ICD‐11 draft diagnostic guidelines open to input by mental health professionals

The World Health Organization (WHO) Department of Mental Health and Substance Abuse has recently created a new Internet platform (http://gcp.network) for members of its Global Clinical Practice Network (GCPN). On this platform, it is possible to find the draft ICD‐11 diagnostic guidelines for several mental disorders, which are being used for ICD‐11 field trials1. These draft guidelines are open to comments by mental health or primary care professionals who have joined the Network.

Several innovations to be introduced in the ICD‐11, part of which have been discussed2, 3, 4, 5, 6, 7, 8, 9 or are related to concerns voiced10, 11, 12, 13, 14, 15 in this journal, are visible in these draft guidelines.

Of particular interest is the section “Boundary with other disorders and normality”, provided for each grouping of disorders and not present in the ICD‐10, which delineates the differential diagnosis between, for instance, schizophrenia and acute and transient psychotic disorder, schizophrenia and psychotic‐like symptoms occurring in the general population, delusional disorder and schizophrenia, schizoaffective disorder and mood disorders with psychotic symptoms, depression and normal grief, depression and prolonged grief disorder, bipolar disorder and primary psychotic disorders.

Also noteworthy are the “Qualifiers” introduced for some disorders. In the case of anorexia nervosa, for instance, since severe underweight status is an important prognostic factor associated with high risk of physical complications and substantially increased mortality, qualifiers “with significantly low body weight” and “with dangerously low body weight”, anchored to body mass index values, are provided. In the case of schizophrenia and other primary psychotic disorders, symptom qualifiers are introduced to indicate the degree to which positive, negative, depressive, manic, psychomotor and cognitive symptoms are present in the current clinical presentation. For each symptom domain, four degrees of severity are specified, and anchor points provided.

The new grouping of Disorders Specifically Associated With Stress is introduced, including disorders that are directly related to exposure to a stressful or traumatic event, or a series of such events or adverse experiences. The grouping includes post‐traumatic stress disorder, complex post‐traumatic stress disorder, prolonged grief disorder, adjustment disorder, and other disorder specifically associated with stress. Acute stress reaction is not considered to be a mental disorder, but rather appears in the ICD‐11 section including reasons for clinical encounters that are not diseases or disorders. The category of complex post‐traumatic stress disorder, not present in either ICD‐10 or DSM‐5, is characterized by the three core elements of post‐traumatic stress disorder (i.e., re‐experiencing the traumatic event(s) in the present, deliberate avoidance of reminders likely to produce this re‐experience, and persistent perceptions of heightened current threat) plus severe and pervasive problems in affect regulation; persistent beliefs about oneself as diminished, defeated or worthless; and persistent difficulties in sustaining relationships and in feeling close to others. The category of prolonged grief disorder, not present in the ICD‐10 and corresponding to “persistent complex bereavement disorder” included in the section III of DSM‐5, is characterized by a pervasive grief response, persisting for an abnormally long period of time following the loss, clearly exceeding expected social or religious norms for the individual's culture and context, and causing significant social impairment.

The grouping of Feeding and Eating Disorders, involving abnormal eating or feeding behaviours that are not better accounted for by another health condition and are not developmentally appropriate or culturally sanctioned, includes the new category of avoidant‐restrictive food intake disorder, whose essential features are avoidance or restriction of food intake, characterized by eating an insufficient quantity or variety of food in order to meet adequate energy or nutritional requirements for the individual, leading to significant weight loss (or failure to gain weight) or other impact on physical health, and not reflecting preoccupation with body weight or shape or a significant body image distortion.

Several expected divergences between the ICD‐11 and the DSM‐5 already discussed in this journal, such as the different characterization of mixed states and schizoaffective disorder and the retention of the one month duration criterion for the diagnosis of schizophrenia, are confirmed in these draft guidelines.

GCPN members are welcome to provide their input on how the draft guidelines can be improved, especially in terms of their clarity and applicability in clinical, research, educational and administrative settings. Comments will be submitted to the ICD‐11 Working Groups responsible for the specific areas and to the WHO Secretariat, so that they can be taken into account before the guidelines are finalized.

Paola Bucci
WHO Collaborating Center for Research and Training in Mental Health, University of Naples SUN, Naples, Italy