Diagnostic Classifications in the 21st Century: how can we capture developmental details

Diagnostic Classifications in the 21st Century: 

developmental dimension

T. Bedirhan Üstün, MD World Health Organization

Classifications, Terminologies, StandardsGeneva, Switzerland

ICD & DSM Integration of developmental concepts

Paradıgms across the 20th century RDoC

ICD Revision Reviews - proposals Field Trials

Outline

A period of Miraculous Growth

Transitions in Life

Transitions in Life

Transitions in Life

Transitions in Life

Transitions in Life

A Developmental Brain Model For Schizophrenia

World Mental Health Surveys: 12 month prevalence of MOOD

disordersKessler & Üstün, 2008 CUP

United StatesUkraineFrance

NetherlandsColombiaLebanon

Belgium

Spain

MexicoItaly

GermanyJapan

PRC Beijing

PRC ShanghaiNigeria

Prevalence

World Mental Health Surveys: Age of Onset

Diagnostic Statistical Manual

1952 DSM I 1968 DSM-II 1980 DSM-III 1987 DSM-III-R 1994 DSM-IV 2000 DSM-IV-TR 2013 DSM 5

ICD-6 ICD-8 ICD-9

ICD-10

ICD-11

International Classification ofDiseases

"Psychiatrists of Europe! Protect your sanctified diagnoses!”

Cartoon by Emil Kraepelin, "Bierzeitung", Heidelberg 1896

Death of the author

Birth of the reader ?

Am J Psychiatry 119:210-216, September 1962doi: 10.1176/appi.ajp.119.3.210© 1962

RELIABILITY OF PSYCHIATRIC DIAGNOSES : 1. A CRITIQUE OF SYSTEMATIC STUDIESAARON T. BECK M.D.1

1 Dept. of Psychiatry, University of Pennsylvania and the Philadelphia General Hospital.

Pertinent systematic studies of the reliability of psychiatric diagnosis were critically examined. It was pointed out that each of these studies presented certain methodological problems which made their findings inconclusive. An experimental design was presented to meet these problems and thus yield a more informative index of reliability. By systematically varying the important variables, such as the level of experience of the psychiatrists, the time interval between interviews, the use of ancillary information, and the degree of refinement of the nosological categories, it will be possible to determine their effects on reliability.

Roger Peele and Paul Luisada, in Washington, D.C., wrote a paper on “hysterical psychoses”

Spitzer went to meet them: During a forty-minute conversation, “hysterical psychoses” was divided into two disorders: Short episodes of delusion and hallucination would be

labelled “brief reactive psychosis,” The tendency to show up in an emergency room without

authentic cause would be called “factitious disorder Then Bob asked for a typewriter, and banged out

criteria sets for factitious disorder and for brief reactive psychosis

On the origins of BOGSAT

ICD – DSM ≈ Common Language ?

Pseudoconsensus ? Communication : ↑ ↓ Mutual data exchange ↔ Confusion

Research & Science : ↑ ↓ Common framework ↔ Straitjacket

Clinical utility : ↑ ↓ Reliable assessment ↔

Reductionism

Public Health : ↑ ↓ Guides decision making ↔

Conformism

Human Rights : ↑ ↓ Protection ↔ Discrimination and

stigma

DSM5 disorder groups1. Neurodevelopmental disorders2. Schizophrenia spectrum and other psychotic disorders3. Bipolar and related disorders4. Depressive disorders5. Anxiety disorders6. Obsessive-compulsive and related disorders7. Trauma- and stressor-related disorders8. Dissociative disorders9. Somatic symptom and related disorders10.Feeding and eating disorders11.Elimination disorders12.Sleep-wake disorders13.Sexual dysfunctions14.Gender dysphoria15.Disruptive, impulse-control, and conduct disorders16.Substance-related and addictive disorders17.Neurocognitive disorders18.Personality disorders19.Paraphilic disorders20.Other mental disorders

Welcome to the Real World DSM5 Field Trials Regier et al 2013

Test-Retest Reliability of Target DSM-5 Diagnoses

at the Child/Pediatric Field Trial Sites

DSM-5 Child/Pediatric Field Trials Unsuccessful in Obtaining Accurate Estimates of Kappa

Autism

spec

trum

diso

rder

bb

ADHD

Disrup

tive m

ood dy

sreg

ulat

ion diso

rder

Mixed

anx

iety

-dep

ress

ive

diso

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Major

dep

ress

ive diso

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Avoidan

t/res

trictive fo

od in

take

diso

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Oppos

ition

al defi

ant d

isord

er

Nonsu

icida

l self-i

njur

y

Bipolar

I/II diso

rder

Posttra

umat

ic stre

ss diso

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– ch

ild/ado

...

Condu

ct diso

rder

0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

1

KA

PP

ADSM-5 Child/Pediatric

Field Trials

Very good

Good

Questionable

Unacceptable

Excellent

23

NIMH will be re-orienting its research away from DSM categories and

toward RDoC.

Search: ‘Insel transforming diagnosis’

Units of analysis Genes Molecules Cells Neural Circuits Physiology Behaviours Self Reports (Paradigms)

Research Domain Criteria NIMHDimensions of Observable neurobiological measures

RDoC Constructs

Brain Disorders: Scale & Scope

Disorders of the Human Connectome

Schizophrenia as a brain disease

Source: Thompson et al. 2001

Somatic Diseases

He

ritab

ility

BreastCancer

Hyper-tension

IschemicHeart

Disease

RheumatoidArthritis

0.8

0.6

0.4

0.2

0

Mental Disorders

He

ritab

ility

Depression ADHD Schizo-phrenia

Bipolar

0.8

0.6

0.4

0.2

0Autism

The Meaning of the Human GenomeProject for Neuropsychiatric Disorders

Steven E. HymanProvost, Harvard University and Professor of Neurobiology,

Harvard Medical School Boston, MA, USA

Gene - Behaviour Pathway(Ustun, 2005)

Genotypes Endophenotypes Phenotypes

N1

N2

N3

G1

G2

G3

G4

P1

P2

P3

P4

B1

B2

B3

GeneticNeuro-physiological Psychological Behavioural

Lieberman, Insel Issue Joint Statement About DSM-5 and RDoC - 14 May 2013

.. they acknowledged that along with the International Classification of Diseases, DSM "represents the best information currently available for clinical diagnosis of mental disorders" and that the two publications "remain the contemporary consensus standard to how mental disorders are diagnosed and treated." … mental illness will be best understood as disorders of brain structure and function that implicate specific domains of cognition, emotion, and behavior," which is the focus of the RDoC initiative

Development

What is New ?

ICD-10• Mental Retardation• Autism, Asperger’s• Scholastic Development

• Hyperkinetic Disorder• Speech Articulation• …

• Gender Identity Disorder

ICD-11• Intellectual Development• Autism Spectrum Disorder• Learning• ADHD• Speech Sound Disorder• Social Communication

Disorder• Gender Ingconruence out

ICD11 βetahttp://www.who.int/classifications/icd/revision

Beta – Browser & Print 10 look & feel

+ descriptions – code structure !

• ICD-11 Beta draft is NOT FINAL

• updated on a daily basis

•NOT TO BE USED for CODING except for agreed FIELD TRIALS

βeta

ICD-11 Features

Internet Based Platform

Content Model

Multi Lingual Representations

Definitions

Input from all Stakeholders

Arabic لعربية 官话 ChineseEnglish EnglishFrançais FrenchРусский язык Russian Español Spanish Deutsch German Português Portuguese

Field Trials for Use Cases

Electronic Health Record Ready

ICD11 Field Trials Basic aims

To test the “fitness of ICD-11 for multiple purposes” Mortality coding Morbidity coding Quality & Safety Other use cases

To ensure the comparability between ICD-10 and ICD-11 To increase consistency, identify improvement paths, and reduce errors

.

Key Assessments:

Applicability – feasibility easy to use

Reliability - consistency gives same results in the hands of all

Utility - added value renders useful information

Core Studies

Study One: Feasibility and Reliability for live Cases

and Case Summaries coding with ICD-10 an 11

Study Two: Basic Questions

Inter-rater reliability The Case information

live medical record

Coded using ICD11 by at least

two different people

Agreement rates measured

Incentives for Participants

ICD-11

Comments Proposals Field Trials Review Mechanism