Questions raised on ICD-11 Beta draft re: Bodily distress disorder

Post #311 Shortlink: http://wp.me/pKrrB-3Yh

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Screenshot: ICD-11 Beta drafting platform, public version, July 31, 2014; Chapter 06 Mental and behavioural disorders: Bodily distress disorder.

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BDD310714

 
Joint Linerarization for Mortality and Morbidity Statistics view selected; “show availability in main linearizations” view selected. Categories designated with three coloured key hover text: “In Mortality and Morbidity, Primary Care High Resource, Primary Care Low Resource. Categories designated with single blue key hover text: “In Mortality and Morbidity.”

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Yesterday, I left the following comments and questions for TAG Mental Health Managing Editors via the ICD-11 Beta drafting platform.

In order to read the comment in situ you will need to be registered with the Beta drafting platform, logged in, then click on the grey and orange quote icon at the end of the category Title.

http://apps.who.int/classifications/icd11/browse/f/en#/http://id.who.int/icd/entity/1121638993

Bodily distress disorder, severe

Comments on title

Suzy Chapman 2014-Jul-23 – 14:01 UTC

Definitions for three uniquely coded severities for Bodily distress disorder: Mild; Moderate; Severe, have recently been inserted into the Beta draft.

The Definition for Bodily distress disorder (BDD) and its three severity characterizations appears to be based on the BDD disorder descriptions in the 2012 Creed, Gureje paper: Emerging themes in the revision of the classification of somatoform disorders [1].

As conceptualized by the ICD-11 Expert Working Group on Somatic Distress and Dissociative Disorders (S3DWG), BDD is proposed to replace the seven ICD-10 Somatoform disorders categories F45.0 to F45.9, and F48.0 Neurasthenia.

The S3DWG’s BDD eliminates the requirement that symptoms be “medically unexplained” as the central defining feature; focuses on identification of positive psychobehavioural responses (excessive preoccupation with bodily 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 symptom(s), resulting in significant impairment of functioning or frequent seeking of reassurance; makes no assumptions about aetiology, and in “[d]oing away with the unreliable assumption of its causality, the diagnosis of BDD does not exclude the presence of (…) a co-occurring physical health condition.”

The S3DWG’s BDD has no requirement for symptom counts, or for symptom patterns or symptom clusters from body or organ systems, which describes a disorder framework with good concordance with DSM-5 Somatic Symptom Disorder (SSD).

According to the Beta draft, BDD’s three severity specifiers are proposed to be characterized on the basis of the extent to which responses to persistent, distressing bodily symptoms are perceived as excessive and on the degree of impairment, not on the basis of number of bodily symptoms and number of body or organ systems affected.

In comparison, psychobehavioural responses do not form part of Fink et al’s (2010) Bodily Distress Syndrome criteria. BDS’s criteria and two severities are based on symptom patterns from body systems (a BDS Modest, single-organ type and a BDS Severe, Multi-organ type).

In 2012, the Lam et al paper [2], set out emerging proposals for the ICD-11 Primary Care Consultation Group’s (PCCG) recommendations for a “Bodily stress syndrome (BSS).”

The PCCG’s proposals described a disorder construct that had good concordance with Fink et al’s Bodily Distress Syndrome, drawing heavily on Fink et al’s criteria set. Although at that point, the PCCG proposed to incorporate some SSD-like psychobehavioural features within their tentative criteria. The PCCG appeared to be proposing a modified version of the Fink et al (2010) BDS construct.

In an Ivbijaro G, Goldberg D (June 2013) editorial [3], the co-authors advance the position that the forthcoming revision of ICD provides an opportunity to include BDS in a revised classification for primary care. According to this June 2013 editorial, the PCCG’s proposal for a modified BDS disorder construct, which it had earlier proposed to call “Bodily stress syndrome (BSS),” appears to have been revised to using the Fink et al “Bodily distress syndrome (BDS)” term.

The editorial implies that BDS (which subsumes the so-called “functional somatic syndromes,” CFS, ME, IBS, Fibromyalgia, chronic pain disorder, MCS and some others, under a single, overarching disorder) was expected to be progressing, imminently, to ICD-11 field trials.

(A revision of the earlier BSS disorder name is not discussed within the editorial; nor whether any modifications to, or deviance from a “pure” BDS construct and criteria were being recommended for the purposes of field testing; nor are the alternative proposals of the S3DWG referenced or discussed; nor are the views of the Revision Steering Group on either set of proposals discussed.)

According to Lam et al (2012) and Ivbijaro and Goldberg (June 2013), the model proposed is that of “autonomic over-arousal,” which the authors consider may be responsible for most or all of the somatic symptoms that are experienced.

Again, compare with the S3DWG’s BDD construct, which makes no assumptions about aetiology and does not exclude the presence of a co-occurring physical health condition, whereas, for both Lam et al’s 2012 BSS and for Fink et al’s BDS, “If the symptoms are better explained by another disease, they cannot be labelled BDS.”

Potential for confusion between divergent disorder constructs:

The term “Bodily distress disorder” and the term “Bodily distress syndrome” (Fink et al, 2010), which is already operationalized in Denmark in research and clinical settings, are often seen being used interchangeably in the literature. For example, in this very recent editorial by Rief and Isaac [4]. Also in papers by Fink and others from 2007 onwards [5].

However, the S3DWG’s defining of a “Bodily distress disorder” construct has stronger conceptual alignment and criteria congruency with DSM-5’s SSD and poor conceptual and criteria congruency with Fink et al’s BDS. That SSD and BDS are very different concepts is acknowledged by Fink, Creed and Henningsen [6] [7].

Although the 2013 Ivbijaro and Goldberg editorial implies that Fink et al’s BDS construct was going forward to ICD-11 field testing, it is the S3DWG’s Bodily distress disorder name and construct that has been entered into the Beta draft – the construct that has stronger conceptual alignment with DSM-5’s SSD.

So the current proposals and intentions for field testing a potential replacement for the SDs remain unclear. This is severely hampering professional and consumer stakeholder scrutiny, discourse and input.

Four questions for TAG Mental Health Managing Editors:

1. Have the S3DWG sub working group, the PCCG working group and the Revision Steering Group reached consensus over a potential replacement framework and disorder construct for ICD-10’s Somatoform disorders and F48.0 Neurasthenia, and the ICD-10-PHC categories: F45 Unexplained somatic symptoms/medically unexplained symptoms, and F48 Neurasthenia?

2. Which recommendations are being progressed to international field testing and does ICD-11 intend to release the protocol or other information on finalized characteristics, diagnostic guidelines, criteria, inclusions, exclusions, differential diagnoses etc, that are planned to be used for the field tests and which would provide the level of detail lacking in the public version of the Beta drafting platform?

3. 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 the DSM-5 SSD construct, what is the rationale for proposing to name this disorder “Bodily distress disorder”?

4. 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?

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. http://www.ncbi.nlm.nih.gov/pubmed/23244611 [Full text behind paywall]

2. Lam TP, Goldberg DP, Dowell AC, Fortes S, Mbatia JK, Minhas FA, Klinkman MS: Proposed new diagnoses of anxious depression and bodily stress syndrome in ICD-11-PHC: an international focus group study. Family Practice (2013) 30 (1): 76-87. Full free text: http://fampra.oxfordjournals.org/content/30/1/76.long

3. 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. Full free text available on 2014/6/1: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3822636/pdf/MHFM-10-063.pdf

4. Rief W, Isaac M. The future of somatoform disorders: somatic symptom disorder, bodily distress disorder or functional syndromes? Curr Opin Psychiatry (2014). Full free: http://journals.lww.com/co-psychiatry/Fulltext/2014/09000/The_future_of_somatoform_disorders___somatic.2.aspx

5. 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.

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

7. Discussions between Prof Francis Creed and Prof Per Fink during Research Clinic for Functional Disorders Symposium presentations, Aarhus University Hospital, May 15, 2014, noted that Fink et al BDS and DSM-5 SSD are “very different concepts.”

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September symposium presentation on BDD:

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

Unfortunately, I cannot attend this September symposia but would be pleased to hear from anyone who may be planning to attend.

Caveats: The ICD-11 Beta drafting platform is not a static document: it is a work in progress, subject to daily edits and revisions, to field test evaluation and to approval by ICD Revision Steering Group and WHO classification experts. Not all new proposals may survive ICD-11 field testing. Chapter numbering, codes and Sorting codes currently assigned to ICD categories may change as chapters and parent/child hierarchies are reorganized. The public version of the Beta draft is incomplete; not all “Content Model” parameters display or are populated; the draft may contain errors and category omissions.

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Further reading:

Dx Revision Watch Post: Definitions for three severities of “Bodily distress disorder” now inserted in ICD-11 Beta draft, July 19, 2014 http://wp.me/pKrrB-3X9

Dx Revision Watch Post: Editorial: Bodily distress syndrome (BDS): the evolution from medically unexplained symptoms (Goldberg and ICD-11-PHC), June 3, 2014: http://wp.me/pKrrB-3Uh

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Definitions for three severities of “Bodily distress disorder” now inserted in ICD-11 Beta draft

Post #310 Shortlink: http://wp.me/pKrrB-3X9

Caveats: The ICD-11 Beta drafting platform is not a static document: it is a work in progress, subject to daily edits and revisions, to field test evaluation and to approval by ICD Revision Steering Group and WHO classification experts. Not all new proposals may survive ICD-11 field testing. Chapter numbering, codes and Sorting codes currently assigned to ICD categories may change as chapters and parent/child hierarchies are reorganized. The public version of the Beta draft is incomplete; not all “Content Model” parameters display or are populated; the draft may contain errors and category omissions.

This report updates on recent additions to the listing for Bodily distress disorder in the public version of the ICD-11 Beta draft.

This is an edited version of the report published on July 19.

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Bodily distress disorder (BDD) is a new, single diagnostic category that has been proposed for ICD-11. It is intended to subsume the seven ICD-10 Somatoform disorders categories F45.0 – F45.9, and F48.0 Neurasthenia.

Bodily distress disorder (BDD) is the term that has been entered into the Beta drafting platform since February 2012.

It is the term and disorder construct that has been proposed by the ICD-11 Expert Working Group on Somatic Distress and Dissociative Disorders (S3DWG), which is chaired by Professor Oye Gureje [1].

Note: the term Bodily stress syndrome (BSS) (Lam et al, 2012) is an alternative disorder term and diagnostic construct that has been proposed by the ICD-11 Primary Care Consultation Group (PCCG), which is chaired by Professor Sir David Goldberg [2].

The disorder term and construct Bodily distress syndrome (BDS) has also been advanced for ICD-11 in a June 2013 editorial by Ivbijaro G and Goldberg D [3].

Neither of the terms Bodily stress syndrome (BSS) or Bodily distress syndrome (BDS) has been entered into the ICD-11 Beta draft.

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ICD-11 Beta drafting platform (public version):

A Definition for category Bodily distress disorder was inserted into the Beta draft in late January 2014.

At that point, no definitions or characterizations for any of the uniquely coded BDD severity specifiers (currently, BDD, mild; BDD, moderate; BDD, severe) had been inserted.

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How is BDD being defined for the purposes of ICD-11?

The psychological and behavioural features that characterize Bodily distress disorder, as currently defined in the Beta draft, are drawn from the disorder conceptualizations in the 2012 Creed, Gureje paper on emerging proposals for the revision of the classification of somatoform disorders [1].

This paper sits behind a paywall but I have had a copy since it was first published.

The paper describes a disorder model that has poor concordance with Fink et al’s Bodily Distress Syndrome construct.

The 2012 Creed, Gureje paper defines BDD as:

“a much simplified set of criteria”;

eliminates the requirement that symptoms be “medically unexplained” as the central defining feature;

focuses on identification of positive psychobehavioural responses (excessive preoccupation with bodily 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 symptom(s), resulting in significant impairment of functioning or frequent seeking of reassurance;

makes no assumptions about aetiology and in “[d]oing away with the unreliable assumption of its causality the diagnosis of BDD does not exclude the presence of (…) a co-occurring physical health condition”;

has no requirement for symptom counts, or for symptom patterns or symptom clusters from body or organ systems

– which describes a disorder framework into which DSM-5′s “Somatic Symptom Disorder (SSD)” could potentially be integrated, facilitating harmonization between a replacement for the ICD-10 Somatoform disorders and DSM-5’s new SSD.

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Whereas, Fink et al’s 2010 Bodily Distress Syndrome criteria are based on impairment and symptom patterns from body systems. Positive psychobehavioural features do not form part of the Fink et al criteria [4–6].

For ICD-11’s BDD, patients may be preoccupied with any bodily symptoms and the presence of a co-occurring physical health condition is not an exclusion.

But for Fink et al’s BDS, “If the symptoms are better explained by another disease, they cannot be labelled BDS.”

BDD’s three severity specifiers are proposed to be characterized on the basis of the extent to which responses to persistent, distressing symptoms are perceived as excessive and on degree of impairment, not on the basis of the number of bodily symptoms and the number of body or organ systems that are affected by the disorder.

In contrast, BDS’s two severities are based on symptom patterns (a BDS Modest, single-organ type and a BDS Severe, Multi-organ type).

Both BDD and BDS are intended to subsume the Somatoform disorders and Neurasthenia.

But BDS seeks to arrogate the so-called “functional somatic syndromes,” CFS, ME, IBS, Fibromyalgia, chronic pain disorder, MCS and some others, and subsume them under a single, overarching BDS diagnosis [6].

So although the BDD and BDS disorder names sound very similar (and the terms are sometimes seen used interchangeably), as defined in the 2012 Creed, Gureje paper and as defined by the recently inserted Beta draft Definitions, ICD-11’s BDD and Fink et al’s BDS present divergent constructs*.

It is the ICD-11 Primary Care Consultation Group‘s 2012 proposals for a “Bodily stress disorder” [2] that had stronger conceptual alignment and criteria congruency with Fink et al’s BDS.

*Discussions between Profs Creed and Fink during the Research Clinic for Functional Disorders Symposium presentations, Aarhus University Hospital, May 15, 2014, noted that Fink et al’s BDS and DSM-5’s SSD are “very different concepts.” 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.

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ICD-11 BDD, mild; moderate and severe specifiers, now defined:

In the last few days, Definitions for the three uniquely coded Severity specifiers:

6B40 Bodily distress disorder, mild

6B41 Bodily distress disorder, moderate

6B42 Bodily distress disorder, severe

have been inserted into the Beta draft.

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

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

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

Chapter 06 Mental and behavioural disorders

Bodily distress disorder [In Mortality and Morbidity, Primary Care High Resource, Primary Care Low Resource Linearizations]

Foundation Id: http://id.who.int/icd/entity/767044268

Parent(s)

Mental and behavioural disorders            ICD-10 : F45

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).

Synonyms

somatoform disorders
Somatization disorder

Exclusions [Ed: with the exception of Hypochondriasis, Exclusions are imported from ICD-10 F45 Somatoform disorders Exclusions.]

lisping
lalling
psychological or behavioural factors associated with disorders or diseases classified elsewhere
nail-biting
sexual dysfunction, not caused by organic disorder or disease
thumb-sucking
tic disorders (in childhood and adolescence)
Tourette syndrome
trichotillomania
dissociative disorders
hair-plucking
Hypochondriasis

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This is the recently added Definition for 6B40 Bodily distress disorder, mild:

http://apps.who.int/classifications/icd11/browse/f/en#/http://id.who.int/icd/entity/1472866636

http://apps.who.int/classifications/icd11/browse/l-m/en#/http://id.who.int/icd/entity/1472866636

6B40 Bodily distress disorder, mild [In Mortality and Morbidity Linearizations]

Foundation Id: http://id.who.int/icd/entity/1472866636

Parent(s)

Definition 

Bodily distress disorder, mild is a form of Bodily distress disorder in which there is excessive attention to bothersome symptoms and their consequences, which may result in frequent medical visits. The person is not preoccupied with the symptoms (e.g., spends less than an hour per day focusing on them). Although the individual expresses distress about the symptoms and they may have some impact on his or her life (e.g., strain in relationships, less effective academic or occupational functioning, abandonment of specific leisure activities) there is no substantial impairment in the person’s personal, family, social, educational, occupational, or other important areas of functioning.

All Index Terms

  • Bodily distress disorder, mild

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Here’s the Definition for 6B41 Bodily distress disorder, moderate:

http://apps.who.int/classifications/icd11/browse/f/en#/http://id.who.int/icd/entity/1967782703

http://apps.who.int/classifications/icd11/browse/l-m/en#/http://id.who.int/icd/entity/1967782703

6B41 Bodily distress disorder, moderate [In Mortality and Morbidity Linearizations]

Foundation Id : http://id.who.int/icd/entity/1967782703

Parent(s)

Definition 

Bodily distress disorder, moderate is a form of bodily distress disorder in which there is persistent preoccupation with bothersome symptoms and their consequences (e.g., spends more than an hour a day thinking about them), typically associated with frequent medical visits such that the person devotes much of his or her energy to focusing on the symptoms and their consequences, with consequent moderate impairment in personal, family, social, educational, occupational, or other important areas of functioning (e.g., relationship conflict, performance problems at work, abandonment of a range of social and leisure activities).

All Index Terms

  • Bodily distress disorder, moderate

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  And here’s the Definition for 6B42 Bodily distress disorder, severe:

http://apps.who.int/classifications/icd11/browse/f/en#/http://id.who.int/icd/entity/1121638993

http://apps.who.int/classifications/icd11/browse/l-m/en#/http://id.who.int/icd/entity/1121638993

6B42 Bodily distress disorder, severe [In Mortality and Morbidity Linearizations]

Foundation Id: http://id.who.int/icd/entity/1121638993

Parent(s)

Definition

Bodily distress disorder, severe is a form of bodily distress disorder in which there is pervasive and persistent preoccupation to the extent that the symptoms may become the focal point of the person’s life, typically requiring extensive interactions with the health care system. Preoccupation with the experienced symptoms and their consequences causes serious impairment in personal, family, social, educational, occupational, or other important areas of functioning (e.g., unable to work, alienation of friends and family, abandonment of nearly all social and leisure activities). The person’s interests may become so narrow so as to focus almost exclusively on his or her bodily symptoms and their negative consequences.

All Index Terms

  • Bodily distress disorder, severe

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What will ICD-11 be field testing?

Field testing of a potential replacement for the existing ICD-10 Somatoform disorders framework is expected to be conducted over the next year or two. Disorders that survive the ICD-11 PHC field tests will require an equivalent disorder in the main ICD-11 classification.

So whatever replaces the existing ICD-10 PHC categories, F45 Unexplained somatic symptoms/medically unexplained symptoms and F48 Neurasthenia, (which is also proposed to be eliminated for the ICD-11 primary care version), will need an equivalent disorder in the main classification.

International field tests across a range of primary care settings had been anticipated to start from June, last year, but there were reported delays. It isn’t known whether consensus has been reached yet over disorder construct and diagnostic criteria for use in the field tests, or whether field testing is now underway.

I cannot confirm whether ICD-11 intends to release a protocol into the public domain for whatever construct it plans to field test, or may already be field testing.

Currently, there is no publicly available protocol or other information on 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.

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So which construct does ICD-11 Revision Steering Group favour?

Although BDD (and now its three severities) have been defined within the Beta draft, much remains unclear for proposals for the revision of this section of ICD-11 Mental and behavioural disorders.

The ICD-11 Primary Care Consultation Group’s alternative 2012 Bodily stress syndrome (BSS) construct – a near clone of Fink et al’s BDS criteria but with some SSD-like psychobehavioural responses tacked on – isn’t the construct that is entered and defined within the Beta draft.

In June 2013, Prof Gabriel Ivbijaro (not, himself, a member of the PCCG) and Prof Sir David Goldberg (who chairs the PCCG) published a joint editorial in Mental Health in Family Medicine, the official journal of The World Organization of Family Doctors (Wonca) Working Party on Mental Health, for which Prof Ivbijaro is Editor in Chief.

The authors advance the position that the forthcoming revision of ICD “provides an opportunity to include BDS in a revised classification for primary care” and imply that BDS (at least at that point) was progressing, imminently, to ICD-11 field trials.

This brief editorial was embargoed from June 2013 to June 2014 and I was unable to obtain a copy until last month, but you can read it now for free and in full here: Bodily distress syndrome (BDS): the evolution from medically unexplained symptoms (MUS).

Note, firstly, that the editorial does not declare Professor Goldberg’s interest as chair of the ICD-11 Primary Care Consultation Group.

It does not clarify whether the views and opinions expressed within the editorial represent the views of the authors or are 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 (RSG), or of any committees on which co-author, Prof Ivbijaro, sits or of any bodies to which Prof Ivbijaro is affiliated.

No publicly posted progress reports are being issued by ICD-11 or by either of the two groups making recommendations for the revision of this section of ICD and I do not have a second source that confirms the status of proposals as they stood in June 2013.

But taking the editorial at face value, it would appear that the PCCG had revised its earlier proposals for a BSS construct (that drew heavily on Fink et al’s BDS criteria but had included the requirement for some psychobehavioural responses) and were now recommending that the Fink et al BDS construct and criteria should progress for ICD-11 PHC field testing and evaluation, that is, using the same disorder name and (presumably) the same criteria set that is already operationalized in research and clinical settings, in Denmark.

(The rationale for the apparent revision of the earlier BSS disorder name is not discussed within the editorial; nor whether any modifications to, or deviance from a “pure” BDS construct and criteria were being recommended for the purposes of ICD-11 field testing.)

The editorial doesn’t clarify whether the PCCG, the S3DWG and the ICD-11 Revision Steering Group (RSG) had reached consensus – it does not mention the alternative proposals of the S3DWG, at all, or discuss what is entered into the Beta draft, or discuss the views and preferences of the Revision Steering Group for any of recommendations made by the two advisory groups, to date.

It is unclear whether a “pure” BDS construct (as opposed to the PCCG’s earlier BSS modification) had already gained Revision Steering Group approval for progressing to field testing, at the point the editorial was drafted, or whether Prof Goldberg was using this Wonca house journal as a platform on which to promote his own opinions and expectations, in a purely personal capacity.

Crucially, it doesn’t explain why, if a BDS-like construct were anticipated to be progressed to field trials in the second half of 2013, it is the S3DWG’s Bodily distress disorder diagnostic construct that has been listed and defined in the Beta draft for Foundation, Mortality and Morbidity, Primary Care High Resource, Primary Care Low Resource linearizations – not the PCCG’s 2012 BSS modification, or the “pure” BDS that Prof Goldberg evidently champions.

As a source of information on the current status of proposals for the revision of the Somatoform disorders this June 2013 editorial is problematic (and now also over a year out of date).

I suspect the politics between the 12 member PCCG (which includes Marianne Rosendal*), the 17 member S3DWG and the ICD-11 Revision Steering Group are intensely fraught given Professor Goldberg’s agenda for the revision of the Somatoform disorders, since fitting BDS into ICD-11 hasn’t proved to be the shoo in that Fink, Rosendal and colleagues had hoped for**, and given that BDS cannot be harmonized with DSM-5’s SSD, as they are conceptually divergent.

*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. 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.
**Presentation, Professor Per Fink, March 19, 2014 Danish parliamentary hearing on Functional Disorders. Prof Fink 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.

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Requests for clarification repeatedly stonewalled:

ICD Revision has been asked several times, via the Beta drafting platform, to clarify current proposals for the framework and disorder construct for a replacement for the ICD-10 Somatoform disorders and to clarify which construct it intends to take forward to field testing. 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 response has been forthcoming.

Lack of publicly posted progress reports by both working groups, confusion over the content of the Beta draft and ICD Revision’s failure to respond to queries from stakeholders is hampering stakeholder scrutiny, discourse and input. It is time clinicians, researchers, allied professionals and advocacy organizations demanded transparency from ICD Revision around current proposals and field trial intentions.

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September symposium presentation on BDD:

In September, Professor Oye Gureje (who chairs the ICD-11 Expert Working Group on Somatic Distress and Dissociative Disorders), will be presenting on Proposals and evidence for the ICD-11 classification of Bodily Distress Disorders, as part of series of symposia on the development of the ICD-11 chapter for mental and behavioural disorders, at the World Psychiatric Association XVI World Congress, in Madrid, Spain, 14–18 September 2014 [7].

Unfortunately, I cannot attend this symposium presentation but would be pleased to hear from anyone who may be planning to attend.

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References:

1. Creed F, Gureje O. Emerging themes in the revision of the classification of somatoform disorders. Int Rev Psychiatry. 2012 Dec;24(6):556-67. http://www.ncbi.nlm.nih.gov/pubmed/23244611 [Full text behind paywall]

2. 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

3. 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. Full free text available on 2014/6/1: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3822636/pdf/MHFM-10-063.pdf

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

5. 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.

6. Fink et al Proposed new BDS diagnostic classification

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

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Further reading:

Dx Revision Watch Post: Editorial: Bodily distress syndrome (BDS): the evolution from medically unexplained symptoms (Goldberg and ICD-11-PHC), June 3, 2014: http://wp.me/pKrrB-3Uh

Extension to timeline official: ICD-11 rescheduled for 2017

Post #292 Shortlink: http://wp.me/pKrrB-3H9

Update at February 8, 2014: ICD Revision has now updated its Timeline page:

May 2017 Present the ICD-11 to the World Health Assembly”

ICD-11_20177

In the last day or so, edited text on two WHO webpages confirms a decision by ICD Revision to postpone release of ICD-11 by a further two years, from 2015 to 2017.

From WHO site: “The International Classification of Diseases 11th Revision is due by 2017”

Also ICD Information Sheet: “…The development phase will continue for three years and ICD-11 will be finalized in 2017.”

And from a note accompanying a slide presentation: “…Now ICD 11 is scheduled in 2017 and ICD-10-CM can be made as a National Linearization.” Bedirhan Üstün, January 29, 2014 [1]

ICD-11 Revision has yet to issue a formal announcement or news release or update its Timeline page to reflect this decision.

There are no reports on the revised schedule on ICD-11 on Facebook or Twitter @WHOICD11 – all very low key.

Delaying the release of ICD-11 has been under consideration for several months.

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Slipping targets

The development process for ICD-11 began in April 2007, with ICD-11 scheduled for dissemination by 2012 and the timelines for the development of ICD-11 and DSM-5 running more or less in parallel [2,3].

Early on in the revision process, the ICD-11 dissemination date was extended. By 2009, the final draft was scheduled for World Health Assembly (WHA) approval in 2014. The WHA approval date was subsequently shunted to 2015 – four years later than originally planned.

ICD-11 is now scheduled for finalization in 2017.

Rationales for extending the timeline:

Pages 8-10: Committee for the Coordination of Statistical Activities, Twenty-second Session 4-6 September 2013, Items for discussion and decision: Item 8 of the provisional agenda, 3 September 2013 [4].

Slide presentation, Bedirhan Üstün, September 9-10, 2013, Slides 29-35: [5].

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Related reports from Dx Revision Watch

January 22, 2014: WHO Collaborating Centre confirms Revision Steering Group seriously considering extension to ICD-11 timeline: http://wp.me/pKrrB-3E8

September 15, 2013: WHO considers further extension to ICD-11 development timeline: http://wp.me/pKrrB-3sc

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References

1. Slideshare: AHIMA ICD-10 ICD-11 switch to ICD-10-CM in the USA, presentation note, Bedirhan Üstün, Coordinator at World Health Organization, January 29, 2014

2. Agenda Item No. 25: Revision of the International Classification of Diseases (ICD-10) and Involvement of Psychology International Union of Psychological Science Committee on International Relations Action, March 28–30, 2008
IUPsyS Mar 08 Agenda Item 25 ICD-10

3. Letter Saxena, WHO, to Ritchie, IUPsyS (International Union for Psychological Science), August 2007
Exhibit 1 WHO Letter Aug 07

4. Committee for the Coordination of Statistical Activities, Twenty-second Session 4-6 September 2013, Items for discussion and decision: Item 8 of the provisional agenda, 3 September 2013, Pages 8-10:
http://unstats.un.org/unsd/accsub/2013docs-22nd/SA-2013-12-Add1-Health-WHO.pdf

5. Slide presentation: ICD Revision: Where are we? Bedirhan Üstün, World Health Organization Classifications, Terminologies, Standards, ICD Revision: Quality Safety Meeting 2013, September 9-10, 2013, Slides 29-35:
http://www.slideshare.net/ustunb/icd-2013-qs-tag-260276686

WHO Collaborating Centre confirms Revision Steering Group seriously considering extension to ICD-11 timeline

Post #289 Shortlink: http://wp.me/pKrrB-3E8

Update at January 30, 2014:

ICD-11 Revision has confirmed that a decision has now been taken to postpone ICD-11 by a further two years, from 2015 to 2017.

From WHO site: “The International Classification of Diseases 11th Revision is due by 2017”

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Information in this report relates to the development of the World Health Organization’s ICD-11. It does not apply to the forthcoming US specific, NCHS developed, clinical modification of ICD-10, known as ICD-10-CM.

Ustun 34

Source: Slide 34: Where are we? What remains to be done? Shall we have ICD WHA submission in 2015 or later? B Üstün, World Health Organization Classifications, Terminologies, Standards ICD Revision: Quality Safety Meeting, September 2013

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The December newsletter of the WHO Collaborating Centre for the Family of International Classifications (FIC) in the Netherlands reports that ICD-11 Revision Steering Group (RSG) is reviewing options for a further extension to the ICD-11 development timeline [1]:

Newsletter on the WHO-FIC, Volume 11, Number 2, 2013, Latest News, Page 3 [PDF]

The Revision Steering Group and WHO Secretariat seriously consider amending the timeline of submitting the ICD-11 for endorsement by the World Health Assembly to allow more time for field testing in multiple countries and settings, and following up on resulting edits. WHO currently discusses options and scenarios with stakeholders.

This announcement from WHO-FIC’s Marijke de Kleijn-de Vrankrijker reinforces information and resources provided in my September report (WHO considers further extension to ICD-11 development timeline) – that ICD-11 Revision is failing to meet development targets and delaying submission of ICD-11 for WHA for approval until 2016, or alternatively, extending the timeline by a further two years, for WHA approval in 2017, is under consideration.

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ICD-11 already four years behind original targets

The revision of ICD-10 and development of the structure for ICD-11 began in 2007. WHO’s original goal had been to complete the revision and release of ICD-11 by 2011-12, Archived documents [2] [3].

By 2009, the date for submission of ICD-11 for WHA approval had been extended to 2014. The launch of the public version of the Beta drafting platform was later postponed from May 2011 to May 2012.

The current projection for submission of ICD-11 for approval to WHA is May 2015, with dissemination in 2015+ [4].

Mayo’s Christopher Chute, MD, chairs the ICD-11 Revision Steering Group. According to Chute, in this paper published in March 2012, publication of ICD-11 is “expected around 2016″:

Chute CG, Huff SM, Ferguson JA, Walker JM, Halamka JD. There Are Important Reasons For Delaying Implementation Of The New ICD-10 Coding System. Health Aff March 2012 DOI: 10.1377/hlthaff.2011.1258
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ICD Revision considers its options

In September, WHO posted this meeting materials document [5] and this slide presentation [6]. The document summarized, inter alia, ICD-11’s progress, current development status, timelines for finalization date and approval by WHO Governing Bodies, and rationales and options for a further shift in the timeline.

You can read extracts from the document and view slides setting out the options currently under consideration in this report: WHO considers further extension to ICD-11 development timeline, selected of which I am appending to this post.

The earliest ICD-11 might be ready for dissemination is late 2015/16 – which may require some further scaling back of the project’s goals.

But if ICD-11 Revision Steering Group does elect to postpone submission for World Health Assembly approval until May 2017, dissemination of ICD-11 may not be viable before 2018.

I will update this post if and when WHO or ICD-11 Revision Steering Group publish a statement of clarification on the WHO website or issue a news release, or if other information becomes available that confirms a revision to the timeline.

Implementation date

I’ve noted some confusion in reporting and comments around ICD-11 approval by WHA and dissemination and implementation dates.

Unlike the U.S. specific ICD-10-CM, there is no mandatory date by which Member States must switch from using ICD-10 to ICD-11.

World Health Assembly adoption of ICD-11 and ICD-11 implementation dates are separate. WHA adoption enables official use for countries who wish to move on to the next edition. But Member States using ICD-10 will transition to the next version at their own convenience [6].

Once approved, prepared for implementation and released, global adoption of ICD-11 isn’t going to happen overnight. It may take several years before WHO Member States transition from ICD-10 to ICD-11. Low resource and developing countries may take longer to prepare for and transition to the new edition.

The annual update process for ICD-10 will continue during the creation of ICD-11.

Extracts from document [5] setting out the rationale and options for postponement of WHA Approval:

[…]

3. Progress and Current Status of ICD Revision:

[…]

BETA PHASE:

At this point in time, 1 September 2013, an ICD2013 Beta version has been produced for review purposes and field trials after 6 years of drafting phases.

The current ICD 2013 Beta version has relatively stable classification lists (i.e. linearizations) for Mortality and Morbidity recording. It will be reviewed by the specific Mortality Reference Group and the Morbidity Reference Group to see how well it fits the purpose and proposed transition from ICD‐10.

In addition, the Beta version has planned processes for:

(i) Systematic international scientific peer review (ii) Submission of additional proposals from public groups and scientists (iii) Conducting field trials for its applicability and reliability (iv) Production support in multiple languages (translations) starting with WHO official languages (v) Preparations for transitions from ICD‐10 to ICD‐11.

[…]

6. Timelines

The current ICD Revision Process timeline foresees that the ICD is submitted to the WHA in 2015 May and could then be implemented. Between now and 2015, there remains 20 months to conduct the remaining tasks summarized above as: 1. Reviews, 2. Additional Proposals, 3. Field Trials, 4. Translations, and 5. Transition Preparations.

Given the technical requirements these steps could be expedited in the next 20 months. The experience obtained thus far, however, suggests that this timeframe will be extremely tight for paying due diligence to the work especially in terms of: appropriate consultations with expert groups; communication and dissemination with stakeholders; and sufficient time for field testing in multiple countries and settings, and carrying out the resulting edits.

WHO Secretariat would like to discuss this with all stakeholders and evaluate the possible options:

a. Keep ICD submission to WHA to 2015 as originally planned and implementation / adoption date may be free by any Member State (current position – no change).

b. Postpone submission to WHA to a later year to allow longer time for field trials and other transition preparations.

[…]

In conclusion:

(a) WHO Secretariat could produce an ICD 2015 ready including Mortality and Morbidity Linearizations, Reference Guide and Index with the appropriate resolution to go to the World Health Assembly. This timeframe, however, is extremely tight for paying due diligence to the work especially in terms of: appropriate consultations with expert groups; and sufficient time for field testing in multiple countries and settings, and carrying out the resulting edits

(b) If the timeline is advanced to 2016, there will be more time to have ICD 2016 version with more translations and incorporations of some field tests results.

(c) If the timeline is advanced to 2017, ICD 2017 will be ready with most Field Test results incorporated and maintenance scheme tested.

[…]

Slide presentation: B Üstün, World Health Organization Classifications, Terminologies, Standards, ICD Revision: Quality Safety Meeting 2013 September 9-10

Where are we? What remains to be done? Shall we have ICD WHA submission in 2015 or later?

Slide 34:

Ustun 34rule

Slide 35: [WHA Approval timeline – options under consideration]

Ustun 35rule

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References:

1. Newsletter on the WHO-FIC, Volume 11, Number 2, 2013, Latest News, Page 3. WHO Collaborating Centre for the Family of International Classifications (FIC) in the Netherlands.

2. IUPsyS Mar 08 Agenda Item 25 ICD-10 International Union of Psychological Science COMMITTEE ON INTERNATIONAL RELATIONS ACTION, March 28–30, 2008, Agenda Item No. 25: Revision of the International Classification of Diseases (ICD-10) and Involvement of Psychology.

3.  Exhibit 1 WHO Letter Aug 07 Letter Saxena, WHO, to Ritchie, IUPsyS (International Union for Psychological Science), August 2007.

4. ICD-11 Timeline: http://www.who.int/classifications/icd/revision/timeline/en/index.html

5. Committee for the Coordination of Statistical Activities, Twenty-second Session 4-6 September 2013, Items for discussion and decision: Item 8 of the provisional agenda, 3 September 2013, Pages 8-10: http://unstats.un.org/unsd/accsub/2013docs-22nd/SA-2013-12-Add1-Health-WHO.pdf

6. Slide presentation: ICD Revision: Where are we? Bedirhan Üstün, World Health Organization Classifications, Terminologies, Standards, ICD Revision: Quality Safety Meeting 2013, September 9-10, 2013, Slides 29-35: http://www.slideshare.net/ustunb/icd-2013-qs-tag-260276686

Omissions in commentary: “Diagnostic Ethics: Harms vs Benefits of Somatic Symptom Disorder”

Post #287 Shortlink: http://wp.me/pKrrB-3Ch

On December 16, Allen Frances, MD, who led the task force responsible for the development of DSM-IV, published a new commentary at Huffington Post titled: Diagnostic Ethics: Harms vs Benefits of Somatic Symptom Disorder.

This commentary is also published at Saving Normal (hosted by Psychology Today) under the title: Diagnostic Ethics: Harms/Benefits- Somatic Symptom Disorder: Advice to ICD 11-don’t repeat DSM 5 mistakes.

There are a two important oversights in this commentary around ICD and DSM-5’s controversial new diagnostic category, Somatic Symptom Disorder (SSD).

Dr Frances writes:

“…The DSM-5 damage is done and will not be quickly undone. The arena now shifts to the International Classification of Diseases 11 which is currently being prepared by the World Health Organization and is due to be published in 2016. The open question is whether ICD 11 will mindlessly repeat the mistakes of DSM-5 or will it correct them?”

But Dr Frances omits to inform his readers that in September, a proposal was snuck into the Diagnosis Agenda for the fall meeting of the NCHS/CMS ICD-9-CM Coordination and Management Committee to insert Somatic Symptom Disorder as an inclusion term into the U.S.’s forthcoming ICD-10-CM*.

*ICD-10-CM has been adapted by NCHS from the WHO’s ICD-10 and will replace ICD-9-CM as the U.S.’s official mandated code set, following implementation on October 1, 2014.

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A foot in the door of ICD

APA has been lobbying CDC, NCHS and CMS to include new DSM-5 terms in the ICD-10-CM.

If NCHS rubber stamps the addition of Somatic Symptom Disorder as an official codable diagnostic term within ICD-10-CM, it could leverage the future replacement of several existing ICD-10-CM Somatoform disorders categories with this new, poorly validated, single diagnostic construct, bringing ICD-10-CM in line with DSM-5.

There are implications for ICD-11, too.

Once SSD is inserted into ICD-10-CM, the presence of this term within the U.S. adaptation of ICD-10 may make it easier for ICD-11 Revision Steering Group to justify the replacement of several existing ICD-10 Somatoform disorders categories with a single, new ICD construct contrived to incorporate SSD-like characteristics and facilitate harmonization between ICD-11 and DSM-5 disorder terms and diagnostic criteria.

Yet Dr Frances, so vocal since December 2012 on the perils of the new Somatic Symptom Disorder construct, has written nothing publicly about this move to insinuate the SSD term into ICD-10-CM and curiously, makes no mention of this important U.S. development in his latest commentary.

Emerging proposals for the Beta draft of ICD-11 do indeed demand close scrutiny. But U.S. professionals and patient groups need to be warned that insertion of Somatic Symptom Disorder into the forthcoming ICD-10-CM is currently under consideration by NCHS and to consider whether they are content to let this barrel through right under their noses and if not, and crucially, what courses of political action might be pursued to oppose this development.

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Only half the story

A second omission: Dr Frances’ commentary references the deliberations of the WHO Expert Working Group on Somatic Distress and Dissociative Disorders (a 17 member group chaired by O Gureje) which published a paper, in late 2012, reviewing the classification of the somatoform disorders, as currently defined, and discussing the group’s emerging proposals for ICD-11 [1].

But as Dr Frances is aware, this is not the only working group that is making recommendations for the revision of ICD-10’s Somatoform disorders.

The WHO Department of Mental Health and Substance Abuse has appointed a Primary Care Consultation group (PCCG) to lead the development of the revision of the mental and behavioural disorders for the ICD-11 primary care classification (known as the ICD-11-PHC), which is an abridged version of the core ICD classification.

The PCCG reports to the International Advisory Group for the Revision of ICD-10 Mental and Behavioural Disorders and comprises a 12 member group of primary care professionals and mental health specialists representing both developed and low and middle-income countries.

The group is chaired by Prof, Sir David Goldberg, professor emeritus at the Institute of Psychiatry, London (a WHO Collaborating Centre), who has a long association with WHO, Geneva, and with the development of primary care editions of ICD.

The PCCG members 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.

(Dr Reed is Senior Project Officer for the International Advisory Group for the Revision of ICD-10 Mental and Behavioural Disorders; Dr Klinkman is Chair, WONCA International Classification Committee; Dr Rosendal is a member of WONCA International Classification Committee.)

The PCCG has been charged with developing and field testing the full set of disorders for inclusion in ICD-11-PHC, in preparation for worldwide adoption. It is anticipated that for the next edition, 28 mental disorder categories commonly managed within primary care will be included.

For all new and revised disorders included in the next ICD Primary Care version there will need to be an equivalent disorder in the ICD-11 core classification and the two versions are being developed simultaneously.

The group will be field testing the replacement for ICD-10-PHC’s F45 Unexplained somatic symptoms over the next couple of years and multi-centre focus groups have already reviewed the PCCG‘s proposals [2].

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The PCCG’s alternative construct – a BDS/SSD mash-up

As set out in several previous Dx Revision Watch posts, according to its own 2012 paper, the Primary Care Consultation Group has proposed a new disorder category, tentatively named, in 2012, as “Bodily stress syndrome” (BSS) which differed in both name and construct to the emerging proposals of the WHO Expert Working Group on Somatic Distress and Dissociative Disorders.

So we have two working groups advising ICD-11 and two sets of proposals.

The defining characteristics of the PCCG’s proposed new disorder, Bodily stress syndrome (as set out in its 2012 paper), draw heavily on the characteristics, criteria and illness model for Per Fink et al’s Bodily Distress Syndrome – a divergent construct to SSD – onto which the PCCG has tacked a tokenistic nod towards selected of the psychobehavioural features that define DSM-5’s Somatic symptom disorder.

Whereas in late 2012, the emerging construct of the other working group advising on the revision of ICD-10’s Somatoform disorders, the WHO Expert Working Group on Somatic Distress and Dissociative Disorders, was much closer to a “pure” SSD construct.

Neither proposed construct may survive the ICD-11 field trials or ICD-11 Revision Steering Group approval.

Fink and colleagues (one of whom, M Rosendal, sits on the Primary Care Consultation Group) are determined to see their Bodily Distress Syndrome construct adopted by primary care clinicians, incorporated into new management guidelines and integrated into the revisions of several European classification systems.

Their aim is to replace ICD-10’s F45 somatoform disorders, pain disorder, neurasthenia (ICD-10 F48), and the so-called “functional somatic syndromes”: Fibromyalgia (ICD-10 M79.7), IBS (ICD-10 K58) and CFS (indexed to ICD-10 G93.3), with their own single, unifying “Bodily Distress Syndrome” diagnosis, a disorder construct that is already in use in research and clinical settings in Denmark.

It remains unknown whether the two groups making recommendations for the revision of ICD-10’s Somatoform disorders have since reached consensus over what disorder name, definition and criteria WHO intends to submit to international field testing over the next year or two.

It’s not yet clear whether this proposed new BDD/BSS/WHATEVER diagnosis for the ICD-11 primary care and core version construct will have greater congruency with DSM-5’s SSD, or with Fink et al’s already operationalized BDS, or would combine elements from both; nor is it known which patient populations the new ICD construct is intended to include and exclude.

(In its 2012 proposed criteria, the PCCG does not specify FM, IBS, CFS or ME as Exclusion terms or Differential diagnoses to its BSS diagnosis.)

If WHO Revision favours the field testing and progression of an SSD-like construct for ICD-11 there will be considerable implications for all patient populations with persistent diagnosed bodily symptoms or with persistent bodily symptoms for which a cause has yet to be established.

If WHO Revision favours the progression of a Fink et al BDS-like construct and illness model, such a construct would shaft patients with FM, IBS and CFS and some other so-called “functional somatic syndromes.”

But Dr Frances says nothing at all in his commentary about the deliberations of the Primary Care Consultation Group despite the potential impact the adoption of a Fink et al BDS-like disorder construct would have on the specific FM, IBS, CFS and ME classifications that are currently assigned discrete codes outside the mental disorder chapter of ICD-10.

In sum:

The proposal to insert SSD into the U.S.’s forthcoming ICD-10-CM needs sunlight, continued monitoring and opposition at the political level by professionals and advocacy groups. Exclusive focus on emerging proposals for ICD-11 obscures the September 2013 NCHS/CMS proposals for ICD-10-CM.

The deliberations of both working groups that are making recommendations for the revision of the Somatoform Disorders for the ICD-11 core and primary care versions demand equal scrutiny, monitoring and input by professional and advocacy organization stakeholders.

It is disconcerting that whilst several paragraphs in Dr Frances’ commentary are squandered on apologia for those who sit on expert working groups, these two crucial issues have been sidelined.

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References

1. Creed F, Gureje O. Emerging themes in the revision of the classification of somatoform disorders. Int Rev Psychiatry. 2012 Dec;24(6):556-67. http://www.ncbi.nlm.nih.gov/pubmed/23244611 [Full text behind paywall]

2. 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 2012 Jul 28. http://www.ncbi.nlm.nih.gov/pubmed/22843638 [Full text behind paywall]

3. Further reading: BDS, BDDs, BSS, BDD and ICD-11, unscrambled

4. ICD-9-CM/PCS Coordination and Maintenance Committee Meeting September 18-19, 2013:
http://www.cdc.gov/nchs/icd/icd9cm_maintenance.htm

September meeting Diagnostic Agenda/Proposals document [PDF – 342 KB]:
http://www.cdc.gov/nchs/data/icd/icd_topic_packet_sept_181913.pdf

Compiled by Suzy Chapman for Dx Revision Watch

ICD-11 December Round up #1

Post #286 Shortlink: http://wp.me/pKrrB-3AJ

“The current ICD Revision Process timeline foresees that the ICD is submitted to the WHA in 2015 May and could then be implemented…experience obtained thus far, however, suggests that this timeframe will be extremely tight for paying due diligence to the work especially in terms of: appropriate consultations with expert groups; communication and dissemination with stakeholders; and sufficient time for field testing in multiple countries and settings, and carrying out the resulting edits.”   B Üstün, September 2013

In this September posting, I reported that a further extension to the ICD-11 timeline is under consideration.

This document and this slide presentation (Slides 29 thru 35) indicate that ICD-11 Revision is failing to meet development targets.

In a review of progress made, current status and timelines (document Pages 5 thru 10), Dr Bedirhan Üstün, Coordinator, Classification, Terminology and Standards, World Health Organization, sets out the options for postponement and discusses whether submission of ICD-11 for World Health Assembly approval should be delayed until 2016, or possibly 2017.

I will update as further information on any decision to extend the timeline emerges.

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Round up of ICD-11 related materials:

Slide presentation: PDF format, mostly in German

58. GMDS-Jahrestagung, Lübeck, 1.-5.9.2013: Symposium, Medizinische, Klassificationen und Termiologien Vortrag Üstün und Jakob, 5.9.2013

ICD-11 Übersicht Üstün und Jakob

Slide presentation: Slideshare format, in English

Regional Conference of the International Society for Adolescent Psychiatry and Psychology (ISAPP)

Diagnostic Classifications in the 21st Century: how can we capture developmental details Bedirhan Üstün, Coordinator, World Health Organization, November 24, 2013

Multisystem diseases and terms with multiple parents:

In 2010, ICD-11 Revision posted this Discussion Document: Multisystem Disorders, Aymé, Chalmers, Chute, Jakob.

The text sets out the feasibility, rationale for and possible scope of a new multisystem disorders chapter for ICD-11 for diseases that might belong to or affect multiple body systems.

A more recent working document (WHO ICD Revision Information Note, R Chalmers, MS docx editing format, dated 29 January 2013) updates the discussion and concludes that a majority of ICD Revision Topic Advisory Groups and experts did not agree with the recommendation to create a new Multisystem Disease Chapter for ICD-11 and that other options for accommodating diseases which straddle multiple chapters were being considered.

According to ICD-11 Beta drafting platform, the ICD-11 Foundation Component will allow for a single concept to be represented in a Multisystem Disease linearization and appear in more than one logically appropriate location. In the linearizations (e.g. Morbidity), a single concept has a single preferred location and references [to the term] from elsewhere [within the same chapter or within a different chapter] are greyed out but link to the preferred location.

For example, skin tumour is both a skin disease and a neoplasm and for ICD-11 is located under two chapters. Other diseases that are proposed to be assigned multiple parents include some eye diseases resulting from diabetes; tuberculosis meningitis (as both an infectious and a nervous system disease) and Premenstrual dysphoric disorder (PMDD), currently proposed to be dual coded under Chapter 15 Diseases of the genitourinary system under parent term, Premenstrual tension syndrome but also listed under Chapter 5 Mental and behavioural disorders under Depressive disorders.

While previous versions of ICD did not support multiple inheritance, there are already over 450 terms with multiple parents within ICD-11.

Editorial commentary, ICD-11 Neurological disorders:

J Neurol Neurosurg Psychiatry doi:10.1136/jnnp-2013-307093

The classification of neurological disorders in the 11th revision of the International Classification of Diseases (ICD-11)

Sanjeev Rajakulendran¹, Tarun Dua², Melissa Harper², Raad Shakir¹

1 Imperial College NHS Healthcare Trust, Charing Cross Hospital, London, UK; 2 Department of Mental Health and Substance Abuse, World Health Organization, Geneva, Switzerland

Published Online First 18 November 2013 [Full text behind paywall]

Abstract: http://www.ncbi.nlm.nih.gov/pubmed/24249782

Single page extract as image: http://jnnp.bmj.com/content/early/2013/11/18/jnnp-2013-307093.extract

(If a single page text file fails to load at the above link, try pasting the editorial title into a search engine and access the page from the search engine link.)

Primary Care version of ICD-11 (ICD-11-PHC):

The ICD-10-PHC is an abridged version of the ICD-10 core classification for use in primary care and low resource settings. A new edition (ICD-11-PHC) is being developed simultaneously with the core ICD-11.

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

The Mental and behavioural disorders section of ICD-11-PHC is expected to list 28 mental and behavioural disorders most commonly managed within primary care settings, as opposed to over 400 disorders in Chapter 5 of the core version.

The following ICD-10-PHC disorders are proposed to be dropped for ICD-11-PHC:

F40 Phobic disorders; F42.2 Mixed anxiety and depression; F43 Adjustment disorder;
F45 Unexplained somatic symptoms; F48 Neurasthenia; Z63 Bereavement, Source [4].

A list of the 28 proposed disorders for ICD-11-PHC, as they stood in 2012*, can be found on Page 51 of Source [5].

*This list may have undergone revision since the source published.

A new disorder term “Anxious depression” is proposed to be field tested for inclusion in ICD-11-PHC and is discussed in this recent paper by Prof, Sir David Goldberg, who chairs the Primary Care Consultation Group (PCCG) charged with the development of the primary care classification of mental and behavioural disorders for ICD-11:

Abstract: http://onlinelibrary.wiley.com/doi/10.1002/da.22206/abstract

Depression and Anxiety

DOI: 10.1002/da.22206

Review ANXIOUS FORMS OF DEPRESSION

David P. Goldberg

Article first published online: 27 NOV 2013 [Full text behind paywall]

There are further commentaries on the proposed new diagnoses of “anxious depression” and “bodily stress syndrome” in this 2012 paper:

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 2012 Jul 28. http://www.ncbi.nlm.nih.gov/pubmed/22843638 [Full text behind paywall]

According to this earlier paper, the Primary Care Consultation Group (PCCG) was still refining a construct and criteria for its proposed new disorder category, which the group had tentatively named as “Bodily stress syndrome” (BSS).

BSS would replace ICD-10-PHC’s Unexplained somatic symptoms and Neurasthenia categories and would be located under a new disorder group section heading called “Body distress disorders,” under which would sit three other discrete disorders. See Page 51 of Source [5].

The characteristics of new disorder 15: Bodily stress syndrome (as they appeared in the paper) might be described as a mash-up between selected of the psychobehavioural characteristics that define DSM-5’s new Somatic symptom disorder (SSD) and selected of the characteristics and criteria for Fink et al’s Bodily Distress Syndrome – rather than a mirror or near mirror of one or the other.

In order to facilitate harmonization between ICD-11 and DSM-5 mental and behavioural disorders, we might envisage pressure on the group to align with or accommodate DSM-5’s new Somatic symptom disorder within any framework proposed to replace the existing ICD Somatoform disorders.

But DSM-5’s SSD and Fink et al’s BDS are acknowledged by Creed, Henningsen and Fink as divergent constructs, so this presents the groups advising ICD Revision with a dilemma if they are also being influenced to recommend a BDS-like construct.

You can compare how these two constructs differ and appreciate why it may be proving difficult to convince ICD Revision of the utility of the PCCG’s BSS construct (and the potential for confusion where different constructs bear very similar names) in my table at the end of Page 1 of this Dx Revision Watch post:

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

Marianne Rosendal (member of the ICD-11 Primary Care Consultation Group; member of WONCA International Classification Committee), Fink and colleagues are eager to see their Bodily distress syndrome construct adopted by primary care clinicians and incorporated into management guidelines and revisions of European classification systems to replace ICD-10’s F45 somatoform disorders, pain disorder, neurasthenia (ICD-10 F48), and the so-called “functional somatic syndromes,”  Fibromyalgia (ICD-10 M79.7), IBS (ICD-10 K58) and CFS (indexed to ICD-10 G93.3). See graphics at end of post.

While Fink et al’s BDS construct seeks to capture somatoform disorders, pain disorder, neurasthenia and the so-called functional somatic syndromes under a single, unifying diagnosis, it is unclear from the 2012 Lam et al paper whether and how the so-called functional somatic syndromes are intended to fit into the Primary Care Consultation Group’s proposed ICD-11 framework.

While the paper does list some exclusions and differential diagnoses, it lists no specific exclusions or differential diagnoses for FM, IBS or CFS and it is silent on the matter of which of the so-called functional somatic syndromes the group’s proposed new BSS diagnosis might be intended to be inclusive of, or might intentionally or unintentionally capture.

Nor is it discussed within the paper what the implications would be for the future classification and chapter location of several currently discretely coded ICD-10 entities, if Bodily stress syndrome (or whatever new term might eventually be agreed upon) were intended to capture all or selected of FM, IBS, CFS and (B)ME – the sensitivities associated with any such proposal would not be lost on Prof Goldberg which possibly accounts for the lacunae in this paper.

Lack of consensus between the two groups advising ICD-11:

The second working group advising ICD-11 on the revision of ICD-10’s Somatoform disorders is the WHO Expert Working Group on Somatic Distress and Dissociative Disorders (S3DWG).

In late 2012, their emerging construct (also published behind a paywall) had considerably more in common with DSM-5’s SSD construct than with Fink et al’s BDS (see: BDS, BDDs, BSS, BDD and ICD-11, unscrambled).

But the S3DWG’s construct Bodily distress disorder (BDD) and Severe bodily distress disorder are yet to be defined and characterised in the public version of the ICD-11 Beta draft.

It remains unknown whether the two groups making recommendations for the revision of ICD-10’s Somatoform disorders have reached consensus over what definition and criteria WHO intends to field trial over the next year or two and what this proposed new diagnosis should be called; whether their proposed BDD/BSS/WHATEVER construct will have greater congruency with DSM-5’s SSD or with Fink et al’s BDS, or what patient populations this new ICD construct is intended to include and exclude.

The absence of information on proposals within the Beta draft, itself, and the lack of working group progress reports placed in the public domain presents considerable barriers for stakeholder comment on the intentions of these two groups and renders threadbare ICD-11’s claims to be an “open” and “transparent” and “inclusive” collaborative process.

Two further papers relating to “Medically unexplained symptoms,” “Bodily distress syndrome” and “Somatoform disorders”:

http://www.sciencedirect.com/science/article/pii/S0163834313002533

General Hospital Psychiatry

Psychiatric–Medical Comorbidity

Is physical disease missed in patients with medically unexplained symptoms? A long-term follow-up of 120 patients diagnosed with bodily distress syndrome

Elisabeth Lundsgaard Skovenborg, B.Sc., Andreas Schröder, M.D., Ph.D.

The Research Clinic for Functional Disorders and Psychosomatics, Aarhus University Hospital, Denmark

Available online 22 October 2013 In Press, Corrected Proof [Full text behind paywall]

http://www.systematicreviewsjournal.com/content/2/1/99

Systematic Reviews 2013, 2:99 doi:10.1186/2046-4053-2-99

Barriers to the diagnosis of somatoform disorders in primary care: protocol for a systematic review of the current status

Alexandra M Murray¹²*, Anne Toussaint¹², Astrid Althaus¹² and Bernd Löwe¹²

1 Department of Psychosomatic Medicine and Psychotherapy, University Medical Center Hamburg-Eppendorf, Hamburg, Germany

2 University Hospital of Psychosomatic Medicine and Psychotherapy, Schön Clinic Hamburg-Eilbek, Hamburg, Germany

Published: 8 November 2013

[Open access article distributed under the terms of the Creative Commons Attribution License]

Finally, brief summaries of selected of the workshops held at the European Association for Consultation-Liaison Psychiatry and Psychosomatics (EACLPP) 2012 Conference, including workshops on “functional disorders and syndromes” and “Bodily distress,” one of which included:

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

“…brief presentations which describe the present state of the proposed changes to Primary care classifications (ICPC and ICD for primary care) (MR) and DSM-V and ICD-11 (FC).”

where presenter “MR” is Marianne Rosendal; “FC” is Francis Creed, member of the ICD-11 Expert Working Group on Somatic Distress and Dissociative Disorders (S3DWG).

Note: ICPC-2 used in primary care is also under revision.

Foreslået ny klassifikation (Suggested new classification, Fink et al): 

Source Figur 1: http://www.ugeskriftet.dk/LF/UFL/2010/24/pdf/VP02100057.pdf

Danish Journal paper Fink P

Fink: Proposed New Classification

+++
References

1. WHO considers further extension to ICD-11 development timeline

2. Committee for the Coordination of Statistical Activities, Twenty-second Session 4-6 September 2013, Items for discussion and decision: Item 8 of the provisional agenda, 3 September 2013 Full document in PDF format

3. Slide presentation: ICD Revision: Where are we? What remains to be done? Shall we have ICD WHA submission in 2015 or later? Bedirhan Ustun, World Health Organization Classifications, Terminologies, Standards, ICD Revision: Quality Safety Meeting 2013, September 9-10, 2013 http://www.slideshare.net/ustunb/icd-2013-qs-tag-26027668

4. Goldberg, D. Guest editorial. A revised mental health classification for use in general medical settings: the ICD11–PHC 1. International Psychiatry, Page 1, February 2011. http://www.rcpsych.ac.uk/pdf/IPv8n1.pdf

5. 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

Compiled by Suzy Chapman for Dx Revision Watch
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