Current classification of eating disorders is failing to classify most clinical presentations; ignores continuities between child, adolescent and adult manifestations; and requires frequent changes of diagnosis to accommodate the natural course of these disorders. The classification is divorced from clinical practice, and investigators of clinical trials have felt compelled to introduce unsystematic modifications. Classification of feeding and eating disorders in ICD-11 requires substantial changes to remediate the shortcomings. We review evidence on the developmental and cross-cultural differences and continuities, course and distinctive features of feeding and eating disorders. We make the following recommendations: a) feeding and eating disorders should be merged into a single grouping with categories applicable across age groups; b) the category of anorexia nervosa should be broadened through dropping the requirement for amenorrhoea, extending the weight criterion to any significant underweight, and extending the cognitive criterion to include developmentally and culturally relevant presentations; c) a severity qualifier "with dangerously low body weight" should distinguish the severe cases of anorexia nervosa that carry the riskiest prognosis; d) bulimia nervosa should be extended to include subjective binge eating; e) binge eating disorder should be included as a specific category defined by subjective or objective binge eating in the absence of regular compensatory behaviour; f) combined eating disorder should classify subjects who sequentially or concurrently fulfil criteria for both anorexia and bulimia nervosa; g) avoidant/restrictive food intake disorder should classify restricted food intake in children or adults that is not accompanied by body weight and shape related psychopathology; h) a uniform minimum duration criterion of four weeks should apply.
The development of the 11th edition of the International Classification of Diseases (ICD) is ongoing, and the diagnostic system is expected to be published in the year 2015. The WPA is supporting the World Health Organization (WHO) in the production of the chapter on mental disorders.
The WPA Past-President, M. Maj, is a member of the International Advisory Group for the ICD-10 revision and the chairperson of the Working Group on Mood and Anxiety Disorders. Several WPA officers or experts have been appointed as chairpersons or members of ICD-11 Working Groups. The chairpersons include W. Gaebel (Working Group on Psychotic Disorders), P. Tyrer (Working Group on Personality Disorders), L. Salvador-Carulla (Working Group on Intellectual Disabilities), O. Gureje (Working Group on Somatic Distress and Dissociative Disorders), and D. Stein (Working Group on Obsessive-Compulsive and Related Disorders).
The WPA Member Societies participated in the WPA-WHO Global Survey of Psychiatrists' Attitudes Towards Mental Disorders Classification 1. This survey collected information from 4887 psychiatrists concerning their regular use of a formal classification system, the classification system most used, and the number of diagnostic categories desired, and their views on the most important purposes of classification, the use of strict criteria versus flexible guidance, how to incorporate severity and functional status in a classification of mental disorders, the utility of a dimensional component, the cultural applicability of current classifications, and the ease of use and the goodness of fit of ICD-10 diagnostic categories. The results of this survey are being used to improve the clinical utility of the ICD-11 chapter on mental disorders.
Several WPA Member Societies and experts are being or will be involved in ICD-11 field trials and in the various translations/adaptations of the diagnostic system. The WPA is actively contributing to the process of harmonization between the ICD-11 and the DSM-5.
Within the frame of the 15th World Congress of Psychiatry, held in Buenos Aires, Argentina in September 2011, several sessions related to the ICD-11 development took place, including a Special Symposium entitled “Developing the ICD-11 classification of mental disorders: field studies and global perspectives”, with the participation of G. Reed, the WHO officer in charge of the process.
World Psychiatry is one of the main channels through which the international psychiatric community is being updated about the ICD-11 development. A special article authored by the ICD-11 International Advisory Group, summarizing the philosophy of the entire process, has been published in the journal 2, as well as the first report of the Working Group on Intellectual Disabilities 3 and a review of evidence and proposals for the ICD-11 classification of feeding and eating disorders 4. Several papers produced by the Working Group on Mood and Anxiety Disorders have been collected in a special supplement to the journal 5. Many relevant contributions have appeared in recent issues of the journal 6–25. All the above articles are available on the WPA website (http://www.wpanet.org).
The current versions of the DSM (DSM-IV-TR) and ICD (ICD-10) describe all mental disorders as polythetic-categorical concepts. Lists of symptoms are presented, and diagnostic category labels are assigned to patients based on observing specific patterns of symptoms. A number of notable conceptual problems emerge when using this strictly categorical system in research and in the clinic. When thorough structured diagnostic interviews are used, typical patients meet criteria for more than one specific diagnosis (a phenomenon termed "comorbidity"). In addition, groups of patients with the same putative categorical label are often heterogeneous with respect to key clinical features, such as severity and prognosis, and patients with symptomatology below diagnostic thresholds are often significantly impaired. Although categorical concepts will always be essential in official nosologies (e.g., in providing diagnostic labels for reimbursement purposes), many of the conceptual problems of a strictly categorical diagnostic system can be overcome by enhancing official nosologies with dimensional concepts. Specific dimensional approaches and directions that may be considered for upcoming revisions of both the DSM and ICD are discussed.
The diagnostic concepts of post-traumatic stress disorder (PTSD) and other disorders specifically associated with stress have been intensively discussed among neuro- and social scientists, clinicians, epidemiologists, public health planners and humanitarian aid workers around the world. PTSD and adjustment disorder are among the most widely used diagnoses in mental health care worldwide. This paper describes proposals that aim to maximize clinical utility for the classification and grouping of disorders specifically associated with stress in the forthcoming 11th revision of the International Classification of Diseases (ICD-11). Proposals include a narrower concept for PTSD that does not allow the diagnosis to be made based entirely on non-specific symptoms; a new complex PTSD category that comprises three clusters of intra- and interpersonal symptoms in addition to core PTSD symptoms; a new diagnosis of prolonged grief disorder, used to describe patients that undergo an intensely painful, disabling, and abnormally persistent response to bereavement; a major revision of "adjustment disorder" involving increased specification of symptoms; and a conceptualization of "acute stress reaction" as a normal phenomenon that still may require clinical intervention. These proposals were developed with specific considerations given to clinical utility and global applicability in both low- and high-income countries.
Although "intellectual disability" has widely replaced the term "mental retardation", the debate as to whether this entity should be conceptualized as a health condition or as a disability has intensified as the revision of the World Health Organization (WHO)'s International Classification of Diseases (ICD) advances. Defining intellectual disability as a health condition is central to retaining it in ICD, with significant implications for health policy and access to health services. This paper presents the consensus reached to date by the WHO ICD Working Group on the Classification of Intellectual Disabilities. Literature reviews were conducted and a mixed qualitative approach was followed in a series of meetings to produce consensus-based recommendations combining prior expert knowledge and available evidence. The Working Group proposes replacing mental retardation with intellectual developmental disorders, defined as "a group of developmental conditions characterized by significant impairment of cognitive functions, which are associated with limitations of learning, adaptive behaviour and skills". The Working Group further advises that intellectual developmental disorders be incorporated in the larger grouping (parent category) of neurodevelopmental disorders, that current subcategories based on clinical severity (i.e., mild, moderate, severe, profound) be continued, and that problem behaviours be removed from the core classification structure of intellectual developmental disorders and instead described as associated features.
With each successive revision of the DSM and ICD, psychiatric comorbidity has become more prevalent. The 'atheoretical' approaches of the DSM and ICD explicitly encourage multiple diagnoses with few exclusionary hierarchies, in the hope that all clinically relevant information will be captured. However, the current strategy of diagnosing 'maximal' comorbidity may not reflect 'optimal' comorbidity. Many clinicians and health information systems, particularly those in developing countries, have a limited capacity for capturing this diagnostic information, and fail to characterize additional diagnoses that are present. This article will address the evolution of our current diagnostic system as a way of understanding the emergence of comorbid psychiatric diagnoses. Alternative diagnostic approaches (a dimensional system, diagnostic hierarchies, and mixed diagnostic categories) that could be used to address the emergence of comorbid psychiatric diagnoses are considered. Future challenges for the next evolution of DSM and ICD are presented.
Global suicide rates among adolescents in the 15-19 age group, according to the latest World Health Organization (WHO) Mortality Database, were examined. Data for this age group were available from 90 countries (in some cases areas) out of the 130 WHO member states. The mean suicide rate for this age group, based on data available for the latest year, was 7.4/100,000. Suicide rates were higher in males (10.5) than in females (4.1). This applies in almost all countries. The exceptions are China, Cuba, Ecuador, El Salvador and Sri Lanka, where the female suicide rate was higher than the male. In the 90 countries (areas) studied, suicide was the fourth leading cause of death among young males and the third for young females. Of the 132,423 deaths of young people in the 90 countries, suicide accounted for 9.1%. The trend of suicide rates from 26 countries (areas) with data available during the period 1965-1999 was also studied. A rising trend of suicide in young males was observed. This was particularly marked in the years before 1980 and in countries outside Europe. The WHO database is the largest of its kind and, indeed, the only information source that can currently be used for analysis of global mortality due to suicide. Methodological limitations are discussed.
This paper updates single risk factors identified by the Northern Finland 1966 Birth Cohort Study up to the end of year 2001 or age 34. Impaired performance (e.g., delayed motor or intellectual development) or adverse exposures (e.g., pregnancy and birth complications, central nervous system diseases) are associated with an increased risk for schizophrenia. However, upper social class girls and clever schoolboys also have an increased risk to develop schizophrenia, contrasted to their peers. Individuals who subsequently develop schizophrenia follow a developmental trajectory that partly and subtly differs from that of the general population; this trajectory lacks flexibility and responsiveness compared to control subjects, at least in the early stages. We propose a descriptive, lifespan, multilevel systems model on the development and course of schizophrenia.
The Danish version of the ICD-10 chapter on mental and behavioural disorders has 380 different diagnoses when three digits are used. This study examines how many of the available diagnoses were used and to what extent in Danish psychiatric hospital-based services in the period from 2001 to 2007, through an analysis of the total number of diagnoses reported to the Danish Psychiatric Central Research Register (n=1,260,097). The 50th percentile (50.1%) was reached by using 16 diagnoses (4.2% of 380 available). The three most frequently registered diagnoses were paranoid schizophrenia, alcohol dependence and adjustment disorder, used 10.2%, 8.3% and 5.9% of the times, respectively. Seven diagnoses (1.8%) were used between 1 and 4 times during the 7-year period. One hundred nine (28.7% of available diagnoses) were used less than 100 times each. These data suggest that it may be sensible to reconsider the number of diagnoses needed in the revision of the ICD-10 chapter on mental and behavioural disorders.
In 2005, the World Health Organization (WHO) launched the second edition of the Mental Health Atlas, consisting of revised and updated information on mental health from countries. The sources of information included the mental health focal points in the Ministries of Health, published literature and unpublished reports available to WHO. The results show that global mental health resources remain low and grossly inadequate to respond to the high level of need. In addition, the revised Atlas shows that the improvements over the period 2001 to 2004 are very small. Imbalances across income groups of countries remain largely the same. Enhancement in resources devoted to mental health is urgently needed, especially in low- and middle-income countries.
The WPA has recently finalized with the World Health Organization (WHO) a Work Plan for the triennium 2009-2011, covering five items: a) the revision of the chapter on mental and behavioural disorders of the ICD-10; b) collaboration in the Mental Health Gap Action Programme (mhGAP); c) partnership on mental health care in emergencies; d) collaboration in the area of substance abuse; e) partnership on involvement of users and carers. I will focus here on the first three of these items.
The commitment of the WPA leadership toward early career psychiatrists was clear from the beginning of this triennium. In fact, the fourth institutional goal of the WPA Action Plan 2008-2011 was “to promote the professional development of early career psychiatrists world-wide” (1). A series of initiatives was defined by the President, Prof. Mario Maj, to pursue this goal: a) launching, in collaboration with a network of centers of excellence, a programme of one-year fellowships for young psychiatrists from low-income countries, who will commit themselves to apply in their country of origin what they have learnt; b) organizing a series of workshops on leadership and professional skills for young psychiatrists; c) facilitating the participation of young psychiatrists in WPA congresses and other scientific meetings; d) stimulating the participation of young psychiatrists in the activities of WPA Scientific Sections; e) joining and assisting Member Societies in the development and implementation of programmes for young psychiatrists (1). A further initiative was to create an Early Career Psychiatrists Council, which should collaborate with the President and the Executive Committee to pursue the above-mentioned goals.
The members of the WPA Early Career Psychiatrists Council have been appointed by WPA Member Societies and subdivided into the following five geographic areas: Europe I, which includes Northern, Southern and Western Europe; Europe II, which includes Central and Eastern Europe; Asia/Australasia; Africa and Middle East; Americas.
The Early Career Psychiatrists Council has actively started its work. The first activity of the Council was to elect a coordinator for each of the five geographic areas. Andrea Fiorillo from Italy has been elected for Europe I, Zuzana Lattova from Czech Republic for Europe II, Prachi Brahmbhatt from Australia for Asia/Australasia, Hussien El Kholy from Egypt for Africa and Middle East, and Felipe Picon from Brazil for Americas.
On December 18, 2009 the five coordinators had a teleconference with the WPA President in order to discuss and finalize the Action Plan of the Council, taking into account the several interesting ideas which emerged during the five teleconferences that the WPA President had with the members of each area in October 2009.
According to the WPA normative instruments, the Early Career Psychiatrists Council is expected to: a) upgrade communication concerning early career psychiatrists between WPA Member Societies and WPA governance; b) identify and address problems concerning early career psychiatrists; c) promote the participation of early career psychiatrists in the various sectorial activities of the WPA; d) contribute to the design of activities to promote the professional development of early career psychiatrists.
In this paper we will briefly describe the Action Plan for 2010 of the WPA Early Career Psychiatrists Council, which consists of the following nine activities.
On March 11, 2011 Japan was struck by a magnitude 9.0Mw earthquake. The results were severe, as more than 15,000 people were killed by the earthquake and the following tsunami 1. The aftermath of the disaster was a level 7 nuclear meltdown in Fukushima, matching only the Chernobyl disaster 1,2. The literature on behavioural reactions after nuclear disasters is scarce 3,4,5, mainly addressing anxiety. In the case of Japan, the nuclear disaster has awakened the memories of the World War II atomic bombs and as such, might have raised a historically based fear among Japanese 6. Our aim was to examine the differences between people whose grandparents were living in the greater area of Hiroshima and Nagasaki during the dropping of the atomic bombs and those whose grandparents were not.
A convenience sample of 140 Japanese was collected during the week of April 24, 2011. Each participant was initially screened by a Japanese interviewer for history of physical or mental disorders and substance abuse. Six participants were excluded from this survey because of positive history of the aforementioned conditions and 12 more participants had a significant number of missing data, leading to a final sample of 122 participants.
The participants (mean age 28.7±9.0 years, 64.2% women, 29.1% married) filled a short questionnaire collecting demographic data and asking a screening question: “were your grandparents exposed to the atomic bomb in Hiroshima or Nagasaki?” A “yes” answer led the interviewer to inquire if the grandparents were living in 1945 in the greater area of Hiroshima or Nagasaki when the atom bombs were dropped. We divided the sample into two groups: grandchildren of people who where in greater Hiroshima and Nagasaki during World War II (n=34) and a comparison group (n=88). Each participant was administered a battery of self-reported questionnaires, including questions about fear of radiation exposure, rated on a four Likert scale ranging from 1 (not at all) to 4 (very much).
Post-traumatic stress disorder (PTSD) symptoms were assessed by the 22-item Impact of Event Scale – Revised (IES-R) 7. This scale was rated from 0 (not at all) to 4 (extremely) and represents the participants’ distress in the following week regarding the Fukushima disaster. This measure was used before and was found to be suitable in other major disasters such as the 2010 Haiti’s earthquake 8.
Grandchildren of Japanese living in Hiroshima and Nagasaki showed higher fear of radiation exposure (mean 3.0±0.9 vs. 2.7±0.8; t=2.131; p=0.035), and higher level of PTSD symptoms (mean 32.8±21.6 vs. 23.0±15.4; t=2.755; p=0.007). There were no significant differences between the groups in age, gender, marital status and distance from Fukushima.
These findings may indicate the existence of a sub-group among the Japanese population who shows a specific vulnerability to PTSD and fear of radiation exposure. Although the sample size was small and the design cross-sectional, this study may be of interest, because this is the first time that a nuclear disaster occurs in a country with prior exposure.
This study may encourage future longitudinal investigations focusing on the long-term psychological and psychiatric sequelae of nuclear disaster 1,3,4,5.
This study was undertaken as part of an exploration of the potential risk for future eating disorders in the black female population of South Africa. Previous research has documented eating attitudes suggesting that such a risk exists in urban populations. A translated version of the Eating Attitudes Test (EAT-26) was applied in a Zulu speaking, rural population (n=361). A prevalence of 3% for abnormal eating attitudes was established. In keeping with the hypothesis, the findings suggest that the risk for developing an eating disorder in a rural population is somewhat lower. In this regard, there does appear to be an urban-rural divide, which may have implications for the prevention of the emergence of eating disorders in black, South African adolescents. However, the validity of the EAT-26 in this population is a consideration in interpreting the data.
Bipolar disorder (BPD) and schizophrenia (SZ) may have some susceptibility genes in common, despite the fact that current nosology separates them into non-overlapping categories. The evidence for shared genetic factors includes epidemiologic characteristics, family studies and overlap in confirmed linkages. Review of these data indicates that there are five genomic regions which may represent shared genetic susceptibility of BPD and SZ. As the genes underlying these confirmed linkages are identified, the current nosology must be changed to reflect the new knowledge concerning the shared etiologies of BPD and SZ.
Autism and related conditions have been described since the 1940s, but official recognition did not come until 1980, with the publication of the DSM-III. Early confusion centered on the validity of the condition, that is, whether it could be considered distinct from childhood schizophrenia. This confusion was clarified with work on clinical phenomenology and genetics of the two conditions. Specifically, differences in clinical features were identified, with autism being marked by profound social difficulties and very early onset relative to schizophrenia. It also became clear that autism was a strongly genetic disorder, distinct from schizophrenia.
Autism was associated, at least initially, with a rather poor outcome, with the earliest studies suggesting that about two-third of individuals, as adults, required institutional care 1,2. Early treatment approaches were centered on psychotherapy (often of parent and child), but gradually shifted as work indicated that structured behavioral and educational approaches were associated with better outcome, as was earlier diagnosis and intervention. It has become increasingly clear that greater public awareness, earlier intervention, and more effective management have had a major impact on the outcome of the condition 1.