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

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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

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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].

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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

BDS, BDDs, BSS, BDD unscrambled

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BDS, BDDs, BSS, BDD and ICD-11, unscrambled

There are two WHO convened working groups charged with making recommendations for the revision of ICD-10’s Somatoform Disorders: the Primary Care Consultation Group (known as the PCCG) and the Expert Working Group on Somatic Distress and Dissociative Disorders (known as the S3DWG).

The revision of ICD-11 is being promoted as an open and transparent process. But to date, neither working group has published progress reports for stakeholder consumption and neither group has published its emerging proposals in public access journals.

Content populated in the public version of the ICD-11 Beta drafting platform sheds little light on proposals.

Consequently, there is considerable confusion around what is being recommended for the revision of ICD-10’s Somatoform Disorders, whether consensus between the two working groups has been reached, and what proposals will progress to field testing during the next two years.

ICD-11 Revision has been asked to clarify when it intends to define and characterize its current proposals within the Beta drafting platform.

The notes below set out some of what is known about the two working groups’ emerging proposals, how they diverge and how they compare with DSM-5’s Somatic Symptom Disorder and with Fink et al’s Bodily Distress Syndrome.

Caveat: the proposals of the two ICD-11 working groups may have undergone revision and refinement since emerging proposals were published, in July and December, last year; the two groups may or may not have reached consensus over how this proposed new ICD construct should be defined and characterized, its inclusions, exclusions and differential diagnoses, or what name it should be given.

What is Bodily Distress Syndrome (BDS)?

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Bodily Distress Syndrome is the name given to a disorder construct developed by Per Fink and colleagues, Aarhus University, that is already in use in Danish research studies and in clinical settings [1].

BDS is described by its authors as “a unifying diagnosis that encompasses a group of closely related conditions such as somatization disorder, fibromyalgia, irritable bowel syndrome and chronic fatigue syndrome.”

Per Fink and colleagues are lobbying for BDS to be integrated into forthcoming classification systems and adopted as a diagnosis by primary care practitioners.

Their proposal is for reclassifying somatoform disorders, pain disorder, neurasthenia and the so-called functional somatic syndromes, including fibromyalgia, irritable bowel syndrome and chronic fatigue syndrome, under a new classification, Bodily Distress Syndrome.

They consider these should be treated and managed as subtypes of the same disorder with CBT, GET, “mindfulness therapy” and in some cases, antidepressants.

The PDF format slide presentation in reference [2] will give an overview of BDS and there is more information and links in an earlier post, in reference [3].

Is Fink et al’s Bodily Distress Syndrome construct the same as DSM-5’s SSD?

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No, Bodily Distress Syndrome is a different construct to DSM-5’s Somatic Symptom Disorder.

Psychological or behavioural characteristics, central for the diagnosis of SSD, do not form part of the BDS criteria.

For BDS, physical symptoms are central to the diagnosis, which is based on identification of symptom patterns (not symptom count) from four body systems:

Cardiopulmonary/autonomic arousal; Gastrointestinal arousal; Musculoskeletal tension; General symptoms.

There is a “Modest” BDS (single-organ type) and a “Severe” BDS (multi-organ type).

If the symptoms are better explained by another disease, they cannot be labelled BDS.

The graphic below compares mutli-organ Bodily Distress Syndrome with Somatic Symptom Disorder, as the DSM-5 draft criteria had stood, in May 2012.

Note the defining characteristics of the DSM-5 SSD construct: the SSD definition calls for positive psychobehavioural characteristics (excessive or maladaptive responses or associated health concerns) in response to persistent distressing somatic symptoms; the requirement that the symptoms are “medically unexplained” is not central to the diagnosis and the symptoms may or may not be associated with a well-recognised medical condition.

The SSD diagnosis can be made in the presence of one or more unspecified, somatic symptoms associated with general medical conditions and diagnosed disease, like multiple sclerosis, cancer, diabetes or angina, or in the so-called “functional somatic syndromes” (for example, IBS, CFS or fibromyalgia) or in complaints with unclear etiology.

Compare Fink et al’s BDS with DSM-5’s SSD, in the table, below:

Depending on screen size/resolution, graphic may not display in full. Click on the image and the image file will load. Graphic: Suzy Chapman

Bodily Distress Syndrome comparison with Somtatic Symptom Disorder

Continued on Page 2

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

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

This report should be read in conjunction with the caveats at the end of the post, on Page 3.

Part One

The technical work associated with the preparation of ICD-11, the field testing and trials evaluation will need to be completed next year if WHO is going to meet its target of presenting ICD-11 for World Health Assembly approval in May 2015, with pilot implementation by 2016.

Three distinct versions of the ICD-11 classification of Mental and Behavioural Disorders are under development: an abridged version for use in primary care, a detailed version for use in specialty settings and a version for use in research.

The ICD-10 Somatoform Disorders are under revision for all three versions and the primary care and speciality versions are being developed simultaneously.

ICD10-PC, the abridged version of ICD, is used in developed and developing countries and in the training of medical officers, nurses and multi-purpose health workers. Globally, more than 90% of patients with mental health problems are managed by practitioners or health workers in general medical or primary care settings – not by psychiatrists.

Over 400 mental disorders are classified in the speciality version of ICD-10 Chapter V. These are condensed to 26 mental disorders for the primary care version – a list can be found on Page 49 of this book chapter, in Table 2.4.

Each disorder in ICD10-PC provides information on patient presentation, clinical descriptions, differential diagnoses, treatments, indications for referrals and information sheets for patients and families.

A revised list of disorders proposed for inclusion in the forthcoming ICD-11-PHC can be viewed on Page 51, in Table 2.5 [1].

For new and revised disorders included in the primary care version there will need to be an equivalent disorder in the core ICD-11 classification.

Existing Somatoform Disorders in the core ICD-10 version can be viewed here: ICD-10 Version: 2010 browser: Somatoform Disorders or from Page 129 in The ICD-10 Classification of Mental and Behavioural Disorders, Clinical descriptions and diagnostic guidelines.

A chart showing the grouping of the detailed core version categories and the 26 corresponding disorders in ICD10-PC can be found here, see Page 8, for F45 Unexplained somatic complaints and F45  Somatoform disorders (ICD-10): Connections between ICD-10 PC and ICD-10 Chapter V.

Where reports of emerging proposals for ICD-11 have been published by ICD revision working group members, the recommendations within them may be subject to refinement or revision following analysis of focus group studies, external review and multicentre field trials to assess the validity and clinical utility of proposals for application in developed and developing countries, in high and low resource settings and across general, speciality and research settings [2].

Not all proposals for new or revised disorders are expected to survive the field trials.

Two working groups are making recommendations for the revision of ICD-10’s Somatoform Disorders:

A WHO Primary Care Consultation Group (known as the PCCG) has been appointed to lead the development of the revision of ICD10-PC, the abridged classification of mental and behavioural disorders for use in primary care settings. The PCCG is charged with developing and field testing the full set of disorders for inclusion in ICD-11-PHC, for which 28 mental disorders are currently proposed.

The PCCG members are SWC Chan, AC Dowell, S Fortes, L Gask, KS Jacob, M Klinkman (Vice Chair), TP Lam, JK Mbatia, FA Minhas, G Reed, and M Rosendal. The PCCG is chaired by Prof, Sir David Goldberg.

A WHO Expert Working Group on Somatic Distress and Dissociative Disorders (known as the S3DWG) was constituted in 2011 to review the scientific evidence for, and clinical utility of the ICD-10 somatoform and dissociative disorders; to review proposals for the DSM-5 somatic symptom disorders and dissociative disorders categories and to consider their suitability or not for global applications; to review proposals and provide draft content for the somatic distress and dissociative disorder categories in line with the overall ICD revision requirements; to propose entities and descriptions for the classification of somatic distress and dissociative disorders for use in diverse global and primary care settings. External reviewers are also consulted on proposals and content.

The full S3DWG membership list is not publicly available but the group is understood to comprise 17 international behavioural health professionals, of which Prof Francis Creed is a member. The S3DWG is Chaired by Prof Oye Gureje.

Responsibilities of ICD-11 working groups are set out on Page 3 (1.1.) of document [3] in the References. Document [3] also includes information on the ICD-11 field trials, from Page 8 (4.).


1. 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
2. PDF WHO ICD Revision Information Note, Field Testing, June 2012
3. Responsibilities of ICD-11 working groups set out on Page 3 of 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., Main Representative to the World Health Organization, International Union of Psychological Science, January, 2013

Continued on Page 2

ICD-11 Beta draft and Bodily Distress Disorders; Per Fink and Bodily Distress Syndrome: Parts One and Two

ICD-11 Beta draft and Bodily Distress Disorders; Per Fink and Bodily Distress Syndrome Parts One and Two

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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 Topic Advisory Group Managing Editors, the ICD Revision Steering Group and WHO classification experts. The current draft may differ to the information in this report.

Part One

On January 6, I posted a brief update on proposals for the revision of ICD-10’s Somatoform Disorders based on what can be seen in the public version of the ICD-11 Beta drafting platform and on a book chapter by Professor, Sir David Goldberg. [1]

Professor Goldberg chairs the working group for revision of the mental health chapter of ICD-1o-PHC, the abridged, primary care version of ICD-10.

For the revision of ICD-10’s Somatoform Disorders sections for ICD-11, a WHO Expert Working Group on Somatic Distress and Dissociative Disorders has been assembled.

Professor Francis Creed (also a member of the DSM-5 Somatic Symptom and Related Disorders Work Group) is a member of this WHO working group, which is chaired by Professor Oye Gureje.

An April 2011 announcement by Stony Brook Medical Center states that Dr Joan E. Broderick, PhD had been appointed to the WHO Expert Working Group on Somatic Distress and Dissociative Disorders and that the first meeting of the group (said to consist of 17 international behavioral health professionals) was expected to be held in June 2011, in Madrid.

WHO has not published a list of  members of this working group or any progress reports and the names and affiliations of the 14 other members are unknown, so I am unable to confirm whether Professor Per Fink is a member of the group, which reports to the International Advisory Group for the Revision of ICD-10 Mental and Behavioural Disorders.

ICD-11 and Bodily Distress Disorders

ICD-11 is currently scheduled for completion in 2015/16. When viewing the public version of the Beta drafting platform please bear in mind the ICD-11 Revision Caveats: that the Beta draft is a work in progress, updated daily, is incomplete, may contain errors and is subject to change; not all proposals may be approved by the ICD-11 Revision Steering Committee or WHO classification experts, or retained following analysis of ICD-11 and ICD-11-PHC field trials.

The Bodily Distress Disorders section of ICD-11 Beta draft Chapter 5 can be found here:

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

As the ICD-11 Beta drafting platform stands at the time of compiling this report, the existing ICD-10 Somatoform Disorders are proposed to be subsumed under or replaced by Bodily Distress Disorders, and Psychological and behavioural factors associated with disorders or diseases classified elsewhere.

The following proposed ICD-11 categories are listed as child categories under parent term, Bodily Distress Disorders, and Psychological and behavioural factors associated with disorders or diseases classified elsewhere:

EC5 Mild bodily distress disorder
EC6 Moderate bodily distress disorder
EC7 Severe bodily distress disorder
EC8 Psychological and behavioural factors associated with disorders or diseases classified elsewhere

No Definition or any other Content Model parameters have been populated for the proposed categories EC5, EC6 and EC7, which are new entities to ICD. (EC8 is a legacy category from ICD-10.)

Note that the sorting codes assigned to categories are subject to frequent change as chapters are reorganized.

From the information currently displaying in the Beta draft, it is not possible to determine:

• how ICD-11 proposes to define Bodily Distress Disorders;

• what diagnostic criteria are being proposed;

whether diagnostic criteria would be based on a requirement for excessive or disproportionate psychological and behavioral characteristics in response to distressing somatic symptoms, such as illness anxiety, symptom focusing, catastrophising, maladaptive coping strategies, avoidance behavior or misattribution; or based on somatic symptom counts, or specific symptom clusters, or number of bodily systems affected, or a combination of these;

how the three Severity Specifiers: Mild, Moderate and Severe would be categorized;

• how the three Severities would be assessed for within primary and secondary care;

whether ICD-11’s proposed Bodily Distress Disorder construct is intended to mirror or incorporate DSM-5’s Somatic Symptom Disorder (SSD) construct, in line with ICD-11/DSM-5 harmonization, or

whether it is intended to mirror or incorporate Per Fink’s Bodily Distress Syndrome (BDS) construct, or to combine elements from both;

whether the Bodily Distress Disorder construct is proposed only to be applied to patients with distressing ‘medically unexplained somatic symptoms’ (MUS), or the so-called ‘Functional somatic syndromes’ (FSS), if the patient is considered to also meet the BDD criteria, or

whether it is proposed to be inclusive of patients with distressing somatic symptoms in the presence of diagnosed illness and general medical conditions, if the patient is considered to also meet the criteria;

• whether the Bodily Distress Disorder construct is proposed to be inclusive of parents or caregivers perceived as encouraging maintenance of sick role behavior or over-involved.

whether the Bodily Distress Disorder construct is proposed to be inclusive of children;

whether it is proposed that all or selected of the following: Neurasthenia and Fatigue syndrome (F48.0), Chronic fatigue syndrome (indexed to G93.3 in ICD-10; classified in ICD-11 Beta draft as an ICD Title term in Chapter 6: Diseases of the nervous system), IBS (K58), and Fibromyalgia (M79.7) should be reclassified under Bodily Distress Disorders;

• whether the Bodily Distress Disorder construct is proposed to subsume ICD-10’s Hypochondriacal disorder with somatic symptoms or incorporate this entity under Illness Anxiety Disorder for ICD-11.

(For ICD-11, ICD-10’s Hypochondriacal disorder [F45.2] is currently proposed to be renamed to Illness Anxiety Disorder and located underANXIETY AND FEAR-RELATED DISORDERS.)

 • what ICD-11 proposes to do with ICD-10’s Neurasthenia;

(ICD-10’s Chapter V Neurasthenia [F48.0] is no longer listed in the public version of the ICD-11 Beta draft. For ICD-11-PHC, the primary care version of ICD-11, the proposal is for the term Neurasthenia to be eliminated. Since terms used in ICD-11-PHC require corresponding terms in the main classification, the intention may be to eliminate Neurasthenia from the main version, or subsume under another term.) [2]

All that can be determined from the Beta draft is that these earlier ICD-11 Beta draft Somatoform Disorders categories appear proposed to be subsumed under or replaced with the new BDD categories, EC5, EC6 and EC7, set out above:

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

I have previously reported that for ICD-11-PHC, the proposal, last year, was for a new disorder section called Bodily distress disorders, under which would sit new category Bodily stress [sic] syndrome.

This category is proposed for the ICD-11 primary care version to include “milder somatic symptom disorders” as well as “DSM-5’s Complex somatic symptom disorder” and would replace “medically unexplained somatic symptoms.” [2]

In a future post (Part Three of this report), I shall be discussing emerging proposals for the ICD-11 construct, Bodily Distress Disorders, which may serve to fill in some of the gaps.

In the meantime, since it is unclear whether and to what extent the ICD-11 Bodily Distress Disorders category is proposed to mirror or incorporate the Bodily Distress Syndrome construct developed by Per Fink et al, Aarhus, Denmark, I am providing some material on Bodily Distress Syndrome in Part Two

Slide presentation: Per Fink: Somatoform disorders – functional somatic syndromes – Bodily distress syndrome (EACLPP lecture, June 2012)

Slide presentation: Per Fink: Somatoform disorders – functional somatic syndromes – Bodily distress syndrome (EACLPP lecture, June 2012)

Post #197 Shortlink: http://wp.me/pKrrB-2pN

Slide presentation: Per Fink: Somatoform disorders – functional somatic syndromes – Bodily distress syndrome (EACLPP lecture, June 2012)

23 slides in PDF format (i.e. no PowerPoint viewer required)

       EACLPP Per Fink Somatoform Disorders

Aarhus University Hospital

The Research Clinic for Functional Disorders and Psychosomatics

Somatoform disorders – functional somatic syndromes – Bodily distress syndrome.

Need for care and organisation of care in an international perspective – EACLPP Lecture

Prof. Per Fink

MD, Ph.D, Dr.Med.Sc.

www.functionaldisorders.dk

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June 2012 EACLPP Annual Conference*

*The European Association of Consultation-Liaison Psychiatry and Psychosomatics (EACLPP) and the European Network of Psychosomatic Medicine (ECPR) have recently merged the two associations to create a new society – the European Association of Psychosomatic Medicine (EAPM).

The Annual Scientific Meeting of the European Association for Consultation-Liaison Psychiatry and Psychosomatics (EACLPP) and the European Conference on Psychosomatic Research (ECPR) was entitled

“Towards a New Agenda: Cross-disciplinary Approach to Psychosomatic Medicine”

The conference was held in the city of Aarhus, Denmark, on 27 – 30 June 2012.

For last year’s conference, a report was published. I will post any report coming out of this year’s conference.

A Conference Abstract document be accessed here:

http://www.eaclpp-ecpr2012.dk/Home/DownloadOral

Selected Extracts:

Page 61 Nagel A

Department of Psychosomatic Medicine and Psychotherapy, University Medical Center Hamburg-Eppendorf & Schön Klinik Hamburg-Eilbek, Germany, Voigt K Department of Psychosomatic Medicine and Psychotherapy, University Medical Center Hamburg- Eppendorf & Schön Klinik Hamburg-Eilbek, Germany

Diagnostic validity of Complex Somatic Symptom Disorder: Which combination of psychological criteria is best suited for DSM-5?

Page 17 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

Page 19 Escobar J

Robert Wood Johnson Medical School, New Brunswick, NJ, USA

An Update on DSM-5

Page 32 Fjorback L

Aarhus University Hospital, Research Clinic for Functional Disorders and Psychosomatics

Mindfulness Therapy for Bodily Distress Syndrome – randomized trial, one-year follow-up, active control

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Notes on Fink et al and Bodily Distress Syndrome (BDS)

According to Fink and colleagues, Bodily Distress Syndrome is a unifying diagnosis that encompasses somatization disorder, so-called “medically unexplained symptoms” (MUS), fibromyalgia, irritable bowel syndrome and chronic fatigue syndrome and some other conditions which they consider to be closely related, with a likely shared underlying aetiology.

See paper: 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.

See article: Per Fink,a Marianne Rosendal b Understanding and Management of Functional Somatic Symptoms in Primary Care: The Concept of Functional Somatic Symptoms

aResearch Clinic for Functional Disorders and Psychosomatics, Aarhus University Hospital, Denmark
bResearch Unit for General Practice, University of Aarhus, Denmark

See Per Fink’s clinical trial for BDS: http://clinicaltrials.gov/ct2/show/NCT01518647

See BDS clinician/patient manual: Specialised Treatment for Severe Bodily Distress Syndromes (STreSS)

According to a June 2012 EACLPP Conference Abstract, the concept of Bodily Distress Syndrome (BDS) “is expected to be integrated into the upcoming versions of classification systems.”

The potential for inclusion of Bodily Distress Disorder/Syndrome within ICD-11 could have significant implications for patients, globally, who are diagnosed with one of the so-called “functional somatic syndromes.” These proposals require very close monitoring by patient organizations in those countries that will be implementing ICD-11, post 2015.

Research and clinical professionals, patient organizations and their professional advisors can register now with ICD Revision for input into the ongoing drafting process and urge organizations and professionals to engage in this process.

Abstracts, oral presentations, EACLPP Conference: 27 – 30 June 2012, Aarhus University Campus, Aarhus – Denmark

http://www.eaclpp-ecpr2012.dk/Home/DownloadOral

Extracts

Page 17 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

Aim: Medically unexplained or functional symptoms and disorders are common in primary care. Empirical research has proposed specific criteria for a new unifying diagnosis for functional disorders and syndromes: Bodily Distress Syndrome (BDS). This new concept is expected to be integrated into the upcoming versions of classification systems.

And from Page 31 of the Conference Abstracts:

Fjorback L

Aarhus University Hospital, Research Clinic for Functional Disorders and Psychosomatics

Mindfulness Therapy for Bodily Distress Syndrome – randomized trial, one-year follow-up, active control

Objective: To conduct a feasibility and efficacy trial of mindfulness therapy in somatization disorder and functional somatic syndromes such as fibromyalgia, irritable bowel syndrome, and chronic fatigue syndrome, defined as bodily distress syndrome (BDS)…

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References and related material:

1] Patients with medically unexplained symptoms and somatisation – a challenge for European health care systems: A white paper of the EACLPP Medically Unexplained Symptoms study group by Peter Henningsen and Francis Creed: http://www.eaclpp.org/working_groups.html
http://www.eaclpp.org/documents/Patientswithmedicallyunexplainedsymptomsandsomatisation_000.doc

2] Creed F, Guthrie E, Fink P, Henningsen P, Rief W, Sharpe M and White. Is there a better term than “Medically unexplained symptoms”? J Psychosom Res: Volume 68, Issue 1, Pages 5-8 January 2010) discusses the deliberations of the EACLPP MUS study group. Editorial also includes references to the DSM and ICD revision processes: http://www.ncbi.nlm.nih.gov/pubmed/20004295

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. The Research Clinic for Functional Disorders and Psychosomatics, Aarhus University Hospital, 8000 Aarhus, Denmark:
http://www.ncbi.nlm.nih.gov/pubmed/20403500

Fink P, Toft T, Hansen MS, Ørnbøl 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.
http://www.ncbi.nlm.nih.gov/pubmed/17244846
Full text: http://www.psychosomaticmedicine.org/content/69/1/30.full

Fink P, Rosendal, M. Recent developments in the understanding and management of functional somatic symptoms in primary care. Current Opinion in Psychiatry 2008, 21:182–188

Rosendal M, Fink P, Falkoe E, Schou Hansen H, Olesen F. Improving the Classification of Medically Unexplained Symptoms in Primary Care. Eur. J. Psychiat. v.21 n.1 Zaragoza ene.-mar. 2007
Text: http://scielo.isciii.es/scielo.php?script=sci_arttext&pid=S0213-61632007000100004
PDF: http://scielo.isciii.es/pdf/ejpen/v21n1/improv3.pdf

4] EURASMUS  http://eurasmus.net/
The multidisciplinary European Research Association for Somatisation and Medically Unexplained Symptoms(EURASMUS) was formed to study the genetic, psychological and physiological mechanisms underlying bodily distress. Co-convenors: Francis Creed, Peter Henningsen

5] Notes from EACLPP Workgroup meeting in Budapest July 2011

EACLPP_WG_Medically_Unexplained_Symptoms_Budapest_2011

Report from Working group meeting on MUS/somatisation/bodily distress, Budapest July 1st 2011

“…We should find out whether the WHO group for classification of somatic distress and dissociative disorders will provide a better diagnostic system for these disorders.”

6] Article: ‘Heartsinks’ and weird symptoms by Tony Dowell, June 15, 2011.

Article Table: Functional somatic syndromes according to medical speciality:
http://www.nzdoctor.co.nz/media/671495/heartsinks.pdf

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

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

Post #190 Shortlink: http://wp.me/pKrrB-2jB


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This four page post is a revised version of content first published on July 2, 2012.

Information in this report relates to proposals for the World Health Organization’s forthcoming ICD-11, currently scheduled for pilot dissemination in 2015+; it does not relate to the existing ICD-10 or to the forthcoming US specific “clinical modification” of ICD-10, known as ICD-10-CM.

Caveat: The ICD-11 Beta drafting process is a work in progress over the next two to three years. The Beta draft is updated on a daily basis. Parent terms, category terms and sorting codes assigned to categories are subject to change as work on chapter reorganization progresses. Images and text in this posting may not reflect the most recently assigned categories and codes. This post reflects the Beta draft as it stood at July 24, 2012. Please also read the ICD-11 Beta Draft Caveats.

This report updates on recent changes to the Somatoform Disorders section of the ICD-11 Beta drafting platform. The Beta drafting platform can be accessed here:

Beta draft Foundation view:

http://apps.who.int/classifications/icd11/browse/f/en

Beta draft Linearization view:

http://apps.who.int/classifications/icd11/browse/l-m/en
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How do the Somatoform Disorders categories currently stand in ICD-10?

ICD-10 Tabular List Version: 2010 can be accessed here: http://apps.who.int/classifications/icd10/browse/2010/en

ICD-10 Chapter V “Somatoform Disorders”

This is the section of ICD-10 that corresponds with the Somatoform Disorders section in DSM-IV. There is a degree of correspondence between current categories for this section of ICD-10 and for DSM-IV, as set out in the (simplified) table, below.

For clinical descriptions and diagnostic guidelines for ICD-10 Somatoform Disorders see Page 129 of the “Blue book”:

ICD-10 Classification of Mental and Behavioural Disorders: Clinical descriptions and diagnostic guidelines: http://www.who.int/classifications/icd/en/bluebook.pdf

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

[Ed: Neurasthenia is not categorized within DSM-IV.]

Source: Mayou R, Kirmayer LJ, Simon G, Kroenke K, Sharpe M: Somatoform disorders: time for a new approach in DSM-V. Am J Psychiat. 2005;162:847–855.
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This screenshot shows how the ICD-11 Beta draft had stood at June 24, 2012:

ICD-11 Beta Draft: Morbidity Linearization view


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For ICD-11 Beta draft, the proposal in June 2012 had been to rename ICD-10’s F45 Somatoform Disorders parent category to Bodily Distress Disorders.

Three new proposed terms: 9R0 Mild bodily distress disorder; 9R1 Moderate bodily distress disorder; 9R2 Severe bodily distress disorder were inserted above the 9R3 thru 9R8 legacy categories imported from ICD-10.

ID : http://who.int/icd#F45

05 Mental and behavioural disorders [Chapter V in ICD-10]

[…]

BODILY DISTRESS DISORDERS  [F45 Somatoform Disorders > F40-F48 Neurotic, stress-related and somatoform disorders in ICD-10]

9R0 Mild bodily distress disorder  [New term to ICD]
9R1 Moderate bodily distress disorder   [New term to ICD]
9R2 Severe bodily distress disorder  [New term to ICD]
9R3 Somatization disorder  [F45.0 in ICD-10]
9R4 Undifferentiated somatoform disorder  [F45.1 in ICD-10]
9R5 Somatoform autonomic dysfunction   [F45.3 in ICD-10]
9R6 Persistent somatoform pain disorder  [F45.4 in ICD-10] 
    ›  9R6.1 Persistent somatoform pain disorder
      9R6.2 Chronic pain disorder with somatic and psychological factors  [Not in ICD-10]
9R7 Other somatoform disorders  [F45.8 in ICD-10]
9R8 Somatoform disorder, unspecified  [F45.9 in ICD-10]

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Hypochondriacal disorder, coded at F45.2 in ICD-10, is currently renamed to Illness Anxiety Disorder for ICD-11 Beta draft and relocated under ANXIETY AND FEAR-RELATED DISORDERS:

http://apps.who.int/classifications/icd11/browse/l-m/en#/http%3a%2f%2fwho.int%2ficd%23F45.2

ID : http://who.int/icd#F45.2

9C5  ANXIETY AND FEAR-RELATED DISORDERS

      ›  9C5.6 Illness Anxiety Disorder

Continued on Page Two

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