energy to symptoms or health concerns; and for the symptoms to be significantly distressing or disruptive to daily life.

Though they differ somewhat in the characterization of their severity specifiers, the S3DWG’s defining of BDD and DSM-5 SSD may be considered essentially similar in conceptualization: no distinction between “medically explained” and “medically unexplained”; a much simplified criteria set to those defining the somatoform disorders, based on “excessive” or “disproportionate” psychological responses to persistent distressing symptoms, and with significant impairment or disruption to functioning.

Whereas, for the Fink et al. (2010) “bodily distress syndrome (BDS),” psychological or behavioural characteristics are not part of the criteria: symptom patterns or clusters from organ/body systems (cardiopulmonary; gastrointestinal; musculoskeletal or general symptoms) are central [2]. The diagnosis is exclusively made on the basis of the somatic symptoms, their complexity and duration, with moderate  to severe impairment of daily life. There is a “Modest: single organ” type and a “Severe: multi-organ” type.

The Fink et al. (2010) BDS construct is considered by its authors to have the ability to capture the somatoform disorders, neurasthenia, “functional symptoms” and the so-called “functional somatic syndromes” under a single, unifying disorder construct which subsumes CFS, ME, fibromyalgia and IBS (which are discretely classified within other chapters of ICD-10), noncardiac chest pain, chronic pain disorder, MCS and some others [7][8][9].

(The various so-called specialty “functional somatic syndromes” are considered by the authors to be an artifact of medical specialization and manifestations of a similar, underlying disorder with a common, hypothesized aetiology.)

Contrast this with the S3DWG’s BDD construct, which makes no assumptions about aetiology and does not exclude symptoms associated with general medical conditions; whereas, for Fink et al. BDS, “If the symptoms are better explained by another disease, they cannot be labelled BDS.”

That DSM-5 SSD and Fink et al. (2010) BDS are differently conceptualized, with different criteria sets, potentially capturing different patient populations has been acknowledged by SSD work group chair, Joel E Dimsdale, and by Fink, Henningsen and Creed [10][11]. In the literature, however, one observes frequent instances where the term “bodily distress disorder” has been used when what is actually being discussed within the paper or editorial is the Fink et al. (2010) “bodily distress syndrome (BDS)” disorder construct.

For example, “bodily distress disorder” is used interchangeably with “bodily distress syndrome” in the editorial (Creed et al. 2010): Is there a better term than “medically unexplained symptoms”? [1].

In this (Rief and Isaac 2014) editorial: The future of somatoform disorders: somatic symptom disorder, bodily distress disorder or functional syndromes? the authors are using the term, “bodily distress disorder” while clearly discussing the Fink et al. (2010) BDS  construct [12].

The S3DWG’s proposed term is seen, here, as “Bodily distress disorder (Fink and Schroder 2010)” in Slide #3 of the symposium presentation: An introduction to “medically unexplained” persistent physical symptoms. (Professor Trudie Chalder, Department of Psychological Medicine, King’s Health Partners, 2014) [13].

This recent paper: Medium- and long-term prognostic validity of competing classification proposals for the former somatoform disorders (Schumacher et al. 2017) compares prognostic validity of DSM-5 “somatic symptom disorder (SSD)” with “bodily distress disorder (BDD)” and “polysymptomatic distress disorder (PSDD)” and discusses their potential as alternatives to SSD for the replacement of the somatoform disorders for the forthcoming ICD-11 [14].

The authors state, “the current draft of the WHO group is based on the BDD proposal.” But the authors  have confirmed that for their study, they had operationalized “Bodily distress disorder based on Fink et al. 2007” [15].

In the (Fink et al. 2007) paper: Symptoms and syndromes of bodily distress: an exploratory study of 978 internal medical, neurological, and primary care patients, the authors conclude: “We identified a general, distinct, bodily distress syndrome or disorder that seems to encompass the various functional syndromes advanced by different medical specialties as well as somatization disorder and related diagnoses of the psychiatric classification.”

There are other examples in the literature and in the field. But these suffice to demonstrate that the term, “bodily distress disorder” is already used synonymously with disorder term “bodily distress syndrome (BDS)” and that researchers/clinicians, including Fink et al., do not differentiate between the two.

If researchers/clinicians do not differentiate between “bodily distress syndrome” and “bodily distress disorder” (and in some cases, one observes the conflations, “bodily distress syndrome or disorder” and “bodily distress syndrome/disorder”), has the S3DWG considered the difficulties and implications for maintaining the discrete identity of its proposed disorder, once ICD-11 is in the hands of its end users – clinicians, allied health professionals and coders; or considered the implications for patients and the particular vulnerability of those diagnosed with one of the so-called, “functional somatic syndromes”; or the implications for data reporting and analysis?

The S3DWG presented its emerging proposals for subsuming most of the ICD-10 somatoform disorder categories between F45.0 – F45.9, and F48.0 Neurasthenia, under a new single category which it proposes to call “bodily distress disorder (BDD)” in 2012 [3] and again in 2016 [4].

Thus far, the S3DWG has published no rationale for its recommendation to repurpose a disorder term already strongly associated with the Fink et al. (2010) disorder construct.

Neither has the group discussed nor acknowledged within its papers the implications for confusion and conflation between its own SSD- like “BDD” construct and the Fink et al. “bodily distress syndrome (BDS).”

Nor has the group’s output discussed the potential difficulties and implications for maintaining construct integrity within and beyond  ICD-11.

There is no justification for introducing a new disorder category into ICD-11 that has greater conceptual alignment with the DSM-5 SSD construct but is proposed to be assigned a disorder name that is closely associated with a divergent (and operationalized)  construct/criteria set, that is already in use in research and clinical settings.

This is unsafe and unsound classificatory practice.

This proposed disorder name should be rejected by the Project Lead for the revision of the Mental or behavioural disorders chapter and by the Joint Task Force that is overseeing the finalization of ICD-11  MMS.

If the S3DWG is unprepared or unwilling to reconsider and recommend an alternative disorder name then I submit that the current proposal to replace the somatoform disorders with a single “bodily distress disorder” category should be abandoned.

ICD-11 should proceed with the ICD-10 status quo, or retire or deprecate the somatoform disorder categories for the next edition.

It is perhaps germane that in 2010, three years prior to the finalization of DSM-5, Creed et al. had advanced: “Somatic symptom disorder is not a term that is likely to be embraced enthusiastically by doctors or patients; it has an uncertain core concept, dubious wide acceptability across cultures and does not promote multidisciplinary treatment. In our discussion, the terms which fit most closely the criteria we have set out above were the following: bodily distress (or stress) syndrome/ disorder, psychosomatic or psychophysical disorder, functional (somatic) syndrome or disorder.” [1]

The authors conclude that “bodily distress disorder” best fitted their “Criteria to judge the value of alternative terms for ‘medically unexplained symptoms.'”

It would appear that the term “bodily distress disorder” can mean anything anyone chooses it to mean – which might be admissible for Humpty Dumpty but unsound classificatory practice for ICD-11 [16].

References:

1 Creed F, Guthrie E, Fink P, Henningsen P, Rief W, Sharpe M, White P. Is there a better term than “medically unexplained symptoms”? J Psychosom Res. 2010 Jan;68(1):5-8. doi:10.1016/j.jpsychores.2009.09.004. [PMID: 20004295]

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. [PMID: 20403500]

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. doi: 10.3109/09540261.2012.741063. [PMID: 23244611]

4 Gureje O, Reed GM. Bodily distress disorder in ICD-11: problems and prospects. World Psychiatry. 2016 Oct;15(3):291-292. doi: 10.1002/wps.20353. [PMID: 27717252]

5 American Psychiatric Association. (2013). Somatic Symptom and Related Disorders. In Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.

6 Frances A, Chapman S. DSM-5 somatic symptom disorder mislabels medical illness as mental disorder. Aust N Z J Psychiatry. 2013 May;47(5):483-4. [PMID: 23653063]

7 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. 2013 Feb;30(1):76-87. doi: 10.1093/fampra/cms037. Epub 2012 Jul 28. [PMID: 22843638]

8 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. [PMID: 24427171]

9 Goldberg DP, Reed GM, Robles R, Bobes J, Iglesias C, Fortes S, de Jesus Mari J, Lam TP, Minhas F, Razzaque B et al. Multiple somatic symptoms in primary care: A field study for ICD-11 PHC, WHO’s revised classification of mental disorders in primary care settings. J Psychosom Res. 2016 Dec;91:48-54. doi:10.1016/j.jpsychores.2016.10.002. Epub 2016 Oct 4. [PMID: 27894462]

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

11 Frances Creed and Per Fink. Presentations, Research Clinic for Functional Disorders Symposium, Aarhus University Hospital, May 15, 2014.

12 Rief W, Isaac M. The future of somatoform disorders: somatic symptom disorder, bodily distress disorder or functional syndromes? Curr Opin Psychiatry September 2014 – Volume 27 – Issue 5 – p315–319. [PMID: 25023885]

13 Chalder, T. An introduction to “medically unexplained” persistent physical symptoms. Presentation, Department of Psychological Medicine, King’s Health Partners, 2014. [Accessed 27 February 2017]

14 Schumacher S, Rief W, Klaus K, Brähler E, Mewes R. Medium- and long-term prognostic validity of competing classification proposals for the former somatoform disorders. Psychol Med. 2017 Feb 9:1-14. doi: 10.1017/S0033291717000149. [PMID: 28179046]

15 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. [PMID: 17244846]

16 Carroll L. Alice’s Adventures in Wonderland. 1885. Macmillan.

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

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

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

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

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

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

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

This report sets the editorial into context.

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ICD-11-PHC

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

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

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

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

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

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

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Does this editorial advance our understanding of current proposals?

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

With its

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

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

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The PCCG’s Bodily stress syndrome (BSS):

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

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

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

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

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

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

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

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

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How viable is BDS for incorporation into ICD-11?

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

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

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

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

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

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Proposed new classification

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

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

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

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

• unacceptability to patients and medical professionals

medico-political sensitivities

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

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

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

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

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Has Professor Fink achieved his goal?

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

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

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

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

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

++
WHO on Twitter:

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

++
So what has been entered into the Beta drafting platform?

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

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

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

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

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

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

++
Forthcoming symposium presentation:

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

++
Field testing:

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

++
Requests for clarification repeatedly stonewalled:

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

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

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

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

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

++
Caveats:

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

++
References:

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

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

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

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

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

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

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

 

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 for the primary care version of ICD-11, which will be known as the ICD-11-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.

+++

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

+++

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

+++
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.

+++
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.)

+++

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.

+++

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.

+++
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].

Moving on

Post #304 Shortlink: http://wp.me/pKrrB-3QY

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.

If writing about complex classificatory revision processes, I suggest you first familiarize yourselves with how the several ICD-11 Beta drafting platform linearizations function and interrelate; that you inform yourselves about the proposals of both of the 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 and 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 the categories located under this section of ICD-10, and that you are also familiar with the construct and criteria for DSM-5’s Somatic symptom disorder, in order that you can provide evidence 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 devalues 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.”

It has become clear to me, down the years, that the majority of ME patients are not interested in evidence based reporting.

I am wasting my time.

For those who have listened, thank you. The site will remain online as a resource.

Suzy Chapman for Dx Revision Watch

“He that reads and grows no wiser seldom suspects his own deficiency, but complains of hard words and obscure sentences, and asks why books are written which cannot be understood.”  Samuel Johnson

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

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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]

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