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11 Clinical Descriptions and Diagnostic Guidelines for Mental and Behavioural Disorders 1 2 3 2 MICHAEL B

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11 Clinical Descriptions and Diagnostic Guidelines for Mental and Behavioural Disorders 1 2 3 2 MICHAEL B WHO REPORT The development of the ICD-11 Clinical Descriptions and Diagnostic Guidelines for Mental and Behavioural Disorders 1 2 3 2 MICHAEL B. FIRST ,GEOFFREY M. REED ,STEVEN E. HYMAN ,SHEKHAR SAXENA 1Department of Psychiatry, Columbia University and Department of Clinical Phenomenology, New York State Psychiatric Institute, 1051 Riverside Drive, New York, NY 10032, USA; 2Department of Mental Health and Substance Abuse, World Health Organization, Geneva, Switzerland; 3Stanley Center for Psychiatric Research, Broad Institute of Harvard and Massachusetts Institute of Technology, Cambridge, MA, USA The World Health Organization is in the process of preparing the eleventh revision of the International Classification of Diseases (ICD-11), scheduled for presentation to the World Health Assembly for approval in 2017. The International Advisory Group for the Revision of the ICD-10 Mental and Behavioural Disorders made improvement in clinical utility an organizing priority for the revision. The uneven nature of the diagnostic information included in the ICD-10 Clinical Descriptions and Diagnostic Guidelines (CDDG), especially with respect to dif- ferential diagnosis, is a major shortcoming in terms of its usefulness to clinicians. Consequently, ICD-11 Working Groups were asked to col- late diagnostic information about the disorders under their purview using a standardized template (referred to as a “Content Form”). Using the information provided in the Content Forms as source material, the ICD-11 CDDG are being developed with a uniform structure. The effectiveness of this format in producing more consistent clinical judgments in ICD-11 as compared to ICD-10 is currently being tested in a series of Internet-based field studies using standardized case material, and will also be tested in clinical settings. Key words: ICD-11, Clinical and Diagnostic Guidelines, clinical utility, Internet-based field studies (World Psychiatry 2015;14:82–90) The International Classification of Diseases and Related classification, and building on earlier work (2), the WHO has Health Problems (ICD), which is the international standard offered the following working definition of clinical utility: for health reporting and health information, is currently in “the clinical utility of a classification construct or category for its tenth revision (ICD-10). The World Health Organization mental and behavioural disorders depends on: a) its value in (WHO) is in the process of preparing the eleventh revision communicating (e.g., among practitioners, patients, families, (ICD-11), scheduled for presentation to the World Health administrators); b) its implementation characteristics in clini- Assembly for approval in 2017. By international treaty, cal practice, including its goodness of fit (i.e., accuracy of WHO is assigned the responsibility “to establish and revise description), its ease of use, and the time required to use it as necessary international nomenclatures of diseases, of cau- (i.e., feasibility); and c) its usefulness in selecting interventions ses of death and of public health practices” and “to standard- and in making clinical management decisions” (3, p. 461). ize diagnostic procedures as necessary” (1). Within the con- On the basis of comments received, structured surveys of text of WHO policies and procedures for the overall ICD practitioners, and input from diverse professional organiza- revision, the WHO Department of Mental Health and Sub- tions whose members treat individuals with mental and be- stance Abuse has technical responsibility for coordinating havioural disorders, the International Advisory Group for the development of the Chapter on Mental and Behavioural the Revision of the ICD-10 Mental and Behavioural Disor- Disorders in ICD-11. ders concluded that there was room for significant improve- The purpose of this paper is to describe the guidance that ments in clinical utility and that these deserved to be a major the Department of Mental Health and Substance Abuse has guiding principle for the revision process (3,4). Moreover, in provided to Working Groups engaged in the ICD-11 revision light of the rapidly changing state of scientific approaches to process, the priorities lying behind that guidance, the proce- mental and behavioural disorders (5-7), the Advisory Group dures implemented by the Department to help the revision concluded that the revision must take into account well- process achieve its goals, and the nature of the diagnostic validated and well-replicated results where they existed, but guidance that will be provided to health care professionals as that it was premature to make still embryonic scientific a part of the Clinical Descriptions and Diagnostic Guidelines understandings the major drivers of specific disease defini- (CDDG) for ICD-11 Mental and Behavioural Disorders. tions. In short, clinical utility deserved to be an organizing Disease classifications have been applied to a large and priority for the revision so long as it did not sacrifice validity growing number of purposes, which can be grouped roughly as established by the best available science. into three major clusters: a) clinical uses; b) public health To put the revision process in context, we begin this essay uses, including provision of a basis for health statistics and a with a brief overview of ICD-10 Chapter on Mental and shared language for health policy; and c) disease-related Behavioural Disorders, approved by the World Health research. Addressing the central clinical purposes of a disease Assembly in 1992. Notably, the time interval between the 82 World Psychiatry 14:1 - February 2015 ICD-10 and ICD-11 revisions will have been the longest trauma or other bodily injury, with delirium) and the course between ICD revisions since the process first began in the of schizophrenia (e.g., episodic with progressive deficit, late 19th century. Unlike the other chapters in the ICD clas- incomplete remission). National modifications of the ICD- sification, which confined their content exclusively to the 10 intended for use in clinical systems (e.g., the ICD-10- names of disorders plus inclusion and exclusion terms, a GM, the German Modification, or the ICD-10-CM, Clinical glossary of terms was developed in 1974 (8) to accompany Modification for the United States) often also include these the eighth revision of the ICD (ICD-8) (9), approved in same 5th character codes, and in some cases assign alterna- 1966. As the introduction to the glossary states, “guidance to tive or additional 5th and even 6th character codes to pro- the... [mental disorders chapter] of ICD-8 has been added vide additional specificity for local clinical use. in the form of a glossary because it has become increasingly The WHO Department of Mental Health and Substance obvious that many key psychiatric terms are acquiring dif- Abuse also developed Diagnostic Criteria for Research (DCR) ferent meanings in different countries [and] unless some (12) (the “green book”), with specified, operationalized diag- attempt is made to encourage uniformity of usage of descrip- nostic criteria for each ICD-10 category that were “deli- tive and diagnostic terms, very little meaning can be attribut- berately restrictive” to allow for the “selection of groups of ed to the diagnostic side of statistics of mental illness based individuals whose symptoms and other characteristics re- on the ICD and in many other ways communication between semble each other in clearly stated ways” (12, p. 1). Conse- psychiatrists will become increasingly difficult” (8, p. 12). quently, in contrast to the CDDG, which are designed The version of the ICD-10 that WHO member countries to allow for cultural variability and clinical judgment, the agree to use as the basis for reporting of health statistics is DCR imposed fixed symptom thresholds (e.g., “at least four called the International Statistical Classification of Diseases of the following”) and frequency/duration requirements and Related Health Problems (10) and is split into three vol- (e.g., “at least twice a week for 3 months”). umes. Volume 1, known as the “tabular list”, contains a list- The differences between the CDDG and the DCR reflect ing of all of the medical conditions included in ICD-10 in the different purposes of these two versions of the classifica- alphanumerical order, ranging from A00 to Z99. In this sta- tion. In clinical settings, the function of the classification is tistical version of the ICD-10, none of the diagnostic codes to help the clinician to find the category that is most likely go beyond the fourth character (e.g., F31.0), with each char- to provide relevant information for treatment and manage- acter corresponding to a hierarchical level of the classifica- ment. Arbitrary or non-consequential exclusion criteria are tion. For example, in the code F31.0, the “F” corresponds to problematic because they increase false negatives, leaving Mental and Behavioural Disorders, “F3” corresponds to the clinician with little guidance; as a result their use is mini- Mood (Affective) Disorders, the “F31” to Bipolar Affective mized in the CDDG. The DCR, on the other hand, had the Disorder, and “F31.0” to Bipolar Affective Disorder, Cur- goal of identifying research populations that were more rent Episode Hypomanic. homogeneous in terms of underlying pathophysiology or From the perspective of the WHO Department of Mental treatment response (e.g., for clinical trials). Unfortunately, Health and Substance Abuse, different versions of the ICD- given limitations in the state of knowledge,
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