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
rder
Major
dep
ress
ive diso
rder
Avoidan
t/res
trictive fo
od in
take
diso
rder
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
rder
– 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