ICD‐11 sessions in the 17th World Congress of Psychiatry

Within the 17th World Congress of Psychiatry, held in Berlin from 8 to 12 October 2017, eight symposia, three workshops, one state‐of‐the‐art lecture and several individual presentations focused on various aspects of the chapter on mental and behavioural disorders of the 11th edition of the International Classification of Diseases and Related Health Problems (ICD‐11), which is expected to be approved by the World Health Assembly in May 2018¹.

As emphasized by many presenters, improving clinical utility of psychiatric diagnosis in ordinary practice is the main objective of the new diagnostic system. The clinical descriptions and diagnostic guidelines provided for the various mental disorders will guide clinicians in their diagnostic practice, but clinical judgment will have to be finally exercised in order to decide whether the features of an individual case approximates sufficiently one of the prototypes proposed in the manual in order to justify the corresponding diagnosis. Precise (or pseudo‐precise) thresholds concerning the number or duration of symptoms will not be included in the system, unless they are convincingly validated by available research.

An effort has been made to harmonize the two main diagnostic systems existing in the psychiatric field – the ICD and the DSM – and indeed the organizational framework (“metastructure”) will be the same in the ICD‐11 as in the DSM‐5. Nevertheless, several intentional differences between the two systems will remain.

In particular, some diagnostic categories will appear in the ICD‐11 that are not included in the DSM‐5. Examples are given by complex post‐traumatic stress disorder (PTSD) and prolonged grief disorder. The category of complex PTSD is characterized by the three core elements of PTSD (i.e., re‐experiencing the traumatic event 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 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.

On the other hand, some diagnostic categories that are included in the DSM‐5 will not appear in the ICD‐11. An example is given by disruptive mood dysregulation disorder, which will be replaced in the ICD‐11 by the subtype “with chronic irritability‐anger” of oppositional defiant disorder. This subtype is marked by prevailing, persistent angry or irritable mood, including often being “touchy” or easily annoyed, that is characteristic of the individual's functioning nearly every day and is observable across multiple settings or domains of functioning (e.g., home, school, social relationships) and is not restricted to the individual's relationship with his/her parents or guardians. The negative mood is often accompanied by regularly occurring severe temper outbursts that are grossly out of proportion in intensity or duration to the provocation.

A reflection of the ongoing debate about these and other controversial diagnostic topics can be found in recent issues of this journal2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15.

Conditions related to sexual health and sleep‐wake disorders will appear in chapters of the classification different from the one on mental disorders. This has been decided in order to address the criticism to the ICD‐10 concerning the problematic distinction between “organic” and “non‐organic” sexual dysfunctions (covered in the ICD‐10, respectively, in the chapters on diseases of the genitourinary system and on mental and behavioural disorders), and between “organic” and “non‐organic” sleep disorders (covered in that system, respectively, in the chapters on diseases of the nervous system and on mental and behavioural disorders).

The new diagnostic system has been tested through several field studies. There were first two large international surveys of views of psychiatrists and psychologists about the classification of mental disorders and the features that would increase its clinical utility. These were followed by so‐called formative field studies, aimed to guide decisions about the basic structure and content of the classification by exploring clinicians’ conceptualizations of the interrelationships among categories of mental disorders.

Internet‐based field studies were then implemented through the Global Clinical Practice Network, including more than 13,000 psychiatrists and other health professionals from more than 150 countries, which used vignette methodologies to examine clinical decision‐making in relationship to the proposed ICD‐11 diagnostic categories and guidelines. Finally, clinic‐based (or ecological implementation) field studies were conducted to assess the reliability and clinical utility of the diagnostic guidelines with real patients. The results of several of these field studies were presented at the World Congress (see also https://gcp.network/en/).

Corrado De Rosa
WHO Collaborating Centre for Research and Training in Mental Health, University of Naples SUN, Naples, Italy