Disorders specifically associated with stress: A case-controlled field study for ICD-11 mental and behavioural disorders

STAIR Narrative Therapy for complex posttraumatic stress disorder: Treating sexual and gender minority trauma

BACKGROUND

Complex PTSD is a recent addition to the ICD-11 diagnostic system.

AIMS

This case study describes the delivery of Skills Training in Affective and Interpersonal Regulation and Narrative Therapy (SNT), a flexible, multi-component therapy that addresses the symptoms of complex posttraumatic stress disorder. SNT balances interventions that address current-day stressors with those that reappraise the meaning of traumatic past events. This paper outlines 16 sessions of SNT with a 55-year-old gay man.

DISCUSSION

The case analysis describes the ways in which SNT is relevant and effective in addressing the client's mulitple concerns. The skills work helped the client effectively  manage ongoing minority stress, discrimination, and micro-aggressions related to his identity as a gay man. Review and re-appraisal of his traumatic memories, which focused on the sudden death of his partner from AIDS along with discussion of events from his childhood that shaped his reactions to this loss, allowed the client to create a more integrated sense of self as well as a more compassionate view of himself. Implications regarding the relevance of SNT for sexual and gender minority individuals are discussed.

[Posttraumatic stress disorder in children and adolescents: results of a cross-sectional study on the effects of the newly formulated PTSD and CPTSD diagnoses in the ICD-11]

BACKGROUND

ICD-11 presents narrowed criteria for posttraumatic stress disorder (PTSD) and introduces complex PTSD (CPTSD) with additional difficulties in self-organization (DSO). These changes can have significant effects on the frequency of the diagnosis. The aim of this study was to investigate which ICD-11 symptom clusters cause children and adolescents to miss the diagnosis and whether caregivers are more likely to attribute changes in DSO to developmental level or to the traumatic event, and how these attributions are in turn related to symptom severity.

METHODS

N = 88 German-speaking children and adolescents (age: 7-17 years) after traumatic events and N = 79 caregivers participated between September 2019 and November 2020 in a survey on PTSD symptom severity (CATS-2) and attribution of DSO symptoms (caregiver questionnaire).

RESULTS

The ICD-11 criteria (CATS‑2 and a developmentally adapted version) showed lower frequency rates for PTSD as compared to DSM‑5 and ICD-10. The ICD-11 clusters re-experiencing and hyperarousal were met the least often. Changes in DSO symptoms were predominantly rated as event-related. This attribution was associated with higher PTSD and DSO symptom severity in caregiver reports. The age-related attribution was associated with higher DSO-symptom severity, but not PTSD symptom severity in caregiver reports.

DISCUSSION

In the context of the diagnostic process and the revision of diagnostic instruments for ICD-11 (C)PTSD, development-specific symptoms should be taken into account. The trauma-related differentiation of DSO symptom changes as compared to development-related fluctuations is challenging and therefore requires several sources of information.

Feasibility and Acceptability of a Mobile App for Prolonged Grief Disorder Symptoms

Background

Mobile apps provide a unique platform for mental health assessment and monitoring. They can provide real time, accessible data on symptoms of mental disorders that may yield rich data for detailed clinical assessment and help individuals gain insight into their current mental state. We developed one of the first apps for tracking symptoms of prolonged grief disorder.

Method

In this pilot feasibility study, we assess the feasibility and acceptability of a new mobile app mGAGE for use once a day for 3 weeks. 27 participants completed mental health assessments at t1 and t2.

Results

Adherence to the app protocol was very high with 100% for the first two weeks of use. A surprising finding was the improvement of grief symptoms at t2. Debriefing interviews revealed general qualitative categories including positive feedback, negative feedback and specific recommendations. Overall, the app was found to be feasible for use for the first two weeks and acceptable for bereaved individuals.

Conclusions

This app could provide valuable data for in depth clinical assessment, may support individuals to gain greater insight into their symptoms and may have a therapeutic effect in terms of improved grief symptoms. Implications for future studies including use in larger intervention studies are discussed.

Examining accurate diagnosis of complex PTSD in ICD-11

BACKGROUND

Complex posttraumatic stress disorder (complex PTSD), the most frequently suggested new category for inclusion by mental health professionals, has been included in the Eleventh Revision of the World Health Organization's International Classification of Diseases (ICD-11). Research has yet to explore whether clinicians' recognition of the distinct complex PTSD symptoms predicts giving the correct diagnosis. The present study sought to determine if international mental health professionals were able to accurately diagnose complex PTSD and identify the shared PTSD features and three essential diagnostic features, specific to complex PTSD.

METHODS

Participants were randomly assigned to view two vignettes and tasked with providing a diagnosis (or indicating that no diagnosis was warranted). Participants then answered a series of questions regarding the presence or absence of each of the essential diagnostic features specific to the diagnosis they provided.

RESULTS

Clinicians who recognized the presence or absence of complex PTSD specific features were more likely to arrive at the correct diagnostic conclusion. Complex PTSD specific features were significant predictors while the shared PTSD features were not, indicating that attending to each of the specific symptoms was necessary for diagnostic accuracy of complex PTSD.

LIMITATIONS

The use of written case vignettes including only adult patients and a non-representative sample of mental health professionals may limit the generalizability of the results.

CONCLUSIONS

Findings support mental health professionals' ability to accurately identify specific features of complex PTSD. Future work should assess whether mental health providers can effectively identify symptoms of complex PTSD in a clinical setting.

[Posttraumatic stress disorder clinical guidelines and treatment standards: focus on the symptoms of the psychophysiological arousal]

The article describes the main diagnostic criteria and principles of posttraumatic stress disorder (PTSD) diagnostic with the consideration of risk factors and specific clinical features. The main biomarkers search trends and existing limitations are considered. The role of the psychophysiological arousal symptoms claster is highlighted in the clinical picture of PTSD as well as in connection with the main cluster of re-experiencing symptoms activation and slowing of sanogenesis process. The necessity of PTSD detection in somatic medicine is thoroughly described. The article presents therapeutic algorithms of the latest international and Russian PTSD treatment clinical guidelines based on the individual combination of psychotherapy and psychopharmacotherapy treatment choice. Additionally the accumulated during the last decades national clinical experience of the anxiety disorders treatment, including the symptoms of psychophysiological arousal is highlighted that determined the list of the recommended drugs indicating the evidence level, in the PTSD treatment standards and guidelines. The treatment choices possibilities with the consideration of different PTSD symptoms cluster expression and comorbid states and individual case distress level specific are presented. Main evidence based psychotherapeutic methods are described.

Enhanced Skills Training in Affective and Interpersonal Regulation (ESTAIR): A New Modular Treatment for ICD-11 Complex Posttraumatic Stress Disorder (CPTSD)

ICD-11 Complex Posttraumatic Stress Disorder (CPTSD) is a relatively new condition; therefore, there is limited available evidence for its treatment. Prior to the recognition of CPTSD as a separate trauma condition, people who met criteria were often diagnosed with multiple co-morbid conditions such as PTSD, anxiety, depression, and emotional dysregulation difficulties. In the absence of a coherent evidence base, treatment tended to involve multiple treatments for these multiple conditions or lengthy phase-based interventions, often delivered in an integrative fashion, which was not standardized. In this paper, we present Enhanced Skills Training in Affective and Interpersonal Regulation (ESTAIR), a new flexible multi-modular approach for the treatment of CPTSD and its transdiagnostic symptoms. ESTAIR is consistent with trauma-informed and patient-centered care, which highlights the importance of patient choice in identification and sequencing in targeting CPTSD symptoms. Directions for future research are discussed.

A cross-sectional examination of sudden-death bereavement in university students

ObjectivesThe objective of this research was to determine the unique contributions of sudden death bereavement to the mental health of university students compared to non-sudden death bereaved university students. Methods: We surveyed 1047 bereaved university students (retention rate 92%) and compared the non-sudden death bereaved university student population to the sudden death bereaved university population on outcomes including mental health symptomatology, and complicated grief using logistic regressions. Results: Sixty two percent of the sample reported sudden death bereavement. There were no differences on measures of PTSD, generalized anxiety disorder, depression, suicidal ideation, and at-risk drinking behavior across types of bereavement. However, sudden death bereavement compared to general bereavement was associated with increased likelihood of complicated grief. Conclusions: Sudden death bereavement in university students is associated with elevated risk of complicated grief. These findings confirm previous research and provide more insight into the unique needs of university student coping with sudden loss.

Interpersonal and Intimate Violence in Mexican Youth: Drug Use, Depression, Anxiety, and Stress during the COVID-19 Pandemic

The COVID-19 pandemic may have increased interpersonal and intimate violence, harmful use of alcohol and other drugs (AODs), and mental health problems. This study uses a valid path model to describe relationships between these conditions of young Mexicans during the second year of the pandemic. A sample of 7420 Mexicans ages 18 to 24-two-thirds of whom are women-completed the Life Events Checklist, the Alcohol, Smoking, and Substance Involvement Screening Test, the Major Depressive Episode Checklist, the Generalized Anxiety Scale, and the Post-traumatic Stress Disorder (PTSD) Checklist. Young Mexicans reported higher rates of victimization and perpetration of interpersonal and intimate violence and mental health symptomatology than those noted pre- and in the first year of the pandemic. The harmful use of AOD rates were similar to those reported by adolescents before. The findings suggest asymmetric victimization and perpetration of intimate violence by gender (with women at a higher risk). More men than women have engaged in the harmful use of AODs (except for sedatives, which more women abuse). More women than men were at risk of all mental health conditions. The path model indicates that being a victim of intimate violence predicts the harmful use of tobacco, alcohol, cocaine, and sedatives, depression, anxiety, and specific PTSD symptoms (such as re-experimentation and avoidance symptoms). Being a victim of interpersonal violence resulted in severe PTSD symptoms (including avoidance, negative alterations in cognition-mood, and hyperarousal signs). The harmful use of sedatives predicted depressive symptoms. Men's victimizing intimate violence model contrasted with that of women, which included being the victim of interpersonal violence and severe PTSD symptoms. The high school youth model had three paths: victimizing intimate violence, victimizing interpersonal abuse, and sedative use, which predicted depression. Our findings could serve as the basis for future studies exploring the mechanisms that predict violence to develop cost-effective preventive programs and public policies and to address mental health conditions during community emergencies.

Case-controlled field study of the ICD-11 clinical descriptions and diagnostic requirements for Bodily Distress Disorders

AIMS

Mental disorders characterized by preoccupation with distressing bodily symptoms and associated functional impairment have been a target of major reconceptualization in the ICD-11, in which a single category of Bodily Distress Disorder (BDD) with different levels of severity replaces most of the Somatoform Disorders in ICD-10. This study compared the accuracy of clinicians' diagnosis of disorders of somatic symptoms using either the ICD-11 or ICD-10 diagnostic guidelines in an online study.

METHODS

Clinically active members of the World Health Organization's Global Clinical Practice Network (N = 1065) participating in English, Spanish, or Japanese were randomly assigned to apply ICD-11 or ICD-10 diagnostic guidelines to one of nine pairs of standardized case vignettes. The accuracy of the clinicians' diagnoses as well as their ratings of the guidelines' clinical utility were assessed.

RESULTS

Overall, clinicians were more accurate using ICD-11 compared to ICD-10 for every presentation of a vignette characterized primarily by bodily symptoms associated with distress and impairment. Clinicians who made a diagnosis of BDD using ICD-11 were generally correct in applying the severity specifiers for the condition.

LIMITATIONS

This sample may represent some self-selection bias and thus may not generalize to all clinicians. Additionally, diagnostic decisions with live patients may lead to different results.

CONCLUSIONS

The ICD-11 diagnostic guidelines for BDD represent an improvement over those for Somatoform Disorders in ICD-10 in regard to clinicians' diagnostic accuracy and perceived clinical utility.

Validation of the Persian Traumatic Grief Inventory- Self Report Plus (TGI-SR+) to Assess Prolonged Grief Severity

The Traumatic Grief Inventory-Self Report Plus (TGI-SR+) is a self-report measure to assess Prolonged Grief Disorder (PGD) in terms of ICD-11 and DSM-5-TR. Till now this measure has shown to yield good psychometric properties in Dutch and French speaking bereaved people. This study aimed to evaluate the psychometric properties of the Persian TGI-SR+. 461 individuals (280 women) fully completed the scales. The participants were recruited using convenience sampling. The Confirmatory factor analysis and concurrent validity, and reliability of the Persian version of the TGI-SR+ were evaluated. Confirmatory factor analysis results of a two-dimensional model support the construct validity of this version of the TGI-SR+, while concurrent validity was shown with significant correlations between the TGI-SR+ and measures of depression, anxiety, and ptsd. These results indicate satisfactory psychometric properties of the instrument, thus supporting the use of the TGI-SR + as a valid measure of PGD in bereaved Iranian adults.

Emerging experience with selected new categories in the ICD-11: complex PTSD, prolonged grief disorder, gaming disorder, and compulsive sexual behaviour disorder

Among the important changes in the ICD-11 is the addition of 21 new mental disorders. New categories are typically proposed to: a) improve the usefulness of morbidity statistics; b) facilitate recognition of a clinically important but poorly classified mental disorder in order to provide appropriate management; and c) stimulate research into more effective treatments. Given the major implications for the field and for World Health Organization (WHO) member states, it is important to examine the impact of these new categories during the early phase of the ICD-11 implementation. This paper focuses on four disorders: complex post-traumatic stress disorder, prolonged grief disorder, gaming disorder, and compulsive sexual behaviour disorder. These categories were selected because they have been the focus of considerable activity and/or controversy and because their inclusion in the ICD-11 represents a different decision than was made for the DSM-5. The lead authors invited experts on each of these disorders to provide insight into why it was considered important to add it to the ICD-11, implications for care of not having that diagnostic category, important controversies about adding the disorder, and a review of the evidence generated and other developments related to the category since the WHO signaled its intention to include it in the ICD-11. Each of the four diagnostic categories appears to describe a population with clinically important and distinctive features that had previously gone unrecognized as well as specific treatment needs that would otherwise likely go unmet. The introduction of these categories in the ICD-11 has been followed by a substantial expansion of research in each area, which has generally supported their validity and utility, and by a significant increase in the availability of appropriate services.

A multi-institutional study of post-traumatic stress disorder and its risk factors in Ethiopian pediatric patients with physical trauma

INTRODUCTION

Post Traumatic Stress Disorder (PTSD) was more common in children who had suffered physical trauma than in adults. Despite its prevalence, the prevalence and factors associated with PTSD in pediatric patients with physical trauma are unknown in Ethiopia. As a result, the purpose of this study was to determine the prevalence of PTSD and associated factors among pediatric patients with physical trauma who attended Northwest Amhara referral hospitals.

METHODS

An institutional-based cross-sectional study design was used in 422 pediatric patients with physical trauma aged 8-18 years from March 15 to May 15/2021. Using a systematic random sampling technique, data were collected from a sample of selected trauma patients via interviews and chart review. A standardized, pre-tested Child PTSD Symptom Scale was used to assess the severity of PTSD. Epidata 4.6 was used to enter the data, and Stata 14.0 was used to analyze it. Bivariable and multivariable binary logistic regression models were used to identify PTSD determinants.

RESULT

The study included 422 paediatric patients who had suffered physical trauma, with a response rate of 97.87 percent. PTSD was found in 22.03 percent of paediatric patients with physical trauma in Northwest Amhara referral hospitals. The study discovered that female gender (AOR = 3.04, 95 percent CI: 1.58-5.84), age of 8 to 10 years old (AOR = 3.70, 95 percent CI: 1.39-9.87), having a chronic medical illness (AOR = 5.99, 95 percent CI: 2.60-13.77), having severe pain (AOR = 3.17, 95 percent CI: 1.12-8.99), low social support (AOR = 8.97, 95 percent CI: 4.04-19 were associated with PTSD.

CONCLUSION AND RECOMMENDATION

The prevalence of PTSD was found to be high among pediatric patients who had experienced physical trauma. Special attention should be given to female patients, aged 8 to 10 years old, who have a chronic illness, for those who complain of severe pain and engaging others to provide good social support systems, are strongly recommended to alleviate PTSD in this segment of population.

Validation of the International Adjustment Disorder Questionnaire in Israel and Switzerland

The ICD-11 has introduced a new conceptualization of adjustment disorder (AjD) as a stress response syndrome with core symptoms of preoccupations and failure to adapt to the stressor. The current study aimed to assess the reliability and validity of the International Adjustment Disorder Questionnaire (IADQ) in two culturally distinct samples from Israel and Switzerland. Two samples were recruited in Israel (N = 1142) and Switzerland (N = 699) during the initial stages of the COVID-19 pandemic. Confirmatory factor analysis indicated that a correlated two-factor model provided an excellent fit to the Israeli and Swiss sample data. The IADQ scores correlated strongly with another measure of AjD symptoms, and with symptoms of depression, anxiety, acute stress, and negative emotions whereas correlations with posttraumatic stress disorder, complex posttraumatic stress disorder, and positive emotions were weaker. In the Swiss sample, 18.8% met diagnostic criteria for probable AjD and 10.2% in the Israeli sample. The current study provides the first evidence of the validity of the German and Hebrew versions of the IADQ and can be used for the screening of this debilitating condition.

[Post-traumatic stress disorder in the focus of international research: from soldier heart to ICD-11]

The article presents the evolution of the post-traumatic stress disorder (PTSD) definition from various war syndromes to PTSD definition as a sovereign disorder and complex PTSD appearance in ICD-11 as distinct diagnosis. It is focused on the epidemiology, gender issues, clinical features and differential diagnostic PTSD aspects. It is considered elaboration of the new international clinical guidelines for the anxiety disorders including PTSD, the new pharmaceutical and psychotherapeutic treatment algorithms for PTSD based on the evidence based research data is presented. Additionally as an illustration case vignette is described.

The latent structure of ICD-11 posttraumatic stress disorder (PTSD) and complex PTSD in a general population sample from USA: A factor mixture modelling approach

The validity of ICD-11 Posttraumatic Stress Disorder (PTSD) and Complex PTSD (CPTSD), as measured by the International Trauma Questionnaire (ITQ; Cloitre et al., 2018) has been supported in many factor analytic and mixture modelling studies. There is, however, a paucity of research investigating the latent structure of the ITQ using factor mixture modelling (FMM). FMM was applied to data collected from a nationally representative sample of U.S. adults (N = 1834). FMM results demonstrated strong support for a two-factor second-order model with four qualitatively distinct latent classes: a 'PTSD class', a 'CPTSD class', a 'DSO' (Disturbances in Self-Organisation) class and a 'low symptoms class'. Sexual abuse increased likelihood of membership to the 'CPTSD' (OR = 3.22) and physical abuse decreased likelihood of membership to the 'PTSD' (OR=0.51). Trauma exposure in adulthood predicted 'PTSD' and 'CPTSD' class membership. The 'CPTSD class' was characterised by higher levels of psychopathological co-morbidities and poorer psychological wellbeing compared to all other classes. Results provide additional support for the validity of PTSD and CPTSD as measured by the ITQ.

Item response model validation of the German ICD-11 International Trauma Questionnaire for PTSD and CPTSD

Background

In the 11th revision of the International Classification of Diseases (ICD-11) posttraumatic stress disorder (PTSD) and the complex variant (CPTSD) were newly conceptualised. The International Trauma Questionnaire (ITQ) was developed as a brief self-report measure to screen for both disorders. The English original version has been rigorously tested and presents convincing psychometric properties. The aim of the current study was to validate the German version by means of item response theory (IRT).

Method

This is a secondary analysis of a representative, trauma-exposed adult sample from the German general population (N = 500). 1- and 2-parameter logistic IRT models (i.e. examination on an item level), diagnostic rates and confirmatory factor analyses were calculated.

Results

All items showed good model fit and acceptable to good performance aligning with the items of the English original except for item C1 (Long time to calm down) which had a high endorsement rate and a low discriminatory power yielding low information gain. CPTSD diagnostic rate of 3.2% was lower than in comparable literature. Confirmatory factor analysis deemed the six first-order, two second-order factors model superior.

Conclusion

Measurement and factorial validity of the German version of the ITQ was confirmed. The German translation matches the English original in most psychometric properties and can thus be used for research and clinical practice.

A global field study of the international classification of diseases (ICD-11) mood disorders clinical descriptions and diagnostic guidelines

BACKGROUND

We report results of an internet-based field study evaluating the diagnostic guidelines for ICD-11 mood disorders. Accuracy of clinicians' diagnostic judgments applying draft ICD-11 as compared to the ICD-10 guidelines to standardized case vignettes was assessed as well as perceived clinical utility.

METHODS

1357 clinician members of the World Health Organization's Global Clinical Practice Network completed the study in English, Spanish, Japanese or Russian. Participants were randomly assigned to apply ICD-11 or ICD-10 guidelines to one of eleven pairs of case vignettes.

RESULTS

Clinicians using the ICD-11 and ICD-10 guidelines achieved similar levels of accuracy in diagnosing mood disorders depicted in vignettes. Those using the ICD-11 were more accurate in identifying depressive episode in recurrent depressive disorder. There were no statistically significant differences detected across classifications in the accuracy of identifying dysthymic or cyclothymic disorder. Circumscribed problems with the proposed ICD-11 guidelines were identified including difficulties differentiating bipolar type I from bipolar type II disorder and applying revised severity ratings to depressive episodes. Clinical utility of ICD-11 bipolar disorders was found to be significantly lower than for ICD-10 equivalent categories.

LIMITATIONS

Standardized case vignettes were manipulated to evaluate specific changes. The degree of accuracy of clinicians' diagnostic judgments may not reflect clinical decision-making with patients.

CONCLUSIONS

Alignment of the ICD-11 with current research appears to have been achieved without sacrificing diagnostic accuracy or clinical utility though specific training may be necessary as ICD-11 is implemented worldwide. Areas in which the ICD-11 guidelines did not perform as intended resulted in further revisions.

Acceptance and commitment therapy on perceived stress and psychological flexibility of psychiatric nurses: a randomized control trial

Background

Nursing in psychiatric wards is considered a highly stressful career due to the type of patients and the problem of communicating with them. Finding appropriate solutions to overcome this stress can improve the general health of nurses and improve their quality of work. The aim was to investigate the impact of Acceptance and Commitment Therapy (ACT) on the perceived stress (PS) and psychological flexibility (PF) of nurses in psychiatric wards.

Methods

A total of 70 nurses of Razi Psychiatric Center of Tehran were randomly selected and divided into two experimental and control groups of 35. In addition to routine interventions, the experimental group was provided with eight 2-h sessions of ACT training, whereas the control group only received routine interventions. Prior to the intervention sessions and a month after the last session, demographic information, PS scale, and Acceptance and Action Questionnaire (2nd Edition) were completed in both groups.

Results

There was a significant difference regarding the PS level (P = 0.002) and PF (P = 0.001) in the control and experimental groups; the experimental group showed lower PS and higher PF.

Conclusions

ACT can lead to reduced PS and improved PF, which can be considered as a solution to empower nurses working in psychiatric wards.

Trial registration

This was registered in Iranian Registry of Clinical Trials (IRCT) (clinical trial code: IRCT20180506039557N1. Registered 2018-10-31. Retrospectively registered,

https://en.irct.ir/trial/31040

Can Clinicians Use Dimensional Information to Make a Categorical Diagnosis of Paraphilic Disorders? An ICD-11 Field Study

BACKGROUND

The diagnosis of paraphilic disorder is a complicated clinical judgment based on the integration of information from multiple dimensions to arrive at a categorical (present/absent) conclusion. The recent update of the guidelines for paraphilic disorders in ICD-11 presents an opportunity to investigate how mental health professionals use the diagnostic guidelines to arrive at a diagnosis which thereby can optimize the guidelines for clinical use.

AIM

This study examined clinicians' ability to use the ICD-11 diagnostic guidelines for paraphilic disorders which contain multiple dimensions that must be simultaneously assessed to arrive at a diagnosis.

METHODS

The study investigated the ability of 1,263 international clinicians to identify the dimensions of paraphilic disorder in the context of written case vignettes that varied on a single dimension only.

OUTCOMES

Participants provided diagnoses for the case vignettes along with dimensional ratings of the degree of presence of five dimensions of paraphilic disorder (arousal, consent, action, distress, and risk).

RESULTS

Across a series of analyses, clinicians demonstrated a clear ability to recognize and appropriately integrate the dimensions of paraphilic disorders; however, there was some evidence that clinicians may over-diagnose non-pathological cases.

CLINICAL TRANSLATION

Clinicians would likely benefit from targeted training on the ICD-11 definition of paraphilic disorder and should be cautious of over-diagnosing.

STRENGTHS AND LIMITATIONS

This study represents a large international sample of health professionals and is the first to examine clinicians' ability to apply the ICD-11 diagnostic guidelines for paraphilic disorders. Important limitations include not generalizing to all clinicians and acknowledging that results may be different in direct clinical interactions vs written case vignettes.

CONCLUSION

These results indicate that clinicians appear capable of interpreting and implementing the diagnostic guidelines for paraphilic disorders in ICD-11.

Changes from ICD-10 to ICD-11 and future directions in psychiatric classification

This article provides a brief overview of the changes from ICD-10 to ICD-11 regarding the classification of mental, behavioral, or neurodevelopmental disorders. These changes include a new chapter structure, new diagnostic categories, changes in diagnostic criteria, and steps towards dimensionality. Additionally, we review evaluative field studies of ICD-11, which provide preliminary evidence for higher reliability and clinical utility of ICD-11 compared with ICD-10. Despite the extensive revision process, changes from ICD-10 to ICD-11 were relatively modest in that both systems are categorical, classifying mental phenomena based on self-reported or clinically observable symptoms. Other recent approaches to psychiatric nosology and classification (eg, neurobiology-based or hierarchical) are discussed. To meet the needs of different user groups, we propose expanding the stepwise approach to diagnosis introduced for some diagnostic categories in ICD-11, which includes categorical and dimensional elements.


Beyond the DSM-5 Diagnoses: A Cross-Cultural Approach to Assessing Trauma Reactions

Although trauma exposure is a global phenomenon, trauma reactions vary considerably across cultures. Western psychiatric diagnoses, such as posttraumatic stress disorder (PTSD), may be limited in capturing the breadth of trauma reactions in cross-cultural contexts. Instead, cross-cultural instruments should examine locally relevant reactions, such as idioms of distress and explanatory models of illness, and account for ongoing stress and adversity. This article explains the need for complementing traditional trauma assessment approaches, how to create culturally sensitive instruments, the style and stance of practicing cultural humility when administering instruments, how to account for ongoing trauma and adversity, and ways to incorporate findings into treatment. These steps can improve culturally sensitive and comprehensive trauma assessment to capture universal and culturally relevant trauma reactions.

Reliability and Validity of a German Standardized Diagnostic Interview Module for ICD-11 Adjustment Disorder

The ICD-11 includes a new definition of adjustment disorder (AjD). The present study aimed to examine interrater reliability, internal consistency, and construct validity of a new diagnostic interview module to assess ICD-11 AjD. Data from two studies that used a standardized diagnostic interview assessment (i.e., DIA-X/M-CIDI and updated DIA-X-5) were used. For interrater reliability, agreement indicators (i.e., κ) were calculated using data from the DIA-X-5 test-retest study (N = 60). To examine internal consistency and construct validity, Cronbach's alpha values and the Kuder-Richardson correlation coefficient were computed along with confirmatory factor and latent class analyses (LCA), using data from the Zurich Adjustment Disorder Study (N = 330). Interrater reliability analyses found an adjusted kappa of 0.807 for the ICD-11 AjD diagnosis. Few items from the impairment criterion of the diagnostic algorithm performed poorly. The internal consistency was acceptable, Cronbach's αs = .43-.80; the lower-bound estimate resulted from the two-item preoccupation symptom pattern. However, both items were significantly associated, OR = 3.14, 95% CI [1.97, 4.99]. Regarding LCA results, a two-class model was favored. We found that 94.3% of all ICD-11 AjD cases belonged to Class 2, OR = 23.69, 95% CI [7.15, 79.54], which was associated with subjectively rated distress, OR = 2.18, 95% CI [1.57, 3.02], and the external measure of the Brief Symptom Inventory global severity index, OR = 2.18, 95% CI [1.57, 3.02]. Overall, the new AjD interview module provided a reliable, valid assessment of the ICD-11 diagnosis; confirmation by other studies is needed.

Examination of the new ICD-11 prolonged grief disorder guidelines across five international samples

Background

Prolonged grief disorder (PGD) is a new disorder included in the 11th edition of the International classification of diseases (ICD-11). An important remit of the new ICD-11 is the global applicability of the mental health disorder guidelines or definitions. Although previous definitions and descriptions of disordered grief have been assessed worldwide, this new definition has not yet been systematically validated.

Method

Here we assess the validity and applicability of core items of the ICD-11 PGD across five international samples of bereaved persons from Switzerland (N = 214), China (N = 325); Israel (N = 544), Portugal (N = 218) and Ireland (N = 830).

Results

The results confirm that variation in the diagnostic algorithm for PGD can greatly impact the rates of disorder within and between international samples. Different predictors of PGD severity may be related to sample differences. Finally, a threshold for diagnosis of clinically relevant PGD symptoms using a new scale, the International Prolonged Grief Disorder Scale (IPGDS), in three samples was confirmed.

Conclusions

Although this study was limited by lack of questionnaire data points across all five samples, the findings for the diagnostic threshold and algorithm iterations have implications for clinical use of the new ICD-11 PGD criteria worldwide.

The first study to explore core items of the ICD-11 PGD definition in five large international samples

Comparison of three different diagnostic algorithms

Preliminary analysis of different thresholds for diagnosis in different groups

Preliminary estimates of PGD prevalence

Development of the new CPTSD diagnosis for ICD-11

BACKGROUND

The diagnosis of complex post-traumatic stress disorder (CPTSD) was proposed several decades ago by scientist-practitioners, almost parallel to the first description of the diagnosis of post-traumatic stress disorder (PTSD). In the previous International Classification of Diseases, version 10 (ICD-10) issued by the World Health Organization (WHO), this symptom constellation was termed 'enduring personality change after catastrophic experience'. This diagnosis has not been clinically influential, nor has it been subjected to much research. Thus, in a multi-stage process of ICD-11 development, the diagnosis of CPTSD was developed.

METHODS

This paper provides a review of the historical lines of development that led to the CPTSD diagnosis, as well as the results since the ICD-11 publication in 2018.

RESULTS

The CPTSD diagnosis comprises the core symptoms of the - newly, narrowly defined - PTSD diagnosis, the three symptom groups of affective, relationship, and self-concept changes. The diagnosis is clinically easy to use in accordance with the WHO development goals for the ICD-11 and has shown good psychodiagnostic properties in various studies, including good discrimination from personality disorder with borderline pattern.

CONCLUSION

The scholarly use of the new diagnosis has resulted in an increasing number of published studies on this topic in the diagnostic and therapeutic fields.

Time elapsed since loss or grief persistency? Prevalence and predictors of ICD-11 prolonged grief disorder using different applications of the duration criterion

BACKGROUND

Prolonged grief disorder (PGD), included in the ICD-11, encompasses a six-month duration criterion, but whether this covers 'time since loss' or 'grief persistency' is unclear. The study estimated prevalence and predictors of probable ICD-11 PGD using different applications of the duration criterion.

METHODS

A register-sampled cohort of bereaved spouses completed self-report questionnaires at two (T1, N=847), six (T2, N=777), and eleven months (T3, N=753) post-loss. The duration criterion was operationalized as single-point PGD (meeting criteria minimally six months post-loss; T2 or T3) and dual-point PGD (meeting criteria at two assessments separated by months; T1+T2 or T2+T3).

RESULTS

Single-point PGD prevalence rates (~15-20%) were significantly higher than dual-point prevalence rates (~10%). While single assessments of PGD varied between T2 and T3, the dual-point prevalence rates did not significantly differ. Early probable grief caseness emerged as the strongest predictor for later PGD.

LIMITATIONS

Without a structured clinical interview, only probable cases of PGD were identified. Caseness relied on a diagnostic algorithm, created by mapping items from different self-report questionnaires. Time frames between assessments did not cover an entire six-month period.

CONCLUSIONS

Momentarily assessed, six-month PGD symptomatology may represent a fluctuating, but remitting grief process for some individuals. Further research could test whether multiple diagnostic indicators during the first year of bereavement improve the identification of genuinely prolonged grief reactions.

Complex PTSD: what is the clinical utility of the diagnosis?

BACKGROUND

The diagnosis of complex posttraumatic stress disorder (CPTSD) was included in the 11th revised edition of the International Classification of Diseases (ICD-11). CPTSD shares trauma-specific symptoms with its sibling disorder PTSD but is additionally characterized by disturbances of the individual's self-organization (DSO). The clinical utility of the CPTSD diagnosis has yet to be thoroughly investigated.

OBJECTIVE

The current study aimed to examine the clinical utility of the CPTSD diagnosis, considering the upcoming implementation of ICD-11 in clinical practice.

METHOD

International field studies, construct- and validity analyses leading up to the inclusion in ICD-11 are reviewed, and the diagnostic measures; International Trauma Questionnaire (ITQ) and International Trauma Interview (ITI) are presented. Also, the relationship between CPTSD and borderline personality disorder (BPD) is elaborated in an independent analysis, to clarify their differences in clinical relevance to treatment. Treatment implications for CPTSD are discussed with reference to existing guidelines and clinical needs.

RESULTS

The validation of ITQ and ITI contributes to the cementation of CPTSD in further clinical practice, providing qualified assessment of the construct, with intended informative value for both clinical communication and facilitation of treatment. CPTSD is found distinguishable from both PTSD and BPD in empirical studies, while the possibility of comorbid BPD/PTSD cases being better described as CPTSD is acknowledged. Practitioners need to employ well-established methods developed for PTSD, while considering additional DSO-symptoms in treatment of CPTSD.

CONCLUSIONS

The inclusion of CPTSD in ICD-11 may potentially facilitate access to more tailored treatment interventions, as well as contribute to increased research focus on disorders specifically associated with stress. The clinical utility value of this additional diagnosis is expected to reveal itself further after ICD-11 is implemented in clinical practice in 2022 and onwards. Yet, CPTSD's diagnostic inclusion gives future optimism to assessing and treating complex posttraumatic stress symptoms.

The revision of the categories of mood, anxiety and stress-related disorders in the ICD-11: a perspective from the Arab region

Background

The World Health Organization estimates that 75% of patients with mental and substance use disorders in low- and middle-income countries do not have access to the care needed. In the Arab World, approximately 100–140 million people suffer from at least one psychiatric disorder. One main criticism of classification systems has been their lack of cultural sensitivity. The International Classification of Diseases, 11th edition aims to improve clinical utility of psychiatric classification across cultures. Mood, anxiety and stress-related disorders are the most common psychiatric manifestations and the most impacted by cultural factors.

Main body

Relying on rigorous field testing, including in three Arab countries, clinically meaningful changes have been introduced in the International Classification of Diseases 11. These include new disorders such as complex post-traumatic stress disorder and prolonged grief disorder. In classifying mood episodes, the pattern of symptoms over time is emphasized. Disorders associated with anxiety provide the basis for a new grouping separate from obsessive-compulsive-related disorders. Lastly, culture and its impact are incorporated into each diagnostic grouping.

Conclusions

This latest version of the International Classification of Diseases prioritizes addressing gaps in the validity and reliability of psychiatric classification. The methodology adopted in this latest revision is encouraging and opens the way to truly global collaboration on refining psychiatric diagnoses and practice.

Cross-cultural generalizability of the ICD-11 PGD symptom network: Identification of central symptoms and culturally specific items across German-speaking and Chinese bereaved

BACKGROUND

Prolonged grief disorder (PGD) is a newcomer to psychopathology and the new ICD-11 diagnostic criteria are conceptualized with an eye towards global applicability. Yet, previous network studies have not used official ICD-11 criteria nor tested whether network structures generalize across cultural groups even though much current research relies on ICD-11 PGD criteria.

METHODS

To overcome these limitations, the present study used data from 539 German-speaking (n = 214) and Chinese (n = 325) bereaved individuals to investigate similarities and differences in network structures of ICD-11 PGD criteria. In addition, network structures were investigated for an expanded supplementary questionnaire of culturally-bound grief symptoms hypothesized to be of relevance in each cultural context.

RESULTS

Results suggested both similarities and differences in network structures between the two samples. Across cultural groups, intense feelings of sorrow and inability to experience joy or satisfaction since the death emerged as most central symptoms. Compared to the standard PGD network, the expanded network showed a better average predictability for Chinese participants, but no improvement for the German-speaking context. Unhealthy behavior change was the most central symptom for Chinese bereaved when additional grief symptoms were included.

CONCLUSIONS

Results of the present study suggest there are culturally-bound symptoms of grief which are not included in the current ICD-11 PGD criteria. These findings provide areas of special clinical attention concerning screening and treatment and present a first step towards a more cultural-sensitive understanding of grief.

CLINICAL TRIALS

NCT03568955.

Measuring stress in clinical and nonclinical subjects using a German adaptation of the Perceived Stress Scale

Background/Objective: Stress is perceived differently across individuals, which might be particularly true for nonclinical and clinical subjects. For this reason, we tested a German adaption of the 10-item Perceived Stress Scale (PSS-10) for model fit and measurement invariance in a big nonclinical and clinical sample. Method: We (1) conducted multiple confirmatory factor analysis (CFA) in 1,248 nonclinical subjects and 575 outpatients, (2) measurement invariance with multigroup CFA, (3) assessed correlations with relevant constructs and (4) calculated internal consistencies for overall stress and the subscales Helplessness and Self-efficacy. Results: In both samples, CFA revealed a robust two-factorial structure with an excellent model fit. Group comparisons revealed strict measurement invariance. Correlations with associated measures support validity. Internal consistencies were good to very good. Conclusions: We show highly satisfactory psychometric properties of the German PSS-10 for nonclinical and clinical individuals. Measurement invariance analyses demonstrated that varying stress levels of people with a different mental health status are due to true interindividual differences.

Anxiety and Fear-Related Disorders in the ICD-11: Results from a Global Case-controlled Field Study

BACKGROUND

This article reports the results of one of a series of global field studies implemented by the World Health Organization (WHO) to evaluate the accuracy, clinical utility, and global applicability of the new diagnostic guidelines for Mental, Behavioural and Neurological Disorders included in the next version of WHO's International Classification of Diseases (ICD-11).

AIMS OF THE STUDY

The purpose of this study was to compare the diagnostic accuracy and clinical utility ratings of global clinicians implementing the ICD-11 diagnostic guidelines for Anxiety and Fear-Related Disorders, relative to those applying ICD-10 guidelines. The study also aimed to identify elements of the guidelines that required further refinement or clarification.

METHODS

1840 global mental health professionals registered with WHO's Global Clinical Practice Network completed the study in one of six study languages. Participants were randomly assigned to apply either the ICD-11 or ICD-10 guidelines to diagnose standardized case vignettes, and to rate the clinical utility of their assigned guidelines.

RESULTS

ICD-11's diagnostic accuracy and clinical utility were equivalent or superior to that of ICD-10. Global clinicians were significantly more accurate in diagnosing Generalized Anxiety Disorder, Specific Phobia and adult cases of Separation Anxiety Disorder when using ICD-11 and provided high clinical utility ratings for these disorders. Clinicians also found the ICD-11 guidelines easy to use, clear, and a good fit to patients they see in their clinical practice. However, clinicians had difficulty with distinguishing the boundary between disorder and normality for subthreshold cases of anxiety, and also with applying the new ICD-11 guidelines on panic attacks.

CONCLUSIONS

The new diagnostic guidelines for Anxiety Disorders in ICD-11 can be applied in an acceptably consistent manner by global clinicians and perform as well or better than the previous guidelines for ICD-10. Study findings also helped identify aspects of the ICD-11 guidelines that required refinement prior to their publication and areas that should be emphasized in training programs.

Optimizing the clinical utility of four proposed criteria for a persistent and impairing grief disorder by emphasizing core, rather than associated symptoms

BACKGROUND

Distinguishing a disorder of persistent and impairing grief from normative grief allows clinicians to identify this often undetected and disabling condition. As four diagnostic criteria sets for a grief disorder have been proposed, their similarities and differences need to be elucidated.

METHODS

Participants were family members bereaved by US military service death (N = 1732). We conducted analyses to assess the accuracy of each criteria set in identifying threshold cases (participants who endorsed baseline Inventory of Complicated Grief ⩾30 and Work and Social Adjustment Scale ⩾20) and excluding those below this threshold. We also calculated agreement among criteria sets by varying numbers of required associated symptoms.

RESULTS

All four criteria sets accurately excluded participants below our identified clinical threshold (i.e. correctly excluding 86-96% of those subthreshold), but they varied in identification of threshold cases (i.e. correctly identifying 47-82%). When the number of associated symptoms was held constant, criteria sets performed similarly. Accurate case identification was optimized when one or two associated symptoms were required. When employing optimized symptom numbers, pairwise agreements among criteria became correspondingly 'very good' (κ = 0.86-0.96).

CONCLUSIONS

The four proposed criteria sets describe a similar condition of persistent and impairing grief, but differ primarily in criteria restrictiveness. Diagnostic guidance for prolonged grief disorder in International Classification of Diseases, 11th Edition (ICD-11) functions well, whereas the criteria put forth in Section III of Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) are unnecessarily restrictive.

Mental, behavioral and neurodevelopmental disorders in the ICD-11: an international perspective on key changes and controversies

An update of the chapter on Mental, Behavioral and Neurodevelopmental Disorders in the International Classification of Diseases and Related Health Problems (ICD) is of great interest around the world. The recent approval of the 11th Revision of the ICD (ICD-11) by the World Health Organization (WHO) raises broad questions about the status of nosology of mental disorders as a whole as well as more focused questions regarding changes to the diagnostic guidelines for specific conditions and the implications of these changes for practice and research. This Forum brings together a broad range of experts to reflect on key changes and controversies in the ICD-11 classification of mental disorders. Taken together, there is consensus that the WHO's focus on global applicability and clinical utility in developing the diagnostic guidelines for this chapter will maximize the likelihood that it will be adopted by mental health professionals and administrators. This focus is also expected to enhance the application of the guidelines in non-specialist settings and their usefulness for scaling up evidence-based interventions. The new mental disorders classification in ICD-11 and its accompanying diagnostic guidelines therefore represent an important, albeit iterative, advance for the field.

When does grief become pathological? Evaluation of the ICD-11 diagnostic proposal for prolonged grief in a treatment-seeking sample

Background: Prolonged grief disorder (PGD) will be newly included in the ICD-11, while a clinically similar diagnosis, persistent complex bereavement disorder (PCBD), has already been added to the DSM-5. Only few studies have evaluated these criteria-sets for prolonged grief. Objective: The aim of this study was to evaluate the ICD-11 accessory symptom threshold and compare the diagnostic performance of the two criteria-sets in treatment-seeking bereaved persons. Method: 113 grief treatment-seeking bereaved persons completed the Interview for Prolonged Grief-13. We used receiver operator characteristic analysis to determine an optimum ICD-11 accessory symptom threshold. We calculated diagnostic rates for PGD and PCBD and examined associations of PGD and PCBD caseness with concurrently assessed psychopathology and prolonged grief symptoms assessed one month later. Results: An ICD-11 threshold of six accessory symptoms distinguished optimally between interview-diagnosed participants with and without prolonged grief. The prevalence of PGD (69%) was significantly higher than that of PCBD (48%) and of PGD with a 6-symptom threshold (47%). PGD caseness was associated with the relation to the deceased, 6-symptom threshold PGD and PCBD caseness with the time since loss. All criteria-sets were linked to concurrent prolonged grief, depression, and general mental distress. PCBD and 6-symptom threshold PGD but not PGD were associated with prolonged grief severity one month later. Conclusions: The results support the validity of PGD and PCBD but, at the same time, they provide further support for differing prevalence rates. Using an empirically determined ICD-11 accessory symptom threshold could prevent the pathologisation of grief reactions.

Clinical Utility and Global Applicability of Prolonged Grief Disorder in the ICD-11 from the Perspective of Chinese and German-Speaking Health Care Professionals

BACKGROUND

Prolonged grief disorder (PGD) is included in the ICD-11 (11th edition of the International Classification of Diseases). The new PGD criteria reflect the requirements and recommendations of the World Health Organization for improved clinical utility and international applicability. Even though the ICD classification system is globally used, no research has investigated how healthcare professionals (HP) in non-Western countries may adopt this change for their own practice.

OBJECTIVE

The present study explored the extent to which the new PGD criteria were accepted and perceived to meet the standards for clinical utility and international applicability among Chinese and German-speaking HP.

METHODS

Individual semistructured interviews were conducted in person, by phone, or online (e.g., via Skype), with 24 Chinese (n = 10) and German-speaking (n = 14) HP working with bereaved populations in China and Switzerland, and analyzed using a qualitative framework analysis. Questions included "what items are currently missing from the PGD criteria?".

RESULTS

Across all HP, the majority supported the inclusion of PGD and were generally aligned with the current criteria. HP found that the criteria distinguished between normal and abnormal grief and considered the criteria easy to use if their modifications were considered. Merits included, among others, improved clinical decision making, research promotion, and social acknowledgment. Main concerns included misdiagnosis, pathologization, and a lack of specificity of criteria. The importance of international applicability was emphasized across Chinese and German-speaking HP. Different grief-specific symptoms were identified by German-speaking and Chinese HP.

CONCLUSIONS

These findings provide evidence for the clinical utility and international applicability of ICD-11 PGD criteria among German-speaking and Chinese HP, as well as cultural similarities and differences in the barriers to implementation of these criteria.

Treating Adults With Complex Posttraumatic Stress Disorder Using a Modular Approach to Treatment: Rationale, Evidence, and Directions for Future Research

ICD-11 complex PTSD (CPTSD) is a new condition, and, therefore, there are as yet no clinical trials evaluating interventions for its treatment. In this paper, we provide the rationale for a flexible multimodular approach to the treatment of CPTSD, its feasibility, and some evidence suggesting its potential benefits. The approach highlights flexibility in the selection of empirically supported interventions (or a set of interventions) and the order of delivery based on symptoms that are impairing, severe, and of relevance to the patient. The approach has many potential benefits. It can incorporate the use of interventions for which there is already evidence of efficacy allowing the leveraging of past scientific efforts. It is also consistent with patient-centered care, which highlights the importance of patient choice in identification of the problems to target, interventions to select, and outcomes to monitor. Researchers on modular treatments of other disorders have found that, compared to disorder-specific manualized protocols, flexible multimodular treatment programs are superior in resolving identified problems and are associated with greater therapist satisfaction and reduced patient burden. We briefly identify types of interventions that have been successful in treating trauma-exposed populations as well as emerging interventions that are relevant to the particular problems associated with exposure to complex trauma. We conclude with examples of how such treatments can be organized and tested. Research is now urgently needed on the effectiveness of existing and new intervention approaches to ICD-11 CPTSD treatment.

ZIEL: Internet-Based Self-Help for Adjustment Problems: Results of a Randomized Controlled Trial

Adjustment Disorder (AjD) represents a healthcare paradox. On the one hand, it is one of the most diagnosed mental disorders worldwide. On the other hand, AjD and its possible treatment options remain a severely neglected field of research. In this context, we developed a self-guided online intervention for adjustment problems, named ZIEL, and tested its efficacy. It is based on and extends a bibliotherapeutic treatment approach for symptoms of AjD. In our study, a total of 98 individuals who had experienced a life event in the last two years, were randomly assigned to care as usual (CAU) or an online intervention group (CAU + online intervention). The primary endpoint was AjD symptom severity measured by Adjustment Disorder–New Module 20 (ADNM-20). Secondary endpoints were depressive symptoms, quality of life and other variables such as satisfaction and usability. Both the intervention and the control group improved comparably well regarding the severity of adjustment disorder symptoms post-treatment. However, participants in the intervention group showed significantly fewer depressive symptoms and a significantly higher quality of life (Cohen’s d: 0.89 (BDI) and −0.49 (SF-12)). The intervention was well-received by users with an above average usability rating. Overall, the results suggest that the ZIEL intervention has the promise to contribute to the treatment of AjD and reduce symptom burden by means of a scalable low-barrier approach.

Legal and Policy Implications in Mexico of Changes in ICD-11 Paraphilic Disorders

INTRODUCTION

The World Health Organization (WHO) has made substantial changes to the classification of paraphilic disorders for the Eleventh Revision of the International Classification of Diseases and Related Health Problems (ICD-11), recently approved by the World Health Assembly. The most important is to limit paraphilic disorders primarily to persistent and intense patterns of atypical sexual arousal involving non-consenting individuals, manifested through persistent sexual thoughts, fantasies, urges, or behaviors, that have resulted in action or significant distress.

AIM

To analyze the legal, regulatory, and policy implications of the changes in the ICD-11 classification of paraphilic disorders for forensic practice, health systems, adjudication of sex offenders, and the provision of treatment in Mexico.

METHODS

An expert Mexican advisory group was appointed to conduct this evaluation following an assessment guide provided by the WHO.

MAIN OUTCOME MEASURES

The WHO assessment guide covered (i) laws related to sexual behaviors; (ii) the relationship between legal and clinical issues for non-forensic health professionals; (iii) implications of mental disorder classification for forensic practice; (iv) other implications of ICD-11 paraphilic disorders proposals; and (v) contextual issues.

RESULTS

A variety of factors in Mexico make it highly unlikely that appropriate, evidence-based treatments for paraphilic disorders will be provided to those who need them, even if they seek treatment voluntarily and have not committed a crime. Mexican law focuses on the punishment of specific sexual behaviors rather than on underlying disorders. A paraphilic disorder would not be considered sufficient grounds for exemption from criminal responsibility. The application and scope of mental health evaluations in Mexican legal proceedings are quite limited, and individuals who commit sexual crimes almost never undergo forensic evaluations to establish the presence of paraphilic disorders. Psychiatric services may be mandated for sex offenders in highly specific circumstances but cannot exceed the duration of the criminal sentence.

CLINICAL IMPLICATIONS

Evaluation and treatment guidelines should be developed based on international evidence and standards and promulgated for use with individuals with paraphilic disorders in forensic and non-forensic poopulations. The much greater specificity and operationalization of the ICD-11 guidelines as compared with the ICD-10 guidelines provide a better basis for identification and case formulation.

STRENGTHS & LIMITATIONS

Major strengths of this analyses were that it was conducted to facilitate international comparability across several participating countries and the fact that it was conducted by a diverse multidisciplinary group representing various relevant legal, forensic and and clinical sectors. A limitation was that it was only possible to examine relevant federal laws and those of Mexico City rather than those of all 32 Mexican states.

CONCLUSION

The descriptions of paraphilic disorders in the ICD-11 could support substantial improvements in the treatment of individuals with paraphilic disorders and the adjudication of sex offenders in Mexico, but specific changes in Mexican law would be required. Martínez-López JNI, Robles R, Fresán A, et al. Legal and Policy Implications in Mexico of Changes in ICD-11 Paraphilic Disorders. J Sex Med 2019;16:1623-1637.

Risk factors and comorbidity of ICD-11 PTSD and complex PTSD: Findings from a trauma-exposed population based sample of adults in the United Kingdom

BACKGROUND

Following the recently published 11th version of the WHO International Classification of Diseases (ICD-11), we sought to examine the risk factors and comorbidities associated with posttraumatic stress disorder (PTSD) and complex PTSD (CPTSD).

METHOD

Cross-sectional and retrospective design. The sample consisted of 1,051 trauma-exposed participants from a nationally representative panel of the UK adult population.

RESULTS

A total of 5.3% (95% confidence interval [CI] = 4.0-6.7%) met the diagnostic criteria for PTSD and 12.9% (95% CI = 10.9-15.0%) for CPTSD. Diagnosis of PTSD was independently associated with being female, being in a relationship, and the recency of traumatic exposure. CPTSD was independently associated with younger age, interpersonal trauma in childhood, and interpersonal trauma in adulthood. Growing up in an urban environment was associated with the diagnosis of PTSD and CPTSD. High rates of physical and mental health comorbidity were observed for PTSD and CPTSD. Those with CPTSD were more likely to endorse symptoms reflecting major depressive disorder (odds ratio [OR] = 21.85, 95 CI = 12.51-38.04) and generalized anxiety disorder (OR = 24.63, 95 CI = 14.77-41.07). Presence of PTSD (OR = 3.13, 95 CI = 1.81-5.41) and CPTSD (OR = 3.43, 95 CI = 2.37-4.70) increased the likelihood of suicidality by more than three times. Nearly half the participants with PTSD and CPTSD reported the presence of a chronic illness.

CONCLUSIONS

CPTSD is a more common, comorbid, debilitating condition compared to PTSD. Further research is now required to identify effective interventions for its treatment.

Complex post-traumatic stress disorder: a new diagnosis in ICD-11

The World Health Organization's proposals in ICD-11, released for comment by member states in 2018, introduce for the first time in a major diagnostic system a distinction between post-traumatic stress disorder (PTSD) and complex post-traumatic stress disorder (CPTSD). This article sets the new diagnosis of CPTSD within the context of previous similar formulations, describes its definition and requirements, and reviews the evidence concerning its epidemiology, differential diagnosis, assessment and treatment.

The factor structure of complex PTSD in combat-exposed Filipino soldiers

The World Health Organization recently released the 11th revision of the International Classification of Diseases with the inclusion of Complex Posttraumatic Stress Disorder (CPTSD). Despite the emerging research examining the symptom structure of CPTSD, to date, none so far have reached consensus on what best represents CPTSD, particularly in soldiers who are exposed regularly in combat situations. This study examined seven latent CPTSD models in a sample of Filipino combat-exposed soldiers (n = 450). Results of confirmatory factor analyses indicated that the correlated 6 factor first-order model (model 2), comprising of re-experiencing, avoidance, persistent sense of current threat, affective dysregulation, negative self-concept, and disturbances in relationships, has the best fit. These findings have implications for understanding CPTSD as a diagnostic entity and provide information on the assessment and crafting of complex trauma interventions, particularly among Filipino combat-exposed soldiers.

The classification of feeding and eating disorders in the ICD-11: results of a field study comparing proposed ICD-11 guidelines with existing ICD-10 guidelines

BACKGROUND

The World Health Organization (WHO) International Classification of Diseases and Related Health Problems (ICD) is used globally by 194 WHO member nations. It is used for assigning clinical diagnoses, providing the framework for reporting public health data, and to inform the organization and reimbursement of health services. Guided by overarching principles of increasing clinical utility and global applicability, the 11th revision of the ICD proposes major changes that incorporate empirical advances since the previous revision in 1992. To test recommended changes in the Mental, Behavioral, and Neurodevelopmental Disorders chapter, multiple vignette-based case-controlled field studies have been conducted which examine clinicians' ability to accurately and consistently use the new guidelines and assess their overall clinical utility. This manuscript reports on the results from the study of the proposed ICD-11 guidelines for feeding and eating disorders (FEDs).

METHOD

Participants were 2288 mental health professionals registered with WHO's Global Clinical Practice Network. The study was conducted in Chinese, English, French, Japanese, and Spanish. Clinicians were randomly assigned to apply either the ICD-11 or ICD-10 diagnostic guidelines for FEDs to a pair of case vignettes designed to test specific clinical questions. Clinicians selected the diagnosis they thought was correct for each vignette, evaluated the presence of each essential feature of the selected diagnosis, and the clinical utility of the diagnostic guidelines.

RESULTS

The proposed ICD-11 diagnostic guidelines significantly improved accuracy for all FEDs tested relative to ICD-10 and attained higher clinical utility ratings; similar results were obtained across all five languages. The inclusion of binge eating disorder and avoidant-restrictive food intake disorder reduced the use of residual diagnoses. Areas needing further refinement were identified.

CONCLUSIONS

The proposed ICD-11 diagnostic guidelines consistently outperformed ICD-10 in distinguishing cases of eating disorders and showed global applicability and appropriate clinical utility. These results suggest that the proposed ICD-11 guidelines for FEDs will help increase accuracy of public health data, improve clinical diagnosis, and enhance health service organization and provision. This is the first time in the revision of the ICD that data from large-scale, empirical research examining proposed guidelines is completed in time to inform the final diagnostic guidelines.

Prolonged grief disorder: clinical utility of ICD-11 diagnostic guidelines

BACKGROUND

The World Health Organization (WHO) International Classification of Disease (ICD-11) is expected to include a new diagnosis for prolonged grief disorder (ICD-11PGD). This study examines the validity and clinical utility of the ICD-11PGD guideline by testing its performance in a well-characterized clinical sample and contrasting it with a very different criteria set with the same name (PGDPLOS).

METHODS

We examined data from 261 treatment-seeking participants in the National Institute of Mental Health (NIMH)-sponsored multicenter clinical trial to determine the rates of diagnosis using the ICD-11PGD guideline and compared these with diagnosis using PGDPLOS criteria.

RESULTS

The ICD-11PGD guideline identified 95.8% [95% confidence interval (CI) 93.3-98.2%] of a treatment-responsive cohort of patients with distressing and impairing grief. PGDPLOS criteria identified only 59.0% (95% CI 53.0-65.0%) and were more likely to omit those who lost someone other than a spouse, were currently married, bereaved by violent means, or not diagnosed with co-occurring depression. Those not diagnosed by PGDPLOS criteria showed the same rate of treatment response as those who were diagnosed.

CONCLUSIONS

The ICD-11PGD diagnostic guideline showed good performance characteristics in this sample, while PGDPLOS criteria did not. Limitations of the research sample used to derive PGDPLOS criteria may partly explain their poor performance in a more diverse clinical sample. Clinicians and researchers need to be aware of the important difference between these two identically named diagnostic methods.

Innovations and changes in the ICD-11 classification of mental, behavioural and neurodevelopmental disorders

Following approval of the ICD-11 by the World Health Assembly in May 2019, World Health Organization (WHO) member states will transition from the ICD-10 to the ICD-11, with reporting of health statistics based on the new system to begin on January 1, 2022. The WHO Department of Mental Health and Substance Abuse will publish Clinical Descriptions and Diagnostic Guidelines (CDDG) for ICD-11 Mental, Behavioural and Neurodevelopmental Disorders following ICD-11's approval. The development of the ICD-11 CDDG over the past decade, based on the principles of clinical utility and global applicability, has been the most broadly international, multilingual, multidisciplinary and participative revision process ever implemented for a classification of mental disorders. Innovations in the ICD-11 include the provision of consistent and systematically characterized information, the adoption of a lifespan approach, and culture-related guidance for each disorder. Dimensional approaches have been incorporated into the classification, particularly for personality disorders and primary psychotic disorders, in ways that are consistent with current evidence, are more compatible with recovery-based approaches, eliminate artificial comorbidity, and more effectively capture changes over time. Here we describe major changes to the structure of the ICD-11 classification of mental disorders as compared to the ICD-10, and the development of two new ICD-11 chapters relevant to mental health practice. We illustrate a set of new categories that have been added to the ICD-11 and present the rationale for their inclusion. Finally, we provide a description of the important changes that have been made in each ICD-11 disorder grouping. This information is intended to be useful for both clinicians and researchers in orienting themselves to the ICD-11 and in preparing for implementation in their own professional contexts.

ICD-11 PTSD and complex PTSD amongst Syrian refugees in Lebanon: the factor structure and the clinical utility of the International Trauma Questionnaire

OBJECTIVE

Support for ICD-11 post-traumatic stress disorder (PTSD) and complex PTSD (CPTSD) is growing; however, few studies include refugees or examine the clinical utility of PTSD/CPTSD classifications. This study sought to provide the first evaluations of (i) the factor structure of ICD-11 PTSD/CPTSD amongst refugees in the Middle East; and (ii) the clinical utility of the International Trauma Questionnaire (ITQ) to identify PTSD/CPTSD in a humanitarian context.

METHOD

Participants were 112 treatment-seeking Syrian refugees living in Lebanon. Factorial validity was assessed using confirmatory factor analysis (CFA) based on responses to the ITQ. Clinical utility of the ITQ was assessed through semi-structured interviews with six Lebanese psychotherapists.

RESULTS

Complex PTSD (36.1%) was more common than PTSD (25.2%), and no sex or age differences were observed at the prevalence or symptomatic levels. CFA results supported a two-factor higher-order model consistent with ICD-11 PTSD/CPTSD. Qualitative findings indicated that the ITQ is generally positively regarded, with some limitations and suggested modifications noted.

CONCLUSION

This is the first study to support the ICD-11 PTSD/CPTSD amongst refugees in the Middle East and the clinical utility of the ITQ in a humanitarian context. Findings support the growing evidence for the cross-cultural applicability of ICD-11 PTSD/CPTSD.

Adjustment disorder diagnosis: Improving clinical utility

OBJECTIVES

Adjustment disorder (AD) is a frequent diagnosis in clinical practice worldwide. After long neglect in mental health research, the new DSM definition and in particular the ICD-11 model of AD is about to create a fresh impulse for research on AD and for refined clinical use of the diagnosis.

METHODS

This paper outlines the clinical features of AD according to the ICD-10, ICD-11 and DSM-5 definitions, and provides case vignettes of patients with AD with clinical presentations of dominating anxiety, depressed mood or mixed symptom presentations. The available clinical assessments and diagnostic tools are described in detail, together with findings on their psychometric properties.

RESULTS

The current AD definitions are consistent with a new nosological grouping of AD with posttraumatic stress disorder in the chapter on trauma- and stressor-related disorders, or stress response syndromes.

CONCLUSIONS

This nosological specification opens new avenues for neurobiological and psychological research on AD and for developing novel therapies.

ICD-11 guidelines for psychotic, mood, anxiety and stress-related disorders in Mexico: Clinical utility and reliability

Background/Objective: The World Health Organization's diagnostic guidelines for ICD-11 mental and behavioural disorders must be tested in clinical settings around the world to ensure that they are clinically useful and genuinely global. The objective is evaluate the inter-rater reliability and clinical utility of ICD-11 guidelines for psychotic, mood, anxiety- and stress-related disorders in Mexican patients. Method: Adult volunteers exhibiting the selected symptoms were referred from the pre-consultation unit of a public psychiatric hospital to an interview by a pair of clinicians, who subsequently assigned independent diagnoses and evaluated the clinical utility of the diagnostic guidelines as applied to each particular case, on the basis of a scale developed for this purpose. Results: 23 clinicians evaluated 153 patients. Kappa scores were strong for psychotic disorders (.83), moderate for stress-related (.77) and mood disorders (.60) and week for anxiety and fear-related disorders (.43). A high proportion of clinicians considered all diagnostic guidelines to be quite to extremely useful as applied to their patients. Conclusions: ICD-11 guidelines for psychotic, stress-related and mood disorders allow adequate inter-rater consistency among Mexican clinicians, who also considered them as clinical useful tools.

Clinical utility of ICD-11 diagnostic guidelines for high-burden mental disorders: results from mental health settings in 13 countries

In this paper we report the clinical utility of the diagnostic guidelines for ICD-11 mental, behavioural and neurodevelopmental disorders as assessed by 339 clinicians in 1,806 patients in 28 mental health settings in 13 countries. Clinician raters applied the guidelines for schizophrenia and other primary psychotic disorders, mood disorders (depressive and bipolar disorders), anxiety and fear-related disorders, and disorders specifically associated with stress. Clinician ratings of the clinical utility of the proposed ICD-11 diagnostic guidelines were very positive overall. The guidelines were perceived as easy to use, corresponding accurately to patients' presentations (i.e., goodness of fit), clear and understandable, providing an appropriate level of detail, taking about the same or less time than clinicians' usual practice, and providing useful guidance about distinguishing disorder from normality and from other disorders. Clinicians evaluated the guidelines as less useful for treatment selection and assessing prognosis than for communicating with other health professionals, though the former ratings were still positive overall. Field studies that assess perceived clinical utility of the proposed ICD-11 diagnostic guidelines among their intended users have very important implications. Classification is the interface between health encounters and health information; if clinicians do not find that a new diagnostic system provides clinically useful information, they are unlikely to apply it consistently and faithfully. This would have a major impact on the validity of aggregated health encounter data used for health policy and decision making. Overall, the results of this study provide considerable reason to be optimistic about the perceived clinical utility of the ICD-11 among global clinicians.