History of ICD · • “After all, the ICD, not the Diagnostic and Statistical Manual of Mental Disorders (DSM), is the official system used across all health settings in the United

Leonard Bohanon, PhD Meghan Castillo, BA

Tracy Morris, BA Shawntonyra Wyatt, BS

History of ICD

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History of ICD

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History of ICD

• “After all, the ICD, not the Diagnostic and Statistical Manual of Mental Disorders (DSM), is the official system used across all health settings in the United States… Clinicians have a choice and a voice in deciding which diagnostic classification system they will find most useful for guiding mental and behavioral health practice in the future. Many clinicians have not realized this over the years and thought they were using, and were required to use, the DSM classification system. Yet, 95% of the world’s health professionals (including physicians, nurses, and psychologists) already use ICD-10.” (Goodheart, 2013, p. 4)

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History of ICD

• “After all, the ICD, not the Diagnostic and Statistical Manual of Mental Disorders (DSM), is the official system used across all health settings in the United States… Clinicians have a choice and a voice in deciding which diagnostic classification system they will find most useful for guiding mental and behavioral health practice in the future. Many clinicians have not realized this over the years and thought they were using, and were required to use, the DSM classification system. Yet, 95% of the world’s health professionals (including physicians, nurses, and psychologists) already use ICD-10.” (Goodheart, 2013, p. 4)

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History of ICD What is the ICD

& Where Did It Come From?

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History of ICD

• End of WWII → United Nations → World Health Organization →

• International Classification of

Diseases

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History of ICD

• Great Exhibition of 1851 in London • → 1st International Statistical

Conference of 1853 • → International Statistical Institute

(ISI) • → International List of Causes of

Death 1893

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History of ICD

• ICD (International List of Causes of Death), diseases that were defined at the time. No Mental-Behavioral Disease category. (There were diseases of the nervous system & the senses.)

• ICD-1, first revision 1900 (in use 1900-1909)

• ICD-2 1909 (1910-1920), renamed International Classification of Causes of Sickness and Death.

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History of ICD

• ICD-3 1920 (1921-1929) • ICD-4 1929 (1930-1938), transform toward categories based

on etiology.

• ICD-5 1938 (1939-1948), practical consideration to comparability between successive ICD versions.

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History of ICD

• Great Exhibition of 1851 in London • → 1st International Statistical Conference of 1853 • → International Statistical Institute (ISI) • → International List of Causes of Death 1893 • → International Classification of Causes of Sickness and

Death • → End of WWII → United Nations • → World Health Organization → International Statistical

Classification of Diseases, Injuries, and Causes of Death (ICD-6)

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History of ICD

• 1948: International Statistical Classification of Diseases, Injuries, and Causes of Death (ICD-6) • 800 Disease Categories • Morbidity & Mortality

• Introduced a new main category:

• Mental, Psychoneurotic, and Personality Disorders

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History of ICD

• ICD-7 1955 (1958-1967) • ICD-8 1965 (1968-1978). Expanded cross-indexing hospital

clinical records. Influenced by adaptations in Israel, Sweden, U.S.

• ICD-9 1975 (1979-1994). International Classification of Diseases and Related Health Problems. Included narrative MBD descriptions similar to DSM-II language.

• ICD-10 1990 (1994 -present). Current version. • ICD-11 (WHA approval expected 2018 )

• World Heath Assembly (WHA) is the decision making body of WHO

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History of ICD

• Great Exhibition of 1851 in London → 1st International Statistical Conference of 1853 → International Statistical Institute (ISI) → International List of Causes of Death 1893 → International Classification of Causes of Sickness and Death → End of WWII → United Nations → World Health Organization → International Statistical Classification of Diseases, Injuries, and Causes of Death (ICD-6) → INTRODUCTION of Mental, Psychoneurotic, and Personality Disorders → International Classification of Diseases and Related Health Problems → International Classification of Diseases

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History of ICD

• Why Is Being Global Important? • Sample of What We’ve Learned from ICD Statistics:

• Depression -- Leading cause of disability in the world • 50% higher rates in women than men

• Not counting communicable diseases, Mental & neurological disorders = Greater disease burden (WHO, 2008)

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History of ICD

• ARE WE THERE YET??

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History of ICD RESISTANCE IS FUTILE. WE’RE HERE!

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History of ICD

• “A history of an illness, even if no longer present, is important information that may alter the type of treatment ordered.” • (U. S. Centers for Disease Control, ICD-10-CM Official

Guidelines for Coding and Reporting)

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ICD Basics • Which ICD?

• "Blue Book", a.k.a. CDDG • http://tinyurl.com/icd10bluebook

• ICD-10-CM (Clinical Modification)

• http://tinyurl.com/cdc10cm

• ICD-10-PCS (Procedure Coding System)

• ICD-10 Diagnostic Criteria for Research ("Green Book")

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ICD Basics • Different Codes

• 7 fold increase in number of possible codes • Up to 7 alphanumeric codes

• Mental Health using only 6 so far • Fnx.xxxx • A few examples:

• Bulimia Nervosa 307.51 F50.2 • Cocaine Dependence 304.2 F14.2 • Cocaine Dependence with Cocaine Induced

Sleep Disorder = F14.281

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ICD Basics • Mental & Behavioural Disorders – all start with F

• Divided into Blocks • F01-F09 due to known medical conditions

• incl. delirium, dementia, organic psychosis, organic mood disorders, etc.

• F10-F19 due to psychoactive substance use • drug abuse & dependence • disorders related to intoxication & withdrawal • substance related mental disorders

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• Divided into Blocks • F20-F29 schizophrenic spectrum

• Schizophrenias (types return) • Delusional Disorder • Schizoaffective Disorder • Schizophreniform disorder = Other

Schizophrenia • Schizotypal Disorder

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• Divided into Blocks • F30-F39 mood disorders

• Bipolar disorders • Unlike DSM, Manic Episode is coded

(F30.x) • Bipolar II is an “Other”

• Depressive Disorders • Mostly same – Persistent Depressive

Disorder Dysthymic Disorder • Cyclothymic

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• Divided into Blocks • F40-F48 anxiety, dissociative, stress-related,

somatoform & other non-psychotic disorders • Phobias • Panic Disorder (organized like DSM IV) • OCD • Traumatic Stress Disorders • Adjustment Disorders • Dissociative Disorders

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• Divided into Blocks • F40-F48 anxiety, dissociative, stress-related,

somatoform & other non-psychotic disorders (cont.) • Somatoform Disorders – return to previous

structure • Somatization • Hypochondriasis

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ICD Basics • Divided into Blocks (cont.)

• F50-F59 associated with medical conditions • Eating Disorders

• BED = “Other” (F50.8) • Sleep Disorders • Sexual Dysfunctions • Psychological and behavioral factors

associated with disorders or diseases classified elsewhere

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• F50-F59 associated with medical conditions (cont.) • Abuse of non-psychoactive drugs (e.g.,

steroids, herbs & folk remedies) • F60-69 Disorders of Adult Personality & Behavior

• Personality disorders • Most familiar categories here • Schizotypal in Schizophrenic Spectrum • Narcissistic PD is in “Other PD’s”

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• F60-F69 Disorders of Adult Personality & Behavior (Cont.) • Impulse Control Disorders

• e.g., pathological gambling • Trichotillomania • NOT Skin Picking Disorder (under Derm.) • Gender Identity Disorders • Paraphilias • Factitious Disorders

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• F70-F79 intellectual disabilities • F80-F89 pervasive & specific developmental

• Specific DD, e.g. Reading or Math Disorder • PDD – includes Autism spectrum

• Asperger's (F84.5)

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• F90-F98 childhood & adolescence • ADHD • Conduct Disorder • ODD • Separation Anxiety • Enuresis & Encopresis

• F99 Unspecified mental disorder

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ICD Basics • “V Codes” & Other similar Codes

• V Codes in general do not convert well • Most convert to Z codes

• More available codes, e.g.: • Z62.3 Hostility towards and scapegoating of

child • Z62.6 Inappropriate (excessive) parental

pressure • Z62.1 Parental overprotection • Z62.891 Sibling Rivalry

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ICD Basics • “V Codes” & Other similar Codes

• V Codes in general do not convert well • Some Classified elsewhere, examples:

• Issues related to abuse are under “T”, e.g. • T74.12XA Child Physical abuse, confirmed,

initial encounter • T74.31XD Adult Psychological Abuse,

confirmed, subsequent encounter • Intentional Self Harm (suicidal and non-

suicidal): X71-X83

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ICD Basics – Compared to DSM • DSM – Proprietary

• Produced by a single national association.

• Provides large portion of ApA revenue

• Designed for the use of (U.S.) psychiatrists.

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• ICD – Open • Produced by global

health agency of UN. • Free open resource

for public health benefit.

• For countries/service providers.

ICD Basics – Comparison (cont.) • DSM – Proprietary

• Dominated by U.S. Anglophone perspective.

• Approved by ApA Board of Trustees.

• Covers only mental disorders

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• ICD – Open • Global,

multidisciplinary, multilingual development.

• Approved by World Health Assembly.

• Covers all health conditions

ICD Basics – WHO • WHO supports the idea that disease definition

“cannot be legitimately managed by a single professional organization representing a single health discipline in a single country with a substantial commercial investment in its products.”

• WHO recognizes contributions from government organizations and professional/disease/consumer organizations make to disease definition.

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ICD Basics – Advantages The global use of the system will allow for:

• Better international comparisons of patient care quality.

• Easier to share best health practices • Clinicians are able to use their clinical judgment in

selecting a dx • Mental Health Clinicians can be realigned with the

global ICD classification system • More flexibility to use a better matching diagnosis.

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ICD Basics – Compared to DSM • DSM:

• categorically defined criteria: stricter & must meet a minimum number of symptoms & duration of symptoms (Goodheart, 2013).

• Uses terms such as: “must meet” • ICD:

• general descriptive diagnostic guidelines with flexibility.

• Uses terms such as: “will probably “

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ICD Basics – Compared to DSM • Guidelines vs. Criteria

• DSM diagnostic criteria designed to set minimum criteria for diagnosis • “must meet”

• ICD diagnostic guidelines designed to allow clinician flexibility • “will probably”

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ICD Basics – Compared to DSM • ICD Diagnostic Guidelines – Excerpted example

• F34.1 Dysthymia (Dysthymic Disorder in CM) • "The essential feature is a very long-standing depression

of mood which is never, or only very rarely, severe enough to fulfill the criteria for recurrent depressive disorder, mild or moderate severity (F33.0 or F33.1). It usually begins early in adult life and lasts for at least several years, sometimes indefinitely. When the onset is later in life, the disorder is often the aftermath of a discrete depressive episode (F32.-) and associated with bereavement or other obvious stress." (CDDG p. 107)

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• F50.2 Bulimia Nervosa • “Bulimia nervosa is a syndrome characterized by

repeated bouts of overeating and an excessive preoccupation with the control of body weight, leading the patient to adopt extreme measures so as to mitigate the "fattening" effects of ingested food.” (CDDG p. 139)

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• F50.2 Bulimia Nervosa (Cont.) • “For a definite diagnosis, all the following are required:

(a)There is a persistent preoccupation with eating, and an irresistible craving for food; the patient succumbs to episodes of overeating in which large amounts of food are consumed in short periods of time.

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• F50.2 Bulimia Nervosa (Cont.) • “For a definite diagnosis, all the following are required

(cont.): (b)The patient attempts to counteract the "fattening" effects of food by one or more of the following: self-induced vomiting; purgative abuse, alternating periods of starvation; use of drugs such as appetite suppressants, thyroid preparations or diuretics. When bulimia occurs in diabetic patients they may choose to neglect their insulin treatment.

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• F50.2 Bulimia Nervosa (Cont.) • “For a definite diagnosis, all the following are required

(cont.): (c)The psychopathology consists of a morbid dread of fatness and the patient sets herself or himself a sharply defined weight threshold, well below the premorbid weight that constitutes the optimum or healthy weight in the opinion of the physician. … [section on “often but not always” earlier episode of anorexia nervosa]

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ICD Basics Multiple Dx. • Record as many diagnoses as necessary for clinical

picture • Include medical diagnoses where appropriate and

with documentation • Include “Z” and other similar codes

• Most relevant dx. first • If in doubt, use order of appearance in ICD

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ICD Basics • Two kinds of "Excludes"

• Excludes1: Not Coded Here - indicates that the code excluded should never be reported with the code “above” the Excludes1 note. An Excludes1 is used to indicate when two conditions cannot occur together.

• Excludes2: Not Included Here - means that the condition excluded is not part of the condition under which it is listed, but a patient may have both conditions at the same time.

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ICD Basics • Two kinds of "Excludes" (examples)

• F10.1 Alcohol Abuse • Excludes1: Alcohol Dependence (F10.2-) • Means the two cannot occur together

• F42 Obsessive Compulsive Disorder • Excludes2: Obsessive-Compulsive Personality

Disorder (F60.5) • Means OCPD is not part of OCD, but the two

can co-exist

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Presenter

Presentation Notes

ICD-10-CM allows coding for two disorders they may occur as separate co-occurring diagnoses (unlike Excludes1 conditions). Benefits is that it provides accurate & specific descriptions of dx.

Taking Culture into Consideration

Quote from DSM-5

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How did DSM-5 attempt to become more culturally inclusive?

• Definition and importance of culture is expanded • The concepts of race and ethnicity are defined and

differentiated. • DSM-5 no longer uses the multi-axial system. • 5 includes an updated version of the Outline of the

Cultural Formulation now called Cultural Formulation Interview (CFI)

• Full version of DSM-5 includes a culture-bound syndromes in Appendix: Dhat, Amok, Brain Fag, Koro

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What does ICD-10 offer that DSM-5 does not?

• Broad descriptions of symptoms, development of symptoms, and patterns • Attention Deficit disorder, ODD, CD • anxiety disorders in childhood and adolescence • Post-traumatic stress • Neurasthenia

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Taking Culture into Consideration

Quote from DSM-5

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How has DSM-5 attempted to become more culturally inclusive?

• Definition and importance of culture is expanded • The concepts of race and ethnicity are defined and

differentiated. • DSM-5 no longer uses the multi-axial system. • 5 includes an updated version of the Outline of the

Cultural Formulation now called Cultural Formulation Interview (CFI)

• Full version of DSM-5 includes culture-bound syndromes in Appendix: Susto, Maladi moun, Taijin kyofusho, Kufungisisa

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What does ICD-10 offer that DSM-5 does not?

• Broad descriptions of symptoms, development of symptoms, and patterns o Attention Deficit disorder, ODD, CD o anxiety disorders in childhood and adolescence o Post-traumatic stress o Dysthymia o Neurasthenia

• International Participation

What's Next? – ICD 11

• Currently Scheduled to be Finalized in 2018 • Open Process (http://tinyurl.com/ICD11Beta)

• Anyone can view the Work in Progress • Anyone can register to be part of the Beta process • Expect to be updated more often (so we will

probably see 11.1, 11.2, etc.) • Three versions:

• CDDG (Diagnostic Guidelines) for specialists (us!) • Diagnostic descriptions for Primary care (only 28

categories) • Diagnostic descriptions for Research

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• Dr. Geoffrey Reed – a Psychologist – is in charge of the mental & behavioral disorders revision @ WHO

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• Because of low and declining reliabilities in diagnosis • ICD 11 is said to focus on Clinical Utility rather than

Validity • Research (Reed et al, 2013) done into Clinicians’

“Natural Taxonomies” of disorders • Card sort – 517 mental health professionals – 8

countries – sorted disorders into the groups where they thought they fit

• Results: “Natural Taxonomy” different than both ICD 10 and DSM IV (at the time), but consistent with ICD 11 • e.g., Clinicians do not view Body Dysmorphic

Disorder and OCD as related

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• Separate larger study (Roberts, 2012) • (n = 1371) • 64 countries across all regions of the world • found greater concordance among clinicians

worldwide than any current diagnostic system!

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• Mental & Behavioural Disorder Categories as emerging currently • Neurodevelopmental disorders • Schizophrenia and other primary psychotic disorders • Catatonia • Mood disorders • Anxiety and fear-related disorders • Obsessive-compulsive and related disorders • Disorders specifically associated with stress • Dissociative disorders • Bodily distress disorder • Feeding and eating disorders • Elimination disorders • Disorders due to Substance Use

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• Categories as emerging currently (cont.) • Impulse Control Disorders • Disruptive Behaviour and Dissocial Disorders • Personality Disorders • Paraphilic Disorders • Factitious Disorders • Neurocognitive Disorders • Psychological and behavioural factors affecting

disorders or diseases classified elsewhere • Mental and behavioural disorders associated with

disorders or diseases classified elsewhere • Sexual Dysfunctions may be moved to "Conditions

Related to Sexual Health"

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Practice with Case Vignettes

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Case #1: F32.3 Severe Depressive Episode w/ psychotic

symptoms DSM-5 ICD-10

Need ≥3 symptoms of melancholic features

No minimum # of melancholic features

Need ≥2 symptoms of atypical features

No minimum # of atypical features

Suggests significant distress and impairment in areas of social functioning

Suggests it is “unwise” to rely on social functioning as an essential criteria for the severity of depression ICD-10-CM: F32.3 Major Depressive disorder, single episode, severe with psychotic features

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ICD-10 Text

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Conversion to ICD-10-CM

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Case #2: F30.1 Manic episode w/o psychotic symptoms

DSM-5 ICD-10 Duration of 1 week Duration of 1 week

≥3 of the symptoms needs to be present; ≥4 symptoms need to be present if the mood is only irritable

No set minimum # of symptoms

Criteria C suggests individuals may be prone to hospitalization to prevent harm to self or others and may include psychotic features

Manic episode with psychotic symptoms is a completely different diagnosis

Bipolar I disorder Excludes1: bipolar disorder (F31.-) major depressive disorder, single episode (F32.-) major depressive disorder, recurrent (F33.-)

ICD-10-CM: F30.1 Manic episode without psychotic symptoms

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Case#3 F20.0 Paranoid Schizophrenia

DSM-5 ICD-10 Duration of at least 6 months including a prodromal period of 1 month

Duration of at least 3 months

Paranoid subtype does not exist Often includes paranoid delusions but may include others

Course specifiers

Excludes1: involutional paranoid state F22 Paranoia F22

ICD-10-CM: F20.0 Paranoid Schizophrenia

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ICD-10 Text

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ICD-10 Text cont.

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Case #4: F50.2 Bulimia Nervosa

DSM-5 ICD-10

Binge eating within a discrete amount of time

Binging= large amounts of food are consumed in short periods of time

Binge eating and compensatory behaviors last at least once per week for 3 months

no minimum duration of symptoms

Specify severity No severity levels Excludes1: anorexia nervosa, binge eating/purging type (F50.02) ICD-10-CM: F50.2 Bulimia nervosa

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Case #5: F60.5 Anakastic Disorder (OCPD)

DSM-5 ICD-10 Must meet ≥4 diagnostic criteria

No minimum # of symptoms

2 added features: 1. Miserly spending 2. Inability to discard warn-out

or worthless objects

ICD-10-CM: 60.5 Obsessive-compulsive Personality Disorder

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Case #6

• ICD-10: F60.31 Borderline Personality Disorder; F32.1 Moderate Depressive Episode

• ICD-10-CM: 60.3 Borderline Personality Disorder; F32.1 Major Depressive Episode, Single episode, Moderate

• DSM-5: F60.31 Borderline Personality Disorder; F32.1 Major Depressive Disorder, Single episode, moderate;

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• Broad descriptions of symptoms, development of symptoms, and patterns • Attention Deficit disorder, ODD, CD • anxiety disorders in childhood and adolescence • Post-traumatic stress • Neurasthenia

Case #6: How many did you guess correctly?

DSM-5 ICD-10 ICD-10-CM

F60.31 Borderline Personality Disorder



F32.1 Major Depressive Disorder, Single episode, moderate

F32.1 Moderate Depressive Episode

F32.1 Major Depressive Episode, Single episode, Moderate

F50.8 Binge Eating Disorder

F50.8 Other Eating Disorder

F50.8 Other Eating Disorder

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Thank you for Attending!

Any other questions?

Documents

History of ICD · • “After all, the ICD, not the Diagnostic and Statistical Manual of Mental Disorders (DSM), is the official system used across all health settings in the United